Early mobilization as a new pathway to improve functional mobility of cardiac patients in High dependency Unit

Funding Acknowledgements

Non funded project

Background

Early mobilization as a multidisciplinary team approach in cardiac High Dependency Unit-B (HDU B) helps to reduce loss of muscle strength, decrease hospital length of stay, improve functional capacity, cognitive levels, enhances the quality of care, and helps to decrease the hospitals costs.

Purpose

Early mobilization means reducing the time of bed rest from admission to first activity. Based on this definition the project aimed to mobilize more than 95% of cardiac patients within 24 hours of admission by September 2019 in HDU B unit.

Methods

HDU B Initiated Early mobilization program as a part of Value improvement project (VIP). Experts from multidisciplinary team (MDT) worked together to improve the functional mobility of patients. A cross section survey was conducted to identify barriers for early mobility in the unit followed by analyzing barriers through Pareto chart.  An early mobility flow chart (Level1-Passive, Level 2-Active assisted, Level 3-Active) framed in order to standardize the practice of mobilizing patients in HDU B. New changes were tested by using methodology of Plan Do Study Act. Staff education, training given regarding the implementation of early mobility protocol. Patients with mobility level 1 and 2 were identified by nurses, requested for Physiotherapy referral by Physicians. Nursing staff education on mobility assessment given an easy access of data about mobility level of patients in handoff communication, which guided the staff to decide on the need of PT consultation for each patient. In coordination with MDT team referral were also given even during weekend for the patients with mobility level 2. To engage patient and family in the early mobility program a new concept of END PYJAMA PARALYSIS was introduced. Patients with mobility level 3 were identified and encouraged to wear their own dress and move outside their room under supervision.This concept aims to build confidence in patients making them feel that they are ready to go home.

Results

With support and co-operation of the MDT, this project became a highly successful project in VIP. Initially 50% of the patients has been mobilized when the program was introduced in the ward during March 2019 which increased gradually to 90% at the end of the month. After introducing the flow chart, there was increase in 93.3% by April 2019. In addition to Physio referral it went to 100% at the end April 2019. End pyjama paralysis and weekend physio referral sustained the 100% compliance to Early mobility till the end of July 2019. Active interventions of the team helped to early mobilize by 100% till the end of September 2019 and currently it is in sustainable phase.

Conclusion

Early mobilization in HDU-B brought significant change in the culture of mobilization. Commitment, cooperation of MDT, a structural system and End pyjamas paralysis program are key factors of the success for the program that promoted patient safety and prevented adverse events.

The 'capsule' of pituitary macroadenomas represents normal pituitary gland: a histopathological study

The goal of trans-sphenoidal pituitary adenoma surgery is radical excision of the tumour with preservation of endocrine function. Our hypothesis was that, even in macroadenomas extending into the suprasellar cistern, the 'capsule' of the tumour is the compressed normal pituitary gland. The biopsy material from 126 patients with pituitary macroadenomas were retrospectively reviewed to look for the presence of normal adenohypophysis. Fourteen patients with macroadenomas operated trans-sphenoidally were studied prospectively, sampling tissue from the periphery of the tumour for histopathology. From the retrospective data, we found that normal adenohypophysis was more often found at histopathology in the extracapsular excisions, rather than in the intracapsular excisions. In the 14 patients studied prospectively, normal adenohypophysial tissue was found histologically at all sites sampled except in areas where the tumour was invasive. In conclusion, while an extracapsular excision would offer the best chance for a surgical cure, preserving parts of the capsule may preserve normal and possibly functioning gland.

Solitary fibrous tumor of the lateral ventricle: CT appearances and pathologic correlation with follow-up

Intracranial solitary fibrous tumors are rare, and intraventricular fibrous tumors are even more unusual. We report a case of solitary fibrous tumor in the region of trigone and body of the left lateral ventricle and discuss the clinical presentation, CT characteristics, and histopathologic features with 1-year follow-up. We speculate that the tumor arose from the perivascular connective tissue of the choroid plexus.

Intratumoral abscess: an unusual complication of ventriculoperitoneal shunt infection

INTRODUCTION

Ventriculoperitoneal shunts were routinely used in the past in children with posterior fossa tumors and hydrocephalus. They can, however, cause a multitude of problems.

CASE REPORT

This report highlights a previously unencountered phenomenon of a pyogenic abscess forming within a posterior fossa ependymoma as a result of shunt infection. The shunt was exteriorized and the child treated with antibiotics before surgery was done. Only a partial excision of the tumor was possible, as the inflammatory response caused by the abscess had obliterated tissue planes.

Diagnostic validity of the Ki-67 labeling index using the MIB-1 monoclonal antibody in the grading of meningiomas

BACKGROUND

About 10% of meningiomas behave aggressively and are graded atypical or malignant with important therapeutic and prognostic implications. Routine histological parameters are inconsistent in the assessment of their aggressive behavior.

AIMS

The aim of this study was to find a threshold level of the MIB-1 labeling index (MIB-1 LI) with the highest diagnostic validity in predicting histological atypia in a meningioma.

SETTING AND DESIGN

This was a retrospective study of all atypical and malignant meningiomas diagnosed at our center between January 1995 and June 2000 and which were identified from the General Pathology Registry.

MATERIAL AND METHODS

These meningiomas were assessed histologically with respect to the individual criteria of atypia. They were categorized according to the WHO 2000 classification as benign, atypical and anaplastic meningiomas, WHO Grades I, II and III respectively and by immunohistochemical analysis using the MIB-1 monoclonal antibody.

STATISTICAL ANALYSIS

The diagnostically useful cut-off level for the prediction of atypia was estimated by calculating the sensitivity and specificity of the MIB-1 LI at various levels and a receiver operated characteristic (ROC) analysis was performed. The correlation between the individual histological parameters was studied and the MIB-1 LI was obtained using Fisher's exact test.

RESULTS

Of the 40 meningiomas studied 21 were benign, 16 atypical and 3 anaplastic. Atypical tumors had a higher MIB-1 LI than benign tumors, with diagnostic validity highest at a threshold of 7%, with a sensitivity of 0.86 and a specificity of 0.93, giving a likelihood ratio of 17. The MIB-1 LI correlated well with mitotic activity and the other individual criteria in the WHO 2000 definition of atypia in a meningioma. MIB-1 LI did not, however, correlate well with brain invasion.

CONCLUSION

The MIB-1 LI has the highest validity in the diagnosis of atypia in meningiomas at a threshold level of 7%. The MIB-1 LI used in conjunction with histological features can help in making a recommendation regarding potentially aggressive behavior in meningiomas.

Intraoperative ultrasound in determining the extent of resection of parenchymal brain tumours--a comparative study with computed tomography and histopathology

BACKGROUND

Radical excision of parenchymal brain tumours is generally associated with a better long-term outcome; however, it is difficult to ascertain the extent of resection at surgery. We used intra-operative ultrasound [IOUS] to help detect residual tumour and define the tumour-brain interface.

METHODS

Thirty-five patients with parenchymal brain lesions including 11 low-grade and 22 high-grade tumours and 2 inflammatory granulomata were included in the study. The IOUS was used to localize tumours not seen on the surface, define their margins and assess the extent of resection at the end of surgery. Multiple samples from the tumour-brain interface which were reported as tumour or normal tissue on IOUS were submitted to histopathology. The IOUS findings were compared with a postoperative contrast enhanced computed tomogram [CT] and with histopathology.

RESULTS

All tumours irrespective of histology were hyperechoic on IOUS. IOUS was useful in localizing those tumours not seen on the surface of the brain. In 71.4% of cases IOUS was useful in defining their margins, however in the remaining cases the margins were ill-defined. The tumour margins were ill-defined in those treated previously by radiation. With regard to the extent of excision, after excluding the cases who were irradiated, it was found that in the 28 patients who had parenchymal neoplasms, there was concordance between the ultrasound findings and the postoperative CT scan in 23 cases. Of the 79 samples taken from the tumor-brain interface which were reported as tumour on ultrasound, 66 had histopathological evidence of tumour while 13 samples were negative for tumour. On the other hand, in the tissue sent from 17 sites where the IOUS showed no residual tumour, 2 were positive for tumour on histopathology while 15 were negative.

INTERPRETATION

In conclusion, IOUS is a cheap and useful real-time tool for localizing tumours not seen on the brain surface, for defining their margins and for determining the extent of resection.

Endolymphatic sac tumor: a rare cerebellopontine angle tumor

Endolymphatic sac tumors (ELST) are rare papillary tumors of the temporal bone. Previously named as aggressive papillary middle ear tumors, they have recently been shown to arise from the endolymphatic sac. They are a rare in cerebello-pontine angle (CPA). We present a case of an ELST who presented as a CPA tumor with hydrocephalus. He underwent a ventriculo-peritoneal shunt initially. On exploration of the CP angle, the tumor was found to be extremely vascular. He was re-explored following embolization, and a subtotal excision of the tumor was done. Extensive petrous bone infiltration and vascularity of the tumor makes total excision almost impossible with high risk of cranial nerve deficits, excessive blood loss and CSF leak. This tumor should be considered in the differential diagnosis of vascular CPA tumors which erode the petrous temporal bone. The relevant literature is reviewed.

Skull base chondroblastoma: a case report

Chondroblastoma is a rare tumor of the skull. Temporal bone is the commonest site of involvement in the skull. We present a thirty one year old man who presented with painless swelling over the left temporal bone, which was near totally excised after preoperative embolization. Management of this unusual tumor and its complications are discussed.

Hemorrhagic necrosis of pituitary adenomas

A clinicopathological study of 41 cases of pituitary apoplexy in a series of 324 surgically treated pituitary adenomas is presented. In 23 patients, the predominant operative finding was hemorrhage with or without necrosis. However, there were 15 (37.7%) cases where pale, necrotic tissue with no evidence of hemorrhage was found at surgery. Pale, necrotic material was particularly found when there was a long interval between the acute clinical event and surgery. It is concluded that the pale, necrotic debris represents one stage in the resorption process of blood after hemorrhagic necrosis of pituitary adenomas. This entity needs to be kept in mind especially since the material closely resemble the pultaceous material seen in craniopharyngiomas and epidermoid cysts.

Determination of Ki-67 labeling index in pituitary adenomas using MIB-1 monoclonal antibody

Proliferative activity of 94 pituitary adenomas was assessed by the determination of the growth fraction, using MIB-1 monoclonal antibody in formalin fixed, paraffin embedded sections. This index was correlated with clinical and radiological evidence of invasiveness. The mean Ki-67 labeling index for all pituitary adenomas was 0.84% (range 0-17.45%). Hardy stage E tumours (1.44%) had a higher Ki-67 labeling index (LI) as compared with Hardy stage 0 tumours (0.36%). The difference in the Ki-67 labeling indices between invasive and non-invasive adenomas was not statistically significant. Hence, the Ki-67 labeling index is not a reliable indicator of invasiveness in pituitary adenomas.

Primary angiitis of the central nervous system: an ante-mortem diagnosis

A rare case of primary angiitis of the central nervous system (PACNS) is reported with its clinical and magnetic resonance imaging (MRI) features. A 20-year-old girl presented with headache, projectile vomiting, unsteadiness of gait and urgency of micturition. She had left seventh nerve upper motor neuron type paresis, increased tone in all four limbs, exaggerated deep tendon reflexes, cerebellar signs, and papilloedema. Cerebrospinal fluid showed lymphocytosis with elevated protein and normal glucose level. Cerebral computerised tomographic scan and MRI showed bilateral diffuse asymmetric supra- and infra-tentorial lesions (predominantly in the supratentorial and left cerebrum). On MRI, the lesions were hyperintense on T2, and proton density-weighted images and hypointense on T1-weighted images. Based on the clinical findings of raised intracranial tension and MRI features, initial diagnoses of gliomatosis cerebrii, tuberculous meningitis, primary central nervous system lymphoma and chronic viral encephalitis were considered. PACNS was not included in the initial differentials and, an open brain biopsy was advised which established the definitive diagnosis.

The calcified intracorporeal vacuole: an aid to the pathological diagnosis of solitary cerebral cysticercus granulomas

Fifty four cases of single small (<20 mm) enhancing CT lesions (SSECTLs) of the brain that were excised between 1987 and 1995 were reviewed histologically. In 28 cases the entire cysticercus or its parts were found. In the remaining 26 cases, most had a histological picture suggestive of a parasitic granuloma. In six of these 26 cases, small ovoid masses corresponding in morphology to the intracorporeal vacuoles of a cysticercus were seen lying free in the cavitary space of the granuloma. This lends further strength to the contention that SSECTLs of the brain are caused by cysticercus, and that in the event of a surgical excision, absence of obvious parasitic parts should necessitate a closer search, as calcareous residues of the parasite might be the only evidence of the cysticercal aetiology in the granuloma.

Cerebral hemodynamic effects of phenylephrine and L-arginine after cortical impact injury

OBJECTIVE

To determine the effects of a pressor agent (phenylephrine and L-arginine) on the abnormal cerebral hemodynamics and on neurologic outcome after a severe cortical impact injury in rats.

DESIGN

Prospective, randomized study.

SETTING

University laboratory.

SUBJECTS

Male Long-Evans rats, weighing 300 to 400 g, fasted overnight.

INTERVENTIONS

The animals were anesthetized with isoflurane, and a severe cortical impact injury (velocity, 5 m/sec; deformation, 3 mm) was produced in the right parietal cortex. Five minutes after impact injury, one of the following three treatments were infused: 1 mL saline intravenously for 10 mins, 300 mg/kg L-arginine in 1 mL saline intravenously for 10 mins, or 0.3 microg/kg/min phenylephrine intravenously for 3 hrs. Mean arterial pressure, intracranial pressure (ICP), cerebral perfusion pressure (CPP), and laser Doppler flow (LDF) at the impact site and in the contralateral parietal cortex were monitored for 3 hrs after the impact injury. Histologic examination of the brain was performed at 2 wks after injury in a separate group of L-arginine- and saline-treated animals.

MEASUREMENTS AND MAIN RESULTS

The immediate response to the impact injury was an increase in ICP, and a decrease in mean arterial pressure, CPP, and LDF. In the saline-treated animals, LDF decreased to <25% of the baseline values at the impact site and stayed at that level for the entire 3-hr monitoring period. On the contralateral side, LDF decreased initially and recovered gradually to approximately 50% of the preimpact baseline value. Infusion of both phenylephrine and L-arginine increased LDF back to near-baseline levels. However, phenylephrine increased ICP significantly, whereas ICP with L-arginine did not change. L-arginine treatment reduced the contusion volume from a median value of 5.28 mm3 to 0.63 mm3.

CONCLUSIONS

Phenylephrine increased cerebral blood flow (CBF) by increasing CPP. L-arginine, however, increased CBF without changing CPP. The improvement in CBF was accompanied by a decrease in neurologic injury. Although the pressor agents are used currently to increase CBF after traumatic brain injury, other strategies may also increase CBF without the potential adverse effects of induced hypertension.

Cysticercosis of the cerebellopontine angle cistern mimicking epidermoid inclusion cyst

We report a case of a cystic lesion in the left cerebellopontine (CP) angle cistern. The magnetic resonance (MR) imaging features closely resembled an epidermoid inclusion cyst, and was interpreted as such. However, at surgery and on histopathological examination the lesion was found to be a cysticercus cyst. It may be impossible to distinguish between the two by imaging. The MR imaging findings of cysticercosis, epidermoid and other common differentials are discussed.

Medullomyoblastoma: A case report

Medullomyoblastoma is a rare tumour seen in childhood. We report a medullomyoblastoma occurring in the cerebellar vermis of a 4 year old boy. The light microscopic features, immunohistochemistry and histogenesis are described.

Argyrophilic nucleolar organizer region proteins (AgNORs) as an index of clinical and radiological invasiveness in pituitary adenomas

Sixty-eight patients with pituitary adenomas were classified into groups based on their invasiveness and functional status. Mean argyrophilic nucleolar organizer region proteins (AgNOR) counts obtained from 200 cells showed no correlation with the invasive status of pituitary adenomas. However, the functional tumours showed significantly higher AgNOR counts than non-functional tumours.

Sacral haemangioma as a cause of coccydynia

We report a 55-year-old woman with coccydynia due to a sacral mass. The histological diagnosis was haemangioma. The MRI findings and the unusual location of this lesion are discussed.

Induction of acute translational response genes by homocysteine. Elongation factors-1alpha, -beta, and -delta

The thiol amino acid homocysteine (HC) accumulates in homocystinuria and homocyst(e)inemia, and is associated with a wide variety of clinical manifestations. To determine whether HC influences the cell's program of gene expression, vascular endothelial cells were treated with HC for 6-42 h and analyzed by differential display. We found a 3-7-fold, time-dependent induction of a 220-base pair fragment, which demonstrated complete sequence identity with elongation factor-1delta (EF-1delta), a member of the multimeric complex regulating mRNA translation. Fibroblasts from cystathionine beta-synthase -/- individuals also showed up to 3.0-fold increased levels of mRNA for EF-1alpha, -beta, and -delta when compared with normal cells, and treatment of normal cells with the HC precursor, methionine, induced a 1.5-2.0-fold increase in EF-1alpha, -beta, and -delta mRNA. This induction was completely inhibited by cycloheximide and reflected a doubling in the rate of gene transcription in nuclear run-on analyses. In HC-treated endothelial cells, pulse-chase studies revealed a doubling in the rate of synthesis of the thiol-containing protein, annexin II, but no change in synthesis of the cysteineless protein, plasminogen activator inhibitor-1. Thus, HC induces expression of a family of acute translational response genes through a protein synthesis-dependent transcriptional mechanism. This process may mediate accelerated synthesis of free thiol-containing proteins in response to HC-induced oxidative stress.

Primary sphenoid and petrous apex esthesioneuroblastoma: case report

A 62-year-old woman presented with raised intracranial pressure and features of a right cerebellopontine angle tumour with extension into the right middle cranial fossa. The patient died before a surgical excision could be performed. The autopsy revealed a primary esthesioneuroblastoma of the sphenoid sinus eroding the petrous bone and extending into the middle cranial fossa with metastatic tumour in the liver, and paratracheal and hilar lymph nodes. Although rare, esthesioneuroblastoma must be considered in the differential diagnosis of petrous-sphenoid lesions.

Smear diagnosis of central nervous system lesions : a critical appraisal

Smears, imprints and frozen sections have been recognised as useful adjuncts to diagnosis by the traditional paraffin section in neurosurgical biopsies. In this study, 251 intracranial space occupying lesions were studied by smears and paraffin sections to determine the causes of error and the possible means to avoid them. There were 63 computed tomography guided stereotactic microbiopsies and 188 open biopsies. The overall diagnostic accuracy was 88. In 6.8 of cases the tumour type was diagnosedcorrectly, but the grade was altered subsequent to examining the paraffin sections owing probably to sampling errors. Only 5.2 of cases had an entirely incorrect diagnosis.

Bilateral basal ganglia germinoma in an Indian boy

Germ cell tumours are rare intracranial tumours. The basal ganglionic location of these tumours comprise a rare group. Bilateral involvement of the basal ganglia by germ cell tumours is distinctly rare and have only been reported in Japanese patients. We present the first report of bilateral basal ganglionic germ cell tumour in a non-Japanese patient.

Testicular embryonal cell carcinoma metastasizing to the site of a previously excised cerebellar haemangioblastoma

We report a patient with von Hippel-Lindau disease in whom a metastatic embryonal cell carcinoma from the testis occurred at exactly the same site from which a cerebellar haemangioblastoma had been excised 12 years earlier.

Clinicoradiological and pathological correlations in patients with solitary cysticercus granuloma and epilepsy: focus on presence of the parasite and oedema formation

A study of the clinical, radiological, and pathological correlations in 43 patients with solitary cysticercus granuloma and epilepsy focused on factors that might help in predicting the presence of the parasite in the granuloma and those that might influence the formation of oedema around the granuloma. The duration of symptoms (< six months and > or = six months) and CT morphology of the granuloma (ring and disc, type A; nodular lesion, type B) were studied as factors that could possibly predict the presence of the parasite in the granuloma. The influence of sex of the patient and the presence of a neutrophilic response in the granuloma on the intensity of oedema around the lesion as seen on CT was also studied. The pathological features were studied in the excised granulomas. The intact or degenerated form of the cysticercus was evident in 22 of 43 specimens. Neither the duration of seizures (P = 0.17) nor the type of lesion on CT (P = 0.16) was predictive of the presence of the parasite in the granuloma. The sex of the patient (P = 0.51) and the neutrophilic response in the specimen (P = 0.73) did not correlate with the degree of oedema on CT indicating that neither of these host factors was a major determinant of oedema production. The findings point to the varied and unpredictable natural history of solitary cysticercus granulomas and the complex nature of host-parasite interactions in individual patients. The inability to predict the presence of the parasite in the granuloma on the basis of the clinical or radiological features precludes a selection of patients with such lesions for cysticidal drug treatment.

Desmoplastic low grade astrocytoma: a case report and review of literature

A 7-year-old girl presented with focal seizures without symptoms of raised intracranial tension. Routine histological, immunocytochemical and ultrastructural methods revealed a desmoplastic low grade cerebral astrocytoma. Follow up for 2 years after biopsy did not show recruitment of neurological symptoms or signs. Biphasic tumours containing glial and mesenchymal elements have been described in the literature under various diagnostic headings. As the histologically benign variants of mixed glial and mesenchymal tumours appear to have a good prognosis, identification of these as separate entities seems imperative. With a review of literature we propose a pathological classification of mixed glial and mesenchymal tumours.

Intracerebellar melanotic schwannoma: a case report

Neuro-axial melanotic schwannoma is a rare entity. We report the clinical, CT and pathological features of a solitary, cellular intracerebellar melanocytic schwannoma in a 65-year-old woman. The probable origin of this type of tumour is discussed.

Intraspinal mesenchymal chondrosarcoma. Case report

A 52-year-old man presented with symptoms of progressive cervical radiculomyelopathy. A myelogram showed an intradural block at the C-6 level. Magnetic resonance T1-weighted imaging revealed a hypointense, sausage-shaped mass extending from C-3 to C-6, located posterolaterally on the right side and pushing the spinal cord to the left and anteriorly. At surgery, a mass was found attached solely to the pia mater, with a normal arachnoid and dura mater overlying it. The mass was excised completely and microscopic examination identified a mesenchymal chondrosarcoma. The patient was symptom-free 6 months after surgery.