Challenging the anticolorectal cancer capacity of quinoxaline-based scaffold via triazole ligation unveiled new efficient dual VEGFR-2/MAO-B inhibitors

Monoamine oxidases (MAOs) and vascular endothelial growth factor receptor-2 (VEGFR-2) are promoters of colorectal cancer (CRC) and central signaling nodes in epithelial-mesenchymal transition (EMT) induced by activating hypoxia-inducible factors (HIFs). Herein, a novel series of rationally designed triazole-tethered quinoxalines were synthesized and evaluated against HCT-116 CRC cells. The tailored scaffolds combine the pharmacophoric themes of both VEGFR-2 inhibitors and MAO inhibitors. All the synthesized derivatives were screened utilizing the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-2H-tetrazolium bromide (MTT) assay for their possible cytotoxic effects on normal human colonocytes, then evaluated for their anticancer activities against HCT-116 cells overexpressing MAOs. The hit derivatives 11 and 14 exhibited IC50 = 18.04 and 7.850 µM, respectively, against HCT-116cells within their EC100 doses on normal human colonocytes. Wound healing assay revealed their efficient CRC antimetastatic activities recording HCT-116 cell migration inhibition exceeding 75 %. In vitro enzymatic assays demonstrated that both 11 and 14 efficiently inhibited VEGFR-2 (IC50 = 88.79 and 9.910 nM), MAO-A (IC50 = 0.763 and 629.1 nM) and MAO-B (IC50 = 0.488 and 209.6 nM) with observed MAO-B over MAO-A selectivity (SI = 1.546 and 3.001), respectively. Enzyme kinetics studies were performed for both compounds to identify their mode of MAO-B inhibition. Furthermore, qRT-PCR analysis showed that the hits efficiently downregulated HIF-1α in HCT-116cells by 3.420 and 16.96 folds relative to untreated cells. Docking studies simulated their possible binding modes within the active sites of VEGFR-2 and MAO-B to highlight their essential structural determinants of activities. Finally, they recorded in silico drug-like absorption, distribution, metabolism, excretion, and toxicity (ADMET) profiles as well as ligand efficiency metrics.

Values-Based Medicine Is an Ethical Concept for Implementing the Ethical Principles in Daily Practice

Values-based medicine (VsBM) is an ethical concept, and bioethical framework has been developed to ensure that medical ethics and values are implemented, pervasive, and powerful parameters influencing decisions about health, clinical practice, teaching, medical industry, career development, malpractice, and research. Neurosurgeons tend to adopt ethics according to their own values and to what they see and learn from teachers. Neurosurgeons, in general, are aware about ethical codes and the patient's rights. However, the philosophy, concept, and principles of medical ethics are rarely included in the training programs or in training courses. The impact of implementing, observing the medical ethics and the patients' value and culture on the course, and outcome of patients' management should not underestimate. The main principles of medical ethics are autonomy, beneficence, nonmaleficence, justice, dignity, and honesty, which should be strictly observed in every step of medical practice, research, teaching, and publication. Evidence-based medicine has been popularized in the last 40-50 years in order to raise up the standard of medical practice. Medical ethics and values have been associated with the medical practice for thousands of years since patients felt a need for treatment. There is no conflict between evidence-based medicine and values-based medicine, as a medical practice should always be performed within a frame of ethics and respect for patients' values. Observing the principles of values-based medicine became very relevant as multicultural societies are dominant in some countries and hospitals in different corners of the world.

The Use of Optical Tracking to Characterize Fracture Gap Motions and Estimate Healing Potential in Comminuted Biomechanical Models of Surgical Repair

Fracture healing is stimulated by micromotion at the fracture site, whereby there exists an optimal amount of strain to promote secondary bone formation. Surgical plates used for fracture fixation are often evaluated for their biomechanical performance using benchtop studies, where success is based on overall construct stiffness and strength measures. Integration of fracture gap tracking to this assessment would provide crucial information about how plates support the various fragments present in comminuted fractures, to ensure there are appropriate levels of micromotion during early healing. The goal of this study was to configure an optical tracking system to quantify 3D interfragmentary motion to assess the stability (and corresponding healing potential) of comminuted fractures. An optical tracking system (OptiTrack, Natural Point Inc, Corvallis, OR) was mounted to a material testing machine (Instron 1567, Norwood, MA, USA), with an overall marker tracking accuracy of 0.05 mm. Marker clusters were constructed that could be affixed to individual bone fragments, and segment-fixed coordinate systems were developed. The interfragmentary motion was calculated by tracking the segments while under load and was resolved into compression-extraction and shear components. This technique was evaluated using two cadaveric distal tibia-fibula complexes with simulated intra-articular pilon fractures. Normal and shear strains were tracked during cyclic loading (for stiffness tests), and a wedge gap was also tracked to assess failure in an alternate clinically relevant mode. This technique will augment the utility of benchtop fracture studies by moving beyond total construct response and providing anatomically relevant data on interfragmentary motion, a valuable proxy for healing potential.

Antiplatelet and Anti-Coagulation Therapy for Left-Sided Catheter Ablations: What Is beyond Atrial Fibrillation?

Aim: International guidelines on the use of anti-thrombotic therapies in left-sided ablations other than atrial fibrillation (AF) are lacking. The data regarding antiplatelet or anticoagulation strategies after catheter ablation (CA) procedures mainly derive from AF, whereas for the other arrhythmic substrates, the anti-thrombotic approach remains unclear. This survey aims to explore the current practices regarding antithrombotic management before, during, and after left-sided endocardial ablation, not including atrial fibrillation (AF), in patients without other indications for anti-thrombotic therapy. Material and Methods: Electrophysiologists were asked to answer a questionnaire containing questions on antiplatelet (APT) and anticoagulation therapy for the following left-sided procedures: accessory pathway (AP), atrial (AT), and ventricular tachycardia (VT) with and without structural heart disease (SHD). Results: We obtained 41 answers from 41 centers in 15 countries. For AP, before ablation, only four respondents (9.7%) used antiplatelets and two (4.9%) used anticoagulants. At discharge, APT therapy was prescribed by 22 respondents (53.7%), and oral anticoagulant therapy (OAC) only by one (2.4%). In patients with atrial tachycardia (AT), before ablation, APT prophylaxis was prescribed by only four respondents (9.7%) and OAC by eleven (26.8%). At discharge, APT was recommended by 12 respondents (29.3%) and OAC by 24 (58.5%). For VT without SHD, before CA, only six respondents (14.6%) suggested APT and three (7.3%) suggested OAC prophylaxis. At discharge, APT was recommended by fifteen respondents (36.6%) and OAC by five (12.2%). Regarding VT in SHD, before the procedure, eight respondents (19.5%) prescribed APT and five (12.2%) prescribed OAC prophylaxis. At discharge, the administration of anti-thrombotic therapy depended on the LV ejection fraction for eleven respondents (26.8%), on the procedure time for ten (24.4%), and on the radiofrequency time for four (9.8%), with a cut-off value from 1 to 30 min. Conclusions: Our survey indicates that the management of anti-thrombotic therapy surrounding left-sided endocardial ablation of patients without other indications for anti-thrombotic therapy is highly variable. Further studies are necessary to evaluate the safest approach to these procedures.

Family-base rare variant association analysis in Saudi Arabian hydrocephalus subjects using whole exome sequencing

BACKGROUND

Hydrocephalus is a highly heterogeneous multifactorial disease that arises from genetic and environmental factors. Familial genetic studies of hydrocephalus have elucidated four robustly associated hydrocephalus associated loci. This study aims to identify potential genetic causation in cases of hydrocephalus, with or without spina bifida and Dandy Walker Syndrome (DWS), using family-based rare variant association analysis of whole exome sequencing.

METHODS

We performed whole exome sequencing in 143 individuals across 48 families where at least one offspring was affected with hydrocephalus (N.=27), with hydrocephalus with spina bifida (N.=21) and with DWS (N.=3), using Illumina HiSeq 2500 instrument.

RESULTS

No pathogenic or putative pathogenic single-nucleotide variants were evident in the four known hydrocephalus loci in our subjects. However, after examining 73 known hydrocephalus genes previously identified from literature, we identified three potentially impactful variants from the cohort. Using a gene panel comprising variants in known neural tube defects loci, we identified a total of 1024 potentially deleterious variants, of which 797 were missense variants and 191 were frameshift variants, 36 were stop gain/loss variants. A small portion of our family pedigree analyses yielded putative genetic signals which may be responsible for hydrocephaly elated phenotypes, however the low diagnostic yield may be due to lack of capture of genetic variants in the exonic regions i.e. structural variants may only be evident from whole genome sequencing.

CONCLUSIONS

We identified three potentially impactful variants from our cohort in 73 known hydrocephalus genes previously identified in literature.

Correction: New silicon substituted BiMeVO x : synthesis and study of structural properties in relation to ionic conductivity

[This corrects the article DOI: 10.1039/D3RA00485F.].

New silicon substituted BiMeVO x : synthesis and study of structural properties in relation to ionic conductivity

Partial substitution of vanadium with silicon in the compound Bi₄V₂O₁₁, which belongs to the Aurivillius family, leads to the creation of a solid solution Bi₄V_2-x Si _x O_11-δ (0 ≤ x ≤ 0.4). The compound with x = 0.1 turns out to be a monoclinic α-form of Bi₄V₂O₁₁, while the compounds with x = 0.2 and x = 0.3 are orthorhombic β-polymorphs, and the compound with x = 0.35 is of tetrahedral γ-polymorph. Electrochemical Impedance Spectroscopy has been used to measure the ionic conductivity of doped samples. The ceramic sample with x = 0.1 has the highest ionic conductivity values.

How to define CSF overdrainage: a systematic literature review

PURPOSE

Overdrainage (OD) is one of the most frequent complications related to drainage of the cerebrospinal fluid (CSF). It is mostly associated with valve-bearing shunt systems but should probably be considered as a risk factor in any type of CSF diversion procedure. There is extreme variation in the reported incidence of OD due to the lack of consensus on defining criteria and an unclear perception of the pathophysiology. Hence, OD is probably underreported and underestimated. The objective of this paper was to establish a definition of OD, based on a systematic review of the literature.

METHODS

A systematic search was conducted in MEDLNE and EMBASE. Studies providing a definition or a description of diagnostic findings related to OD in ventriculoperitoneal shunt treated hydrocephalus were included. Non-English titles, abstracts and manuscripts were excluded. Extracted descriptions were graded into five groups (class I-V studies) based on how precise the terminology used to describe OD was. Class I studies were included for further analysis and characteristics of OD were extracted. The quality of included descriptions was assessed by a clinical expert panel.

RESULTS

A total of 1309 studies were screened, 190 were graded into groups, and 22, which provided specific definitions or descriptions of OD, were graded as class I studies. We extracted 32 different characteristics consistent with OD (e.g., clinical symptoms, radiological signs, and syndromes).

CONCLUSION

There was an overall agreement that CSF overdrainage following implantation of a ventriculoperitoneal shunt in a mixed pediatric and adult population is characterized as a persistent condition with clinically manifestations as postural dependent headache, nausea, and vomiting and/or radiological signs of slim ventricles and/or subdural collections.

The ASPECT Hydrocephalus System: a non-hierarchical descriptive system for clinical use

In patients with hydrocephalus, prognosis and intervention are based on multiple factors. This includes, but is not limited to, time of onset, patient age, treatment history, and obstruction of cerebrospinal fluid flow. Consequently, several distinct hydrocephalus classification systems exist. The International Classification of Diseases (ICD) is universally applied, but in ICD-10 and the upcoming ICD-11, hydrocephalus diagnoses incorporate only a few factors, and the hydrocephalus diagnoses of the ICD systems are based on different clinical measures. As a consequence, multiple diagnoses can be applied to individual cases. Therefore, similar patients may be described with different diagnoses, while clinically different patients may be diagnosed identically. This causes unnecessary dispersion in hydrocephalus diagnostics, rendering the ICD classification of little use for research and clinical decision-making. This paper critically reviews the ICD systems for scientific and functional limitations in the classification of hydrocephalus and presents a new descriptive system. We propose describing hydrocephalus by a system consisting of six clinical key factors of hydrocephalus: A (anatomy); S (symptomatology); P (previous interventions); E (etiology); C (complications); T (time-onset and current age). The "ASPECT Hydrocephalus System" is a systematic, nuanced, and applicable description of patients with hydrocephalus, with a potential to resolve the major issues of previous classifications, thus providing new opportunities for standardized treatment and research.

Primary prevention implantable cardioverter-defibrillator use in non-ischemic dilated cardiomyopathy based on arrhythmic risk stratification and left ventricular reverse remodeling prediction

Sudden cardiac death (SCD) and significant ventricular arrhythmias in patients with dilated cardiomyopathy (DCM) have been markedly reduced over the last couple of decades as a result of the advances in pharmacological and non-pharmacological treatment. Primary prevention implantable cardioverter-defibrillator (ICD) plays an important role in the treatment of patients at risk of SCD caused by ventricular arrhythmias. However, the arrhythmic risk stratification in patients with DCM remains extremely challenging, and the decision for primary prevention ICD implantation based on left ventricular ejection fraction (LVEF) solely appears to be insufficient. This review provides an update on current evidence for primary prevention ICD implantation, arrhythmic risk stratification, and left ventricular reverse remodeling (LVRR) prediction in patients with DCM in addition to most recent guideline recommendations for primary prevention ICD implantation in DCM patients and a proposed multiparametric algorithm based on arrhythmic risk stratification and left ventricular reverse remodeling (LVRR) prediction to better identify patients who are likely to benefit from primary prevention ICD.

OGC P47 The Role of Endoscopic Ultrasound Scan In Staging Patients With Oesophageal Cancer- A Retrospective Single Centre Study

Background

There are conflicting opinions on the role of Endoscopic Ultrasound (EUS) in the staging of oesophageal cancer (OG) patients which can complicate and delay intervention. We aim to audit the use of EUS in the OG cancer staging pathway as well as assess accuracy in selected cases.

Methods

A retrospective audit of the hospital database of patients diagnosed with oesophageal carcinoma between January 2016 and March 2021.The duration between the first MDT and EUS performed was calculated. Concordance between initial CT and EUS stage as well as histology in patients that were offered direct to surgery were evaluated using Cohen's Weighted Kappa.

Results

A total of 301 patients were identified. Overall, there was a moderate agreement (K=0.526) between CT and EUS reported T Staging(p<0.001). There was substantial agreement (K=0.798) between CT reporting T2, T3 and EUS(p<0.0005). Twenty-seven patients underwent upfront surgery-11 were T1, 16 were T2 and T3 disease. Comparing to final histology, EUS reported an accurate T1 stage in 36.3% compared with 0% with CT (p=0.018), whereas T2 and T3 disease were accurately reported with EUS and CT in 43.7% and 37.5% respectively (p=0.375). The median number of days between first MDT and EUS was 14 days (8,18) and this was requested after CT and PET CT results were available in 80% of cases.

Conclusions

This audit demonstrates minor differences between EUS and CT for T2 and T3 disease and therefore unlikely to alter management. However, EUS is superior to CT for staging Tx and T1 disease and is therefore likely to impact on the treatment options. EUS also contributed to prolonged pre-treatment staging time. Adopting a selective approach to EUS could result in overall reduction of waiting times from referral to decision making and increase cost-effectiveness.

Outcomes of catheter ablation of ventricular tachycardia in non-ischemic idiopathic dilated cardiomyopathy: A systematic review and meta-analysis

Objective

To perform a systematic review and meta-analysis of available trials regarding the outcomes of ventricular tachycardia (VT) ablation in patients with non-ischemic dilated cardiomyopathy (NIDCM).

Methods

A comprehensive database search of large four electronic databases, including PubMed, Cochrane, Scopus, and Institute for Scientific Information network meta-analysis, identified five studies enrolling 666 patients for patients with idiopathic dilated cardiomyopathy (IDCM) underwent catheter ablation (CA) for VT. The short-term outcomes assessed included procedural success, VT non-inducibility and procedural complications, whereas the long-term outcomes assessed included VT recurrence, heart transplantation, antiarrhythmic drugs (AAD) use after ablation and death.

Results

A total of 5 observational studies reported outcomes in 666 patients with NIDCM undergoing VT CA. The complete procedural success was moderately high; 65.5% of the patients (95% CI 0.402- 0.857, p < 0.001) and the procedural complications occurred in 5.8% of the patients (95% CI 0.040–0.076, P = 0.685). Epicardial mapping and ablation were performed among 61.5% and 37% of patients with NIDCM respectively. During a follow up period of 12 to 45 months, there were VT recurrence in 34.2% of the patients (95% CI 0.301–0.465, p < 0.080), death in 20.2% of the patients (95% CI 0.059–0.283, p < 0.017) and heart transplantation in 12.9% of the patients (95% CI −0.026–0.245, P < 0.012).

Conclusion

Ventricular tachycardia CA is effective and safe approach for management of patients with NIDCM with the epicardial approach to be considered as initial strategy especially in presence of ECG and CMR findings suggestive of epicardial substrate. A multicenter randomized trial is crucial to look at the short- and long-term outcomes of VT ablation in NIDCM especially with the advances in mapping and ablation techniques and predictors of success.

FAIR assessment tools: evaluating use and performance

Publishing research data using a findable, accessible, interoperable, and reusable (FAIR) approach is paramount to further innovation in many areas of research. In particular in developing innovative approaches to predict (eco)toxicological risks in (nano or advanced) material design where efficient use of existing data is essential. The use of tools assessing the FAIRness of data helps the future improvement of data FAIRness and therefore their re-use. This paper reviews ten FAIR assessment tools that have been evaluated and characterized using two datasets from the nanomaterials and microplastics risk assessment domain. The tools were grouped into four categories: online and offline self-assessment survey based, online (semi-) automated and other tools. We found that the online self-assessment tools can be used for a quick scan of a user's dataset due to their ease of use, little need for experience and short time investment. When a user is looking to assess full databases, and not just datasets, for their FAIRness, (semi-)automated tools are more practical. The offline assessment tools were found to be limited and unreliable due to a lack of guidance and an under-developed state. To further characterize the usability, two datasets were run through all tools to check the similarity in the tools' results. As most of the tools differ in their implementation of the FAIR principles, a large variety in outcomes was obtained. Furthermore, it was observed that only one tool gives recommendations to the user on how to improve the FAIRness of the evaluated dataset. This paper gives clear recommendations for both the user and the developer of FAIR assessment tools.

P-EGS01 Cholecystectomy after gall stone pancreatitis

Background

According to the UK guidelines for the management of acute pancreatitis commissioned by the British Society of Gastroenterology,

All patients presenting with gallstone pancreatitis should be considered for cholecystectomy when they are well enough to undergo surgery. In cases of mild biliary pancreatitis, cholecystectomy should ideally be performed during the index admission or within 2 weeks of discharge as interval cholecystectomy is associated with a significant risk of readmission for recurrent biliary events.

In cases of severe gallstone pancreatitis, cholecystectomy may need to be delayed until collections have improved, unless the patient is well enough for surgery and the gallbladder is some distance from the collection

Methods

Methods

Inclusion Criteria

Exclusion Criteria

Results

80 patients were collected during the study period, 96 % of them were classified as mild pancreatitis

Cholecystectomy rate

Total percentage of cholecystectomies performed for mild gall stone pancreatitis during index admission or within 2 weeks from discharge : 37%

Percentage of early cholecystectomies for eligible patients (i.e.after ruling out unfit patients, patients declining treatment, previous cholecystectomy..etc) : 54%

Re-admission rate

Re-admission rate for early cholecystectomy patients : 7.4%

Re-admission rate for delayed cholecystectomy patients : 20.7%

Conclusions

Management and Outcome of Post-Infectious Multiloculated Hydrocephalus: A Case Series

Background and importance:

Infection following ventriculoperitoneal shunt (VPS) placement is a recognized complication, with variable incidence rates worldwide. Development of post-infectious multiloculated hydrocephalus (MLH) is likely if VPS infection is improperly managed, in turn affecting the prognosis. There is a lack of studies from Saudi Arabia regarding patients' functional outcome in relation to different variables.

Objectives:

To study the causative organisms, related variables and patient outcomes in MLH after VPS infection.

Methods:

This case series is a retrospective chart review of pediatric patients diagnosed with hydrocephalus from 2011 to 2019. Patients were included if they were aged <18 years, had confirmed cerebrospinal fluid/blood infection with radiological evidence of MLH, and were regularly followed-up. Functional status score was used to evaluate the outcomes.

Results:

A total of 150 patients underwent VPS insertion during the study period, of which 12 (8%) had postinfection MLH. The mean age at diagnosis and follow-up was 9 and 19 months, respectively. Ten patients developed MLH after their first VPS infection and one each developed MLH following the second and third VPS infections. Cerebrospinal fluid cultures mostly grew only single organisms (6/12), with Staphylococcus species being the most common. All patients underwent navigated endoscopic fenestration; nine patients required VPS placement and three required redo endoscopic fenestration surgery. All patients were developmentally delayed, with the majority (75%) having a functional status score of 6–10.

Conclusion:

Development of MLH after VPS infection is debilitating and requires prompt treatment. Although the overall functional outcome is poor, evolving neuroendoscopic techniques with tailored preoperative planning may play a role in reducing the adverse effect of shunt multiplicity, shunt infections and the higher failure rate among patients with complex hydrocephalus.

Numerical Investigation of the Dynamical Behavior of a Fluid-Filled Microparticle Suspended in Human Arteriole

The study of artificial microparticles (capsules and vesicles) has gained a growing interest with the emergence of bio-engineering. One of their promoting applications is their use as therapeutic vectors for drug delivery, when capsules and vesicles release their capacity in a targeted environment. The dynamic behavior of capsules and vesicles in confined or unbounded flows was widely studied in the literature and their mechanical response was truthfully described using constitutive laws with good agreement with experiences. However, in a context of biological application, to our knowledge, none of published studies investigating the mechanical response of deformable microparticle took into account the real physiological conditions: the rheological properties of blood such as carrying fluid and the mechanical properties of blood vessels. In this paper, we consider a hyperelastic microparticle suspended in human arteriole. We investigate the deformation of the microparticle resulting from its interaction with blood flow and the arteriolar wall using various capillary numbers and respecting physiological properties of blood and arterial wall. The influence of the blood viscosity model (Newtonian versus shear thinning) is investigated and a comparison with a rigid microchannel and a muscle-embedded arteriole is carried out. The fluid structure interaction (FSI) problem is solved using arbitrary Lagrangian Eulerian (ALE) method. Our simulations have revealed that the arteriolar wall distensibility deeply influences both the deformation and velocity of the microparticle: the deformation strongly increases while the velocity decreases in comparison to an infinitely rigid wall. In the context of therapeutic procedure of targeted drug-delivery, a particular attention should be addressed to these observations, in particular for their implication in the burst mechanism.

An Elderly Man Suffers a Renal Cell Carcinoma Metastasis in the Pineal Gland: Lessons Learned and Ethical Considerations

Metastases to the pineal gland are rare and reported cases have consisted mainly of lung and gastrointestinal primary malignancies. Here we report the third case in the literature of pineal gland metastasis from renal cell carcinoma.

A 69-year-old man, status post excision of right renal cell carcinoma 20 years ago, presented with a one-month history of urinary incontinence. Images revealed a solitary mass in the pineal region with obstructive hydrocephalus. Endoscopic third ventriculostomy (ETV) and biopsy of pineal mass were performed. The histological diagnosis of the biopsy was inconclusive. The patient was scheduled for a follow-up and readmission for a repeat biopsy, however, was lost to follow-up. No attempts were made by the hospital team or patient relations department to contact him. Eventually, the patient presented after 18 months to the emergency room (ER) with confusion, forgetfulness, gait disturbance, weakness of lower extremities, and vision loss due to enlarged pineal mass. Another ETV and biopsy were performed. The histological findings were compatible with metastasis from renal cell carcinoma. The patient died after three months due to rapid general deterioration in his condition.

The lessons that have been learned from this case are: 1) Metastatic tumor should be considered in the differential diagnosis of pineal region tumors, particularly in elderly patients and with a known history of malignancy; 2) If the first biopsy is inconclusive, a rapid plan and a strict follow-up for a repeat biopsy should be made; 3) Elderly patients should have special care; they should be well informed about their condition and should be contacted regularly to ensure that they receive the optimal management plan.

A Retrospective Study on the Avoidability of Ventriculoperitoneal Shunt Infections in a University Hospital in Al-Khobar, Saudi Arabia

Ventriculoperitoneal shunt infection is a major complication and the main cause of shunt failure, contributing to a high rate of morbidity and mortality among patients requiring prolonged hospitalization. Shunt infection-related complications are considered a global burden of hydrocephalus worldwide. In our hospital, King Fahad Hospital of the University, the rate of infections in similar cases reached 8% during the period from 1999 to 2001; an increase in this rate was observed in the past two years.

This study analyzed the infections that occur after ventriculoperitoneal shunt placement in patients with hydrocephalus and related conditions during the period from January 2012 to April 2017. The objectives of this study were to analyze the rate of cerebrospinal fluid infections in different age groups at the King Fahd Hospital of the University and to identify the causative pathogens and methods of reducing the rate and consequences of such infections. In this retrospective study, the electronic medical records of 266 patients were reviewed and those of 131 patients were included and analyzed. We found that the prevalence rate of shunt-related infections was 24.4%, which indicates the importance of this problem. Staphylococcus epidermidis is the most commonly implicated microorganism. The most affected age groups were those of preschool children and infants. Individuals who were older than 74 years were the least affected. It was found that delayed infections were the most common type of VP shunt infection among the study population and there was no difference in the most common organisms between early, delayed, and late infections. The mean duration of antibiotic treatment used was 19.76 days. In conclusion, postoperative infections are significantly common in patients who undergo shunt-related surgeries.

The Correlation between Histopathology of Herniated Lumbar Intervertebral Disc and Clinical Findings

Objective

Prolapsed lumbar disc is one of the most frequent diseases, which is usually presented by motor and sensory deficits. Consistency of herniated disc may play a significant role in surgical treatment and postoperative improvement. The objective of this study is to assess whether the histopathological degeneration in the sample of lumbar discs operated on is correlated to clinical variables and surgical outcomes.

Materials and Methods

A randomized double-blind prospective study of lumbar disc prolapse cases over a period of 24 months was done. Forty cases were initially included in the study. All the included cases with a scheduled lumbar discectomy in the Department of Neurosurgery, King Fahd University Hospital, Al-Khobar, Saudi Arabia, during this period were examined histologically.

Results

Finally, 21 patients were only considered in this study due to loss of follow-up of the other 19 patients; of these 21 patients, 18 were male and 3 were female. The youngest patient was 32 years old, and the oldest was 72 years old. There is no significant correlation between the major histopathological changes of the prolapsed discs and the clinical findings of low back pain (correlation coefficient = 0.058, P < 0.8), duration of sciatica (correlation coefficient = -0.337, P < 0.1), paresthesia (correlation coefficient = 0.111, P < 0.6), motor weakness (correlation coefficient = 0.274, P < 0.2), and reflex (correlation coefficient = 0.081, P < 0.7). Meanwhile, the correlation coefficient between numbness and histopathological degeneration score (HPDS) is not defined because all reported cases were presented with numbness.

Conclusions

There is no significant correlation between the histopathological changes of the prolapsed discs and some clinical findings. Moreover, the different types of prolapsed discs' histopathological changes have no impact on the outcome of the surgery. We also concluded that the disc material undergoes certain degenerative processes with age.

Extrusion of Anterior Abdominal Wall by a Ventriculoperitoneal Shunt - An Uncommon Complication: Case Report and Literature Review

Ventriculoperitoneal shunt (VP-shunt) is a commonly performed procedure for the management of hydrocephalus. Migration of the distal end of VP-shunt is one of the rarest complications. The authors report a case of an 11-year-old boy who presented with a spontaneous extrusion of the distal end of the VP-shunt through an intact abdominal wall. Literature was reviewed regarding the possible causes of such complication and the management approach in similar cases. The suggested phenomenon for this case could be attributed to the continuous hammer effect of the cerebrospinal fluid (CSF) pulsations on the abdominal wall. It is important to assess the future need for long-term CSF diversion, as in this case, the patient did not require reinsertion of a new shunt system because he was shunt independent.

Depression and Anxiety Disorders in a Sample of Saudi Persons with Brain Tumor

BACKGROUND: Depression and anxiety (DA) are common in persons with brain tumor (PBT) and are associated with neurocognitive deficits. The terms DA and affective disorders are often used interchangeably in this study. Objective: This was a pilot study, conducted with the purpose of better assessing DA symptoms in association with socioeconomic and clinical characteristics in PBT. METHOD: A cross-sectional study was conducted on a sample of PBT (N = 102), recruited from a neurosurgical department. The tools employed were the Beck Depression Inventory-II (BDI-II) and the Hospital Anxiety and Depression Scale (HADS). The self-rating instruments proved feasible and reliable in screening for the severity of DA symptoms. The HADS is designed to measure the severity of anxiety and depressive symptoms in non-psychiatric hospital outpatients and does not assess the common somatic symptoms of these two disorders. The BDI-II evaluates the severity of depressive symptoms with items related to physical symptoms. RESULTS: Although our study did not, for the most part, yield results of statistical significance, it, however, demonstrated that anxiety and depressive disorders existed in PBT, showing a relatively higher rate in age groups 30&ndash;49 years. CONCLUSION: It was unclear whether these symptoms were invalidated by response bias, participant&rsquo;s functional status, natural reaction to a fearing situation or just presentation of pseudodepression arose as a result of organic deficits. There is a need for further research to examine these factors.

Management of atrial fibrillation after transcatheter aortic valve replacement: Challenges and therapeutic considerations

Atrial Fibrillation (AF) is very common among patients with severe aortic stenosis. Moreover, new onset AF (NOAF) is a frequent finding after Transcatheter Aortic Valve Replacement (TAVR). There is a significant impact of AF on outcomes in patients undergoing TAVR including mortality, thrombo-embolic and bleeding events. There is lack of clear evidence about the optimal management of AF in TAVR patients. This review aims to summarize the epidemiology, predictors, prognosis, therapeutic considerations and challenges in the management of AF in patients undergoing TAVR.

P1449Anti-thrombotic management for electrophysiological procedures: results of the European Heart Rhythm Association (EHRA) young investigators survey

Funding Acknowledgements

none

Background

Electrophysiological studies (EPS), with or without ablation, require percutaneous introduction of catheters into the heart to record local electrical activity. Instrumentation of catheters within the blood causes activation of the clotting cascade, increasing the risk of thrombus formation. To date, the electrophysiological community lacks international guidelines on the use of anti-thrombotic therapies before, during and after EPS.

Purpose

To survey the current practice regarding the use of anti-thrombotic therapies across member countries of the European Heart Rhythm Association (EHRA).

Methods

The survey was conducted in February 2019. Electrophysiologists from EHRA member countries were contacted to complete the survey by e-mail, utilizing the EHRA Young EP network. They were asked to answer a questionnaire containing information on anti-thrombotic and anticoagulation management before, during and after left-sided EPS and ablation: atrial tachycardia (AT), accessory pathway (AP) and ventricular tachycardia (VT).

Results

We obtained 41 answers responses from 40 centers in 15 European EHRA member countries. Regarding of antiaggregation, the most used antiplatelet is aspirin (100% before, during and after ablation). The most used anticoagulant was novel oral anticoagulants (NOAC) before ablation (47.1%), during hospitalization (85.2%) and at discharge (70.3%). The administration of anti-thrombotic therapy depended on the procedure time only in 10 cases (24.4%).

For AP, before ablation, only 4 centers (9.7%) administered anti-platelets and 2 (4.9%) anticoagulants. During ablation, heparin was used by 85.4% of respondents maintaining ACT target 300-350 s in 36.6% of cases. At discharge, antiaggregation therapy was prescribed by 22 colleagues (53.7%) and anticoagulation only by one (2.4%).

In patients with AT, before ablation, antiaggregation prophylaxis was prescribed by only 4 centers (19.5%) and anticoagulation by 11 (26.8%). During procedure, almost all centers (40, 97.6%) used heparin with ACT target 300-350 s in 58.5% of cases. At discharge, antiplatelet therapy was recommended by 12 colleagues (29.3%) and anticoagulation by 24 (58.5%).

Regarding VT, before procedure, 8 centers (19.5%) prescribed antiaggregation and 5 (12.2%) anticoagulation prophylaxis. During ablation, all centers used heparin, maintaining ACT target 300-350 s in 58% of cases. The use of antiaggregation or anticoagulation depended on the left ventricle (LV) access in 15 centers (37.5%) and on LV ejection fraction in 11 (26.8%). At discharge, anti-thrombotic therapy was recommended by 16 colleagues (39%) and anticoagulation by 13 (31.7%).

Conclusion

Our survey showed that there is considerable variation in the management of anti-thrombotic therapy surrounding left-sided EPS and ablation. Further studies are necessary to evaluate the right approach to these procedures.

Spontaneous Regression of Pineal Region Arachnoid Cyst: A Case Report and Review of Literature

Arachnoid cyst is a rare benign cerebrospinal fluid-filled cyst that can develop anywhere in the brain along the arachnoid membrane and usually unaccompanied by the anomalous development of the brain structure. These cysts are usually located in the middle cranial fossa. However, they are also denoted in other regions. Arachnoid cysts are mostly asymptomatic and diagnosed incidentally. Spontaneous regression of arachnoid cysts in different anatomical regions of the brain has been reported in the literature. However, to the best of our knowledge, this is the first case reporting an unusual spontaneous regression of arachnoid cyst in the pineal region in a 3-year-old child presented to our hospital with hydrocephalus without alarming signs and was treated conservatively as the patient was stable, and the cyst showed spontaneous regression. A comprehensive review of the literature regarding spontaneous regression of arachnoid cysts has been collected and discussed in this article.

P955Assessment of coronary and myocardial reperfusion as well as left ventricular infarct size and function following streptokinase administration immediately after Primary coronary intervention

Background

Reperfusion injury might be considered a consequence of insufficient myocardial perfusion (MP) due to microthrombi (MT) embolization into the microcirculation. Streptokinase (SK) a fibrinolytic agent, if injected into the culprit artery immediately after primary percutaneous coronary intervention (PPCI) might tackle and dissolve these MT resulting in better MP and function.

Methods

Sixty four patients presenting within 24 hours by their first ST elevation myocardial infarction, underwent PPCI, then equally divided into 2 groups; G1 received 250 kU of intracoronary SK (ICSK) vs saline in G2. Successful coronary perfusion was defined as corrected TIMI frame count (cTFC) <28 frames, and successful MP as TIMI myocardial blush grade (TMBG) 3. Evaluation of left ventricular (LV) function was done by comparing the baseline LV global longitudinal strain (GLS) before and 1-month after PPCI. Assessment of infarct size was done by measuring peak CK-MB, CK-MB area under the curve and ST segment resolution (STR) 90 min after PPCI.

Results

Thirty minutes after ICSK, cTFC (fig) was significantly lower (P≤0.05), while TMBG (fig) was significantly higher (P≤0.02) in G1 vs G2. Peak CK-MB, CK-MB area under the curve were significantly lower (P≤0.015 & P≤0.001 respectively) while STR≥70%was significantly higher in G1 (P≤0.045). Multivariate logistic regression analysis showed that the likelihood of achieving successful MP post-PPCI is associated with ICSK administration [OR=0.123, 95% CI (0.02–0.75), P≤0.024] and total ischemic time (ROC curve). Multivariate linear regression analysis showed that each of, immediate ICSK administration post-PPCI and TMBG were independent predictors for LV GLS improvement after one month. No significant difference in bleeding risk between G1&2 (p=1).

Conclusion

ICSK given immediately after primary PCI was an independent predictor of successful coronary and myocardial reperfusion. It significantly led to reduction of infarct size and improvement of LV GLS.

A trial of three non-invasive blood pressure monitors compared with invasive blood pressure assessment in atrial fibrillation and sinus rhythm

OBJECTIVE

To investigate the accuracy of three non-invasive blood pressure (BP) devices in atrial fibrillation (AF) compared with invasive arterial BP.

METHODS

One hundred patients aged 45-90 years, 63% male (50 in AF and 50 age matched controls in sinus rhythm [SR]) were identified with arterial lines measuring beat-to-beat BP fluctuation. Non-invasive BP measurements utilising the manual sphygmomanometer (MS), PulseCor R6.5 (PC) and automated sphygmomanometer (AS) were taken simultaneously with invasive BP in a randomised sequence. This was repeated three times in each patient.

RESULTS

In SR differences in systolic BP (SBP) for MS, AS and PC were -0.34 mm Hg (95% CI -2.31 to 1.63; P = .733), -3.80 mm Hg (95% CI -5.73 to -1.87; P = .0001) and -3.90 mm Hg (95% CI -5.90 to -1.90; P = .0001) and for diastolic BP (DBP) were 6.02 mm Hg (95% CI 4.39-7.64; P < .0001), 8.95 mm Hg (95% CI 7.36-10.55; P < .0001) and 7.54 mm Hg (95% CI 5.89-9.18; P < .0001), respectively. In AF mean differences in SBP for MS, AS and PC were -7.33 mm Hg (95% CI -9.11 to -5.55; P < .0001), -5.29 mm Hg (95% CI -7.08 to -3.50; P < .0001) and -5.75 mm Hg (95% CI -7.54 to -3.96; P < .0001) respectively and for DBP were 5.28 mm Hg (95% CI 4.03-6.54; P < .0001), 6.26 mm Hg (95% CI 5.00-7.52; P < .0001) and 6.89 mm Hg (95% CI 5.64-8.15; P < .0001) respectively.

CONCLUSIONS

The MS is accurate in SR because of direct assessment of Korotkoff sounds. Non-invasive BP assessment in AF is significantly less accurate. These findings have important prognostic and therapeutic implications.

Awareness of spina bifida among family of affected child. A cross sectional questionnaire

Objectives:

To evaluate the awareness of spina bifida (SB), risk factors and possible preventive measures among mothers who had been following in our clinic with a spina bifida affected child.

Methods:

A cross-sectional questionnaire-based study with 38 mothers of SB patients who are following at SB and hydrocephalus clinic at King Fahad University Hospital, Khobar, Eastern Province, Saudi Arabia.

Results:

Thirty-eight mother were included in this questionnaire. Most of the participants were Saudi (94.7%). Ten out of 38 women (26.3%) had used medications during pregnancy (pain medications and herbal drugs), 4 out of 38 (10.5%) had been exposed to imaging radiation, while 9 (23.7%) had experienced moderate to high grade fever (39-41°C) during pregnancy. Moreover, the majority (86.8%) of these women did not receive folic acid (FA) before pregnancy, and 42.1% of them did not have FA during their first trimester. Only one (2.6%) gave positive family history of SB while, 6 (15.8%) reported having other SB children.

Conclusion:

There is a considerably low level of awareness in mothers of SB patients despite prevalence of this anomaly in the Eastern province. This necessitates an effort from health care providers to educate the community about this birth defect entity. Furthermore, genetic counseling should be encouraged especially in those who have a positive familial history for better understanding. Also, larger sample size with randomized controlled trials and larger epidemiological studies should be implemented.

Relationship between biomarkers of muscle damage and redox status in response to a weightlifting training session: effect of time-of-day

The aims of the present study were to: (1) investigate the effect of a weightlifting training session and time-of-day (TOD) upon biological parameters (i.e., oral temperature, hematological, C-reactive protein (CRP), and oxidative stress) and (2) assess their possible link with muscle damage responses. Nine weightlifters (21 ± 0.5 years) performed, in a randomized order, three Olympic-Weightlifting sessions (i.e., at 08:00, 14:00, and 18:00). Blood samples were collected at rest, 3 min and 48 h after each training session. Between pre- and post-training session, ANOVA showed significant increases in oxidative stress markers at the three TODs (p < 0.01) and significant increases for creatine kinase (CK) and lactate dehydrogenase (LDH) only at 08:00 and 18:00 (p < 0.05). At rest, the results showed a significant diurnal variation for the majority of the selected parameters except for malondialdehyde (MDA), total bilirubin, and CRP with higher values observed at 18:00 (p < 0.05). After the training session, given the higher rate of increase during the morning session, these diurnal variations persisted for temperature and WBC (p < 0.01) and were suppressed for CK, LDH, uric acid (UA), catalase, and glutathione peroxidase. The main significant correlations (p < 0.001) were observed between: (1) CK and MDA (r = 0.6) and CK and UA (r = 0.66 and r = 0.82) during the morning and evening training sessions; (2) CK and CRP only during the morning session (r = 0.5); and (3) CRP and WBC during the three training sessions (r = 0.8). In conclusion, the present findings: (1) confirm that the muscle damage responses could be induced by a high level of oxidative stress and (2) suggest to avoid scheduling training sessions in the morning given the higher muscle damage, inflammatory, and oxidative responses at this TOD.

Incidence and risk factors of peripheral venous catheter-related adverse events in cardiology department of a Tunisian university hospital: A prospective observational study

AIM

The purpose of our study was to determine the incidence and risk factors of Peripheral Venous Catheter-Related Adverse Events (PVCAEs) in a cardiology department of a university hospital.

PATIENTS AND METHODS

We carried out a prospective observational study from Mars 2017 to May 2017 in the cardiology department of the University Hospital of Farhat Hached in Sousse, Tunisia. During this period, we actively followed-up all inserted PVCs (every 12hours) from insertion up to 48hours after removal. Regression analyses were applied and significance limits were set at P<0.05.

RESULTS

Data were analysed for 210 PVCs (794 PVC-days) in 148 patients. The incidence of PVCAEs was 33.33% with density of incidence of 8.81/1000 PVC-days. PVCAEs were mainly pain (50%) and mechanical events (31.42%). Infections accounted for 11.42%. The most frequent mechanical PVCAEs, was haematoma (15.71%). Multivariate analysis revealed as independent factors for the occurrence of PVCAEs: the hydro electrolytic nature of the injected product (OR=13.42, P<10-3), the medicinal nature of the injected product (OR=5.08, P=0.003), bad cutaneous state (OR=8.08, P=0.003), admission during nightshift (OR=3.76; P=0.014) and advanced age (OR=1.04, P=0.042).

CONCLUSION

Multicenter studies would be very useful to better analyze risk factors associated with PVCAEs.

Effect of adding midazolam to bupivacaine during rectus sheath block: a randomised controlled trial

BACKGROUND

Various adjuvants have been tried to improve quality and increase duration of local anaesthetics during various nerve blocks. We aimed to evaluate the effect of adding midazolam to bupivacaine on rectus sheath (RS) block in patients undergoing umbilical or epigastric hernia repair.

METHODS

In all, 60 adult patients were divided into two equal groups, each group included 30 patients. Group I received 20 ml of bupivacaine hydrochloride 0.25% + midazolam 50 μg/kg in 2 ml saline 0.9% (Midazolam group, n = 30), whereas Group II received 20 ml of bupivacaine hydrochloride 0.25% + 2 ml saline (Control group, n = 30) for RS block on each side. The primary outcome was post-operative 48 h morphine consumption, whereas secondary outcomes included analgesia duration, post-operative pain, as evaluated by visual analogue scale (VAS) for pain scoring at 1, 2, 6, 12, 24 and 48 h post-operatively, reported post-operative nausea and or vomiting (PONV), somnolence or any adverse drug reactions.

RESULTS

The current study showed that addition of midazolam to bupivacaine for RS blockade provided good analgesia as evidenced by a statistically significant less morphine consumption in the post-operative 48 h [11.2 (5.3-18.3) vs. 25.9 (15.2-31.0) mg, P = 0.002], longer duration of analgesia, lower VAS during post-operative 48 h, lower incidence of PONV, somnolence and pruritus.

CONCLUSION

Midazolam addition to bupivacaine for RS blockade provided adjuvant analgesia as supported by less morphine consumption, longer duration of analgesia, and lower VAS score.