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The management of intracranial malignancies in pregnancy poses unique challenges to the perioperative team. We describe the successful surgical management of a meningioma in a 28-year-old previously healthy patient, in her third trimester of pregnancy, who first presented with a generalised seizure. Without clear guidelines on the management of intracranial malignancies in pregnancy, a multidisciplinary approach was essential in providing a management plan for the patient’s seizures and on the timing of her surgical intervention. Hormone-mediated tumour growth was a significant factor in opting for urgent surgical intervention and we discuss the current evidence linking hormones to tumour growth in pregnancy.

Objective and subjective methods of assessing time taken for accommodative change (ToAC) include accommodative dynamics (AD) and accommodative facility (AF). This study investigates the validity of novel metrics derived from the AD-profile and explores their relationship with AF. AD were assessed using a modified open-field autorefractor in 43 healthy adults. Non-linear regression curves were fitted to the data to derive: latency-of-accommodation (nLoA) and -disaccomodation (nLoD), Time-for-accommodation (ToA) and -disaccommodation (ToD), and objective-ToAC (oToAC). Latencies were also calculated through visual inspection of the AD data as in previous studies (pLoA and pLoD). AF was used to assess subjective-ToAC. Statistical analysis explored the relationships between the AD-metrics and AF. Subjects were assessed on three visits to examine intra- and inter-observer repeatability. nLoA and nLoD were greater than pLoA (p = 0.001) and pLoD (p = 0.004) respectively. nLoA and nLoD also demonstrated greater intra- and inter-observer repeatability than pLoA and pLoD. AF demonstrated a moderate, inverse correlation with ToA (p = 0.02), ToD (p = 0.007), and oToAC (p = 0.007). ToD was the single best accommodative predictor of AF (p = 0.011). The novel method for deriving latency was more repeatable, but not interchangeable with the techniques used in previous studies. ToD was the most repeatable metric with the greatest association with AF.

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Background: Guidelines for acute upper gastrointestinal bleeding (UGIB) recommend use of proton pump inhibitors (PPI) administered by continuous IV infusion (CI). Although data suggest comparable outcomes with CI and IV push (IVP) dosing post-endoscopy, there are limited data to support IVP PPI as the pre-endoscopy regimen. Objective: To evaluate the impact of a pharmacist-managed protocol for reducing PPI CIs and substitution of PPI IVP dosing in hemodynamically stable patients with suspected acute upper gastrointestinal bleeding (UGIB) prior to endoscopic intervention. Design, Setting, and Participants: Retrospective study; Tertiary-care community teaching hospital; Hemodynamically stable adults with confirmed or suspected UGIB. Hemodynamic stability was defined as a systolic blood pressure >90 mmHg, heart rate <100 beats, mean arterial pressure >65 mmHg, and no requirement for vasopressors. Intervention : All iterations of treatment recommendations encouraged an initial pantoprazole 80 mg IVP dose. In the pre-intervention group, patients were then treated at the at the provider's discretion with the majority receiving CI pantoprazole. After implementation of the original protocol (Phase I), all hemodynamically stable patients were allowed 1 bag of CI pantoprazole (80 mg infused over 10 hours) before being transitioned by the pharmacist to pantoprazole 40 mg IVP every 12 hours. After internal analysis, the protocol was revised to allow patients to be immediately transitioned to IVP dosing without an initial CI (Phase II). Main Outcome: Incidence of continued bleeding or re-bleeding within 7 days of initial PPI dose. Results: A total of 325 patients were included across all 3 study phases. The median number of CI bags per patient was reduced from 4 pre-intervention, to 1.5 in phase I, and to 0 in phase II (P <.001). The primary endpoint of continued bleeding or re-bleeding within 7 days was similar across all 3 groups (5.0% vs 6.5% vs 5.2%, P =.92). Mean intravenous pantoprazole costs were reduced by $21.73/patient. Conclusions: Movement toward preferential use of IVP PPI prior to endoscopy for hemodynamically stable patients with confirmed or suspected UGIBs resulted in similar rates of continued bleeding or re-bleeding and generated modest cost savings. These findings warrant further investigation. [ABSTRACT FROM AUTHOR]

In 2018, the US military developed the Military Acute Concussion Evaluation-2 (MACE-2) to inform the acute evaluation of mild traumatic brain injury (mTBI). However, researchers have yet to investigate false-positive rates for components of the MACE-2, including the Vestibular-Ocular Motor Screening (VOMS) and modified Balance Error Scoring System (mBESS), in military personnel. To examine factors associated with false-positive results on the VOMS and mBESS in US Army Special Operations Command (USASOC) personnel. Cross-sectional study. Military medical clinic. A total of 416 healthy USASOC personnel completed the medical history, VOMS, and mBESS evaluations. False-positive rates for the VOMS (≥2 on VOMS symptom items, >5 cm for near point of convergence [NPC] distance) and mBESS (total score >4) were determined using χ2 analyses and independent-samples t tests. Multivariable logistic regressions (LRs) with adjusted odds ratios (aORs) were performed to identify risk factors for false-positive results on the VOMS and mBESS. The VOMS item false-positive rates ranged from 10.6% (smooth pursuits) to 17.5% (NPC). The mBESS total score false-positive rate was 36.5%. The multivariable LR model supported 3 significant predictors of VOMS false-positives, age (aOR = 1.07; 95% CI = 1.02, 1.12; P =.007), migraine history (aOR = 2.49; 95% CI = 1.29, 4.81; P =.007), and motion sickness history (aOR = 2.46; 95% CI = 1.34, 4.50; P =.004). Only a history of motion sickness was a significant predictor of mBESS false-positive findings (aOR = 2.34; 95% CI = 1.34, 4.05; P =.002). False-positive rates across VOMS items were low and associated with age and a history of mTBI, migraine, or motion sickness. False-positive results for the mBESS total score were higher (36.5%) and associated only with a history of motion sickness. These risk factors for false-positive findings should be considered when administering and interpreting VOMS and mBESS components of the MACE-2 in this population. [ABSTRACT FROM AUTHOR]