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No AccessJournal of UrologyDysfunctional Voiding/Neurogenic Bladder1 Sep 1998MAGNETIC RESONANCE IMAGING IN CHILDREN WITH VOIDING DYSFUNCTION: IS IT INDICATED? JOAO L. PIPPI SALLE, GIANPAOLO CAPOLICCHIO, ANNE-MARIE HOULE, OLIVIER VERNET, ROMAN JEDNAK, AUGUSTIN M. O'GORMAN, JOSE L. MONTES, and JEAN-PIERRE FARMER JOAO L. PIPPI SALLEJOAO L. PIPPI SALLE More articles by this author , GIANPAOLO CAPOLICCHIOGIANPAOLO CAPOLICCHIO More articles by this author , ANNE-MARIE HOULEANNE-MARIE HOULE More articles by this author , OLIVIER VERNETOLIVIER VERNET More articles by this author , ROMAN JEDNAKROMAN JEDNAK More articles by this author , AUGUSTIN M. O'GORMANAUGUSTIN M. O'GORMAN More articles by this author , JOSE L. MONTESJOSE L. MONTES More articles by this author , and JEAN-PIERRE FARMERJEAN-PIERRE FARMER More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(01)62702-2AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: We evaluated the role of magnetic resonance imaging (MRI) of the lumbosacral spinal cord in children with complicated voiding dysfunction and normal neuro-orthopedic examination. Materials and Methods: We reviewed the records of 32 consecutive children with complicated enuresis who were referred for neurosurgical evaluation, including those with a history of refractory voiding dysfunction or incontinence associated with persistent vesicoureteral reflux, encopresis, or associated leg or back pain. Nine patients were excluded from study because of urethral or anorectal anomalies, or failure to meet the inclusion criteria. Eligible for study inclusion were 23 children with a mean age of 8.9 years. Complete neurological and orthopedic examinations were normal in all patients except 1 with mild scoliosis and 1 with congenital facial palsy. Results: Urodynamic studies revealed instability in 14 cases, hypertonia in 7, hyporeflexia in 2 and detrusor-sphincter dyssynergia in 4. Skeletal abnormalities, mostly spina bifida occulta, were detected in 16 of the 23 children (70%). Spinal MRI was normal in 21 patients (91.3%), including 1 with a tethered cord and lipoma associated with a complex skeletal abnormality, and 1 with a nonprogressive, nonsurgical T7 to T9 syrinx. Only the case of lipoma required neurosurgical intervention. Conclusions: The value of MRI is limited in children with voiding dysfunction and a normal neuro-orthopedic assessment. This study should be reserved for patients with associated neuro-orthopedic findings or complex skeletal deformity on plain x-ray. References 1 : Enuresis. In: . Philadelphia: W. B. Saunders Co.1992: 365. chapt.11. Google Scholar 2 : Neurological implications of the changing approach in management of occult spinal lesions. J. Urol.1988; 140: 1299. Link, Google Scholar 3 : Occult spinal dysraphism: clinical and urodynamic outcome after division of the filum terminale. J. Urol.1990; 144: 426. Link, Google Scholar 4 : The tethered spinal cord: its protean manifestations, diagnosis and surgical correction. Child. Brain1976; 2: 145. Google Scholar 5 : Neuropathology of the lower urinary tract. In: . Philadelphia: W. B. Saunders Co.1992: 399. chapt.13. Google Scholar 6 : A rare cause of occult neuropathic bladder in children: the tethered cord syndrome. Ped. Med. Chir.1988; 10: 641. Google Scholar 7 : Prevalence of spina bifida occulta in patients with functional disorders of the lower urinary tract and its relation to urodynamic and neurophysiological measurements. Brit. Med. J.1989; 298: 357. Google Scholar 8 : Urinary tract infection in girls: prevalence of spina bifida occulta. J. Urol.1970; 103: 348. Link, Google Scholar 9 : Minor defects in the sacrum and neurogenic bladder dysfunction. Brit. J. Urol.1985; 57: 154. Google Scholar 10 : Occult spinal dysraphism (the tethered cord) and the urologist. AUA Update Series1995; 14. lesson 10. Google Scholar 11 : Value of magnetic resonance imaging of the lumbosacral spinal cord in patients with voiding dysfunction. J. Urol.1996; 156: 1421. Link, Google Scholar 12 : Spinal dysraphism: use of magnetic resonance imaging in evaluation. Clin. Ped.1990; 29: 228. Google Scholar 13 : Occult spinal dysraphism: a rare but detectable cause of voiding dysfunction. Urol. Clin. N. Amer.1980; 7: 349. Google Scholar 14 : Occult spinal dysraphism: a series of 73 cases. Pediatrics1975; 55: 826. Google Scholar 15 : Spina bifida occulta associated with a low-placed conus medullaris. J. Spin. Disorders1988; 1: 194. Google Scholar 16 : Impact of urodynamic studies on the surgical management of spinal cord tethering. J. Neurosurg.1996; 85: 555. Google Scholar 17 : Terminology related to neuromuscular dysfunction of the lower urinary tract. International Continence Society. Brit. J. Urol.1981; 53: 333. Google Scholar 18 : What volume can a child store in the bladder at a safe pressure? J. Urol.1993; 149: 561. Abstract, Google Scholar 19 : The filum terminale syndrome. J. Bone Joint Surg.1953; 35A: 711. Google Scholar From the Departments of Pediatric Urology, Neurosurgery and Radiology, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada© 1998 by American Urological Association, Inc.FiguresReferencesRelatedDetailsCited byBroughton G, Clayton D, Tanaka S, Thomas J, Adams M, Brock J and Pope J (2011) The Usefulness of Lumbosacral Magnetic Resonance Imaging in the Management of Isolated Dysfunctional EliminationJournal of Urology, VOL. 186, NO. 4S, (1715-1720), Online publication date: 1-Oct-2011.Afshar K, Blake T, Jaffari S, MacNeily A, Poskitt K and Sargent M (2007) Spinal Cord Magnetic Resonance Imaging for Investigation of Nonneurogenic Lower Urinary Tract Dysfunction—Can the Yield be Improved?Journal of Urology, VOL. 178, NO. 4S, (1748-1751), Online publication date: 1-Oct-2007.Kaufman M, DeMarco R, Pope J, Scarpero H, Adams M, Trusler L and Brock J (2018) High Yield of Urodynamics Performed for Refractory Nonneurogenic Dysfunctional Voiding in the Pediatric PopulationJournal of Urology, VOL. 176, NO. 4S, (1835-1837), Online publication date: 1-Oct-2006.NOGUEIRA M, GREENFIELD S, WAN J, SANTANA A and LI V (2018) TETHERED CORD IN CHILDREN: A CLINICAL CLASSIFICATION WITH URODYNAMIC CORRELATIONJournal of Urology, VOL. 172, NO. 4 Part 2, (1677-1680), Online publication date: 1-Oct-2004.MOSIELLO G, CAPITANUCCI M, GATTI C, ADORISIO O, LUCCHETTI M, SILVERI M, SCHINGO P and De GENNARO M (2018) How to Investigate Neurovesical Dysfunction in Children With Anorectal MalformationsJournal of Urology, VOL. 170, NO. 4 Part 2, (1610-1613), Online publication date: 1-Oct-2003.Parekh D, Pope J, Adams M and Brock J (2018) THE USE OF RADIOGRAPHY, URODYNAMIC STUDIES AND CYSTOSCOPY IN THE EVALUATION OF VOIDING DYSFUNCTIONJournal of Urology, VOL. 165, NO. 1, (215-218), Online publication date: 1-Jan-2001.FARHAT W, BÄGLI D, CAPOLICCHIO G, O’REILLY S, MERGUERIAN P, KHOURY A and McLORIE G (2018) THE DYSFUNCTIONAL VOIDING SCORING SYSTEM: QUANTITATIVE STANDARDIZATION OF DYSFUNCTIONAL VOIDING SYMPTOMS IN CHILDRENJournal of Urology, VOL. 164, NO. 3 Part 2, (1011-1015), Online publication date: 1-Sep-2000. Volume 160Issue 3 Part 2September 1998Page: 1080-1083 Advertisement Copyright & Permissions© 1998 by American Urological Association, Inc.MetricsAuthor Information JOAO L. PIPPI SALLE More articles by this author GIANPAOLO CAPOLICCHIO More articles by this author ANNE-MARIE HOULE More articles by this author OLIVIER VERNET More articles by this author ROMAN JEDNAK More articles by this author AUGUSTIN M. O'GORMAN More articles by this author JOSE L. MONTES More articles by this author JEAN-PIERRE FARMER More articles by this author Expand All Advertisement PDF downloadLoading ...

BACKGROUND: In December 2019, COVID-19 emerged and rapidly spread worldwide. Transmission of SARS-CoV-2, the virus that causes COVID-19, is high; as a result, countries worldwide have imposed rigorous public health measures, such as quarantine. This has involved the suspension of medical school classes globally. Medical school attachments are vital to aid the progression of students' confidence and competencies as future physicians. Since the outbreak of COVID-19, medical schools have sought ways to replace medical placements with virtual clinical teaching. OBJECTIVE: The objective of this study was to review the advantages and disadvantages of virtual medical teaching for medical students during the COVID-19 pandemic based on the current emerging literature. METHODS: A brief qualitative review based on the application and effectiveness of virtual teaching during the COVID-19 pandemic was conducted by referencing keywords, including medical student virtual teaching COVID-19, virtual undergraduate medical education, and virtual medical education COVID-19, in the electronic databases of PubMed and Google Scholar. A total of 201 articles were found, of which 34 were included in the study. Manual searches of the reference lists of the included articles yielded 5 additional articles. The findings were tabulated and assessed under the following headings: summary of virtual teaching offered, strengths of virtual teaching, and weaknesses of virtual teaching. RESULTS: The strengths of virtual teaching included the variety of web-based resources available. New interactive forms of virtual teaching are being developed to enable students to interact with patients from their homes. Open-access teaching with medical experts has enabled students to remain abreast of the latest medical advancements and to reclaim knowledge lost by the suspension of university classes and clinical attachments. Peer mentoring has been proven to be a valuable tool for medical students with aims of increasing knowledge and providing psychological support. Weaknesses of virtual teaching included technical challenges, confidentiality issues, reduced student engagement, and loss of assessments. The mental well-being of students was found to be negatively affected during the pandemic. Inequalities of virtual teaching services worldwide were also noted to cause differences in medical education. CONCLUSIONS: In the unprecedented times of the COVID-19 pandemic, medical schools have a duty to provide ongoing education to medical students. The continuation of teaching is crucial to enable the graduation of future physicians into society. The evidence suggests that virtual teaching is effective, and institutions are working to further develop these resources to improve student engagement and interactivity. Moving forward, medical faculties must adopt a more holistic approach to student education and consider the mental impact of COVID-19 on students as well as improve the security and technology of virtual platforms.

Tethered cord syndrome (TCS) is a challenging disorder with a complex multifactorial etiology, which includes a thickened terminal filum, postrepair myelo­ meningocele, lipomyelomeningocele, and postoperative arachnoid adhesions.7 There are specific indications for surgery and clear surgical options including meticulous microscopic untethering of the cord, dividing the termi­ nal filum, addressing the local pathology, and dividing adhesions. The use of adjuncts such as microsurgical techniques and intraoperative monitoring with micro­ stimulation and recording has proved to be useful in re­ ducing surgical morbidity.9 Unfortunately, as is common with such troublesome pathologies, the story often doesn’t end there. A number of patients who have undergone sur­ gical treatment for TCS can present with clinical and ra­ diological evidence of recurrent tethering.7 The treatment of recurrent cases, particularly those with multiple pre­ vious procedures or in whom the underlying pathology may not allow for compete microsurgical release, is par­ ticularly challenging. Considerable surgical acumen and skill are necessary to avoid neural injury and deal with postoperative complications such as wound breakdown, CSF leakage, and further recurrence of scar tissue, which naturally contracts, leading to further tethering. There are a host of surgical techniques to avoid re­ tethering and also several treatment options available. These include simple ideas like frequent patient turning while he or she is in the prone position postoperatively and early mobilization to avoid gravitational contact between the neural structures and the dura mater, and the use of synthetic dural substitutes to minimize adhe­ sions.5 Other methods to minimize retethering include intradural retention sutures placed with subsequent du­ raplasty using autologous thoracolumbar fascia,11 and a technique of retaining the cord in the midline by fine stay sutures, between the pia mater and the conus and the anterior dura to posterior osseous elements.10 In keeping with its severity, there have even been drastic measures such as sectioning of the entire cord at a functionless lev­ el in cases of recurrent TCS.1 Other less desperate treat­ ment options include conservative, symptom­driven care, and reexploratory microsurgical untethering operations. Repeated operations for TCS have the general complica­ tions that accompany additional surgery, namely lack of an adequate vascular infrastructure, wound breakdown, and danger to the underlying neural structures. For the aforementioned reasons, alternative surgical options to manage recurrent or refractory tethered cord syndrome are welcome. In this issue of Journal of Neurosurgery: Spine, Hsieh et al.4 report on the use of ver­ tebral subtraction osteotomy to treat 2 cases of recurrent TCS. As is common with novel operative techniques, the seeds for surgical innovation were planted in a cadaveric study.2 Using a fresh­frozen human cadaver model, those authors demonstrated that vertebral subtraction at T­11 and T­12 significantly reduced tension in the terminal fi­ lum and lumbosacral nerve roots. In a natural follow­up, Hsieh et al. have elegantly shown how lateral thinking in surgery can be used to treat a complex problem. Using 2 well­described cases of repeated surgically treated TCS, they described the application of vertebral subtraction osteotomy to manage this challenging condition. The 2 patients described had undergone 4–5 previous surgeries, and in the patient in Case 2, a synthetic dural graft had previously been used in a futile attempt to prevent reteth­ ering. The initial conclusions from both cases would sug­ gest that a posterior vertebral subtraction of 15–25 mm can lead to marked reduction in terminal filum tension, equivalent of releasing 90% of neural elements. Such an attempt in a field of recurrent dense fibrosis would cer­ tainly not be without a danger to neuronal function. Although the authors should be commended for the application of lessons learned in one area of spine sur­ gery to another challenging surgical field, the approach 275 277 See the corresponding article in this issue, pp 278–286.

Deep brain stimulation (DBS) is the most rapidly expanding field in neurosurgery. Movement disorders are well-established indications for DBS, and a number of other neurological and psychiatric indications are currently being investigated. Numerous contemporary opinions, reviews, and viewpoints on DBS fail to provide a comprehensive account of how this method came into being. Misconceptions in the narrative history of DBS conveyed by the wealth of literature published over the last 2 decades can be summarized as follows: Deep brain stimulation was invented in 1987. The utility of high-frequency stimulation was also discovered in 1987. Lesional surgery preceded DBS. Deep brain stimulation was first used in the treatment of movement disorders and was subsequently used in the treatment of psychiatric and behavioral disorders. Reports of nonmotor effects of subthalamic nucleus DBS prompted its use in psychiatric illness. Early surgical interventions for psychiatric illness failed to adopt a multidisciplinary approach; neurosurgeons often worked "in isolation" from other medical specialists. The involvement of neuro-ethicists and multidisciplinary teams are novel standards introduced in the modern practice of DBS for mental illness that are essential in avoiding the unethical behavior of bygone eras. In this paper, the authors examined each of these messages in the light of literature published since 1947 and formed the following conclusions. Chronic stimulation of subcortical structures was first used in the early 1950s, very soon after the introduction of human stereotaxy. Studies and debate on the stimulation frequency most likely to achieve desirable results and avoid side effects date back to the early days of DBS; several authors advocated the use of "high" frequency, although the exact frequency was not always specified. Ablative surgery and electrical stimulation developed in parallel, practically since the introduction of human stereotactic surgery. The first applications of both ablative surgery and chronic subcortical stimulation were in psychiatry, not in movement disorders. The renaissance of DBS in surgical treatment of psychiatric illness in 1999 had little to do with nonmotor effects of subthalamic nucleus DBS but involved high-frequency stimulation of the very same brain targets previously used in ablative surgery. Pioneers in functional neurosurgery mostly worked in multidisciplinary groups, including when treating psychiatric illness; those "acting in isolation" were not neurosurgeons. Ethical concerns have indeed been addressed in the past, by neurosurgeons and others. Some of the questionable behavior in surgery for psychiatric illness, including the bygone era of DBS, was at the hands of nonneurosurgeons. These practices have been deemed as "dubious and precarious by yesterday's standards."

OBJECT: Awake craniotomy is currently a useful surgical approach to help identify and preserve functional areas during cortical and subcortical tumor resections. Methodologies have evolved over time to maximize patient safety and minimize morbidity using this technique. The goal of this study is to analyze a single surgeon's experience and the evolving methodology of awake language and sensorimotor mapping for glioma surgery. METHODS: The authors retrospectively studied patients undergoing awake brain tumor surgery between 1986 and 2014. Operations for the initial 248 patients (1986-1997) were completed at the University of Washington, and the subsequent surgeries in 611 patients (1997-2014) were completed at the University of California, San Francisco. Perioperative risk factors and complications were assessed using the latter 611 cases. RESULTS: The median patient age was 42 years (range 13-84 years). Sixty percent of patients had Karnofsky Performance Status (KPS) scores of 90-100, and 40% had KPS scores less than 80. Fifty-five percent of patients underwent surgery for high-grade gliomas, 42% for low-grade gliomas, 1% for metastatic lesions, and 2% for other lesions (cortical dysplasia, encephalitis, necrosis, abscess, and hemangioma). The majority of patients were in American Society of Anesthesiologists (ASA) Class 1 or 2 (mild systemic disease); however, patients with severe systemic disease were not excluded from awake brain tumor surgery and represented 15% of study participants. Laryngeal mask airway was used in 8 patients (1%) and was most commonly used for large vascular tumors with more than 2 cm of mass effect. The most common sedation regimen was propofol plus remifentanil (54%); however, 42% of patients required an adjustment to the initial sedation regimen before skin incision due to patient intolerance. Mannitol was used in 54% of cases. Twelve percent of patients were active smokers at the time of surgery, which did not impact completion of the intraoperative mapping procedure. Stimulation-induced seizures occurred in 3% of patients and were rapidly terminated with ice-cold Ringer's solution. Preoperative seizure history and tumor location were associated with an increased incidence of stimulation-induced seizures. Mapping was aborted in 3 cases (0.5%) due to intraoperative seizures (2 cases) and patient emotional intolerance (1 case). The overall perioperative complication rate was 10%. CONCLUSIONS: Based on the current best practice described here and developed from multiple regimens used over a 27-year period, it is concluded that awake brain tumor surgery can be safely performed with extremely low complication and failure rates regardless of ASA classification; body mass index; smoking status; psychiatric or emotional history; seizure frequency and duration; and tumor site, size, and pathology.

BACKGROUND: Use of robotic systems for minimally invasive surgery has rapidly increased during the last decade. Understanding the causes of adverse events and their impact on patients in robot-assisted surgery will help improve systems and operational practices to avoid incidents in the future. METHODS: By developing an automated natural language processing tool, we performed a comprehensive analysis of the adverse events reported to the publicly available MAUDE database (maintained by the U.S. Food and Drug Administration) from 2000 to 2013. We determined the number of events reported per procedure and per surgical specialty, the most common types of device malfunctions and their impact on patients, and the potential causes for catastrophic events such as patient injuries and deaths. RESULTS: During the study period, 144 deaths (1.4% of the 10,624 reports), 1,391 patient injuries (13.1%), and 8,061 device malfunctions (75.9%) were reported. The numbers of injury and death events per procedure have stayed relatively constant (mean = 83.4, 95% confidence interval (CI), 74.2-92.7 per 100,000 procedures) over the years. Surgical specialties for which robots are extensively used, such as gynecology and urology, had lower numbers of injuries, deaths, and conversions per procedure than more complex surgeries, such as cardiothoracic and head and neck (106.3 vs. 232.9 per 100,000 procedures, Risk Ratio = 2.2, 95% CI, 1.9-2.6). Device and instrument malfunctions, such as falling of burnt/broken pieces of instruments into the patient (14.7%), electrical arcing of instruments (10.5%), unintended operation of instruments (8.6%), system errors (5%), and video/imaging problems (2.6%), constituted a major part of the reports. Device malfunctions impacted patients in terms of injuries or procedure interruptions. In 1,104 (10.4%) of all the events, the procedure was interrupted to restart the system (3.1%), to convert the procedure to non-robotic techniques (7.3%), or to reschedule it (2.5%). CONCLUSIONS: Despite widespread adoption of robotic systems for minimally invasive surgery in the U.S., a non-negligible number of technical difficulties and complications are still being experienced during procedures. Adoption of advanced techniques in design and operation of robotic surgical systems and enhanced mechanisms for adverse event reporting may reduce these preventable incidents in the future.

PURPOSE: The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH). METHODS: A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years. RESULTS: Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications. CONCLUSIONS: aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.

BACKGROUND: To our knowledge, no publication providing overarching guidance on the conduct of systematic reviews of observational studies of etiology exists. METHODS AND FINDINGS: Conducting Systematic Reviews and Meta-Analyses of Observational Studies of Etiology (COSMOS-E) provides guidance on all steps in systematic reviews of observational studies of etiology, from shaping the research question, defining exposure and outcomes, to assessing the risk of bias and statistical analysis. The writing group included researchers experienced in meta-analyses and observational studies of etiology. Standard peer-review was performed. While the structure of systematic reviews of observational studies on etiology may be similar to that for systematic reviews of randomised controlled trials, there are specific tasks within each component that differ. Examples include assessment for confounding, selection bias, and information bias. In systematic reviews of observational studies of etiology, combining studies in meta-analysis may lead to more precise estimates, but such greater precision does not automatically remedy potential bias. Thorough exploration of sources of heterogeneity is key when assessing the validity of estimates and causality. CONCLUSION: As many reviews of observational studies on etiology are being performed, this document may provide researchers with guidance on how to conduct and analyse such reviews.

BACKGROUND: Social media is a popular online tool that allows users to communicate and exchange information. It allows digital content such as pictures, videos and websites to be shared, discussed, republished and endorsed by its users, their friends and businesses. Adverts can be posted and promoted to specific target audiences by demographics such as region, age or gender. Recruiting for health research is complex with strict requirement criteria imposed on the participants. Traditional research recruitment relies on flyers, newspaper adverts, radio and television broadcasts, letters, emails, website listings, and word of mouth. These methods are potentially poor at recruiting hard to reach demographics, can be slow and expensive. Recruitment via social media, in particular Facebook, may be faster and cheaper. OBJECTIVE: The aim of this study was to systematically review the literature regarding the current use and success of Facebook to recruit participants for health research purposes. METHODS: A literature review was completed in March 2017 in the English language using MEDLINE, EMBASE, Web of Science, PubMed, PsycInfo, Google Scholar, and a hand search of article references. Papers from the past 12 years were included and number of participants, recruitment period, number of impressions, cost per click or participant, and conversion rate extracted. RESULTS: A total of 35 studies were identified from the United States (n=22), Australia (n=9), Canada (n=2), Japan (n=1), and Germany (n=1) and appraised using the Critical Appraisal Skills Programme (CASP) checklist. All focused on the feasibility of recruitment via Facebook, with some (n=10) also testing interventions, such as smoking cessation and depression reduction. Most recruited young age groups (16-24 years), with the remaining targeting specific demographics, for example, military veterans. Information from the 35 studies was analyzed with median values being 264 recruited participants, a 3-month recruitment period, 3.3 million impressions, cost per click of US $0.51, conversion rate of 4% (range 0.06-29.50), eligibility of 61% (range 17-100), and cost per participant of US $14.41. The studies showed success in penetrating hard to reach populations, finding the results representative of their control or comparison demographic, except for an over representation of young white women. CONCLUSIONS: There is growing evidence to suggest that Facebook is a useful recruitment tool and its use, therefore, should be considered when implementing future health research. When compared with traditional recruitment methods (print, radio, television, and email), benefits include reduced costs, shorter recruitment periods, better representation, and improved participant selection in young and hard to reach demographics. It however, remains limited by Internet access and the over representation of young white women. Future studies should recruit across all ages and explore recruitment via other forms of social media.

BACKGROUND: The COVID-19 pandemic has prompted the decrease of in-person visits to reduce the risk of virus transmission. Telemedicine is an efficient communication tool employed between healthcare providers and patients that prevents the risk of exposure to infected persons. However, telemedicine use is not infallible; its users reported multiple issues that complicated the expansion of this technology. So, this systematic review aimed to explore the barriers and challenges of telemedicine use during the pandemic and to propose solutions for improving future use. METHODS: A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement. PubMed, Scopus, Web of Science, Academic Search Complete, CINAHL, Embase, and Science Direct were used to look for articles addressing barriers and challenges, in addition to articles proposing solutions. Studies were screened by title and abstract, followed by a full-text review. Risk of bias assessment was done using Critical Appraisal Skills Program for qualitative studies, Newcastle-Ottawa Scale for cross-sectional studies, and A MeaSurement Tool to Assess Systematic Reviews for systematic reviews. After the extraction of data, a narrative synthesis and analysis of the outcomes were performed. RESULTS: Among 1194 papers identified, only 27 studies were included. Barriers and challenges were assembled under 7 categories: technical aspects, privacy, data confidentiality and reimbursement, physical examination and diagnostics, special populations, training of healthcare providers and patients, doctor-patient relationship, and acceptability. Poor internet connection and lack of universal access to technology were among the technical barriers. Concerns about patient privacy and reimbursement hindered the use of telemedicine too. Physical examination and certain procedures were impossible to perform via telemedicine. Training both healthcare providers and patients was deficient. The doctor-patient relationship was troubled by telemedicine, and both healthcare providers and patients were reluctant to use telemedicine. CONCLUSION: Widespread use of telemedicine is still hampered by various barriers and challenges. Healthcare providers should work with various stakeholders to implement the proposed solutions. More research and policy changes are essential to optimize telemedicine utilization.

The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encouraged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient's health condition and in consultation with that patient and, where appropriate and/or necessary, the patient's caregiver. Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient's case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional's responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.

BACKGROUND AND PURPOSE: To investigate the feasibility and safety of a combined intravenous (IV) and intra-arterial (IA) approach to recanalization in patients with ischemic stroke. MATERIALS AND METHODS: Subjects ages 18 to 80 with an NIH Stroke Scale (NIHSS) > or =10 at baseline had IV recombinant tissue plasminogen activator (rt-PA) started (0.6 mg/kg, 60 mg maximum over 30 minutes) within 3 hours of onset. Additional rt-PA was then administered via microcatheter at the site of the thrombus up to a total dose of 22 mg over 2 hours of infusion or until thrombolysis. Primary comparisons were with similar subsets of placebo and rt-PA-treated subjects from the NINDS rt-PA Stroke Trial. RESULTS: The 80 subjects had a median baseline NIHSS score of 18. The median time to initiation of IV rt-PA was 140 minutes as compared with 108 minutes for placebo and 90 minutes for rt-PA-treated subjects in the NINDS rt-PA Stroke Trial. The 3-month mortality in Interventional Management Study (IMS) subjects (16%) was numerically lower but not statistically different than the mortality of placebo (24%) and rt-PA-treated subjects (21%) in the NINDS rt-PA Stroke Trial. The rate of symptomatic intracerebral hemorrhage (6.3%) in IMS subjects was similar to that of rt-PA-treated subjects (6.6%) but higher than the rate in placebo-treated subjects (1.0%, P=0.018) in the NINDS rt-PA Stroke Trial. IMS subjects had a significantly better outcome at 3 months than NINDS placebo-treated subjects for all outcome measures (odds ratios > or =2). CONCLUSIONS: A randomized trial of standard IV rt-PA as compared with a combined IV and IA approach is needed.

OBJECTIVE: We evaluated evidence for utility of shunting in idiopathic normal pressure hydrocephalus (iNPH) and for predictors of shunting effectiveness. METHODS: We identified and classified relevant published studies according to 2004 and 2011 American Academy of Neurology methodology. RESULTS: Of 21 articles, we identified 3 Class I articles. CONCLUSIONS: Shunting is possibly effective in iNPH (96% chance subjective improvement, 83% chance improvement on timed walk test at 6 months) (3 Class III). Serious adverse event risk was 11% (1 Class III). Predictors of success included elevated Ro (1 Class I, multiple Class II), impaired cerebral blood flow reactivity to acetazolamide (by SPECT) (1 Class I), and positive response to either external lumbar drainage (1 Class III) or repeated lumbar punctures. Age may not be a prognostic factor (1 Class II). Data are insufficient to judge efficacy of radionuclide cisternography or aqueductal flow measurement by MRI. RECOMMENDATIONS: Clinicians may choose to offer shunting for subjective iNPH symptoms and gait (Level C). Because of significant adverse event risk, risks and benefits should be carefully weighed (Level B). Clinicians should inform patients with iNPH with elevated Ro and their families that they have an increased chance of responding to shunting compared with those without such elevation (Level B). Clinicians may counsel patients with iNPH and their families that (1) positive response to external lumbar drainage or to repeated lumbar punctures increases the chance of response to shunting, and (2) increasing age does not decrease the chance of shunting being successful (both Level C).

Lower back pain is the leading cause of disability worldwide. Discogenic pain secondary to intervertebral disc degeneration is a significant cause of low back pain. Disc degeneration is a complex multifactorial process. Animal models are essential to furthering understanding of the degenerative process and testing potential therapies. The adult human lumbar intervertebral disc is characterized by the loss of notochordal cells, relatively large size, essentially avascular nature, and exposure to biomechanical stresses influenced by bipedalism. Animal models are compared with regard to the above characteristics. Numerous methods of inducing disc degeneration are reported. Broadly these can be considered under the categories of spontaneous degeneration, mechanical and structural models. The purpose of such animal models is to further our understanding and, ultimately, improve treatment of disc degeneration. The role of animal models of disc degeneration in translational research leading to clinical trials of novel cellular therapies is explored.

Abstract The adoption of immersive virtual reality (I-VR) as a pedagogical method in education has challenged the conceptual definition of what constitutes a learning environment. High fidelity graphics and immersive content using head-mounted-displays (HMD) have allowed students to explore complex subjects in a way that traditional teaching methods cannot. Despite this, research focusing on learning outcomes, intervention characteristics, and assessment measures associated with I-VR use has been sparse. To explore this, the current systematic review examined experimental studies published since 2013, where quantitative learning outcomes using HMD based I-VR were compared with less immersive pedagogical methods such as desktop computers and slideshows. A literature search yielded 29 publications that were deemed suitable for inclusion. Included papers were quality assessed using the Medical Education Research Study Quality Instrument (MERSQI). Most studies found a significant advantage of utilising I-VR in education, whilst a smaller number found no significant differences in attainment level regardless of whether I-VR or non-immersive methods were utilised. Only two studies found clear detrimental effects of using I-VR. However, most studies used short interventions, did not examine information retention, and were focused mainly on the teaching of scientific topics such as biology or physics. In addition, the MERSQI showed that the methods used to evaluate learning outcomes are often inadequate and this may affect the interpretation of I-VR’s utility. The review highlights that a rigorous methodological approach through the identification of appropriate assessment measures, intervention characteristics, and learning outcomes is essential to understanding the potential of I-VR as a pedagogical method.

BACKGROUND: Translation of evidence-based interventions into hospital systems can provide immediate and substantial benefits to patient care and outcomes, but successful implementation is often not achieved. Existing literature describes a range of barriers and facilitators to the implementation process. This systematic review identifies and explores relationships between these barriers and facilitators to highlight key domains that need to be addressed by researchers and clinicians seeking to implement hospital-based, patient-focused interventions. METHODS: We searched MEDLINE, PsychInfo, Embase, Web of Science, and CINAHL using search terms focused specifically on barriers and facilitators to the implementation of patient-focused interventions in hospital settings. To be eligible, papers needed to have collected formal data (qualitative or quantitative) that specifically assessed the implementation process, as experienced by the staff involved. RESULTS: Of 4239 papers initially retrieved, 43 papers met inclusion criteria. Staff-identified barriers and facilitators to implementation were grouped into three main domains: system, staff, and intervention. Bi-directional associations were evident between these domains, with the strongest links evident between staff and intervention. CONCLUSIONS: Researchers and health professionals engaged in designing patient-focused interventions need to consider barriers and facilitators across all three identified domains to increase the likelihood of implementation success. The interrelationships between domains are also crucial, as resources in one area can be leveraged to address barriers in others. These findings emphasize the importance of careful intervention design and pre-implementation planning in response to the specific system and staff context in order to increase likelihood of effective and sustainable implementation. TRIAL REGISTRATION: This review was registered on the PROSPERO database: CRD42017057554 in February 2017.

Traumatic brain injury (TBI) remains a major public health problem globally. In the United States the incidence of closed head injuries admitted to hospitals is conservatively estimated to be 200 per 100,000 population, and the incidence of penetrating head injury is estimated to be 12 per 100,000, the highest of any developed country in the world. This yields an approximate number of 500,000 new cases each year, a sizeable proportion of which demonstrate significant long-term disabilities. Unfortunately, there is a paucity of proven therapies for this disease. For a variety of reasons, clinical trials for this condition have been difficult to design and perform. Despite promising pre-clinical data, most of the trials that have been performed in recent years have failed to demonstrate any significant improvement in outcomes. The reasons for these failures have not always been apparent and any insights gained were not always shared. It was therefore feared that we were running the risk of repeating our mistakes. Recognizing the importance of TBI, the National Institute of Neurological Disorders and Stroke (NINDS) sponsored a workshop that brought together experts from clinical, research, and pharmaceutical backgrounds. This workshop proved to be very informative and yielded many insights into previous and future TBI trials. This paper is an attempt to summarize the key points made at the workshop. It is hoped that these lessons will enhance the planning and design of future efforts in this important field of research.

The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and where appropriate and necessary the patient's guardian or carer. It is also the health professional's responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.

OBJECTIVE: Patient's trust in their physician is crucial for desirable treatment outcomes such as satisfaction and adherence. In oncology, trust is possibly even more essential, due to the life-threatening nature of cancer. A review was undertaken of the current knowledge of the conceptualization, assessment, correlates, and consequences of cancer patients' trust in their physician. METHODS: The empirical literature published in peer-reviewed journals between October 1988 and October 2008 was searched, employing all combinations and variations of the following keywords: trust, physician-patient relations, and cancer. RESULTS: The search identified 45 relevant papers, only 11 of which drew attention to the conceptualization of trust, and 5 of which focused on trust as the primary subject of interest. Trust in physicians was strong overall. Patients' trust appeared to be enhanced by the physician's perceived technical competence, honesty, and patient-centred behaviour. A trusting relationship between patient and physician resulted in facilitated communication and medical decision making, a decrease of patient fear, and better treatment adherence. CONCLUSIONS: A lack of focus on trust and the conceptualization thereof, strong methodological variations between studies and a possible publication bias lead us to conclude that cancer patients' trust in their physician deserves more systematic, theoretically based, research attention. Consequently, studies are needed aimed at gaining a thorough understanding of the nature and impact of cancer patients' trust in their physician, and how the interaction between physician and patient may contribute to such trust.