Variations in morphology of cystic artery: systematic review and meta-analysis

Background

Variations in cystic artery anatomy are not unusual in occurrence, hence considerably crucial during hepatobiliary surgical planning and execution. This systematic review and meta-analysis of the anatomical variations of cystic artery (CA) was undertaken to emphasize their significance in surgical practice.

Methods

The PICO model was adopted, both MeSH term and free keywords were utilized for the search strategy. The risk of bias in each study was calculated by the anatomy quality assurance (AQUA) tool.

Result

The search strategy identified 8204 records, extracted 5529 studies, and evaluated 117 abstracts. Out of these 117 studies, 53 met the eligibility criteria. The CA was absent in 2% of instances (95% CI: 0.01-0.04), indicating that 98% of cases had the CA. In 10071 participants from 29 investigations, double cystic arteries were found in 13% (95% CI: 11-16%), with significant heterogeneity (I2 = 91%). In 46 studies with a total of 9928 participants, 89% of the individuals had CA originating from RHA (95% CI: 85%-92%) with significant heterogeneity (I2=94.3%) and a predictive range of 43%-99%.

Conclusion

The cystic artery is primarily derived from the right hepatic artery, followed by aberrant, proper, and left hepatic arteries. It is located anterior to common hepatic ducts and cystic ducts. The mean length and diameter of CA were 20.77 mm and 1.91 mm Short cystic arteries are common (20%) Congenital anomalies like absent and double cystic arteries have low prevalence but must be conside-red during surgery.

PROTAC-Design-Evaluator (PRODE): An Advanced Method for In-Silico PROTAC Design

PROTAC (proteolysis-targeting chimeras) is a rapidly evolving technology to target undruggable targets. The mechanism by which this happens is when a bifunctional molecule binds to a target protein and also brings an E3 ubiquitin ligase in proximity to trigger ubiquitination and degradation of the target protein. Yet, in-silico-driven approaches to design these heterobifunctional molecules that have the desired functional properties to induce proximity between the target protein and E3 ligase remain to be established. In this paper, we present a novel in-silico method for PROTAC design and to demonstrate the validity of our approach, we show that for a BRD4-VHL-PROTAC-mediated ternary complex known in the literature, we are able to reproduce the PROTAC binding mode, the structure of the ternary complex formed therein, and the free energy (ΔG) thermodynamics favoring ternary complexation through theoretical/computational methodologies. Further, we demonstrate the use of thermal titration molecule dynamics (TTMD) to differentiate the stability of PROTAC-mediated ternary complexes. We employ the proposed methodology to design a PROTAC for a new system of FGFR1-MDM2 to degrade the FGFR1 (fibroblast growth factor receptor 1) that is overexpressed in cancer. Our work presented here and named as PROTAC-Designer-Evaluator (PRODE) contributes to the growing literature of in-silico approaches to PROTAC design and evaluation by incorporating the latest in-silico methods and demonstrates advancement over previously published PROTAC in-silico literature.

Correlation between Transcranial Ultrasound and CT Head to Detect Clinically Significant Conditions in Post-craniectomy Patients Performed by Emergency Physician: A Pilot Study

Background

The main objective is to detect clinically significant conditions by transcranial ultrasound (TCS) in post-decompressive craniectomy (DC) patients who come to the emergency department.

Materials and methods

This was a cross-sectional observational study. We studied 40 post-DC patients. After primary stabilization, TCS was done. Computer tomography of head was done within 2 hours of performing TCS. The correlation between both modalities were assessed by the measurement of lateral ventricle (LV) (Bland-Altman plot), Midline shift and mass lesion. Additionally, normal cerebral anatomy, 3rd and 4th ventricles and external ventricular drainage (EVD) catheter visualization were also done.

Results

About 14/40 patients came with non-neurosurgical complaints and 26/40 patients came with neurosurgical complaints. Patients with non-neurosurgical complaints (4/14) had mass lesions and 1/14 had MLS. Patients with neurosurgical complaints (11/26) had mass lesions and about 5 patients had MLS. A good correlation was found between TCS and CT of head in measuring LV right (CT head = 17.4 ± 13.8 mm and TCS = 17.1 ± 14.8 mm. The mean difference (95% CI) = [0.28 (-1.9 to 1.33), ICC 0.93 (0.88-0.96)], Left [CT head = 17.8 ± 14.4 mm and TCS = 17.1 ± 14.2 mm, the mean difference (95% CI) 0.63 (-1.8 to 0.61), ICC 0.96 (0.93-0.98)], MLS [CT head = 6.16 ± 3.59 (n = 7) and TCS = 7.883 ± 4.17 (n = 6)] and mass lesions (kappa 0.84 [0.72-0.89] [95% CI] p-value < 0.001). The agreement between both modalities for detecting mass lesions is 93.75%.

Conclusion

Point of care ultrasound (POCUS) is a bedside, easily operable, non-radiation hazard and dynamic imaging tool that can be used for TCS as a supplement to CT head in post-DC patients in emergency as well as in ICU. However, assessment of the ventricular system (pre/post-EVD insertion), monitoring of regression/progression of mass lesion, etc. can be done with TCS. Repeated scans are possible in less time which can decrease the frequency of CT head.

How to cite this article

Chouhan R, Sinha TP, Bhoi S, Kumar A, Agrawal D, Nayer J, et al. Correlation between Transcranial Ultrasound and CT Head to Detect Clinically Significant Conditions in Post-craniectomy Patients Performed by Emergency Physician: A Pilot Study. Indian J Crit Care Med 2024;28(3):299-306.

Re-Admissions of 'Unknown' Traumatic Brain Injury Patients - Inadequacy of Rehabilitative Services in a Developing Country

BACKGROUND

In neurosurgical practice, continuous care after discharge and the ability to detect subtle indicators of clinical deterioration are mandatory to prevent the progression of a disease. The care of 'unknown' patients discharged to rehabilitation homes may not have this privilege, especially in resource-poor countries such as India.

OBJECTIVE

We have attempted to study the causes and outcomes of re-admissions of 'unknown' patients with previous traumatic brain injury (TBI) to estimate the quality of nursing care in our rehabilitation centers.

MATERIAL AND METHODS

The electronic hospital records of all consecutive 'unknown' TBI patients with unplanned re-admissions at our institute from January 2014 to December 2018 were retrospectively reviewed and analyzed for the factors determining the risk and outcomes of re-admission.

RESULTS

Out of 245 patients sent to rehabilitation homes at discharge, 47 patients (19.18%) were re-admitted. A total of 33 patients (70%) were re-admitted between 1 month and 1 year. Out of these, 38 patients (80.9%) were re-admitted because of preventable causes. Fifteen patients (31.9%) died during the hospital stay. The rest of the 32 (68%) patients were discharged after the management of the concerned condition with an average hospital stay of 9 ± 11.1 days. The average Glasgow coma scale (GCS) at re-admission of the patients who died was 6 (range 3-11). Two patients were brought in the brain dead status, whereas 20 patients (42.6%) had a GCS of 5 or below at the time of re-admission. The risk of mortality among patients with non-preventable causes was 88.9% (8/9) compared to preventable causes 18.4% (7/38). However, preventable causes for re-admission are much more common, resulting in nearly a similar overall contribution to mortality.

CONCLUSIONS

There is a high rate of mortality and morbidity in 'unknown' patients with TBI because of poor post-discharge care in developing countries. Because preventable causes are the major contributor to re-admissions, the re-admission rate is a good indicator of a lack of adequate rehabilitative services. The need for improving the post-discharge management of 'unknown' patients with TBI in resource-poor countries cannot be over-emphasized.

Hospitals Should Offer Straws Only on Demand to the Public and Patients-An Environmental and Patient Care Imperative

Plastic straws have become the poster child of waste associated with unnecessary single-use plastics. The visibility of straws littering the land and marine environments has influenced proposals to decrease the use of plastic straws. These include bans on plastic straws at the city, state, and national levels and by many corporations. However, most hospitals continue to use plastic straws in hospital dining areas and for patients. Hospital dining areas are like other public dining areas, so eliminating plastic straws should be straightforward. Regarding the use of straws by patients, we review evidence and propose that patients should not be routinely given straws. Instead, physicians and nursing staff should request straws depending on the patient's medical needs. Plastic straws make up only a tiny fraction of hospital waste but can be a catalyst to create awareness and decrease unnecessary plastic use in other areas of the hospital. Mitigating climate change requires a concerted effort from hospital leadership and healthcare providers. Only then will hospitals be able to fulfill their climate pledge of net zero emissions by 2050.

A Novel Method for Prediction of Raised Intracranial Pressure Through Automated ONSD and ETD Ratio Measurement From Ocular Ultrasound

The paper presents a novel framework for the prediction of the raised Intracranial Pressure (ICP) from ocular ultrasound images of traumatic patients through automated measurement of Optic Nerve Sheath Diameter (ONSD) and Eyeball Transverse Diameter (ETD). The measurement of ONSD using an ocular ultrasound scan is non-invasive and correlates with the raised ICP. However, the existing studies suggested that the ONSD value alone is insufficient to indicate the ICP condition. Since the ONSD and ETD values may vary among patients belonging to different ethnicity/origins, there is a need for developing an independent global biomarker for predicting raised ICP condition. The proposed work develops an automated framework for the prediction of raised ICP by developing algorithms for the automated measurement of ONSD and ETD values. It is established that the ONSD and ETD ratio (OER) is a potential biomarker for ICP prediction independent of ethnicity and origin. The OER threshold value is determined by performing statistical analysis on the data of 57 trauma patients obtained from the AIIMS, New Delhi. The automated OER is computed and compared with the conventionally measured ICP by determining suitable correlation coefficients. It is found that there is a significant correlation of OER with ICP (r = .81, p ≤ .01), whereas the correlation of ONSD alone with ICP is relatively less (r = .69, p = .004). These correlation values indicate that OER is a better parameter for the prediction of ICP. Further, the threshold value of OER is found to be 0.21 for predicting raised ICP conditions in this study. Scatter plot and Heat map analysis of OER and corresponding ICP reveal that patients with OER ≥ 0.21, have ICP in the range of 17 to 35 mm Hg. In the data available for this research work, OER ranges from 0.17 to 0.35.

Automated intracranial hemorrhage detection in traumatic brain injury using 3D CNN

Objectives

Intracranial hemorrhage (ICH) is a prevalent and potentially fatal consequence of traumatic brain injury (TBI). Timely identification of ICH is crucial to ensure timely intervention and to optimize better patient outcomes. However, the current methods for diagnosing ICH from head computed tomography (CT) scans require skilled personnel (Radiologists and/or Neurosurgeons) who may be unavailable in all centers, especially in rural areas. The aim of this study is to develop a neurotrauma screening tool for identifying ICH from head CT scans of TBI patients.

Materials and Methods

We prospectively collected head CT scans from the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi. Approximately 738 consecutive head CT scans from patients enrolled in the department were collected for this study spanning a duration of 9 months, that is, January 2020 to September 2020. The metadata collected along with the head CT scans consisted of demographic and clinical details and the radiologist's report which was used as the gold standard. A deep learning-based 3D convolutional neural network (CNN) model was trained on the dataset. The pre-processing, hyperparameters, and augmentation were common for training the 3D CNN model whereas the training modules were set differently. The model was trained along with the save best model option and was monitored by validation metrics. The Institute Ethics Committee permission was taken before starting the study.

Results

We developed a 3D CNN model for automatically detecting the ICH from head CT scans. The screening tool was tested in 20 cases and trained on 200 head CT scans, with 99 normal head CT and 101 CT scans with some type of ICH. The final model performed with 90% sensitivity, 70% specificity, and 80% accuracy.

Conclusion

Our study reveals that the automated screening tool exhibits a commendable level of accuracy and sensitivity in detecting ICH from the head CT scans. The results indicate that the 3D CNN approach has a potential for further exploring the TBI-related pathologies.

Posterior pedicle inferior turbinate flap for recurrent cerebrospinal fluid leak following endoscopic transsphenoidal surgery

BACKGROUND

Adequate reconstruction of skull base following endoscopic transsphenoidal surgery is the most crucial step in reducing postoperative morbidity and mortality. Although, the success rate of traditional nasoseptal flap is very high, specific surgical scenarios preclude its use. A variety of vascularised endonasal and tunnelled scalp flaps have been described in the literature to address such situations. Posterior pedicle inferior turbinate flap (PPITF) is one such locally available vascularised flap.

METHODS

Two patients with recurrent CSF leak following endoscopic transsphenoidal resection of pituitary adenoma were included. The nasoseptal flap was not available in both patients due to previous surgery. Hence, a PPITF based on the posterolateral nasal artery, a branch of sphenopalatine artery, was harvested and used for skull base reconstruction.

RESULTS

In both patients, CSF leak subsided in the immediate postoperative period. In one patient, sensorium improved and was subsequently discharged in stable condition. Other patient succumbed to meningitis in the postoperative period.

CONCLUSIONS

The PPITF is a valuable alternative to the conventional nasoseptal flap when the latter is not available and it is very important for an endoscopic skull base surgeon to be familiar with the technique of harvesting and using the PPITF.

Pathological Spectrum and β-APP Immunoreactivity as a Diagnostic Tool of Diffuse Axonal Injury following Traumatic Brain Injury: A Novel Classification

Aim  Different deposition patterns and grading systems used to define and identify DAI remain discordant and to date these are a challenge in clinical practice. Our main objective was to study the post-mortem axonal changes and develop a grading system to identify DAI on the basis of histopathological and immunoreactive β-amyloid precursor protein (β-APP) observations in severe TBI cases. Methods  Prospective study with 35 decedents with sTBI (GCS score ≤ 8) was conducted and samples were collected from three different sites-corpus callosum, thalamus and brain stem. Serial sections from each site were stained with hematoxylin and eosin (H&E), and immunohistochemistry (IHC) of β-APP. Results  We developed a grading system based on histopathological characteristics to assess the overall damage of axonal injury. We found maximum histopathological changes in cases with prolonged stay. Corpus callosum showed maximum changes in both gradings. Curiously, we also detected axonal swellings with H&E staining. Usually neglected, the thalamus also showed significant histopathological and immunoreactive changes for sTBI. Conclusion  Our study based on histopathological and β-APP scoring system to define and identify DAI thus facilitates accurate diagnosis of DAI post mortem, which has forensic implications, and may further contribute toward survival and improvement of quality of life of sTBI patients.

Identifying barriers and facilitators along the hepatitis C care cascade to inform human-centered design of contextualized treatment protocols for vulnerable populations in Austin, Texas: a qualitative study

BACKGROUND

Hepatitis C virus (HCV) is a leading cause of liver-related mortality and morbidity. Despite effective direct acting antivirals and a simplified treatment algorithm, limited access to HCV treatment in vulnerable populations, including people experiencing homelessness (PEH) and people who inject drugs (PWID), hinders global elimination. Adapting the evidence-based, simplified HCV treatment algorithm to the organizational and contextual realities of non-traditional clinic settings serving vulnerable populations can help overcome specific barriers to HCV care. The first phase of the Erase Hep C study aimed to identify barriers and facilitators specific to these vulnerable populations to design the site-specific, simplified treatment protocols.

METHODS

Forty-two semi-structured qualitative interviews, guided by the Practical, Robust Implementation and Sustainability Model (PRISM) framework, were conducted with clinic staff, community-based organizations providing screening and linkage to care, and patients diagnosed with HCV, to identify contextual barriers and facilitators to treatment at a local community health center's Health Care for the Homeless program in Austin, Texas. Audio-recorded interviews were systematically analyzed using thematic analysis informed by the PRISM framework and design thinking, to anchor barriers and facilitators along the HCV care cascade. Findings were fed into human-centered design workshops to co-design, with clinic staff, site-specific, simplified HCV treatment protocols.

RESULTS

The specific needs of PEH and PWID patient populations informed barriers and facilitators of HCV care. Barriers included tracking patients who miss critical appointments or labs, medication access and adherence, and patient HCV knowledge. Clinical teams leveraged existing facilitators and incorporated solutions to barriers into clinic workflows to improve care coordination and medication access. Actionable solutions included augmenting existing staff roles, employing HCV care navigation throughout the cascade, and standardizing medication adherence counseling.

CONCLUSIONS

Clinic staff identified HCV care facilitators to leverage, and designed actionable solutions to address barriers, to incorporate into site-specific treatment protocols to improve patient HCV outcomes. Methods used to incorporate staff and patient experiential knowledge into the design of contextualized treatment protocols in non-traditional clinic settings could serve as a model for future implementation research. The next phase of the study is protocol implementation and patient enrollment into a single-arm trial to achieve HCV cure.

Alterations of oligodendrocyte progenitor cells (OPCs) with survival time in humans following high impact brain trauma

BACKGROUND

As there is a lack of comprehensive literature regarding the molecular environment of the human brain emphasizing on oligodendrocyte progenitor cells (OPCs) following high impact brain trauma. The protagonist of OPCs post severe traumatic brain injury (sTBI) provides a significant thrust towards estimating time elapsed since trauma as well as developing novel therapeutic approaches. The present study was carried out to study post trauma alterations pertaining to myelin sheath and oligodendrocyte response with survival time.

MATERIALS AND METHODS

In the present study, victims (both male and female) of sTBI (n = 64) were recruited and contrasted with age and gender matched controls (n = 12). Post mortem brain samples from corpus callosum and grey white matter interface were collected during autopsy examination. Extent of myelin degradation and response of OPC markers Olig-2 and PDGFR-α were evaluated using immunohistochemistry and qRT-PCR. STATA 14.0 statistical software was used for data analysis with P-value<0.05 considered statistically significant.

RESULTS

Timewise qualitative correlation with extent of demyelination performed using LFB-PAS/IHC-MBP, IHC Olig-2 and mRNA expression revealed tendency towards remyelination in both corpus callosum and grey white matter interface. Number of Olig-2 positive cells was significantly higher in sTBI group as compared to control group (P-value: 0.0001). Moreover, mRNA expression studies of Olig-2 showed significant upregulation in sTBI patients. mRNA expression of Olig-2 and PDGFR-α in sTBI patients showed significant variation with respect to survival time (p value:0.0001).

CONCLUSION

Detailed assessment of post TBI changes implementing various immunohistochemical and molecular techniques shall potentially reveal intriguing and important inferences in medicolegal practices and neurotherapeutics.

Development, implementation, and feasibility of site-specific hepatitis C virus treatment workflows for treating vulnerable, high-risk populations: protocol of the Erase Hep C study - a prospective single-arm intervention trial

BACKGROUND

Hepatitis C virus (HCV) is the leading indication for liver transplantation and liver-related mortality. The development of direct-acting antivirals (DAA) and a simplified treatment algorithm with a > 97% cure rate should make global elimination of HCV an achievable goal. Yet, vulnerable populations with high rates of HCV still have limited access to treatment. By designing locally contextualized site-specific HCV treatment workflows, we aim to cure HCV in vulnerable, high-risk populations, including people experiencing homelessness (PEH) and people who inject drugs (PWID), in Austin, TX, USA.

METHODS

Our implementation science study will utilize a qualitative and design thinking approach to characterize patient and systemic barriers and facilitators to HCV treatment in vulnerable, high-risk populations seeking care across seven diverse primary care clinics serving PEHs and PWIDs. Qualitative interviews guided by the Practical, Robust Implementation and Sustainability Model (PRISM) framework will identify barriers and facilitators by leveraging knowledge and experience from both clinic staff and patients. Data synthesized using thematic analysis and design thinking will feed into workshops with clinic stakeholders for idea generation to design site-specific HCV treatment workflows. Providers will be trained on the use of a simplified HCV treatment algorithm with DAAs and clinic staff on the new site-specific HCV treatment workflows. These workflows will be implemented by the seven diverse primary care clinics serving vulnerable, high-risk populations. Implementation and clinical outcomes will be measured using data collected through interviews with staff as well as through medical chart review.

DISCUSSION

Our study provides a model of how to contextualize and implement site-specific HCV treatment workflows targeting vulnerable, high-risk populations in other geographic locations. This model can be adopted for future implementation research programs aiming to develop and implement site-specific treatment workflows for vulnerable, high-risk populations and in primary care clinical settings for other disease states beyond just HCV.

TRIAL REGISTRATION

Registered on ClinicalTrials.gov on July, 14, 2022. Identifier: NCT05460130 .

Diagnostic Accuracy of Ocular Ultrasonography in Identifying Raised Intracranial Pressure among Pediatric Population

INTRODUCTION

Role of CT scan, MRI, ophthalmoscopy, direct monitoring by a transducer probe in identifying raised intracranial pressure (ICP) in emergency department is limited. There are few studies correlating elevated optic nerve sheath diameter (ONSD) measured by point of care ultrasound (POCUS) with raised ICP in pediatrics emergencies. We studied the diagnostic accuracy of ONSD, crescent sign, and optic disc elevation in identifying increased ICP in pediatrics.

METHODS

Prospective observational study was done between April 2018 and August 2019 after ethics approval. Out of 125 subjects, 40 patients without clinical features of raised ICP were recruited as external controls and 85 with clinical features of raised ICP as study subjects. Their demographic profile, clinical examination, and ocular ultrasound findings were noted. This was followed by CT scan. Out of 85 patients, 43 had raised ICP (cases) and 42 had normal ICP (disease controls). Diagnostic accuracy of ONSD in identifying raised ICP was evaluated using STATA.

RESULTS

The mean ONSD in case group was 5.5 ± 0.6 mm, 4.9 ± 0.5 mm in disease control group and external control group was 4.8 ± 0.3 mm. Cut-off of ONSD for raised ICP at ≥4.5 mm had a sensitivity and specificity of 97.67% and 10.98%, while ≥5.0 mm showed a sensitivity and specificity of 86.05% and 71.95%. Crescent sign and optic disc elevation had good correlation with increased ICP.

CONCLUSION

ONSD ≥5 mm by POCUS identified raised ICP in pediatric population. Crescent sign and optic disc elevation may function as additional POCUS signs in identifying raised ICP.

Equitable Implementation of Mailed Stool Test-Based Colorectal Cancer Screening and Patient Navigation in a Safety Net Health System

BACKGROUND

Mailed stool testing programs increase colorectal cancer (CRC) screening in diverse settings, but whether uptake differs by key demographic characteristics is not well-studied and has health equity implications.

OBJECTIVE

To examine the uptake and equity of the first cycle of a mailed stool test program implemented over a 3-year period in a Central Texas Federally Qualified Health Center (FQHC) system.

DESIGN

Retrospective cohort study within a single-arm intervention.

PARTICIPANTS

Patients in an FQHC aged 50-75 at average CRC risk identified through electronic health records (EHR) as not being up to date with screening.

INTERVENTIONS

Mailed outreach in English/Spanish included an introductory letter, free-of-charge fecal immunochemical test (FIT), and lab requisition with postage-paid mailer, simple instructions, and a medical records update postcard. Patients were asked to complete the FIT or postcard reporting recent screening. One text and one letter reminded non-responders. A bilingual patient navigator guided those with positive FIT toward colonoscopy.

MAIN MEASURES

Proportions of patients completing mailed FIT in response to initial cycle of outreach and proportion of those with positive FIT completing colonoscopy; comparison of whether proportions varied by demographics and insurance status obtained from the EHR.

KEY RESULTS

Over 3 years, 33,606 patients received an initial cycle of outreach. Overall, 19.9% (n = 6672) completed at least one mailed FIT, 5.6% (n = 374) tested positive during that initial cycle, and 72.5% (n = 271 of 374) of those with positive FIT completed a colonoscopy. Hispanic/Latinx, Spanish-speaking, and uninsured patients were more likely to complete mailed FIT compared with white, English-speaking, and commercially insured patients. Spanish-speaking patients were more likely to complete colonoscopy after positive FIT compared with English-speaking patients.

CONCLUSIONS

Mailed FIT outreach with patient navigation implemented in an FQHC system was effective in equitably reaching patients not up to date for CRC screening.

Gamma Knife Stereotactic Radiosurgery for Giant Intracranial Tumors - A Series of 70 Patients

Background and Objective

Surgery remains the primary option in large intracranial tumors, but significant number of patients may not be amenable for surgery. We explored the role of stereotactic radiosurgery as an alternative to external beam radiation therapy (EBRT) in such patients. Our study objective was to assess the clinicoradiological outcomes of large intracranial tumors (volume ≥20 cm³) managed with gamma knife radiosurgery (GKRS).

Materials and Methods

This was a single-center, retrospective study conducted from January 2012 to December 2019. Patients with intracranial tumor volume ≥20 cm³ who received GKRS and had a minimum of 12 months of follow-up were included. Clinical, radiological, and radiosurgical details and clinicoradiological outcomes of the patients were obtained and analyzed.

Results

Seventy patients who had a pre-GKRS tumor volume ≥20 cm³ with >12 months of follow-up were included. The mean age of the patients was 41.9 ± 13.6 (range 11-75) years. Majority (97.1%) received GKRS in a single fraction. Mean pretreatment target volume was 31.9 ± 15.1 cm³. At a mean follow-up of 34.2 ± 17.1 months, tumor control was achieved in 91.4% (n = 64) of the patients. Adverse radiation effects were observed in 11 (15.7%) patients, but were symptomatic in only one (1.4%) patient.

Conclusion

The present series defines "large intracranial lesions" for GKRS and demonstrates excellent radiological and clinical outcomes in these patients. GKRS may be considered as the primary option in such large intracranial lesions in which surgery carries significant risk based on patient-related factors.

Trends in Stereotactic Radiosurgery for Intracranial and Spinal Pathologies: Analysis of the Top 100 Most Cited Articles

There is a plethora of papers on the role of stereotactic radiosurgery (SRS) in various benign and malignant intracranial tumors, and it is possible to overlook the most important and landmark studies. Thus, the necessity of citation analysis arises, which reviews the most cited articles and recognizes the impact made by these articles. Utilizing the 100 most cited articles describing the use of SRS for intracranial and spinal pathologies, this article aims to provide meaningful information regarding the historical trends and recent directions in which this field is headed. We performed a search of the Web of Science database using the keywords "stereotactic radiosurgery," "gamma knife," "GKRS," "gamma knife radiosurgery," "LINAC," and "Cyberknife" on May 14, 2022. Our search retrieved a total of 30,652 articles published between the years 1968 and 2017. The top 100 cited articles were arranged in descending order based on citation count (CC) and citation per year (CY). The journal with the largest number of publications as well as citation count was the International Journal of Radiation Oncology Biology Physics (n = 33), followed by Journal of Neurosurgery (n = 25). The most cited article was authored by Andrews, which was published in 2004 in The Lancet (1699 CC, 89.42 CY). Flickinger, with 25 papers and 7635 total citations, was the author with the highest impact. Lunsford, with 25 publications and total citations of 7615, was a close second. The USA was the leading country with the maximum number of total citations (n = 23,054). Ninety-two articles described the use of SRS for intracranial pathologies (metastases, n = 38; AVM, n = 16; vestibular schwannoma, n = 9; meningioma, n = 8; trigeminal neuralgia, n = 6; sellar lesion, n = 2; glioma, n = 2; functional, n = 1; and procedure related, n = 10). Eight studies describing spinal radiosurgery were included, out of which four were on spinal metastases. Citation analyses of the top 100 articles revealed that the focus of research in the field of SRS started with functional neurosurgery and progressed to benign intracranial tumors and AVMs. More recently, central nervous system (CNS) metastases have received the maximum attention with 38 articles, including 14 randomized controlled trials finding a place in the top 100 cited articles. Presently, the use of SRS is concentrated in developed countries. Efforts need to be made for more widespread use in developing nations to bring the maximum possible benefits of this focused noninvasive treatment to a wider population.

Role of Stereotactic Radiosurgery for Cavernous Sinus Hemangiomas - An Individual Patient Data-Based Meta-Analysis

Context

Cavernous sinus haemangiomas (CSHs) are rare vascular malformations arising from the micro-circulation of the cavernous sinus. The current treatment options are micro-surgical excision of CSH, stereotactic radiosurgery (SRS), and fractionated radiation therapy (FRT).

Aims

We conducted a meta-analysis assessing the effect and complications of SRS in CSH and compared the pooled results after surgical excision of CSH. The aim of the study is to provide valuable insight into the role of SRS in the treatment of CSHs.

Materials and Methods

The literature search revealed a total of 21 articles with 199 patients who met our inclusion criteria, and these were analyzed for this study.

Results

There were 138 (69.3%) female and 61 (30.7%) male patients. The mean age at the time of radiosurgery was 48.4 ± 14.9 years. The mean tumor volume at the time of SRS was 17.4 cm³ (range 0.3-138 cm³). Fifty (25%) patients had undergone surgery before SRS, whereas 149 (75%) patients received standalone SRS. A total of 186 (93.5%) patients were treated by gamma knife radiosurgery (GKRS), whereas 13 got treated by Cyberknife. The mean tumor volume in CK-F, GKRS, and GKRS-F groups was 36.6 ± 26.3, 15.4 ± 18.4, and 86.0 ± 19.5 cm³, respectively. The mean marginal dose was 21.8 ± 2.9 Gy, 14.0 ± 1.9 Gy, and 25 ± 0.0 Gy in CK-F, GKRS, and GKRS-F groups, respectively. The mean marginal dose of SRS was 14.6 ± 2.9 Gy. The mean follow-up period after SRS was 35.8 ± 31.6 months. Significant clinical improvement was seen in 106 patients out of 116 (91.4%) after SRS with remarkable shrinkage, 22 patients out of 27 (81.5%) with minimal shrinkage, and nine patients out of 13 (69.2%) with stationary tumor shrinkage. The sixth cranial nerve (CN6) was the most commonly involved nerve in 73 patients (36.7%). 30/65 (89%) experienced an improvement in the abducent nerve function following SRS. 115/120 (95.8%) patients primary treated with SRS experienced clinical improvement, whereas the rest of the five patients remained clinically stable.

Conclusion

Radiosurgery SRS is a safe and effective option in patients with CSHs and resulted in more than 50% decrease in tumor volume in 72.4% of the patients.

Early Gamma Knife Therapy (Without EBRT) in Operated Patients of Glioblastoma Multiforme

Background

The standard therapy for glioblastoma (GBM) has been external beam radiotherapy (EBRT) with concomitant temozolomide (TMZ) given for six cycles, after maximum possible surgical resection although recurrences after chemoradiation are mostly in-field.

Objective

To compare the effects of early GKT (without EBRT) along with TMZ to those receiving standard chemoradiotherapy (EBRT + TMZ) after surgery.

Methods

This was a retro-prospective study on histologically proven GBMs operated at our center between January 2016 and November 2018. The EBRT group consisted of 24 patients who received EBRT + TMZ for six cycles. The GKT arm consisted of 13 consecutive patients who received Gamma Knife within 4 weeks of surgery along with lifelong temozolomide. Patients were followed up every 3 months with CEMRI brain and PET-CT. The primary endpoint was overall survival (OS) with progression-free survival (PFS) being the secondary endpoint.

Results

At a mean follow-up of 13.7 months, the median overall survivals in GKT and EBRT groups were 11.07 and 13.03 months, respectively (HR = 0.59; P value = 0.19; 95% CI: 0.27-1.29). The median PFS for GKT group was 7.03 months (95% CI: 4.17-17.3) as compared to 11.07 months (95% CI: 5.33-14.03) for the EBRT group. There was no statistical difference in the PFS or OS between the GKT and EBRT groups.

Conclusion

Our study shows that Gamma Knife therapy (without EBRT) to residual tumor/tumor bed after primary surgery with concurrent temozolomide has similar progression-free (PFS) and overall survival (OS) rates when compared to conventional treatment (EBRT).

Role of Gamma Knife Radiosurgery in the Management of Functional Disorders - A Literature Review

Background

Role of radiosurgical lesioning in functional disorders has been restricted because of development of deep brain stimulation (DBS) techniques. However, many elderly patients with comorbidities and coagulation abnormalities may not be eligible for DBS. Radiosurgical lesioning may be a good alternative in such cases. The objective of the study was to review the role of radiosurgical lesioning for functional targets in common functional disorders.

Materials and Methods

Literature reports pertaining to common disorders were reviewed. Disorders included are tremors (essential tremors, tremor-dominant Parkinson's disease [PD], multiple sclerosis [MS] related refractory tremors), Parkinson's disease (for rigidity, bradykinesia, drug-induced dyskinesias), dystonia, and obsessive-compulsive disorder (OCD).

Results

The most commonly performed procedure was ventral intermediate nucleus (VIM) lesioning for essential tremors and tremor-dominant PD, with about 90% patients demonstrating improvement. Intractable OCD with 60% responders is a promising indication. Other disorders are less commonly treated, with dystonia being the least commonly treated entity. Subthalamic nucleus (STN) and globus pallidus interna/posteroventral pallidum (GPi) lesioning are very rarely reported, and the available literature suggests caution due to high rates of adverse effects.

Conclusions

Outcomes for radiosurgical lesioning for essential tremors (VIM) and OCD (anterior limb of internal capsule [ALIC]) are encouraging. Radiosurgical lesioning offers a lower immediate risk profile in patient population with several comorbidities; however, long-term adverse effects due to radiation are a concern, especially for STN and GPi lesioning.

Correlation Based on the WHO Grading with Tumor Control and Clinical Outcome Following Gamma Knife Radiosurgery in Meningiomas

Background and Aim

The aim of this study was to study the effect of Gamma Knife (GK) on meningiomas based on the World Health Organization's (WHO) grading system in terms of tumor control and final clinical outcome.

Methodology

This retrospective study included clinicoradiological and GK characteristics of patients who had undergone GK for meningiomas at our institute from April 1997 until December 2009.

Results

Of 440 patients, 235 underwent secondary GK for residual/recurrent lesion and 205 received primary GK. Of the 137 patients whose biopsy slide could be reviewed, 111 patients had grade I, 16 had grade II, and 10 had grade III meningiomas. Good tumor control rates were seen in 96.3% of grade I meningioma patients, 62.5% of 16 grade II, and 10% of grade III meningioma patients at median follow-up of 40 months. Age, sex, Simpson's grade of excision, and increasing peripheral dose of GK did not affect the response to radiosurgery (P > 0.05). Multivariate analysis showed that high-grade tumor and radiotherapy prior to GK were important negative predictors for progression of tumor size after GK radiosurgery (GKRS) (P < 0.05). In patients with WHO grade I meningioma, radiation therapy prior to GKRS and repeat surgery were predictors for poorer outcome.

Conclusion

In WHO grades II and III meningiomas, no factors affected tumor control except the histology itself.

Role of Stereotactic Radiosurgery in Glial Tumors

Glial tumors are a relatively new indication for stereotactic radiosurgery (SRS). Traditionally, SRS has been considered to be an inadequate treatment for glial tumors as these are diffuse tumors, but SRS is a highly focused treatment. Tumor delineation can be challenging given the diffuse nature of the gliomas. It has been recommended to include the T2/fluid-attenuated inversion recovery (FLAIR) altered signal intensity areas in addition to the contrast enhancing part in the treatment plan of glioblastoma in order to increase the coverage. Some have recommended to include 5 mm margins to cover up for the diffusely infiltrative nature of the glioblastoma. The most common indication of SRS in patients with glioblastoma multiforme is tumor recurrence. SRS has also been used as a boost to the residual tumor or tumor bed after surgical excision before conventional radiotherapy. The addition of bevacizumab has been recently tried along with SRS in patients with recurrent glioblastoma to decrease radiation toxicity. Besides, SRS has also been used in patients with low-grade gliomas following recurrence. Brainstem gliomas, which are usually low-grade gliomas, are another indication for SRS. Outcomes following the use of SRS are comparable with external beam radiotherapy in brainstem gliomas, whereas the risks of radiation-induced complications is less. SRS has also been used in other glial tumors such as gangliogliomas and ependymomas.

Role of Stereotactic Radiosurgery in the Management of Dural AV Fistula

Dural arteriovenous fistulas (DAVFs) are a relatively rare intracranial vascular malformation. The various treatment options for DAVFs include observation, compression therapy, endovascular therapy, radiosurgery, or surgery. A combination of these therapies may also be used. The treatment choice for DAVFs depends on the type of fistula, the severity of symptoms, DAVF angioarchitecture, and the efficacy and safety of treatments. The use of stereotactic radiosurgery (SRS) in DAVFs started in the late 1970s. There is a delay before the fistula gets obliterated after SRS and there is a risk of hemorrhage from the fistula till the fistula gets obliterated. Initial reports described the role of SRS in small DAVFs without severe symptoms, which were inaccessible by endovascular or surgical measures or in combination with embolization in larger DAVFs. SRS can be appropriate for indirect cavernous sinus DAVF fistulas (Barrow type B, C, and D). Borden types II and III and Cognard types IIb-V DAVFs have a high risk of hemorrhage and are traditionally considered less favorable to be treated with SRS as immediate treatment is required to decrease the risk of hemorrhage. However, recently SRS has been tried in these high-grade DAVF as a monotherapy. Factors that have a positive impact on the obliteration rates of DAVF following SRS are the location of DAVF with the cavernous sinus DAVF having much better obliteration rates than DAVF located at other locations, Borden Type I or Cognard Types III or IV DAVFs, absence of CVD, hemorrhage at the time of initial presentation, and target volume lesser than 1.5 mL.

Tumor Control and Hearing Preservation After Gamma Knife Radiosurgery for Vestibular Schwannomas in Neurofibromatosis Type 2-A Retrospective Analysis of 133 Tumors

OBJECTIVE

This study was conducted with the aim to estimate long-term tumor control and hearing preservation rates in patients with neurofibromatosis 2 (NF2)-related vestibular schwannoma (VS), document retreatment success rate, and assess the associated predictive factors.

METHODS

This was a retrospective analysis of patients with NF2-associated VS who underwent Gamma Knife radiosurgery (GKRS) between 2009 and 2020 and had a minimum follow-up of 1 year. Loss of tumor control was defined as greater than 10% increase in volume in more than one follow-up imaging or the need for retreatment in the form of repeat GKRS or surgery. The Kaplan-Meier method was used to evaluate actuarial tumor control and hearing preservation rates.

RESULTS

In total, 85 patients with 133 VSs were included in the study. The mean age was 29.8 years. In total, 57 tumors showed tumor regression, 35 showed stable disease, and 23 progressed in size at last follow up. Actuarial tumor control rates after 1, 3, 5, and 9 years were 95%, 79%, 75%, and 55%, respectively, with overall tumor control rate being 85%. Hearing worsened in 39 patients, and facial nerve dysfunction occurred in 4 patients. Five tumors underwent retreatment with GKRS at a median duration of 27.6 months (19-36 months) following the first GKRS.

CONCLUSIONS

This is the largest radiosurgical series of NF2-associated VS reported to date. GKRS provides a high rate of long-term local tumor control with a low risk of neurologic deprivation for patients with these tumors. The need for retreatment with GKRS, although low, is associated with good tumor control and lesser complications.

Complications of Decompressive Craniectomy: A Case-Based Review

Background Decompressive craniectomy (DC) is a frequently performed procedure to treat intracranial hypertension following traumatic brain injury (TBI) and stroke. DC is a salvage procedure that reduces mortality at the expense of severe disability and compromises the quality of life. The procedure is not without serious complications.

Methods We describe the complications following DC and its management in a case-based review in this article.

Results Complications after DC are classified as early or late complications based on the time of occurrence. Early complication includes hemorrhage, external cerebral herniation, wound complications, CSF leak/fistula, and seizures/epilepsy. Contusion expansion, new contralateral epidural, and subdural hematoma in the immediate postoperative period mandate surgical intervention. It is necessary to repeat non-contrast CT head at 24 hours and 48 hours following DC. Late complication includes subdural hygroma, hydrocephalus, syndrome of the trephined, bone resorption, and falls on the unprotected cranium. An early cranioplasty is an effective strategy to mitigate most of the late complications.

Conclusions DC can be associated with a number of complications. One should be aware of the possible complications, and timely intervention is required.

Comparison of Infection Rates Following Immediate and Delayed Cranioplasty for Postcraniotomy Surgical Site Infections: Results of a Meta-Analysis

Postoperative surgical site infections (SSIs) in neurosurgery are rare. However, they pose a formidable challenge to the treating neurosurgeon and substantially worsen patient outcomes. These infections require prompt intervention in the form of débridement, including removal of craniotomy bone. Reconstruction of the craniotomy defect can be performed along with the débridement or can be performed at a later time. Although there have been concerns about performing cranioplasty at the same time as débridement, recent studies have advocated performance of cranioplasty at the same time as the débridement, as it avoids the morbidity associated with having a craniectomy defect and avoids the need for another surgical procedure. We conducted a literature review and meta-analysis to examine the data on immediate cranioplasties and delayed cranioplasties performed for postcraniotomy SSIs. We analyzed 15 articles with a total of 353 patients. Our analysis revealed that the pooled proportion of treatment failure was 10.4% (95% confidence interval [CI] 5.9%-17.8%) when an immediate cranioplasty was done and 16.1% (95% CI 7.2%-32.1%) when delayed cranioplasty was done. The pooled proportion of treatment failure was 12% (95% CI 5.9%-22.9%) when the same bone was used for cranioplasty and was 8% (95% CI 3%-20%) when prosthetic material such as titanium was used for cranial vault reconstruction. Thus, the rate of treatment failure was less when an immediate single-stage cranioplasty was done compared with a delayed cranioplasty following SSIs.

Recurrent Pericardial Effusion Due to Panhypopituitarism: A Rare Case Report

INTRODUCTION

A female patient, 48 years of age, with a complaint of recurrent episodes of diffuse chest pain, vertigo, and shortness of breath in the last five years, presented needing immediate medical attention.

CASE PRESENTATION

The patient was evaluated and suspected of severe hypotension, cold hands, and feet with distended neck veins and muffled heart sounds. ECG revealed low voltage complexes and large pericardial effusion with a collapse in the diastole of the right auricle and ventricle. The provisional diagnosis was kept as pericardial effusion with hemodynamic compromise. Detailed history disclosed that she had suffered similar events five years before, during which a pericardial tap was performed, and the patient was on anti-tuberculosis treatment for nine months. The symptoms continued despite the treatments. She had a history of severe postpartum hemorrhage, failure of lactation, and early menopause with a history of hysterectomy dated ten years back. The biochemical study indicated decreased LH, FSH, TSH, ACTH, and serum cortisol levels. MRI brain revealed empty sella. The hormonal replacement was started with clinical improvement.

CONCLUSIONS

Although hypothyroidism is an extremely rare cause of pericardial effusion, detailed history and further investigations are imperative to form a definitive diagnosis.

Long-term lead and mortality following pacemaker and defibrillator implantation in adult congenital heart disease

Background

Adult congenital heart disease (ACHD) survival has dramatically improved in recent decades. As such, clinicians now face the complex long-term interactions of congenital and chronic heart diseases. One area of continuing mortality in this group is arrhythmias, especially in those with cardiovascular implantable electronic devices (CIEDs). With these developments in survival, the long-term outcomes of the CIED systems and their effects on mortality are beginning to be elucidated.

Aims

This study aims to compare the effects of system location, surgical history, patient demographics and congenital disease complexity on lead survival, complication distributions and patient mortality in ACHD CIED patients.

Methods

A retrospective cohort of 250 ACHD CIED patients with follow up at a heart centre was collated from clinical correspondence letters and CEID records. Data was collected on demographics, mortality and lead survival and complications. Survival data was analysed with Kaplan-Meier (KM) curves and hazard ratio tests.

Results

Complex ADHD patient survival was less than the non-complex cohort (HR 0.38, 95% CI 0.22–0.67, p&lt;0.01). Lead survival was longer in non-surgical patients (HR 1.42, 95% CI 1.13–1.78, p&lt;0.01) and longer in female patients (HR 1.35, 95% CI 1.07–1.69, p&lt;0.01) (Figure 1). No significant differences in mortality or lead survival were seen between epicardial and transvenous systems.

Conclusions

Complex ACHD is associated with worse patient mortality in CEID patients. Surgical history and male gender are associated with worsened lead survival.

Funding Acknowledgement

Type of funding sources: None.

Cervical Spine Fracture with Extreme Dislocation in a Patient with Ankylosing Spondylitis: A Case Report and Systematic Review of the Literature

Background

Ankylosing spondylitis (AS) is a seronegative arthropathy which results in pathological ossification of the ligaments, disc, endplates and apophyseal structures. Cervical spinal fractures are more common in patients with ankylosing spondylitis than in patients without ankylosing spondylitis due to coexistent osteoporosis and kyphotic alignment of the spine. The risk of fracture-dislocation and associated spinal cord injury is also more in these patients. Management of cervical spine fractures in patients with ankylosing spondylitis is more challenging.

Case Description

We report a 56-year-old male patient who presented to our emergency department following a road traffic accident. He had ASIA B spinal cord injury at C7 level. CT scan revealed a C6-7 fracture-dislocation with features suggestive of AS. The fracture involved all the three columns and extended through C7 body anteriorly and through the C6-7 disc posteriorly. The treating team was not aware that he had AS, and thus, precautions related to his head position were not taken. He underwent reduction of the fracture-dislocation and 360° fixation.

Conclusions

The management of cervical spine fractures in patients with ankylosing spondylitis is challenging. They need long segment fixation in their preoperative spinal alignment. Proper preoperative planning can result in good outcome.

Safety and feasibility of intramedullary injected bone marrow-derived mesenchymal stem cells in acute complete spinal cord injury: phase 1 trial

OBJECTIVE

The intramedullary route holds the potential to provide the most concentration of stem cells in cases of spinal cord injury (SCI). However, the safety and feasibility of this route need to be studied in human subjects. The aim of this study was to evaluate the safety and feasibility of intramedullary injected bone marrow-derived mesenchymal stem cells (BM-MSCs) in acute complete SCI.

METHODS

In this prospective study conducted over a 2-year period, 27 patients with acute (defined as within 1 week of injury) and complete SCI were randomized to receive BM-MSC or placebo through an intramedullary route intraoperatively at the time of spinal decompression and fusion. Institutional ethics approval was obtained, and informed consent was obtained from all patients. Safety was assessed using laboratory and clinicoradiological parameters preoperatively and 3 and 6 months after surgery.

RESULTS

A total of 180 patients were screened during the study period. Of these, 27 were enrolled in the study. Three patients withdrew, 3 patients were lost to follow-up, and 8 patients died, leaving a total of 13 patients for final analysis. Seven of these patients were in the stem cell group, and 6 were in the control group. Both groups were well matched in terms of sex, age, and weight. No adverse events related to stem cell injection were noted for laboratory and radiological parameters. Five patients in the control group and 3 patients in the stem cell group died during the follow-up period.

CONCLUSIONS

Intramedullary injection of BM-MSCs was found to be safe and feasible for use in patients with acute complete SCI.

Managing Traumatic Brain Injury During the Coronavirus Disease 2019 Pandemic-A Case-Matched Controlled Analysis of Immediate Outcomes

OBJECTIVE

The primary objective of this study was to evaluate the outcome of patients with traumatic brain injury (TBI) during the coronavirus disease 2019 (COVID-19) pandemic and to compare their outcome with case-matched controls from the prepandemic phase.

METHODS

This is a retrospective case-control study in which all patients with TBI admitted during COVID-19 pandemic phase (Arm A) from March 24, 2020 to November 30, 2020 were matched with age and Glasgow Coma Scale score-matched controls from the patients admitted before March 2020 (Arm B).

RESULTS

The total number of patients matched in each arm was 118. The length of hospital stay (8 days vs. 5 days; P < 0.001), transit time from emergency room to operation room (150 minutes vs. 97 minutes; P = 0.271), anesthesia induction time (75 minutes vs. 45 minutes; P = 0.002), and operative duration (275 minutes vs. 180 minutes; P = 0.002) were longer in arm A. Although the incidence of fever and pneumonia was significantly higher in arm A than in arm B (50% vs. 26.3%, P < 0.001 and 27.1% vs. 1.7%, P < 0.001, respectively), outcome (Glasgow Outcome Scale-Extended) and mortality (18.6% vs. 14.4% respectively; P = 0.42) were similar in both the groups.

CONCLUSIONS

The outcome of the patients managed for TBI during the COVID-19 pandemic was similar to matched patients with TBI managed at our center before the onset of the COVID-19 pandemic. This finding suggests that the guidelines followed during the COVID-19 pandemic were effective in dealing with patients with TBI. This model can serve as a guide for any future pandemic waves for effective management of patients with TBI without compromising their outcome.

Management of Pediatric and Adolescent Traumatic Thoracolumbar Spondyloptosis

BACKGROUND

Complete subluxation of >100% of one vertebral body with respect to the adjacent vertebra is defined as spondyloptosis. It is the severest form of injury caused by high-energy trauma. Pediatric patients with a traumatic spine injury, particularly spondyloptosis are surgically demanding as reduction and achieving realignment of the spinal column requires diligent planning and execution.

OBJECTIVE

To enlighten readers about this rare but severest form of thoracolumbar spine injury and its management.

METHODS

Retrospective analysis of patients treated here with spondyloptosis between 2008 and 2016 was done.

RESULTS

Seven children, ranging from 9 to 18 years (mean years) age were included in the study. Five patients had spondyloptosis at thoracolumbar junction and one each in the lumbar and thoracic spine. All patients underwent single-stage posterior surgical reduction and fixation except one patient who refused surgery. Intraoperatively, cord transection was seen in five patients while dura was intact in one patient. The mean follow-up period was 17 months (1-36 months) during which one patient expired due to complications arising from bedsores. All patients remained American Spinal Injury Association (ASIA) A neurologically.

CONCLUSIONS

Traumatic spondyloptosis is a challenging proposition to treat and the aim of surgery is to stabilize the spine. Rehabilitation remains the most crucial but the neglected part and dearth of proper rehabilitation centers inflict high mortality and morbidity in developing countries.

O-Arm Assisted Anterior Odontoid Screw Fixation in Type II and Rostral Type III Odontoid Fractures: Single Center Surgical Series of 50 Patients

BACKGROUND

Accuracy of screw placement is one of the important factors necessary for adequate union in odontoid fractures with malposition rates as high as 27.2% with standard techniques.

OBJECTIVE

To evaluate efficacy of intraoperative O-arm assistance in improving accuracy of anterior odontoid screw placement and clinco-radiological outcome in type II and III odontoid fractures.

MATERIAL AND METHODS

In this retrospective study, surgery consisted of anterior odontoid screw fixation under intraoperative O-arm assistance over 5 years. Demographical, clinical, radiological, operative details and postoperative events were retrieved from hospital database and evaluated for fusion and surgical outcome.

RESULTS

50 patients (Mean age 34.6 years, SD 14.10, range: 7-70 years; 44 males and 6 females) with Type II and Type III odontoid fracture underwent O-arm assisted anterior screw placement. The mean interval between injury and surgery was 12 days (range 1-65 days). Mean operating time was 132.2 min ± SD 33.56 with average blood loss of 93 ml. ±SD 61.46. With our technique, accurate screw placement was achieved in 100% patients. At the mean follow-up of 26.4 month (SD13.75), overall acceptable fusion rate was 97.8% with non-union in 2.2% patients. Morbidity occurred in two patients; one patient developed fixation failure while other patient had nonunion which was managed with posterior C1-C2 arthrodesis. We had surgical mortality in one patient due to SAH. So overall our procedure was successful in 94% patients and among patients whose follow-up was available, acceptable fusion rates of 97.8% were achieved.

CONCLUSION

We conclude that use of intraoperative three-dimensional imaging using O-arm for anterior odontoid screw fixation improves accuracy and leads to improved radiological and clinical outcomes. It further enables us to extend the indications of odontoid screw fixation to selected complex Type II and rostral Type III odontoid fractures.

Changes in Epidemiology of Acetaminophen Overdoses in an Urban County Hospital After 20 Years

INTRODUCTION

Acetaminophen (APAP) toxicity is the main cause of acute liver failure in the United States. A prior series (1992-1995) identified 71 hospitalized adults with APAP toxicity through the International Statistical Classification of Disease and Related Health Problems, 9th revision (ICD-9) code at Parkland Hospital, Dallas, TX.

METHODS

We used a laboratory database search of serum APAP levels from 2011 to 2015 to identify patients with APAP toxicity in the same hospital.

RESULTS

We identified 140 patients hospitalized for APAP toxicity from 27,143 APAP levels obtained; 35 required Intensive Care Unit (ICU) admission, and there were no deaths. APAP toxicity/100,000 admissions was similar between eras.

DISCUSSION

APAP toxicity continues unabated after 20 years but with improved overall outcomes.

Reducing the environmental footprint of gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement

Climate change and the destruction of ecosystems by human activities are among the greatest challenges of the 21st century and require urgent action. Health care activities significantly contribute to the emission of greenhouse gases and waste production, with gastrointestinal (GI) endoscopy being one of the largest contributors. This Position Statement aims to raise awareness of the ecological footprint of GI endoscopy and provides guidance to reduce its environmental impact. The European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) outline suggestions and recommendations for health care providers, patients, governments, and industry. MAIN STATEMENTS 1: GI endoscopy is a resource-intensive activity with a significant yet poorly assessed environmental impact. 2: ESGE-ESGENA recommend adopting immediate actions to reduce the environmental impact of GI endoscopy. 3: ESGE-ESGENA recommend adherence to guidelines and implementation of audit strategies on the appropriateness of GI endoscopy to avoid the environmental impact of unnecessary procedures. 4: ESGE-ESGENA recommend the embedding of reduce, reuse, and recycle programs in the GI endoscopy unit. 5: ESGE-ESGENA suggest that there is an urgent need to reassess and reduce the environmental and economic impact of single-use GI endoscopic devices. 6: ESGE-ESGENA suggest against routine use of single-use GI endoscopes. However, their use could be considered in highly selected patients on a case-by-case basis. 7: ESGE-ESGENA recommend inclusion of sustainability in the training curricula of GI endoscopy and as a quality domain. 8: ESGE-ESGENA recommend conducting high quality research to quantify and minimize the environmental impact of GI endoscopy. 9: ESGE-ESGENA recommend that GI endoscopy companies assess, disclose, and audit the environmental impact of their value chain. 10:  ESGE-ESGENA recommend that GI endoscopy should become a net-zero greenhouse gas emissions practice by 2050.

LINC-02. Gamma Knife Radiosurgery as an efficacious treatment for Pediatric Central Nervous System Tumors: A Retrospective Study of 61 Neoplasms

PURPOSE: Brain tumors have an incidence of 1.15 to 5.14 cases per 100,000 children and are associated with significant morbidity and mortality. Radiosurgery has become a promising approach to manage these pediatric CNS tumors. The aim of the present study was to analyse the efficacy of radiosurgery in the treatment of a variety of pediatric tumors of CNS METHODS: This retrospective study was conducted from 1997-2012 at a single Neurosurgery centre. All paediatric patients (≤ 18 years of age) with CNS tumours who were treated with gamma knife radiosurgery (GKRS) and had a minimum follow up of 6 months were included in the study. Patients with lesions other than tumours were excluded. Clinical, radiological and GKRS planning data was collected and analysed in all patients. RESULTS: A total of 76 children with brain tumors had GKRS during the study period. Of these, 40 children (with 61 neoplasms) had follow up available and were included in the study. The mean age was 16 years (6-18 years). 17 patients received primary GKRS, 20 patients received secondary and 3 patients received both. The median tumor volume was 3.3cm3 (0.14 - 38.9 cm3). The mean dose was 12.56 Gy at 50% isodose line. The majority of the tumors were Meningioma (n=20) followed by Acoustic Schwannoma (n=17). The mean treatment time was 67.04 minutes. 33 tumors responded favourably to GKRS, 24 showed a stable size, 3 had no response while 1 progressed requiring surgery. CONCLUSION: GKRS has the potential to become an indispensable tool in the management of pediatric brain neoplasms

Gamma knife radiosurgery as an efficacious treatment for paediatric central nervous system tumours: a retrospective study of 61 neoplasms

PURPOSE

Brain tumours have an incidence of 1.15 to 5.14 cases per 100,000 children and are associated with significant morbidity and mortality. Radiosurgery has become a promising approach to manage these paediatric CNS tumours. The aim of the present study was to analyse the efficacy of radiosurgery in the treatment of a variety of paediatric tumours of CNS.

METHODS

This retrospective study was conducted from 1997 to 2012 at a single Neurosurgery centre. All paediatric patients (≤ 18 years of age) with CNS tumours who were treated with gamma knife radiosurgery (GKRS) and had a minimum follow up of 6 months were included in the study. Patients with lesions other than tumours were excluded. Clinical, radiological and GKRS planning data was collected and analysed in all patients.

RESULTS

A total of 76 children with brain tumours had GKRS during the study period. Of these, 40 children (with 61 neoplasms) had follow-up available and were included in the study. The mean age was 16 years (6-18 years). Seventeen patients received primary GKRS, 20 patients received secondary, and 3 patients received both. The median tumour volume was 3.3 cm³ (0.14-38.9 cm3). The mean dose was 12.56 Gy at 50% isodose line. The majority of the tumours were meningioma (n = 20) followed by acoustic schwannoma (n = 17). The mean treatment time was 67.04 min. Thirty-three tumours responded favourably to GKRS, 24 showed a stable size, 3 had no response while 1 progressed, requiring surgery.

CONCLUSION

GKRS has the potential to become an indispensable tool in the management of paediatric brain neoplasms.