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To determine whether implanting an annular closure device (ACD) following a lumbar discectomy procedure in patients with large defects in the annulus fibrosus lowers the risk of reoperation after 4 years. In a multicenter randomized trial, patients with large annular defects following single-level lumbar discectomy were intraoperatively randomized to additionally receive an ACD or no treatment (Controls). Clinical and imaging follow-up were performed at routine intervals over 4 years of follow-up. Main outcomes included reoperations at the treated lumbar level, leg pain scores on a visual analog scale, Oswestry Disability Index (ODI), and Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the SF-36 questionnaire. Among 550 patients (ACD 272, Control 278), the risk of reoperation over 4 years was 14.4% with ACD and 21.1% with Controls ( =0.03). The reduction in reoperation risk with ACD was not significantly influenced by patient age ( =0.51), sex ( =0.34), body mass index ( =0.21), smoking status ( =0.85), level of herniation ( =0.26), leg pain severity at baseline ( =0.90), or ODI at baseline ( =0.54). All patient-reported outcomes improved in each group from baseline to 4 years (all <0.001). The percentage of patients who achieved the minimal clinically important difference without a reoperation was proportionally higher in the ACD group compared to Controls for leg pain ( =0.07), ODI ( =0.10), PCS ( =0.02), and MCS ( =0.06). The addition of a bone-anchored ACD following lumbar discectomy in patients with large post-surgical annular defects reduces the risk of reoperation and provides better long-term pain and disability relief over 4 years compared to lumbar discectomy only.

To investigate the effect of locally applied nimodipine prolonged-release microparticles on angiographic vasospasm and secondary brain injury after experimental subarachnoid hemorrhage (SAH). 70 male Wistar rats were categorized into three groups: 1) sham operated animals (control), 2) animals with SAH only (control) and the 3) treatment group. SAH was induced using the double hemorrhage model. The treatment group received different concentrations (20%, 30% or 40%) of nimodipine microparticles. Angiographic vasospasm was assessed 5 days later using digital subtraction angiography (DSA). Histological analysis of frozen sections was performed using H&E-staining as well as Iba1 and MAP2 immunohistochemistry. DSA images were sufficient for assessment in 42 animals. Severe angiographic vasospasm was present in group 2 (SAH only), as compared to the sham operated group (p<0.001). Only animals within group 3 and the highest nimodipine microparticles concentration (40%) as well as group 1 (sham) demonstrated the largest intracranial artery diameters. Variation in vessel calibers, however, did not result in differences in Iba-1 or MAP2 expression, i.e. in histological findings for secondary brain injury. Local delivery of high-dose nimodipine prolonged-release microparticles at high concentration resulted in significant reduction in angiographic vasospasm after experimental SAH and with no histological signs for matrix toxicity.

Objective In this case report we describe a successful interdisciplinary approach (including flow redirection and endovascular occlusion) applied to a patient with a continuously growing extracranial giant aneurysm of the right internal carotid artery (ICA) due to known Ehlers–Danlos syndrome. Case presentation A 42-year-old man with a continuously growing extracranial giant aneurysm of the right ICA sought treatment after failed surgery of a similar lesion of the left ICA. A multidisciplinary consultation was held at the end of 2008. Treatment strategy The treatment strategy consisted of flow redirection in order to secure sufficient cerebral perfusion prior to surgical trapping of the carotid aneurysm. Flow redirection was achieved by placement of a double-barrel extracranial–intracranial bypass. Subsequent surgical trapping failed due to the extreme size of the aneurysm, making certain identification of surrounding structures impossible. The aneurysm was then successfully occluded by neuroradiological intervention. In a further procedure, a large intra-aneurysmal hematoma was surgically removed to reduce the remaining bulging aneurysm sac. Conclusions This case report describes a successful interdisciplinary approach for the treatment of a rare giant extracranial ICA aneurysm in a patient with Ehlers–Danlos syndrome. Treatment options for this type are few and carry high risks. Flow redirection via extracranial–intracranial bypass followed by endovascular occlusion appears to be a good treatment approach.

BackgroundAccording to current evidence, adding decompressive craniectomy (DC) to best medical therapy reduces case fatality rate of malignant middle cerebral artery infarction by 50–75%. There is currently little information available regarding the outcome of subgroups, in particular of patients with extensive infarctions exceeding the territory of the middle cerebral artery.MethodsThe records of 101 patients with large hemispheric infarctions undergoing DC were retrospectively reviewed. Twenty-seven patients had additional ACA and/or PCA infarcts. Sequential CTs were used for postoperative follow-up. Intracranial pressure (ICP) was monitored via a ventricular catheter in comatose patients. The main aim of treatment was to keep midline shift below 10 mm and ICP below 20 mmHg. If midline shift increased despite preceding DC, repeat surgery with removal of clearly necrotic tissue was considered. For the current analysis, Glasgow Coma Scale (GCS) at 14 days and modified Rankin Scale (mRS) at 3 months were used as outcome parameters. mRS 2 and 3 were defined as “moderate disability”, mRS 4 as “severe disability”, and mRS 5 and 6 as “poor outcome”. These outcome parameters were correlated to age, gender, side, vascular territory, and time delay after stroke, GCS at the time of decompression, maximum ICP, maximum midline shift, and delay of maximum shift.ResultsThe median age of the 39 female and 62 male patients was 56 years (range, 5–79 years). Overall, 12 patients died in the acute stage (11.9%). Twenty-three (22.8%) patients recovered to moderate disability at 3 months (mRS ≤ 3), 45 (44.6%) to severe disability and 33 (32.6%) suffered a poor outcome (mRS 5 or 6). Twenty patients (19.8%) required additional necrosectomy due to secondary increasing midline shift and/or intracranial hypertension. Patients recovering to moderate disability at 3 months were in the median 10 years younger than patients with less favorable outcome (P < 0.001) and had a higher GCS prior to surgery (P < 0.001). Eleven of the 27 patients with infarctions exceeding the MCA territory needed secondary surgery, indicating a higher necrosectomy rate as for isolated MCA infarction. At 3 months, the distribution of the outcomes in terms of mRS was comparable between the patients suffering from extended infarctions and patients having isolated MCA stroke. Infarctions exceeding the territory of the middle cerebral artery were seen in 30% of the group recovering to moderate disability and thus as frequent as in the groups suffering a less favorable outcome.ConclusionsIntensified postoperative management including possible secondary decompression with necrosectomy may further reduce case fatality rate of patients with large hemispheric infarction. Age above 60 years and severely reduced level of consciousness are the most significant factors heralding unfavorable recovery. Patients suffering infarctions exceeding the MCA territory have a comparable chance of favorable recovery as patients with isolated MCA infarction.

This research study examined public school district responses in Pennsylvania, through analysis of fiscal patterns, given decreased revenues and increased mandatory expenditures from 2008-2013. This descriptive quantitative study examined both revenues and expenditures for the aggregate group of Pennsylvania school districts and further explores fiscal patterns by average wealth through the use of deciles. The study was organized around the following four research questions: (1) How did school district revenues change? (2) How did school district expenditures change? (3) Did revenues and expenditure patterns vary by wealth? (4) What were the major legislative events in education and fiscal factors that occurred during this time period and how did they impact the fiscal pattern for revenues and expenditures? The methodology used was primarily quantitative incorporating descriptive statistics specific to revenue and expenditure data from 2008-2013. Fiscal data was collected from the Pennsylvania Department of Education web site for all five hundred public school districts in the state. Secondary sources were also utilized to determine the impact of policy, legislative actions, and overall economic variables on fiscal elements specific to the public school finance landscape during the period of study. Analysis of key fiscal elements and secondary information was completed for all public school districts and further examined by average district wealth through decile information. This study found that between 2008-2013, fiscal responses and patterns changed due to revenue and expenditure variables for the aggregate group of Pennsylvania districts and differed for these districts based on average wealth. Key findings of this study included: (1) State policy decisions and legislative actions, specifically the reduction of state funding and lack of full restoration that coincided with the infusion and elimination of federal ARRA funding, had adverse effects on total school district revenues, especially 2011-12. (2) The recession of 2007-2009, along with limitations on local real estate tax increases imposed by Act 1 of 2006, restricted the ability for school districts to raise local revenue in order to counterbalance state revenue decreases, especially in 2011-12 when the Act 1 base index reached a five year low of 1.4%. (3) Increased benefit expenditures, due primarily to increased mandatory payments to PSERS, constrained the ability for school districts to meet overall obligations and forced challenging decisions, especially from 2011-13, when employer contribution rates increased from 5.54% to 12.36%. (4) State policy decisions and legislative actions, with regards to the interaction of state and federal revenues, adversely affected poorer districts to a greater degree than wealthy districts, counter to the intent of how those revenues were designed to be allocated. (5) The decrease of total revenue and increase of mandatory expenditures, specific to benefits, adversely affected poorer districts to a greater degree than wealthy districts, in the ability to meet rising costs associated with staff, more often forcing decisions fiscally necessary, but not educationally sound. (6) With mandatory expenditures projected to rise, as employer contribution rates to PSERS continues to rise, school districts will face further challenges in the future in an Act 1 environment, unless future policy and legislative actions provide relief in the form of increased state funding, equitable allocation and overall pension reform. Findings assert that long-range fiscal planning is paramount when addressing school district fiscal needs and that managing costs such as collective bargaining agreements and competing in a choice environment, given Charter School Costs, are important in managing the balance between revenues and expenditures. Future research aligned to further exploration of legislative impacts on school funding along with possible reform efforts specific to the state pension system and revenue generated through local real estate taxes will emerge in the coming years as key focus areas for understanding and practice.

Abstract OBJECTIVE Intracisternal continuous therapy is a concept in the treatment of cerebral vasospasm after subarachnoid hemorrhage. The purpose of the current study was to investigate the effect of intracisternal nimodipine after induced vasospasm. METHODS Sixty-five male Wistar rats were randomized into 4 groups: the control sham-operated group, the control subarachnoid hemorrhage-only group, and the treatment groups receiving 5 or 10 μL/hour of intracisternal nimodipine continuously for 5 days via subcutaneously implanted Alzet osmotic pumps (Durect Corp., Cupertino, CA). Vasospasm was analyzed 5 days later by means of digital subtraction angiography. Morphological examination of the brain parenchyma was performed using Nissl-staining, c-Fos immunohistochemistry, and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling. RESULTS Detailed analysis of the digital subtraction angiography was possible for 31 animals. Significant angiographic vasospasm was induced in the double hemorrhage-only group compared with the sham-operated group (P = 0.002). Among the 4 groups, there were statistically significant differences of the arterial vessel caliber as measured by digital subtraction angiography (P = 0.001, Kruskal-Wallis test). The treatment group receiving 5 μL/hour of nimodipine and the control sham-operated group demonstrated the largest intracranial artery diameters with a significant difference between control subarachnoid hemorrhage-only group and the treatment group receiving 10 μL/hour of nimodipine (P = 0.0328, Wilcoxon rank-sum test). Variation in vessel calibers, however, did not result in different brain tissue alterations, even when using sensitive markers for the induction of the stress response or apoptosis. CONCLUSION Intracisternal nimodipine lavage with 5 μL/hour, but not with 10 μL/hour leads to significant arterial relaxation. Further research is needed to elucidate the underlying cause of the decreasing nimodipine effect at higher dosage.

Bomb calorimetry and x-ray powder diffraction, XRD, were used to elucidate the steric effects in the exchange of alkyltrimethylammonium, ATMA , cations with five standard smectite clays. An examination of the combustion energies of ATMA organo-clays show a stair-step increase generally in between dodecyltrimethylammonium, DDTMA, and tetradecyltrimethylammonium, TDTMA, indicating an increase in combustible material present in the clay. A similar stair-step increase was seen in the d-spacing values associated with these organo-clays indicative of the formation of different layering arrangements within the interlamellar region, i.e. pseudobi/tri-layers and paraffin-type layers. This novel approach to organo-clay analysis demonstrates that pairing organo-clay combustion energies with d-spacing data validates different layering arrangements of organic cations within the gallery spacing. A closer look at the data reveals that neither size or shape of the organic cation individually dictate the exchange process but both aspects of the organic cation must be considered.

A new strain of MRSA (methicillin resistant staphylococcus aureus) has been found in the general population of Calgary, Alta., but P.E.I.'s chief health officer says it will likely take a long time before it reaches the East Coast. Reports from Calgary say the new MRSA strain is stronger and can make infections far worse. Strong antibiotics seem to have little to no effect on the new strain.