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Objective Postprandial hyperinsulinemic hypoglycemia with neuroglycopenia is an increasingly recognized complication of Roux-en-Y gastric bypass and gastric sleeve surgery that may detrimentally affect patient quality of life. One likely causal factor is glucagon-like peptide-1 (GLP-1), which has an exaggerated rise following ingestion of carbohydrates after bariatric surgery. This paper sought to assess the role of GLP-1 receptor agonists (GLP-1RAs) in managing postprandial hypoglycemia following bariatric surgery. Methods MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and Scopus were systematically and critically appraised for all peer-reviewed publications that suitably fulfilled the inclusion criteria established a priori. This systematic review was developed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols (PRISMA-P). It followed methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions and is registered with PROSPERO (International Prospective Register of Systematic Reviews; identifier CRD420212716429). Results and Conclusions Postprandial hyperinsulinemic hypoglycemia remains a notoriously difficult to manage metabolic complication of bariatric surgery. This first, to the authors' knowledge, systematic review presents evidence suggesting that use of GLP-1RAs does not lead to an increase of hypoglycemic episodes, and, although this approach may appear counterintuitive, the findings suggest that GLP-1RAs could reduce the number of postprandial hypoglycemic episodes and improve glycemic variability.

Women with obesity are at risk of pelvic floor dysfunction with a 3-fold increased incidence of urge urinary incontinence (UUI) and double the risk of stress urinary incontinence (SUI). The National Institute for Health and Care Excellence (NICE) and European Association of Urology (EAU) recommend that women with a body mass index ≥30 kg/m2 should consider weight loss prior to consideration for incontinence surgery. This systematic review and meta-analysis will assess this recommendation to aid in the counselling of women with obesity-related urinary incontinence (UI). Medical Literature Analysis and Retrieval System online (MEDLINE), EMBASE, Cochrane, ClinicalTrials.gov, and SCOPUS were systematically and critically appraised for all peer reviewed manuscripts that suitably fulfilled the inclusion criteria established a priori and presented original, empirical data relevant to weight loss intervention in the management of urinary incontinence. Thirty-three studies and their outcomes were meta-analysed. Weight loss interventions were associated in a decreased prevalence in UI (OR 0.222, 95% CI [0.147, 0.336]), SUI (OR 0.354, 95% CI [0.256, 0.489]), UUI (OR 0.437, 95% CI [0.295, 0.649]) and improved quality of life (PFDI-20, SMD -0.774 (95% CI [−1.236, −0.312]). This systematic review and meta-analysis provide evidence that weight loss interventions are effective in reducing the prevalence of obesity-related UI symptoms in women. Bariatric surgery in particular shows greater sustained weight loss and improvements in UI prevalence. Further large scale, randomized control trials assessing the effect of bariatric surgery on women with obesity-related UI are needed to confirm this study's findings.\ud \ud

OBJECTIVEThe aims of this study were to evaluate a multiyear experience with subdural evacuating port system (SEPS) placement for chronic subdural hematoma (cSDH) in the intensive care unit at a tertiary neurosurgical center and to compare SEPS placement with bur hole evacuation in the operating room.METHODSAll cases of cSDH evacuation were captured over a 7-year period at a tertiary neurosurgical center within an integrated health care delivery system. The authors compared the performance characteristics of SEPS and bur hole placement with respect to recurrence rates, change in recurrence rates over time, complications, length of stay, discharge disposition, and mortality rates.RESULTSA total of 371 SEPS cases and 659 bur hole cases were performed (n = 1030). The use of bedside SEPS placement for cSDH treatment increased over the 7-year period, from 14% to 80% of cases. Reoperation within 6 months was higher for the SEPS (15.6%) than for bur hole drainage (9.1%) across the full 7-year period (p = 0.002). This observed overall difference was due to a higher rate of reoperation during the same hospitalization (7.0% for SEPS vs 3.2% for bur hole; p = 0.008). Over time, as the SEPS procedure became more common and modifications of the SEPS technique were introduced, the rate of in-hospital reoperation after SEPS decreased to 3.3% (p = 0.02 for trend), and the difference between SEPS and bur hole recurrence was no longer significant (p = 0.70). Complications were uncommon and were similar between the groups.CONCLUSIONSOverall performance characteristics of bedside SEPS and bur hole drainage in the operating room were similar. Modifications to the SEPS technique over time were associated with a reduced reoperation rate.

External ventricular drains (EVDs) historically have a high rate of infection, and EVD infections are a cause of significant morbidity and mortality. We have shown previously that a simple infection control protocol reduced the rate of EVD infections during a 3-year period, and the present study examines whether infection rates were durably reduced over an additional 4 years.Retrospective analysis of EVDs placed in the intensive care unit of a tertiary neurosurgical center over an additional 4 year follow-up period.In the 4-year follow-up period, 189 EVDs were placed in 173 patients. The previously observed decrease in cerebrospinal fluid culture positivity from 9.8% in the baseline period to 0.8% in the first 3 years of the protocol period continued in the 4-year follow-up period (0%, 0 of 189 EVD placements, 0 per 1000 catheter-days; P0.001 compared with baseline). The previously observed decrease in the rate of ventriculitis from 6.3% to 0.8% also continued in the follow-up period (0%, 0 of 189 EVD placements, 0 per 1000 catheter-days; P0.001 compared with baseline). Over the total 7 years of protocol use, the rate of culture positivity was 0.3% (1 of 308 EVD placements, 0.29 per 1000 catheter-days) and the rate of ventriculitis was 0.3% (1 of 308 EVD placements, 0.29 per 1000 catheter-days). The only observed infection over 7 years occurred in a patient who removed their own EVD.A straightforward EVD infection control protocol substantially and durably reduces EVD infections to a near-zero rate.

Glomus tumors are difficult to manage surgically because they are vascular tumors that are topographically associated with important vascular and neuronal structures. Hence, there is a strong risk of incomplete resection and a high morbidity rate. In addition, they grow slowly. Recent treatments have increasingly involved a combination of surgical resection and radiosurgery. We present our experience in treating glomus tumors of the skull base with stereotactic radiosurgery as an upfront therapy.We analyzed data from 13 consecutive patients with glomus tumors that were initially treated with stereotactic radiosurgery in our institute from February 2010 to April 2012. The tumor control rate, resolution of symptoms, and the complication rate were tabulated.All patients were female with a median age of 63 (mean 62.7+/-14.6 years). The median treatment dose was 25.8 Gy (27.6 Gy +/- 9.5 Gy) and the median tumor volume 10.4 mL (9.2 +/- 6.5). The median follow-up was 47.4 months (51.8+/-11.2 months, range 31-74). The tumor control rate was 92.3%; 46.7% of the patients had noticeable tumor shrinkage. This happened at a median interval of 17 months (18.7+/-6.8) after treatment. Most patients with tinnitus had resolution of their symptoms (87.5%). Four patients presented with new symptoms and four patients with worsening of pre-existing symptoms. The time course of symptomatic improvement followed that of tumor size reduction. However, there was no statistical correlation between the amount of tumor reduction and symptomatic relief.Stereotactic radiosurgery (SRS) is an effective upfront treatment option in the management of glomus tumors.

To compare the safety and effectiveness of three methods of reversing coagulopathic effects of warfarin in patients with potentially life-threatening intracranial hemorrhage.A retrospective electronic medical record review of 63 patients with warfarin-related intracranial hemorrhage between 2007 and 2010 in an integrated health care delivery system was conducted. The three methods of rapid warfarin reversal were fresh-frozen plasma (FFP), activated factor VII (FVIIa; NovoSevenRT [Novo Nordisk, Bagsværd, Denmark]), and prothrombin complex concentrate (PCC; BebulinVH [Baxter, Westlake Village, California, USA], ProfilnineSD [Grifols, North Carolina, USA]), each used adjunctively with vitamin K (Vit K, phytonadione). We determined times from reversal agent order to laboratory evidence of warfarin reversal (international normalized ratio [INR]) in the first 48 hours and compared INR rebound rates and complications in the first 48 hours.Reversal with FFP took more than twice as long compared with FVIIa or PCC. To reach an INR of 1.3, mean (±SD) reversal times were 1933 ± 905 minutes for FFP, 784 ± 926 minutes for FVIIa, and 980 ± 1021 minutes for PCC (P0.001; P0.01 between FFP and FVIIa, P0.05 between FFP and PCC). INR rebound occurred in 0 of 31 patients for FFP, 4 of 8 for FVIIa, and 0 of 7 for PCC (P = 0.001). Complications were uncommon. FVIIa was 15 and 3.5 times as expensive as FFP and PCC, respectively.As an adjunct to Vit K for rapid warfarin reversal, FVIIa and PCC appear more effective than FFP. Either FVIIa or PCC are reasonable options for reversal, but FVIIa is considerably more expensive and may have greater risk of INR rebound.

BACKGROUND External ventricular drains (EVDs) are associated with high rates of infection, and EVD infections cause substantial morbidity and mortality. OBJECTIVE To determine whether the introduction of an evidence-based EVD infection control protocol could reduce the rate of EVD infections. METHODS This was a retrospective analysis of an EVD infection control protocol introduced in a tertiary care neurointensive care unit. We compared rates of cerebrospinal fluid culture positivity and ventriculitis for the 3 years before and 3 years after the introduction of an evidence-based EVD infection control protocol. A total of 262 EVD placements were analyzed, with a total of 2499 catheter-days. RESULTS The rate of cerebrospinal fluid culture positivity decreased from 9.8% (14 of 143; 11.43 per 1000 catheter-days) at baseline to 0.8% (1 of 119; 0.79 per 1000 catheter-days) in the EVD infection control protocol period (P = .001). The rate of ventriculitis decreased from 6.3% (9 of 143; 7.35 per 1000 catheter-days) to 0.8% (1 of 119; 0.79 per 1000 catheter-days; P = .02). CONCLUSION The introduction of a simple, evidence-based infection control protocol was associated with a dramatic reduction in the risk of EVD infection.

De 1930 a 1935, tous les evenements qui se sont passes dans la petite ville allemande de Thalburg en Basse-Saxe sont analyses dans leurs moindres details. Pour la premiere fois, la stupefiante montee de l’hitlerisme en Allemagne est decrite et expliquee au quotidien. Interrogeant des centaines de temoins, depouillant les journaux locaux et les archives de la ville, William S. Allen a demonte les rouages du mecanisme implacable qui a conduit a la transformation du Reich, au deperissement de la democratie et au triomphe de la dictature. Cette etude, profondement originale, depeint la facilite avec laquelle quelques hommes sans scrupule peuvent imposer leur loi a une nation entiere, et montre comment, lentement, insidieusement mais surement, on devient nazi. Date de premiere edition : 1967.

An acute subdural hematoma (SDH) requiring surgical intervention is treated with craniotomy or craniectomy, in part because it is generally accepted that coagulated blood present in the acute phase cannot be adequately evacuated by less-invasive means such as bur hole drainage. However, a hyperacute SDH in the first few hours after trauma can have mixed-density components on CT scans that are thought to represent subdural blood that is not yet fully coagulated. The authors report a case in which a hyperacute SDH in a patient receiving antiplatelet therapy was treated with the novel technique of temporizing subdural evacuation port system (SEPS) placement. Placement of an SEPS in the intensive care unit allowed for rapid surgical treatment of the patient's elevated intracranial pressure (ICP) by drainage of 70 ml of fresh subdural blood. After initial SEPS-induced stabilization, the patient underwent operative treatment of the SDH by craniotomy. The combined approach of emergency SEPS placement followed by craniotomy resulted in a dramatic recovery, with improvement from coma and extensor posturing to a normal status on neurological evaluation 5 weeks later. In appropriately selected cases, patients with a hyperacute SDH may benefit from SEPS placement to quickly treat elevated ICP, as a bridge to definitive surgical treatment by craniotomy.

Background and Purpose Hypertonic saline (3% NaCl) infusions can be used to treat acute neurologic hyponatremia (ANH) in critically ill patients with neurological and neurosurgical disorders such as subarachnoid hemorrhage. Adjustments in the rate of hypertonic saline infusions to treat ANH are needed to achieve a goal sodium range and are usually made on an empiric basis. To date, no data are available to determine how reliably such adjustments achieve stable, normal serum sodium concentrations or how often iatrogenic hypernatremia occurs during the course of treatment with hypertonic saline. Methods We have instituted a standardized sliding-scale hypertonic saline protocol to minimize patient-to-patient variability of hypertonic saline administration and to attempt to achieve safe rates of sodium correction and stable maintenance of serum sodium concentration with minimal overshoot. Here, we present a retrospective analysis of the performance characteristics of our standardized hypertonic saline protocol over a 1-year period, in 49 patients. Results The mean rate of initial sodium correction was 0.44 ± 0.36 (mEq/l)/h. During the maintenance infusion phase, 84.3 ± 17.8% of the time was spent in goal range (Na 136–145 mEq/l), 14.9 ± 18.1% of the time was spent in mild undershoot (Na 130–135 mEq/l), and 0.7 ± 3.1% of the time was spent in overshoot (Na >145 mEq/l). No adverse events attributable to infusion of hypertonic saline were encountered. Conclusion Our hypertonic saline sliding-scale protocol for treatment of ANH can be used reliably and achieves normal sodium concentrations in a safe manner with minimal overshoot.

Dominant lethals and translocation induction were assayed in mice after 276 R spermatogonial X-irradiation. Inbred A/Jax strain matings showed a much higher foetal mortality than did the CBA strain matings both in controls and in irradiated groups. No significant irradiation induction of dominant lethals was found. No strain-by-treatment interaction in embryonic death was found for males of either strain when mated to CBA females. Neither did the dominant lethal study reveal any differences between the two types of reciprocal hybrids between the strains, mated to CBA females, albeit the irradiated F1 (A/Jax x CBA) group showed a significant increase of foetal mortality compared to its control. The frequencies of spermatocytes with translocations after spermatogonial irradiation of CBA, A/Jax, F1 (CBA x A/Jax) and F1 (A/Jax x CBA) males were 0.040, 0.044, 0.047 and 0.047 respectively. No translocations were found in the control males. The estimates of the amount of dominant lethals expected from these frequencies seem to be somewhat higher than the actual results. The variances for the means of spermatocytes with translocations were significantly higher for both types of hybrids than for both strains.

Outlines an interdisciplinary university course, Historical and Psychological Analyses of Genocide, which dealt with the Nazi treatment of Jews during World War II. The course examines psychological and sociohistorical principles which could result in mass murder. Concludes that such an approach promotes a thorough explanation of such an event. (KC)

No abstract available

The authors report a case of hypertrophic pachymeningitis, a rare cause of spinal cord compression. In this patient, dural inflammation was associated with a histologically identical pulmonary lesion. Such an association has not been described previously and supports the hypothesis that this disease is related to other connective tissue disorders.

The mouse specific-locus test with visible markers (SLT) has been the only extensively used method for detecting and quantifying the induction of heritable point mutations (intragenic changes and small deficiencies) in mammals. Mutations are detected in first-generation offspring; and scoring is simple, objective, and rapid. Different germ-cell stages can be sampled, including those of greatest pertinence for genetic risk assessment. The differential probability of involving the various loci of the marked set makes the method capable of detecting qualitative (as well as quantitative) differences between the actions of mutagens. Control SLT frequencies for males reported by 4 sets of investigators are in excellent agreement and were summed as a "historical control" (801406 observations) for use in our calculations. Experimental results were classified as positive, negative, or inconclusive based upon a multiple-decision procedure produced by the testing of the following 2 hypotheses: (1) the mutation frequency (induced + spontaneous) of treated mice is not higher than the spontaneous mutation frequency, and (2) the induced mutation frequency of treated mice is no less than 4 times the historical-control mutation frequency. Each hypothesis was tested at the 5% significance level. Because of the low mutation frequency in a very large control, the SLT is capable of yielding positive results in relatively small samples. We reviewed 58 publications, SLT results have been reported for 25 chemical agents, of which 17 (representing 21 chemical classes) gave results that were positive or negative by our criteria. The frequency of positive agents was 6 of 14, 5 of 5, and 0 of 1 conclusively tested, respectively, in spermatogonia, post-spermatogonial stages, and unspecified male germ cells. Depending on the chemical used, post-spermatogonial stages can be of greater, less, or equal sensitivity relative to spermatogonia. The SLT was strongly positive for some chemicals that are not mutagenic (or only weakly so) in lower systems, and there are several examples of the reverse situation. Factors which presumably operated to cause these differences (e.g., metabolism, transport, repair in germ cells) are likely also to operate for transmitted point mutations in man.

The mouse spot test, developed 23 years ago, is an in vivo assay capable of detecting genetic effects of several kinds, including intragenic mutations, minute deficiencies, deletions (through breakage or nondisjunction) of various amounts of chromosomal material, and somatic crossing-over. The method involves exposing embryos that are heterozygous for a number of coat-color markers to the test agent, and, 3 weeks later, looking for clones of mutant cells, i.e., spots of color expressing the recessive marker in an otherwise black fur. Spots having other causes may also be induced, specifically white midventral spots due to cytotoxic effects, and certain spots resulting from misdifferentiation. Spot-test results have, to date, been reported from 7 laboratories. Because the control results for any one cross and solvent were found to be reasonably consistent between the laboratories, we pooled these to develop a "historical" control with which experimental results for the same cross and solvent were compared. Experimental results were classified as positive, negative, or inconclusive on the basis of a multiple-decision procedure produced by the testing of the following 2 hypotheses: (1) the mutation frequency (induced + spontaneous) in treated mice is not higher than the mutation frequency in the appropriate pooled control, and (2) the induced mutation frequency of the treated mice is no less than 4 times as high as the observed mutation frequency in the appropriate pooled control. Each hypothesis was tested at the 5% significance level. To date, 30 substances have been employed in the spot test, including 3 that are solvents for some of the others. Of the remaining 27 (26 compounds and 1 mixture), 16 were positive, 6 negative, and 5 inconclusive. The 26 compounds fell into 27 chemical classifications (using a system provided for use by the GENE-TOX program). The inadequacies in the design and reporting of some past experiments indicate a need for a carefully specified protocol. When properly done, the spot test will fulfill a useful role in mutagenicity testing programs because (1) it is an in vivo mammalian assay, (2) it detects genetic effects of many kinds, and (3) it is relatively rapid. Since the test appears well suited to the identification of potent mutagens, its main value should be in screening large numbers of substances and singling out the potentially worst offenders to be further studied in germ-line mutagenesis tests.

Book reviewed in this article: Not for Export By GLEN WILLIAMS Threshold Firms By GUY STEED The Language of the Skies: the Bilingual Air Traffic Control Conflict in Canada, By SANDFORD F. BORINS

Progress in the quantitative use of CT numbers for patient diagnosis has been limited because of scanner drift, energy dependence, and various artifacts. The nature of these errors is discussed, and methods of evaluating them are described. In addition, remedial measures are mentioned, including the use of a three-point calibration phantom.

After treatment of postmeiotic stages of spermatogenesis of the mouse with TEM (0.2 or 0.4 mg/kg), dose- and stage-of-spermatogenesis-dependent frequencies of cytogenetic aberrations can be observed in early embryos. The frequencies of first-cleavage metaphases exhibiting structural aberrations (all of the chromosome type), the frequencies of 2 cell embryos and of 4--8 cell embryos containing nuclei accompanied by micronuclei or nuclei connected by bridges show a close correlation to frequencies of preimplantation loss of embryos recorded in a dominant lethal test. The frequencies of morulae/blastulae exhibiting blastomeres with micronuclei show a close correlation to the frequencies of total (pre- and post-implantation) loss of embryos. This indicates delayed expression of TEM-induced chromosomal damage which could persist undetected in very early stages of embryogenesis.

A phantom is presented which permits the evaluation of streaking artifacts produced in CT reconstructions by abrupt edges. Its application is demonstrated by results obtained from nine CT scanners. It is observed that even in regions where streaking is not readily apparent, edge-induced artifacts can significantly increase the variance in the reconstruction.

We have tested the effects of TEM in 3 strains of mice using the sperm morphology assay. In addition, we have made an attempt to evaluate this test system with respect to experimental design, statistical problems and possible inter-laboratory differences. Treatment with TEM results in significant increases in the percent of abnormally shaped sperm. These increases are readily detectable in sperm treated as spermatocytes and spermatogonial stages. Our data indicate possible problems associated with inter-laboratory variation in slide analysis. We have found that despite the introduction of such sources of variation, our data were consistent with respect to the effects of TEM. Another area of concern in the sperm morphology test is the presence of “outlier” animals. In our study, such animals comprised 4% of the total number of animals considered. Statistical analysis of the slides from these animals have shown that this problem can be dealt with and that when recognized as such, “outliers” do not effect the outcome of the sperm morphology assay.

Female offspring to the 13th generation of a population in which the males have been irradiated with 276 R X-rays to the spermatogonia in each generation, and offspring from the corresponding control population were irradiated with doses of 65 R or 100 R and their production studied. No significant differences between the groups at either dose level were found in numbers of litters or in litter size. An increase in length of the gestation period was noted in all groups. The feasibility of using reproductive capacity as an alternative to mortality in determining differences in radiosensitivity is considered. It is concluded that offspring to unirradiated groups do not stand a lesser risk from irradiation than offspring to previously irradiated groups.

Offspring to the 7th, 8th and 9th generations of our mouse population were used in sib and non-sib matings to determine the rates of intra-uterine death. Families with 3 or more pairs of offspring tested in sib matings were divided according to the rate of intra-uterine death into classes below 10% or above 15%. It was supposed that the latter to a considerable degree carried recessive lethals and were for that reason called “lethal”, while those with less than 10% death were called “non-lethal”. Fertility and intra-uterine death were studied in non-sib matings from these two classes of families and in matings of sons with females from the inbred CBA strain. Breeding performance was also studied. A significant difference between groups was observed in only one of the comparisons made. The “lethal” group was superior to the “non-lethal” in the number of females made pregnant in tests of sons. In the other comparisons the “lethal” group more often showed a better performance than the “non-lethal” group. It is concluded that the present data do not indicate any overall deleterious effects of recessive lethals in heterozygotes nor do they indicate any clear heterotic effects.