Safety and occlusion rates of surgical treatment of unruptured intracranial aneurysms: a systematic review and meta-analysis of the literature from 1990 to 2011.

BACKGROUND AND PURPOSE: Surgical clipping of unruptured intracranial aneurysms (UIAs) has recently been challenged by the emergence of endovascular treatment. We performed an updated systematic review and meta-analysis on the surgical treatment of UIAs, in an attempt to determine the aneurysm occlusion rates and safety of surgery in the modern era. METHODS: A detailed protocol was developed prior to conducting the review according to the Cochrane Collaboration guidelines. Electronic databases spanning January 1990-April 2011 were searched, complemented by hand searching. Heterogeneity was assessed using I(2), and publication bias with funnel plots. Surgical mortality and morbidity were analysed with weighted random effect models. RESULTS: 60 studies with 9845 patients harbouring 10 845 aneurysms were included. Mortality occurred in 157 patients (1.7%; 99% CI 0.9% to 3.0%; I(2)=82%). Unfavourable outcomes, including death, occurred in 692 patients (6.7%; 99% CI 4.9% to 9.0%; I(2)=85%). Morbidity rates were significantly greater in higher quality studies, and with large or posterior circulation aneurysms. Reported morbidity rates decreased over time. Studies were generally of poor quality; funnel plots showed heterogeneous results and publication bias, and data on aneurysm occlusion rates were scant. CONCLUSIONS: In studies published between 1990 and 2011, clipping of UIAs was associated with 1.7% mortality and 6.7% overall morbidity. The reputed durability of clipping has not been rigorously documented. Due to the quality of the included studies, the available literature cannot properly guide clinical decisions.

Congenital heart disease in pregnancies complicated by maternal diabetes mellitus. An international clinical collaboration, literature review, and meta-analysis.

PURPOSE: Investigation of the incidence and distribution of congenital structural cardiac malformations among the offspring of mothers with diabetes type 1 and of the influence of periconceptional glycemic control. METHODS: Multicenter retrospective clinical study, literature review, and meta-analysis. The incidence and pattern of congenital heart disease in the own study population and in the literature on the offspring of type 1 diabetic mothers were compared with the incidence and spectrum of the various cardiovascular defects in the offspring of nondiabetic mothers as registered by EUROCAT Northern Netherlands. Medical records were, in addition, reviewed for HbA(1c) during the 1st trimester. RESULTS: The distribution of congenital heart anomalies in the own diabetic study population was in accordance with the distribution encountered in the literature. This distribution differed considerably from that in the nondiabetic population. Approximately half the cardiovascular defects were conotruncal anomalies. The authors' study demonstrated a remarkable increase in the likelihood of visceral heterotaxia and variants of single ventricle among these patients. As expected, elevated HbA(1c) values during the 1st trimester were associated with offspring fetal cardiovascular defects. CONCLUSION: This study shows an increased likelihood of specific heart anomalies, namely transposition of the great arteries, persistent truncus arteriosus, visceral heterotaxia and single ventricle, among offspring of diabetic mothers. This suggests a profound teratogenic effect at a very early stage in cardiogenesis. The study emphasizes the frequency with which the offspring of diabetes-complicated pregnancies suffer from complex forms of congenital heart disease. Pregnancies with poor 1st-trimester glycemic control are more prone to the presence of fetal heart disease.

Chondromas of the spine: report of two cases and review of the literature.

We report two cases of vertebral chondroma presenting with spinal cord compression. In one case there was ultimate malignant transformation.

Vincristine and intestinal pseudo-obstruction in children: report of 5 cases, literature review, and suggested management.

Summary: Intestinal pseudo-obstruction is a rare complication resulting from a variety of disorders. Symptoms include abdominal pain, nausea, vomiting, diarrhea, constipation, and malnutrition. Vincristine-related pseudo-obstruction has been reported in the literature, but its description in children and recommendations for management are lacking. A review of the literature revealed 21 reported pediatric cases of vincristine-related pseudo-obstruction. Most have, however, been attributed to a drug interaction with itraconazole, accidental vincristine overdose, or liver failure. Potential genetic causes are rarely addressed. We present here 5 cases of pseudo-obstruction related to vincristine without any identifiable predisposing factors, and a suggested algorithm for management

L'entretien motivationnel, une nouvelle "panacée" dans la prise en charge de patients toxicodépendants ? Une revue de littérature [Motivational interviewing, the new "panacea" for treatment of substance use disorders ? A review of literature]

Cet article aborde l'entretien motivationnel (EM), considéré comme un style thérapeutique centré sur le client et directif, visant à développer la motivation au changement par l'exploration et la résolution de l'ambivalence (Miller, W.R., Rollnick, S., 2002. Motivational interviewing: preparing people for change. The Guilford Press, New York, p. 25). Après une brève présentation théorique de ce style thérapeutique, nous présentons un survol des principaux résultats empiriques relatifs à la question de son efficacité dans la prise en charge des troubles liés à l'utilisation de substances psychoactives. Malgré un corpus important de travaux qui mettent en évidence les effets de l'EM, la question des « ingrédients actifs » reste encore relativement peu explorée. Quelques hypothèses permettant de mieux comprendre le succès de l'EM sont évoquées.

Spectrum of digoxin-induced ocular toxicity: a case report and literature review.

BACKGROUND: Digoxin intoxication results in predominantly digestive, cardiac and neurological symptoms. This case is outstanding in that the intoxication occurred in a nonagenarian and induced severe, extensively documented visual symptoms as well as dysphagia and proprioceptive illusions. Moreover, it went undiagnosed for a whole month despite close medical follow-up, illustrating the difficulty in recognizing drug-induced effects in a polymorbid patient. CASE PRESENTATION: Digoxin 0.25 mg qd for atrial fibrillation was prescribed to a 91-year-old woman with an estimated creatinine clearance of 18 ml/min. Over the following 2-3 weeks she developed nausea, vomiting and dysphagia, snowy and blurry vision, photopsia, dyschromatopsia, aggravated pre-existing formed visual hallucinations and proprioceptive illusions. She saw her family doctor twice and visited the eye clinic once until, 1 month after starting digoxin, she was admitted to the emergency room. Intoxication was confirmed by a serum digoxin level of 5.7 ng/ml (reference range 0.8-2 ng/ml). After stopping digoxin, general symptoms resolved in a few days, but visual complaints persisted. Examination by the ophthalmologist revealed decreased visual acuity in both eyes, 4/10 in the right eye (OD) and 5/10 in the left eye (OS), decreased color vision as demonstrated by a score of 1/13 in both eyes (OU) on Ishihara pseudoisochromatic plates, OS cataract, and dry age-related macular degeneration (ARMD). Computerized static perimetry showed non-specific diffuse alterations suggestive of either bilateral retinopathy or optic neuropathy. Full-field electroretinography (ERG) disclosed moderate diffuse rod and cone dysfunction and multifocal ERG revealed central loss of function OU. Visual symptoms progressively improved over the next 2 months, but multifocal ERG did not. The patient was finally discharged home after a 5 week hospital stay. CONCLUSION: This case is a reminder of a complication of digoxin treatment to be considered by any treating physician. If digoxin is prescribed in a vulnerable patient, close monitoring is mandatory. In general, when facing a new health problem in a polymorbid patient, it is crucial to elicit a complete history, with all recent drug changes and detailed complaints, and to include a drug adverse reaction in the differential diagnosis.

Verrucous Carcinoma of the Vulva: A Case Report and Review of the Literature.

Verrucous carcinoma of the vulva is a rare lesion (1). Affecting essentially postmenopausal women, this lesion is a distinct and particular entity in vulval carcinoma classification and its scalability is uncertain and unpredictable. Here, we present a case concerning a 48-year-old patient, without follow-up after a condyloma acuminate of the vulva (large left lip). The origin of this case will be discussed in this article. The treatment decided was only surgical. A review of literature shows the rarity of this lesion of the female genital tract.

Memory mixed with desire : a preliminary study of philosophy and literature in the works of Friedrich Nietzsche and Milan Kundera

Memory Mixed with Desire: A preliminary study of Philosophy and Literature in the works of Friedrich Nietzsche and Milan Kundera Robert Spinelli Brock University, Department of Philosophy This thesis studies intertextuality in the works of Friedrich Nietzsche and Milan Kundera through the primary themes of memory and forgetting. The thesis starts with two introductory chapters that delineate memory according to Nietzsche and Kundera respectively. From here, I move into a discussion of Nietzsche's Ubermensch as an example of the type of forgetting that Nietzsche sees as a cure for the overabundance of memory that has led to Christian morality. Next, I explore the Kunderan concept of kitsch as the polar opposite of what Nietzsche has sought in his philosophy, finishing the chapter by tying the two thinkers together in a Kunderan critique of Nietzsche. The thesis ends with a chapter devoted to the Eternal Return beginning with an exegesis of Nietzsche's idea and ending with a similar exegesis of Kundera's treatment of this thought. What I suggest in this chapter is that the Eternal Return might itself be a form of kitsch even in its attempt to revalue existence.

Emptying the bell jar: an exploration of adolescent responses to a women's literature unit /

This study examines adolescent student responses to a women's literature unit taught within a grade 12 Writer's Craft course. Current research (Gilligan, 1989, Pipher, 1994 & Slack, 1999) suggests that there is a great under-representation of female authors in the high school literature curriculum. The use of women's literature may draw attention to important literary figures who are historically overlooked within the curriculum. It gives voice to a marginalized group and presents students with alternative subjects and heroes. It encourages students to develop a critical perspective and reevaluate assumptions about institutions, ideologies, language and culture. It also allows me, as a teacher, to reflect on my own teaching practices and explore alternate feminist pedagogical principles and teaching styles encouraging multiplicity of voices, deconstruction of power relations, and alternative assessment tools within the classroom. As an educator, it is important for me to teach curriculum that is relevant and meaningful to students and help them become critical, self-reflective thinkers. It is also important for me to assist students in their exploration of self and encourage them to expand their awareness of historical, social and global issues. Sylvia Plath's (1963) The belljar is used as the primary text taught within this unit. In this novel, the bell jar is a central image that signifies entrapment and isolation. "To the person in the bell jar, blank and stopped as a dead body, the world itself is the bad dream"(p.l 54). As a metaphor, the bell jar resonates with young readers in a variety of ways.

Palynology of late-glacial and postglacial sediments in Georgian Bay, Ontario, Canada, as related to the Great Lakes history /

This investigation comprises three parts: (1) the source, mechanism of transport, and distribution of pollen, spores and other palynomorphs in Georgian Bay bottom sediments and a comparison of these data with the contemporary vegetation, (2) the relative significance of fluvial transportation of pollen and spores, and (3) the late- and postglacial history of vegetational and climatic changes in the Georgicin Bay region. Modem pollen and spore assemblages in Georgian Bay do reflect the surrovinding vegetation when preservation and pollen production by the different species are considered and accounted for. Relative pollen percentage and concentration isopoll patterns indicate that rivers contribute large quantities of pollen and spores to Georgian Bay. This is further substantiated by large amounts of pollen and spores which were caught in traps in the Moon, Muskoka, and Nottawasaga Rivers which flow into Georgian Bay. The majority of pollen and spores caught in these traps were washed into the rivers by surface water runoff and so reflect the vegetation of the watershed in a regional sense. In a 12.9 metre long sediment core from northeastern Georgian Bay the relative percentage and absolute pollen concentrations allow correlation of Georgian Bay Lake phases with climatic and forest history. Four distinct pollen zones are distinguished: zone GB IV which is the oldest, reflects the succession from open spruce woodland to boreal forest; zone GB III represents a period of pine-mixed hardwoods forests from about 10,000 to 7,500 years ago. A pine-maplehemlock association dominated in zone GB II, although during the culmination of postglacial warming about 4,000 to 5,000 years ago the Georgian Bay forests had a more deciduous character. Zone GB I clearly shows European man's disturbance of the forest by logging activities.

An investigation of geological and geochemical characteristics of late-Quaternay sediments in the Georgian Bay Region, Southern Ontario

Core samples of postglacial sediments and sediment surface samples from Shepherd Lake on the Bruce Peninsula, Harts Lake on the Canadian Shield, and two cores from Georgian Bay (core P-l in the western deep part and core P-7 in the eastern shallow part) have been analyzed for pH, grain size distribution, water content, bulk density, loss on ignition at 4500C and 11000 C, major oxides (Si02 ,A1203,!FeO,MgO,CaO, Na20,K20,Ti02 ,MnO and P205) and trace elements (Ba,Zr,Sr,y,S, Zn,Cu,Ni,Ce and Rb). The sediment in Georgian Bay are generally fine grained (fine silt to very fine silty clay) and the grain size decreases from the Canadian Shield (core p-7) towards the Bruce Peninsula (core P-l) along the assumed direction of sediment transport. This trend coincides with a decrease in sorting coefficient and an increase in roundness. Other physical characteristics, such as water content, bulk density and loss on ignition are positively correlated with the composition of sediments and their compaction, as well as with the energy of the depositional environment. Analyses of sediment surface samples from Shepherd Lake and Harts Lake indicate the influence of bedrock and surficial deposits in the watershed on pH condition that is also influenced by the organic matter content and probably I ! I man's activities. Organic matter content increases significantly in the surface sediment in these small lakes as a result of either natural eutrophication or anthropogenic organic loading. The extremely high organic matter content in Shepherd Lake sediment indicates rapid natural eutrophication in this closed basin and high biological productivity during postglacial time, probably due to high nutrient levels and shallow depth. The chemical composition of the Canadian Shield bedrock is positively correlated with the chemical characteristics of predominantly inorganic lake sediments that were derived from the Shield rocks by glacial abrasion and by postglacial weathering and erosion of both bedrock and surficial deposits. High correlation coefficients were found between organic matter in lake sediments and major oxides (Si02,AI203,.~FeO, MgO,CaO,K20 and MnO) , as well as some trace elements (Ba,Y, S,Zn,Cu,Ni and Rb). The chemical composition of sediments in Harts Lake and core P-7 in Georgian Bay on the Canadian Shield differs from the chemistry of sediments in Shepherd Lake and core P-l in Georgian Bay on the Bruce Peninsula. The difference between cores P-l and P-7 is indicated by values of Si02 , AI203 ,:LFeo,Mgo,CaO,Ba,Zr,Sr,y and S, and also by the organic matter content. This study indicates that the processes of sediment transport, depositional environment, weathering of the rocks and surficial deposits in the watershed, as well as chemical composition of source rocks all affect the chemical characteristics of lake sediments. The stratigraphic changes and variations in lake sediment chemistry with regard to major oxides, trace elements, and organic matter content are probably related to the history of glacial and postglacial lake stages of the Georgian Bay Region and, therefore, the geochemical data can make a useful contribution to a better understanding of the Late-Quaternary history of the Great Lakes.

A conceptual analysis of research literature on teachers' ideology and literacy practices: extending the dialogue through a secondary analysis of high school English as an additional language contexts /

This thesis provides a conceptual analysis of research literature on teachers' ideology and literacy practices as well as a secondary analysis of three empirical studies and the ways in which the ideologies of the English as an Additional Language (EAL) (Street, 2005) teachers in these contexts impact the teaching of literacy in empowering/disabling ways. Several major theoretical components of Cummins (1996, 2000), Gee (1996, 2004) and Street (1995, 2001) are examined and integrated into a conceptual triad consisting of three main areas: power and ideology, validation of students ' cultural and linguistic backgrounds, and teaching that empowers. This triad provides the framework for the secondary analysis of three empirical studies on the ideologies of secondary EAL teachers. Implications of the findings from the conceptual and secondary analyses are examined in light of the research community and secondary school teachers of EAL.

Pen and sunlight sketches of scenery reached by the Grand Trunk Railway system and connections with summer routes and fares to principal points : including Niagara Falls, Thousand Islands, Rapids of the St. Lawrence, Montreal, Quebec, Parry Sound, Georgian Bay, Muskoka Lakes, Adirondacks, Lake St. John, Mackinac Island, Midland District Lakes, the White Mountains, the Suquenay River, Rangeley Lakes and the sea-shore.--

At head of title: "Great tourist route of America".

Tourist travel via Grand Trunk Railway System : and connections, including Niagara Falls and Gorge, the Highlands of Ontario, comprising Georgian Bay, Muskoka Lakes ; St. Lawrence River, Montreal, Quebec, the Saguenay River, the Rangeley Lakes, White Mountains, and the Atlantic Sea-Coast /

Previous editions of this work have appeared under the title: Gateways of tourist travel.