Diagnostic Yield of Stereotactic Brain Biopsy in a Sub-Saharan Tertiary Center: A Comprehensive 10-Year Retrospective Analysis

BACKGROUND

Stereotactic brain biopsy is a crucial minimally invasive surgical technique leveraged to obtain tissue specimens from deep-seated intracranial lesions, offering a safer alternative to open craniotomy for patients who cannot tolerate the latter. Despite its effectiveness, the diagnostic yield varies across different centers and has not been widely studied in Sub-Saharan Africa.

METHODS

A single-center retrospective analysis was conducted on 67 consecutive stereotactic brain biopsy procedures carried out by experienced neurosurgeons between January 2012 and December 2022 at a tertiary center in Sub-Saharan Africa. Preoperative clinical status, biopsy type, postoperative complication rate, and histological diagnosis were meticulously analyzed. Factors associated with negative biopsy results were identified using IBM Statistical Package for the Social Sciences SPSS version for Mac, with Fisher exact test employed to detect differences in patient characteristics. Statistical significance was pegged at P < 0.05.

RESULTS

The overall diagnostic yield rate was 67%. Major contributors to negative biopsy outcomes were superficial location of the lesion, lesion size less than 10 cc, and the use of the Cape Town Stereotactic System. Enhanced yield rates of up to 93% were realized through the application of magnetic resonance imaging-based images, Stealth Station 7, and frozen section analysis. No correlation was observed between the number of cores obtained and the yield rate. Procedure complications were negligible, and no procedure-related mortality was recorded.

CONCLUSIONS

The diagnostic yield rate from our study was somewhat lower than previously reported in contemporary literature, primarily attributed to the differing definitions of diagnostic yield, the dominant use of the older framed Cape Town Stereotactic System, computed tomography-based imaging, and the absence of intraoperative frozen section. Nevertheless, biopsies conducted using the frameless system were comparable with studies from other global regions. Our findings reaffirm that stereotactic brain biopsy when complemented with magnetic resonance imaging-based imaging, frameless stereotactic systems and intraoperative frozen section is a safe, effective, and reliable method for obtaining histological diagnosis.

Non-pharmaceutical interventions to reduce COVID-19 transmission in the UK: a rapid mapping review and interactive evidence gap map

BACKGROUND

Non-pharmaceutical interventions (NPIs) were crucial in the response to the COVID-19 pandemic, although uncertainties about their effectiveness remain. This work aimed to better understand the evidence generated during the pandemic on the effectiveness of NPIs implemented in the UK.

METHODS

We conducted a rapid mapping review (search date: 1 March 2023) to identify primary studies reporting on the effectiveness of NPIs to reduce COVID-19 transmission. Included studies were displayed in an interactive evidence gap map.

RESULTS

After removal of duplicates, 11 752 records were screened. Of these, 151 were included, including 100 modelling studies but only 2 randomized controlled trials and 10 longitudinal observational studies.Most studies reported on NPIs to identify and isolate those who are or may become infectious, and on NPIs to reduce the number of contacts. There was an evidence gap for hand and respiratory hygiene, ventilation and cleaning.

CONCLUSIONS

Our findings show that despite the large number of studies published, there is still a lack of robust evaluations of the NPIs implemented in the UK. There is a need to build evaluation into the design and implementation of public health interventions and policies from the start of any future pandemic or other public health emergency.

Imaging the acute abdomen in pregnancy: a radiological decision-making tool and the role of MRI

Acute abdominal pain in pregnancy poses a significant diagnostic challenge. The differential diagnosis is wide, clinical assessment is difficult, and the use of conventional imaging methods is restricted due to risks to the fetus. This can lead to delay in diagnosis, which increases the risk of maternal and fetal harm. Imaging techniques not involving ionising radiation are preferred. Sonography remains first line, but anatomical visualisation can be limited due to displacement of adjacent structures by the gravid uterus. MRI provides excellent cross-sectional soft-tissue assessment of the abdomen and pelvis, and no study to date has demonstrated significant deleterious effects to the fetus at any gestation; however, there remains a theoretical risk of tissue heating by radiofrequency pulses, and there must be consideration of benefit versus potential risk for any use of magnetic resonance imaging (MRI) in pregnancy. With a limited protocol of sequences, a broad spectrum of pathologies can be evaluated. Computed tomography carries the highest exposure of ionising radiation to the fetus, but may be necessary, particularly in cases of trauma. The patient must be kept informed and any potential risks to the patient and fetus should be clearly explained. We present a radiological decision-making tool to guide choice of imaging and best establish the underlying diagnosis in the acute pregnant abdomen. In addition, using illustrative examples from our practice at a large tertiary centre, we review the advantages and disadvantages of each imaging method, with particular focus on the utility of MRI.

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

GPU accelerated Cartesian GRAPPA reconstruction using CUDA

BACKGROUND AND OBJECTIVE

GRAPPA (Generalized Auto-calibrating Partially Parallel Acquisition) is an advanced parallel MRI reconstruction method (pMRI) that enables under-sampled data acquisition with multiple receiver coils to reduce the MRI scan time and reconstructs artifact free image from the acquired under-sampled data. However, the reduction in MRI scan time comes at the expense of long reconstruction time. It is because the GRAPPA reconstruction time shows exponential growth with increasing number of receiver coils. Consequently, the conventional CPU platforms may not adhere to the requirements of fast data processing for MR image reconstruction.

METHODS

Graphics Processing Units (GPUs) have recently emerged as a viable commodity hardware to reduce the reconstruction time of pMRI methods. This paper presents a novel GPU based implementation of GRAPPA using custom built CUDA kernels, to meet the rising demands of fast MRI processing. The proposed framework exploits intrinsic parallelism in the calibration and synthesis phases of GRAPPA reconstruction process, aiming to achieve high speed MR image reconstruction for various GRAPPA configuration settings using different number of receiver coils, auto-calibration signals (ACS), sizes of GRAPPA kernel and acceleration factors. In-vivo experiments (using 8, 12 and 30 receiver coils) are performed to compare the performance of the proposed GPU accelerated GRAPPA with the CPU based GRAPPA extensions and GPU counterpart.

RESULTS

The results indicate that the proposed method achieves up to ≈47.8× , ≈17× and ≈3.8× speed up gains over multicore CPU (single thread), multicore CPU (8 thread) and Gadgetron (GPU based GRAPPA) respectively, without compromising the reconstruction accuracy.

CONCLUSIONS

The proposed method reduces the GRAPPA reconstruction time by employing the calibration phase (GRAPPA weights estimation) and synthesis phase (interpolation) on GPU. Our study shows that the proposed GPU based parallel framework for GRAPPA reconstruction provides a solution for high-speed image reconstruction while maintaining the quality of the reconstructed images.

Tangent vector-based gradient method with l12-regularization: Iterative half thresholding algorithm for CS-MRI

OBJECT

This paper presents a new method using tangent vector-based l₁₂-regularization for compressed sensing MR image reconstruction.

MATERIALS AND METHODS

The proposed method with l₁₂-regularization is tested on four datasets: (i) 1-D sparse signal (ii) numerical cardiac phantom, (iii & iv) two sets of in-vivo cardiac MRI datasets acquired using 30 receiver coil elements with Cartesian and radial trajectories on 3T scanner. The results are compared with standard CS reconstruction, which utilizes l₁-regularization. The experiments were also conducted for two different types of samplings: (i) cartesian sub-sampling and (ii) 2D random Gaussian sub-sampling.

RESULTS

The quality of the reconstructed images is validated through Root Mean Square Error (RMSE) and Peak Signal-to-Noise Ratio (PSNR). The results show that the proposed method outperforms the standard CS reconstructions in our experiments with an improvement of 54.8% in RMSE and 14.3% in terms of PSNR. Moreover, the Gaussian random sub-sampling-based image reconstruction results are better than the Cartesian sub-sampling-based reconstruction results.

CONCLUSION

The results show that the proposed method yields a good sparse signal approximation and superior convergence behavior, which implies a promising technique for the reconstruction of cardiac MR images as compared to the conventional CS algorithm.

Neutrophil-Lymphocyte Ratio and Absolute Lymphocyte Count as Prognostic Markers in Patients Treated with Curative-intent Radiotherapy for Non-small Cell Lung Cancer

AIMS

The neutrophil-lymphocyte ratio (NLR) and the absolute lymphocyte count (ALC) have been proposed as prognostic markers in non-small cell lung cancer (NSCLC). The objective of this study was to examine the association of NLR/ALC before and after curative-intent radiotherapy for NSCLC on disease recurrence and overall survival.

MATERIALS AND METHODS

A retrospective study of consecutive patients who underwent curative-intent radiotherapy for NSCLC across nine sites in the UK from 1 October 2014 to 1 October 2016. A multivariate analysis was carried out to assess the ability of pre-treatment NLR/ALC, post-treatment NLR/ALC and change in NLR/ALC, adjusted for confounding factors using the Cox proportional hazards model, to predict disease recurrence and overall survival within 2 years of treatment.

RESULTS

In total, 425 patients were identified with complete blood parameter values. None of the NLR/ALC parameters were independent predictors of disease recurrence. Higher pre-NLR, post-NLR and change in NLR plus lower post-ALC were all independent predictors of worse survival. Receiver operator curve analysis found a pre-NLR > 2.5 (odds ratio 1.71, 95% confidence interval 1.06-2.79, P < 0.05), a post-NLR > 5.5 (odds ratio 2.36, 95% confidence interval 1.49-3.76, P < 0.001), a change in NLR >3.6 (odds ratio 2.41, 95% confidence interval 1.5-3.91, P < 0.001) and a post-ALC < 0.8 (odds ratio 2.86, 95% confidence interval 1.76-4.69, P < 0.001) optimally predicted poor overall survival on both univariate and multivariate analysis when adjusted for confounding factors. Median overall survival for the high-versus low-risk groups were: pre-NLR 770 versus 1009 days (P = 0.34), post-NLR 596 versus 1287 days (P ≤ 0.001), change in NLR 553 versus 1214 days (P ≤ 0.001) and post-ALC 594 versus 1287 days (P ≤ 0.001).

CONCLUSION

NLR and ALC, surrogate markers for systemic inflammation, have prognostic value in NSCLC patients treated with curative-intent radiotherapy. These simple and readily available parameters may have a future role in risk stratification post-treatment to inform the intensity of surveillance protocols.

Needs of Young African Neurosurgeons and Residents: A Cross-Sectional Study

Introduction: Africa has many untreated neurosurgical cases due to limited access to safe, affordable, and timely care. In this study, we surveyed young African neurosurgeons and trainees to identify challenges to training and practice.

Methods: African trainees and residents were surveyed online by the Young Neurosurgeons Forum from April 25th to November 30th, 2018. The survey link was distributed via social media platforms and through professional society mailing lists. Univariate and bivariate data analyses were run and a P-value < 0.05 was considered to be statistically significant.

Results: 112 respondents from 20 countries participated in this study. 98 (87.5%) were male, 63 (56.3%) were from sub-Saharan Africa, and 52 (46.4%) were residents. 39 (34.8%) had regular journal club sessions at their hospital, 100 (89.3%) did not have access to cadaver dissection labs, and 62 (55.4%) had never attended a WFNS-endorsed conference. 67.0% of respondents reported limited research opportunities and 58.9% reported limited education opportunities. Lack of mentorship (P = 0.023, Phi = 0.26), lack of access to journals (P = 0.002, Phi = 0.332), and limited access to conferences (P = 0.019, Phi = 0.369) were associated with the country income category.

Conclusion: This survey identified barriers to education, research, and practice among African trainees and young neurosurgeons. The findings of this study should inform future initiatives aimed at reducing the barriers faced by this group.

952 In-Patient Trauma Surgery in COVID-19 Positive Patients Carries A Significantly Higher Mortality Risk When Compared to In-Patient Covid-19 Negative Patients and Day Case Trauma Patients

Introduction

Covid-19 caused many service changes, yet Trauma surgery continued throughout. We compare mortality rates from In-Patient (IP) and Day Case (DC) trauma patients and compare the mortality rates of patients who tested positive or negative for Covid-19.

Method

We reviewed all trauma admissions that underwent surgical intervention in both our IP and DC services during 31 days from March 23^rd 2020. We recorded their sex, age, operation, Covid-19 symptoms, Covid-19 test results and mortality. The findings were compared between the groups.

Results

In total 127 patients underwent surgery (66 IP; 61 DC). There were 6 deaths (9.1%) within the IP group and 0 deaths in the DC group (p = 0.006). In the IP group 8 patients (12.1%) tested positive for Covid-19 of which 4 died (50%) compared to the remaining 58 patients (87.9%) of which 2 (3.4%) died (p < 0.001). A higher mortality rate was observed in patients with symptoms but a negative Covid-19 test (6.7%) than patients in whom a test was never indicated (2.3%).

Conclusion

Covid-19 positive patients requiring in-patient admission for trauma surgery have a significantly higher mortality rate than both in-patient admissions that were Covid-19 negative or asymptomatic and patients that were treated with Day Case Trauma surgery.

890 Predictive Factors for Mortality Following Trauma & Orthopaedic Surgery in The Covid-19 Pandemic. The Manchester Equation

Introduction

Covid-19 caused many service changes including limitations on operations due to potential increased mortality risk to patients. We report our findings from Trauma & Orthopaedic (T&O) surgical mortality through this period and the effectiveness of using a scoring system (The Manchester Equation) to predict likelihood of mortality.

Method

We reviewed all T&O admissions that underwent surgical intervention during the height of the pandemic. We recorded numerous factors for each patient including mortality and Covid status. From this we created a scoring system which is the product of Covid status, Anaesthetic type, Medical co-morbidities and other medical factors and ASA Score. We then analysed the findings to determine whether the score could be predictive of mortality rate.

Results

Of 123 patients undergoing surgery 6 deaths were observed (mean score of 51.3) compared to 117 patients surviving (mean score 31.9), p = 0.001. A score of less than 32 carried a 0% chance of death whereas a score of 32 or more resulted in a 14.6% mortality rate (p = 0.01).

Conclusion

The Manchester Equation can be used to help predict the mortality rate of T&O surgery in the presence of Covid-19 and may be useful for clinical decision making and consent purposes.

Transfer learning in deep neural network-based receiver coil sensitivity map estimation

INTRODUCTION

The success of parallel Magnetic Resonance Imaging algorithms like SENSitivity Encoding (SENSE) depends on an accurate estimation of the receiver coil sensitivity maps. Deep learning-based receiver coil sensitivity map estimation depends upon the size of training dataset and generalization capabilities of the trained neural network. When there is a mismatch between the training and testing datasets, retraining of the neural networks is required from a scratch which is costly and time consuming.

MATERIALS AND METHODS

A transfer learning approach, i.e., end-to-end fine-tuning is proposed to address the data scarcity and generalization problems of deep learning-based receiver coil sensitivity map estimation. First, generalization capabilities of a pre-trained U-Net (initially trained on 1.5T receiver coil sensitivity maps) are thoroughly assessed for 3T receiver coil sensitivity map estimation. Later, end-to-end fine-tuning is performed on the pre-trained U-Net to estimate the 3T receiver coil sensitivity maps.

RESULT AND CONCLUSION

Peak Signal-to-Noise Ratio, Root Mean Square Error and central line profiles (of the SENSE reconstructed images) show a successful SENSE reconstruction by utilizing the receiver coil sensitivity maps estimated by the proposed method.

Predicting the Risk of Disease Recurrence and Death Following Curative-intent Radiotherapy for Non-small Cell Lung Cancer: The Development and Validation of Two Scoring Systems From a Large Multicentre UK Cohort

AIMS

There is a paucity of evidence on which to produce recommendations on neither the clinical nor the imaging follow-up of lung cancer patients after curative-intent radiotherapy. In the 2019 National Institute for Health and Care Excellence lung cancer guidelines, further research into risk-stratification models to inform follow-up protocols was recommended.

MATERIALS AND METHODS

A retrospective study of consecutive patients undergoing curative-intent radiotherapy for non-small cell lung cancer from 1 October 2014 to 1 October 2016 across nine UK trusts was carried out. Twenty-two demographic, clinical and treatment-related variables were collected and multivariable logistic regression was used to develop and validate two risk-stratification models to determine the risk of disease recurrence and death.

RESULTS

In total, 898 patients were included in the study. The mean age was 72 years, 63% (562/898) had a good performance status (0-1) and 43% (388/898), 15% (134/898) and 42% (376/898) were clinical stage I, II and III, respectively. Thirty-six per cent (322/898) suffered disease recurrence and 41% (369/898) died in the first 2 years after radiotherapy. The ASSENT score (age, performance status, smoking status, staging endobronchial ultrasound, N-stage, T-stage) was developed, which stratifies the risk for disease recurrence within 2 years, with an area under the receiver operating characteristic curve (AUROC) for the total score of 0.712 (0.671-0.753) and 0.72 (0.65-0.789) in the derivation and validation sets, respectively. The STEPS score (sex, performance status, staging endobronchial ultrasound, T-stage, N-stage) was developed, which stratifies the risk of death within 2 years, with an AUROC for the total score of 0.625 (0.581-0.669) and 0.607 (0.53-0.684) in the derivation and validation sets, respectively.

CONCLUSIONS

These validated risk-stratification models could be used to inform follow-up protocols after curative-intent radiotherapy for lung cancer. The modest performance highlights the need for more advanced risk prediction tools.

The Impact of COVID-19 on Neurosurgical Services in Africa

INTRODUCTION

COVID-19 has affected the global provision of neurosurgical services. We sought to review the impact of COVID-19 on the neurosurgical services in Africa.

METHODS

A cross-sectional survey was distributed to African neurosurgeons seeking to review demographics, national and neurosurgical preparedness, and change in clinical services in April 2020.

RESULTS

A total of 316 responses from 42 countries were received. Of these, 81.6% of respondents were male and 79.11% were under the age of 45 years. In our sample, 123 (38.92%) respondents were in training. Most (94.3%) respondents stated they had COVID-19 cases reported in their country as of April 2020. Only 31 (41.50%) had received training on managing COVID-19. A total of 173 (54.70%) respondents were not performing elective surgery. There was a deficit in the provision of personal protective equipment (PPE): surgical masks (90.80%), gloves (84.80%), N95 masks (50.80%), and shoe covers (49.10%). Health ministry (80.40%), World Health Organization (74.50%), and journal papers (41.40%) were the most common sources of information on COVID-19. A total of 43.60% had a neurosurgeon in the COVID-19 preparedness team; 59.8% were concerned they may contract COVID-19 at work with a further 25.90% worried they may infect their family. Mental stress as a result of COVID-19 was reported by 14.20% of respondents. As of April 2020, 73.40% had no change in their income.

CONCLUSIONS

Most African countries have a national COVID-19 policy response plan that is not always fully suited to the local neurosurgery services. There is an ongoing need for PPE and training for COVID-19 preparedness. There has been a reduction in clinical activities both in clinic and surgeries undertaken.

A Continental Survey on the Impact of COVID-19 on Neurosurgical Training in Africa

Background

Containment measures for COVID-19 have affected surgical training globally. We sought to assess how neurosurgical training has been affected across Africa in April 2020.

Methods

A cross-sectional survey was distributed to African Neurosurgical trainees seeking to review demographics and effects of COVID on training.

Results

A total of 123 neurosurgery trainees responded from 23 African countries and a further 6 were abroad. A total of 91.80% were men, and 96.70% were training in public institutions. Only 41% had received training in COVID-19 with 61.79% worried that they would contract COVID-19 while performing their clinical duties. There was a marked reduction in clinical activities including a median reduction of elective surgery (−80%), clinics (−83%), and emergency surgery (−38.50%). A total of 23.58% of residents did not receive a formal salary, with 50% on less than $1000 USD gross per month.

Conclusions

This is the first continental survey of neurosurgery trainees in Africa. COVID-19 has significantly affected clinical and learning opportunities. There are concerns of the long-term effects on their training activities for an uncertain period of time during this pandemic. Although there has been a global increase in e-learning, there is need to evaluate if this is accessible to all trainees.

Transfer learning in deep neural network based under-sampled MR image reconstruction

In Magnetic Resonance Imaging (MRI), the success of deep learning-based under-sampled MR image reconstruction depends on: (i) size of the training dataset, (ii) generalization capabilities of the trained neural network. Whenever there is a mismatch between the training and testing data, there is a need to retrain the neural network from scratch with thousands of MR images obtained using the same protocol. This may not be possible in MRI as it is costly and time consuming to acquire data. In this research, a transfer learning approach i.e. end-to-end fine tuning is proposed for U-Net to address the data scarcity and generalization problems of deep learning-based MR image reconstruction. First the generalization capabilities of a pre-trained U-Net (initially trained on the human brain images of 1.5 T scanner) are assessed for: (a) MR images acquired from MRI scanners of different magnetic field strengths, (b) MR images of different anatomies and (c) MR images under-sampled by different acceleration factors. Later, end-to-end fine tuning of the pre-trained U-Net is proposed for the reconstruction of the above-mentioned MR images (i.e. (a), (b) and (c)). The results show successful reconstructions obtained from the proposed method as reflected by the Structural SIMilarity index, Root Mean Square Error, Peak Signal-to-Noise Ratio and central line profile of the reconstructed images.

0936 Cardiometabolic Disorders are Independently Associated with Excessive Daytime Sleepiness in Young Adults

Introduction

Cardiometabolic risk factors (CMR), including obesity, hypertension, diabetes and hypercholesterolemia, have been associated with sleep apnea and insufficient sleep, both of which can lead to excessive daytime sleepiness (EDS). We hypothesized that CMR are associated with EDS in young adults independent of sleep apnea, sleep duration and mental health disorders (MHD).

Methods

The Penn State Child Cohort is a population-based longitudinal sample of 700 children (8.7±1.7y), of whom 421 were followed-up 8.3 years later during adolescence (17.0±2.3y) and 425 another 7.0 years later during young adulthood (24.4±2.6y). Subjects underwent a 9-h in-lab polysomnography in childhood and adolescence and parent- or self-reported standardized surveys at all time points. Self-reports in young adulthood and in-lab measurements in childhood were used to ascertain CMR and sleep apnea. Parent-reports in childhood and self-reports in young adulthood were used to ascertain the presence of MHD and EDS. Logistic regression models adjusted for age, race, sex, snoring/observed apneas, insomnia symptoms, and sleep duration in young adulthood as well as mean arterial blood pressure, body mass index percentile and apnea/hypopnea index in childhood.

Results

CMR (OR=2.71, 95%CI=1.69-4.36) and MHD (OR=4.61, 95%CI=2.79-7.62) were associated with EDS in univariate models. After adjusting for covariates in childhood and young adulthood, CMR and MHD remained independently associated with EDS (OR=2.32, 95%CI=1.29-4.16 and OR=2.78, 95%CI=1.59-4.87, respectively).

Conclusion

EDS in young adults with CMR or MHD does not solely arise from sleep apnea, insufficient sleep or other sleep disturbances. EDS may be the result of central pathophysiologic mechanisms or the functional impairment associated with cardiovascular, metabolic and mental health disorders. These data further support that youth with these disorders should be screened for EDS and appropriately managed.

Support

National Institutes of Health (R01HL136587, R01HL97165, R01HL63772, UL1TR000127)

The College of Surgeons of East, Central, and Southern Africa: Successes and Challenges in Standardizing Neurosurgical Training

BACKGROUND

The College of Surgeons of East, Central, and Southern Africa (COSECSA) is a regional accrediting body for general and specialty surgical training programs that has recently expanded to include neurosurgery. As neurosurgical services expand in sub-Saharan Africa, the structure of training and accreditation has become a vital issue.

METHODS

We review the founding and current structures of COSECSA neurosurgical training, identifying accomplishments and challenges facing the expansion of neurosurgical training in this region.

RESULTS

The COSECSA model has succeeded in several countries to graduate qualified neurosurgeons, but challenges remain. Programs must balance the long duration of training required to promote surgical excellence against an overwhelming clinical need that seeks immediate solutions.

CONCLUSION

Harnessing global collaboration, rapidly expanding local infrastructure, and a robust multinational training curriculum, COSECSA has emerged as a leader in the effort to train neurosurgeons and is anticipated to dramatically improve on the markedly unmet need for neurosurgical care in sub-Saharan Africa.

Neurosurgery in East Africa: Foundations

This article is the first in a series of 3 articles that seek to provide readers with an understanding of the development of neurosurgery in East Africa (Foundations), the challenges that arise in providing neurosurgical care in developing countries (Challenges), and an overview of traditional and novel approaches to overcoming these challenges to improve healthcare in the region (Innovations). We review the history and evolution of neurosurgery as a clinical specialty in East Africa. We also review Kenya, Uganda, and Tanzania in some detail and highlight contributions of individuals and local and regional organizations that helped to develop and shape neurosurgical care in East Africa. Neurosurgery has developed steadily as advanced techniques have been adopted by local surgeons who trained abroad, and foreign surgeons who have dedicated part of their careers in local hospitals. New medical schools and surgical training programs have been established through regional and international partnerships, and the era of regional specialty surgical training has just begun. As more surgical specialists complete training, a comprehensive estimation of disease burden facing the neurosurgical field is important. We present an overview with specific reference to neurotrauma and neural tube defects, both of which are of epidemiologic importance as they gain not only greater recognition, but increased diagnoses and demands for treatment. Neurosurgery in East Africa is poised to blossom as it seeks to address the growing needs of a growing subspecialty.

Neurosurgery in East Africa: Innovations

In the last 10 years, considerable work has been done to promote and improve neurosurgical care in East Africa with the development of national training programs, expansion of hospitals and creation of new institutions, and the foundation of epidemiologic and cost-effectiveness research. Many of the results have been accomplished through collaboration with partners from abroad. This article is the third in a series of articles that seek to provide readers with an understanding of the development of neurosurgery in East Africa (Foundations), the challenges that arise in providing neurosurgical care in developing countries (Challenges), and an overview of traditional and novel approaches to overcoming these challenges to improve healthcare in the region (Innovations). In this article, we describe the ongoing programs active in East Africa and their current priorities, and we outline lessons learned and what is required to create self-sustained neurosurgical service.

Effects of pioglitazone on ventricular myocyte shortening and Ca(2+) transport in the Goto-Kakizaki type 2 diabetic rat

Pioglitazone (PIO) is a thiazolidindione antidiabetic agent which improves insulin sensitivity and reduces blood glucose in experimental animals and treated patients. At the cellular level the actions of PIO in diabetic heart are poorly understood. A previous study has demonstrated shortened action potential duration and inhibition of a variety of transmembrane currents including L-type Ca(2+) current in normal canine ventricular myocytes. The effects of PIO on shortening and calcium transport in ventricular myocytes from the Goto-Kakizaki (GK) type 2 diabetic rat have been investigated. 10 min exposure to PIO (0.1-10 microM) reduced the amplitude of shortening to similar extents in ventricular myocytes from GK and control rats. 1 microM PIO reduced the amplitude of the Ca(2+) transients to similar extents in ventricular myocytes from GK and control rats. Caffeine-induced Ca(2+) release from the sarcoplasmic reticulum and recovery of Ca(2+) transients following application of caffeine and myofilament sensitivity to Ca(2+) were not significantly altered in ventricular myocytes from GK and control rats. Amplitude of L-type Ca(2+) current was not significantly decreased in myocytes from GK compared to control rats and by PIO treatment. The negative inotropic effects of PIO may be attributed to a reduction in the amplitude of the Ca(2+) transient however, the mechanisms remain to be resolved.

Phytochemical and biological assessments on Lipidium meyenii (maca) and Epimidium sagittatum (horny goat weed)

The effects of Lipidium meyenii (maca, LM) and Epimidium sagittatum (horny goat weed, ES) have been investigated due to their involvement in fertilization. Both of the drugs showed good results before, during and after fertilization in male and female mice. The results revealed that the crude extract of Lipidium meyenii caused a significant decrease in the no. of writhes at 300 and 500mg/kg (p<0.05) as compare to control, Epimidium sagittatum and standard drug. The gross behavioral, open field, exploratory behaviour, forced swimming test for stress, diuretic activity, chronic toxicity with the effect on reproduction of both male and female and change in body weight were also studied. The phytochemical study showed the presence of tannin, alkaloid, carbohydrate, rich protein and absence of sterol in LM, whereas ES shows presence of sterol and less protein. LS improve in muscle activity and exploratory behaviours without any toxic effects on mice and their pups. It does not have diuretic effect for first two hour but act normally after initial phase of drug therapy. Epimidium sagittatum has dual action that is at low dose it has slight stimulation action and at high dose little depressive effect. ES also has some diuretic effect. Overall these results suggest that LM is highly effective remedy for treatment of impotency and reduces stress and depression, because of dual effect ES not only suggested as an anxiolytic medicine but also effective in female hormonal disorder.

Heparin-enhanced ADP-induced platelet aggregation in patients undergoing cardiopulmonary bypass surgery

Heparin has been shown to enhance ADP-induced platelet aggregation in patients undergoing cardiopulmonary bypass surgery. This effect appears to be maximal throughout the initial 30 minutes of systemic heparinization and once reached is maintained throughout the bypass procedure. The prebypass state is regained following heparin reversal by protamine sulphate. It is possible that this effect of heparin on platelet function may contribute towards some of the platelet microembolization phenomena seen in patients following cardiopulmonary bypass surgery.

Paediatric day case tonsillectomy: a safe, feasible and an economical way to treat patients – Yorkhill experience

Introduction

Day case surgery is widely encouraged as it has many benefits. In this study, we evaluate the feasibility of paediatric tonsillectomies as day case surgery procedures in a tertiary paediatric centre.

Methods

The outcome of paediatric tonsillectomy performed as day case procedures was studied for four months. We recorded complication rates in comparison to the standard in-patient practice.

Results

23 paediatric patients were included in this study. The age of the patients ranged from four to 11 years, with mean age of 6.5. No patients suffered post-operative complications within the first 24 h. Two patients were re-admitted due to a post-operative complication (8.6%) and one patient for a non-operative cause (4.3%) beyond the initial 24 h.

Conclusion

Paediatric Day Case Paediatric Tonsillectomy is a safe, feasible and an economical way to manage patients. It should be practised as a day case where appropriate and when criteria are met.

Comparative study of titanium(IV)-based exchangers in aqueous and mixed solvent systems

The antimonate, arsenate, tungstate, molybdate and selenite of titanium have been synthesized. Their composition and chemical and thermal stability have been determined. Effects of pH and temperature on ion-exchange capacity have been studied. Titanium antimonate was found to be the most stable. The utility of these ion-exchangers for analytical separations was examined by determining the distribution coefficients for 26 metal ions in some aqueous, non-aqueous and mixed solvent systems. Quantitative separations of HgCd, PbCu and PbZn have been achieved on titanium tungstate columns, and LaBa mixtures have been separated on a titanium arsenate column.

Spasmolytic effects of Scrophularia nodosa extract on isolated rabbit intestine

Scrophularia nodosa (figwort), an indigenous medicinal plant grows in moist and cultivated waste ground. It contains saponins, cardioactive glycosides, flavonoids, resin, sugar and organic acids. It is traditionally used for anti-inflammatory purpose and in skin disorders. It has diuretic and cardiac stimulant properties. The present studies were carried out on crude extract of Scrophularia nodosa and its n-hexane, chloroform, ethyl acetate, n-butanol and aqueous fractions. During phytochemical studies seven known compounds of flavonoid nature were isolated from the chloroform fraction of crude extract of S. nodosa. The structures of these compounds were elucidated by spectroscopic (UV, IR, Mass (EIMS, HREIMS) and NMR ((1)H-NMR, (13)C-NMR, DEPT, and (1)H-(1)H, COSY, HMQC, HMBC and NOESY) techniques. Compound 1 was identified as 5, 4`-hydroxy-3, 6, 7-trimethoxyflavone, compound 2 as 5-hydroxy-3,6,7,4'-tetramethoxyflavone, compound 3 as Centaurein, compound 4 as 5-hydroxy-7,8,2',3',4'-pentamethoxyflavone (Serpyllin), compound 5 as Kaempferol 7-O-α-L-rhamnopyranoside, compound 6 as sakuranetin 4'-O (6''-O-α-L-rhamnopyranosyl)-β-D-glucopyranoside (Vitexoside) and compound 7 as Spinoside. Crude extract and its fractions were tested on isolated rabbit intestine (in vitro) for their effects. The results of crude extract and its fractions in different doses showed the decrease in normal movement of the smooth muscles of rabbit intestine (jejunum). The chloroform fraction showed maximum relaxant effect (77.37%) at 15mg/ml dose and aqueous fraction showed 38.56% spasmogenic response which was not present in the crude extract. Further study was carried out on different fractions to investigate the possible mechanism of action of S. nodosa extract. For this purpose spasmolytic effect of different fractions were compared with agonist and antagonist activities of standard drugs including adrenaline, atropine andacetylcholine (1x10(-2), 1x10(-4) and 10(-6) M conc.). It is concluded that the chemical constituents present in S. nodosa having spasmolytic action are possibly acting through muscarinic receptors.