Lars Kihlström

EFFECTS OF USING COMBINED TRANSPETROSAL SURGICAL APPROACHES TO TREAT PETROCLIVAL MENINGIOMAS

OBJECTIVESurgical treatment may be required for large petroclival meningiomas; however, surgery for these lesions is a major undertaking, and modern surgical approaches are still associated with considerable morbidity and recurrence rates. We analyzed our series of transpetrosally operated petroclival meningiomas to obtain detailed information regarding the surgery outcomes with respect to facial nerve effects, hearing changes, general neurological and psychosocial differences, and recurrence rates to identify opportunities for improvement. METHODSBetween 1994 and 2004, we used transpetrosal approaches to operate on 29 patients for petroclival meningiomas larger than 30 mm. All patients were analyzed in detail regarding neurological outcomes and hearing abilities after surgery. Swedish-speaking patients were contacted for a psychosocial follow-up evaluation using the short-item 36 (SF-36) form. ResultsAfter surgery, the Glasgow Outcome Score improved in 14 patients, was unchanged in 11 patients, and worsened in four patients. Facial nerve function was found to be of House-Brackmann Grade 3 or worse in six patients (including three individuals with transcochlear surgery and facial nerve rerouting). Of the 23 patients who underwent hearing-preservation surgery, serviceable hearing was preserved in 17 individuals. Nineteen Swedish patients were contacted for psychosocial evaluation. Three patients could not participate for health reasons; of the remaining 16 patients, 12 reported physical health scores that were below mean values for the general population. For patients who did not experience very serious neurological compromise, we found that unexpected painful trigeminal neuropathy and unilateral swallowing difficulties conveyed a negative influence on health. Three years after surgery, the patients reported more normalized health scores. CONCLUSIONGenerally, outcomes compared well with current reports. Outcomes can be improved, however by improving patients psychosocial support; striving to decompress, preserve, and minimize dissection of ill-defined planes of cranial nerves; and using Simpson Grade 4 gamma knife approaches when radicality is precluded. Currently, the performance of transpetrosal surgery for petroclival meningiomas is a major undertaking that significantly affects a patients health for several years; however, the approaches that we used allowed a high degree of tumor control with relatively little neurological morbidity.

The Swedish duty hour enigma

BackgroundThe Swedish resident duty hour limit is regulated by Swedish and European legal frameworks. With a maximum average of 40 working hours per week, the Swedish duty hour regulation is one of the most restrictive in the world. At the same time, the effects of resident duty hour limits have been neither debated nor researched in the Swedish context. As a result, little is known about the Swedish conceptual framework for resident duty hours, their restriction, or their outcomes: we call this “the Swedish duty hour enigma.” This situation poses a further question: How do Swedish residents themselves construct a conceptual framework for duty hour restrictions?MethodsA case study was conducted at Karolinska University Hospital, Stockholm – an urban, research-intensive hospital setting. Semi-structured interviews were carried out with 34 residents currently in training in 6 specialties. The empirical data analysis relied on theoretical propositions and was conducted thematically using a pattern-matching technique. The interview guide was based on four main topics: the perceived effect of duty hour restrictions on (1) patient care, (2) resident education, (3) resident well-being, and (4) research.ResultsThe residents did not perceive the volume of duty hours to be the main determinant of success or failure in the four contextual domains of patient care, resident education, resident well-being, and research. Instead, they emphasized resident well-being and a desire for flexibility.ConclusionsAccording to Swedish residents’ conceptual framework on duty hours, the amount of time spent on duty is not a proxy for the quality of resident training. Instead, flexibility, organization, and scheduling of duty hours are considered to be the factors that have the greatest influence on resident well-being, quality of learning, and opportunities to attain the competence needed for independent practice.

Safety and Efficacy of TachoSil (Absorbable Fibrin Sealant Patch) Compared With Current Practice for the Prevention of Cerebrospinal Fluid Leaks in Patients Undergoing Skull Base Surgery: A Randomized Controlled Trial

BACKGROUNDnCerebrospinal fluid (CSF) leakage associated with incomplete sealing of the dura mater is a major complication of intradural procedures.nnnOBJECTIVEnTo compare the efficacy and safety of adjunctive TachoSil (Takeda Pharma A/S, Roskilde, Denmark) with current practice for the prevention of postoperative CSF leaks in patients undergoing elective skull base surgery involving dura mater closure.nnnMETHODSnPatients were intraoperatively randomized to TachoSil or current practice immediately before primary dura closure by suturing ± duraplasty. Choice of adjunctive treatment in the current practice group was at the surgeons discretion. Primary efficacy endpoint was occurrence of clinically evident verified postoperative CSF leak or clinically evident pseudomeningocele within 7 weeks after surgery or treatment failure (third application of trial treatment or use of other treatment).nnnRESULTSnA total of 726 patients were randomized to TachoSil (n = 361) or current practice (n = 365). More current practice patients had sutures plus duraplasty for primary dura closure compared with TachoSil (49.6% vs 35.7%) and fewer had sutures only (45.5% vs 63.2%). The primary endpoint of estimated leak rate favored TachoSil with events in 25 (6.9%) patients vs 30 (8.2%) current practice patients; however, this was not statistically significant (odds ratio: 0.82; 95% confidence interval: 0.47, 1.43; P = .485). Both treatments were well tolerated with similar frequency of adverse events.nnnCONCLUSIONnVery low rates of postoperative CSF leaks can be achieved in patients undergoing skull base surgery of various indications. Although the study did not meet its primary endpoint, TachoSil appears to be safe and effective for the prevention of CSF leaks and associated complications.

Long-term control and predictors of seizures in intracranial meningioma surgery: a population-based study

BackgroundThe aim of this retrospective study was to investigate the long-term seizure control and antiepileptic drug (AED) prescriptions, as well as identifying predictors of seizure(s) before and after surgery in a population-based cohort of operated intracranial meningioma patients.MethodsA total of 113 consecutive adult (>u200918xa0years old) patients with newly diagnosed meningioma operated at the Karolinska University Hospital between 2006 and 2008 were included and followed up until the end of 2015. Data on seizure activity and AED prescriptions were obtained through chart review and telephone interview. Logistic regression and survival analysis were applied to identify risk factors for pre- and postoperative seizures.ResultsA total of 21/113 (18.6%) patients experienced seizures before surgery of which 8/21 (38.1%) went on to become seizure-free after surgery. Thirteen (14%) patients experienced new-onset seizures after surgery. The regression analysis revealed tumor diameteru2009≥u20093.5xa0cm as a risk factor for preoperative seizures (OR 3.83, 95% CI 1.14–12.87). Presence of headache (OR 0.19, 95% CI 0.05–0.76) and skull base tumor location (OR 0.14, 95% CI 0.04–0.44) decreased the risk of preoperative seizures. Postoperative seizures were associated with tumor diameteru2009≥u20093.5xa0cm (OR 2.65, 95% CI 1.06–6.62) and history of preoperative seizures (OR 3.50, 95% CI 1.55–7.90).ConclusionSeizures are common before and after intracranial meningioma surgery. Approximately one third of patients with preoperative seizures become seizure-free on long-term follow-up after surgery, while 14% experienced new-onset seizures after surgery. Larger tumor size, absence of headache, and non-skull base location were associated with preoperative seizures, while tumor size and preoperative seizures were associated with postoperative seizures.

Roles, tasks and educational functions of postgraduate programme directors: a qualitative study

Background A programme director is often required to organise postgraduate medical education. This leadership role can include educational as well as managerial duties. Only a few published studies have explored programme directors’ own perceptions of their role. There is a need to explore the use of theoretical frameworks to improve the understanding of educational roles. Objective To explore programme directors’ own perceptions of their role in terms of tasks and functions, and to relate these roles to the theoretical framework developed by Bolman and Deal. Methods Semi-structured interviews were conducted with 17 programme directors between February and August 2013. The data were subjected to content analysis using a deductive approach. Results The various roles and tasks included by participants in their perceptions of their work could be categorised within the framework of functions described by Bolman and Deal. These included: structuring the education (structural function); supporting individuals and handling relations (human resource function); negotiating between different interests (political function); and influencing the culture at the departmental level (symbolic function). The functions most often emphasised by participants were the structural and human resource functions. Some tasks involved several functions which varied over time. Conclusions Programme directors’ own perceptions of their roles, tasks and functions varied widely. The theoretical framework of Bolman and Deal might be helpful when explaining and developing these roles.