The Legal Void Outside Brain Death in India: The Legislative Need of 'DNR' in Brain Death.

Objective: The legal definitions of brain death are tantamount for legal dogmas and sometimes criminal intimidation of the treating doctors. The tests for brain death are only applicable to patients planned for organ transplantation. We intend to discuss the necessity of the "Do Not Resuscitate (DNR)" legislature in cases of brain death patients and applicability of tests for brain death irrespective of the intention for organ donation. Methods: A comprehensive review of the literature was performed till May 31, 2020 from the MEDLINE (1966 to July 2019) and Web of Science (1900 to July 2019). Search criteria included all publications with the MESH terms: "Brain Death/legislation and jurisprudence"[Mesh] OR "Brain Death/organization and administration"[Mesh] AND "India" [Mesh]. We also discuss the different opinions and implications of brain death versus brain stem death in India with the senior author (KG) who was responsible for South Asia's first multi-organ transplant after certifying brain death. Additionally, a hypothetical scenario of a DNR case is discussed in the current legal paradigm of India. Results: The systematic search yielded only five articles reporting a series of brain stem death cases with an acceptance rate of organ transplant among brain stem deaths being 34.8%. The most common solid organs transplanted were the kidney (73%) and liver (21%). A hypothetical scenario of a DNR and possible legal implications of the same under the current 'Transplantation of Human Organs Act (THOA)' of India remains unclear. A comparison of brain death laws in most Asian countries shows a similar pattern regarding the declaration of brain death and the lack of knowledge or legislature regarding DNR cases. Conclusion: After the determination of brain death, discontinuation of organ support requires the consent of the family. The lack of education and the lack of awareness have been major impediments in this medico-legal battle. There is also an urgent need to make laws for cases that do not qualify for brain death. This would help in not only realistic realization but also better triage of the health care resources while legally safeguarding the medical fraternity.

Mobile phones and "inattention" injuries: the risk is real.

Mobile phones though indispensable have a flip side: in fact, they adversely affect our ergonomics and mobility. They share an etiologic burden on the changed profile of inattention injuries; and now have proven to be a necessary evil in the changing lifestyles. We aimed to evaluate the role of mobile phones as a causative factor in these head and neck injuries. We evaluated various injury statistics published throughout the world that attributed the concurrence of neurological injuries to portable handheld communication devices. We evaluated the dangers posed by simultaneous engagement on phone and mobility and examined the impact on walking and field of view. We have also reviewed the current management strategies to combat this new mode of injury. The recent sensation Pokémon Go has been discussed as a case study of a spike in the incidence of injuries due to mobile phone use. Age >35 years old is a risk factor for mobile phone use and injuries as they have a higher chance of being distracted (81%) when compared to millennials (70% distracted). The highest incidence was that of head injuries being 33.1% of the estimated total followed by face, including eyelid, eye area, and nose (32.7%); and neck (12.5%). The most common injury diagnoses included laceration (26.3% of estimated total), contusion/abrasion (24.5%), and internal organ injury (18.4%). A heightened sense of self-protection and a multitasking attitude remains at the core of the trouble despite having knowledge of the required behavior. The health hazard of mobile phone use driving or walking needs to be highlighted with special emphasis on public education, law adherence, and technological solutions to mitigate the risk. The onus lies on the public as any technological advance would only work on the multitasking strategy and the price would be paid by the vulnerable road users.

Clinical Outcome, Cognitive Function, and Quality of Life after Endoscopic Third Ventriculostomy versus Ventriculo-Peritoneal Shunt in Non-Tumor Hydrocephalus.

BACKGROUND: Endoscopic Third Ventriculostomy (ETV) is increasingly being accepted as the treatment of choice in place of Ventriculo-Peritoneal (VP) Shunt for hydrocephalus. However, their differences in cognitive and Quality of Life (QOL) scores have not been studied much in children. OBJECTIVE: To compare the outcome, cognitive function, and QOL between ETV and VP shunt. METHODS: Patients of non-tumor hydrocephalus treated with ETV or/and VP shunt underwent cognitive assessment (using modified child MMSE standardized as per the age group) and QOL (using PedsQL as per the age group in Physical, Emotional, Social, and School Functioning domains) in addition to the outcome of not requiring additional intervention. RESULTS: Out of 139 patients, there were 29 infants and 40 children upto 14 years. Among these children, ETV was the primary intervention in 45, VP shunt in 24, and could be studied for a mean follow-up of 1.7 years. Though ETV required lesser additional intervention than VP shunt (19.2% vs. 28.6%) in toddlers and older children, there was no overall significant difference. Subnormal cognitive scores were noted in 25%, 40%, and 50% after ETV, single shunt procedure, and multiple shunt procedures, respectively, with no statistically significant difference. Among the different domains of QOL, the child reported scores in the social domain were significantly better after ETV than VP shunt (475[+13] vs. 387[+43], P value 0.03), whereas most other scores were non-significantly better following ETV. CONCLUSION: Patients who underwent ETV show a trend for better clinical outcome, cognitive function, and QOL with significantly better child-reported QOL scores in the social domain.

The Aftermath of COVID-19 Lockdown- Why and How Should We Be Ready?

INTRODUCTION: Severe acute respiratory syndrome, coronavirus 2 (SARS-COV 2) has inexplicably and irreversibly changed the way of neurosurgery practice. There has been a substantial reduction in neurosurgical operations during the period of lockdown. The lockdown might be the most effective measure to curtail viral transmission. Once we return to the normalization of the lifestyle, there will be a backlog of unoperated pending cases along with the possibility of further spread of the coronavirus. METHODS: We reviewed the available literature and protocols for neurosurgical practice in different geographic locations. We drafted a consensus statement based on the literature and protocols suggested by the World Health Organization (WHO) and various professional societies to prevent the spread of SARS-COV2 while streamlining the neurosurgical practice. RESULTS: The consensus statement suggests the patient triage, workflow, resource distribution, and operational efficacy for care providers at different stages of management. The priority is set at personal protection while ensuring patients' safety, timely management, and capacity building. We performed a detailed subsection analysis for the management of trauma and set up for COVID-free hospitals for simultaneous management of routine neurosurgical indications. In this time of medicolegal upheaval, special consent from the patients should be taken in view of the chances of delay in management and the added risk of corona infection. The consensus statements are applicable to neurosurgical setups of all capacities. CONCLUSION: Along with the glaring problem of infection, there is another threat of neurosurgery emergency building up. This wave may overwhelm the already stretched systems to the hilt. We need to flatten this curve while avoiding contagion. These measures may guide neurosurgery practitioners to effectively manage patients ensuring the safety of caregivers and care seekers both.

Gamma Knife Radiosurgical Pallidotomy for Dystonia: Not a Fallen Angel.

The authors report a case of successful management of right side hemidystonia with gamma knife radiosurgery. A 24-year-old male with a history of birth asphyxia subsequently developed worsening right-sided torsional hemidystonia which failed to respond to the medical management. MRI of the brain was unremarkable. Stereotactic gamma knife radiosurgery (GKRS) was performed to create a lesion in the left posteroventral globus pallidum. The patient gradually improved over a course of 18 months without any complication. He obtained 61% improvement in dystonia rating scale. Radiosurgical pallidotomy is often viewed with suspicion and functional neurosurgeons show reluctance in preferring it to stereotactic radio frequency lesioning or stimulation surgery. The authors would like to highlight the chances of not only control, but also cure of the disease with this cost-effective treatment modality.

Letter to the Editor: Is Golf the New Football or Have We Made It So?

Lumbar Spine Injuries: Primary Prevention in Amateur and Professional Golf Players Sir, We read with interest the article by Goebel et al. 1 (Goebel D, Drollinger F, Drollinger A. Lumbar Spine Injuries: Primary Prevention in Amateur and Professional Golf Players. Sports Med Int Open. 2018; 2:179-184). We have been deeply interested in this sport and delved on the musings of competitiveness causing athletes to put un-natural strains on their bodies and vice-versa. While we do understand the cause of Lumbar spine injuries caused by athletes putting undue stress on their bodies, we need to understand that the reason for the same.

Proxy war against head injury: Myriads of conflicting laws and gender-based discrimination.

This article is the culmination of two axioms. The first is the authors' belief that the practice of medicine is, if anything, a social profession. The second is the glaring realization that conscience is the worst motivator. When we combine the two, we understand why a war needs to be waged for a stronger legislation making the wearing of helmets compulsory, and why doctors need to be at the forefront of this war.

Need for Grass Root Innovation in Developing Countries: Case for Stationary Binder Clips in Scalp Hemostasis.

OBJECTIVE: The primary training in any surgical practice starts with tissue handling and effective hemostasis. Neurosurgical procedures start with an incision in the scalp and require summative use of mechanical hemostats and bipolar coagulation to achieve hemostasis. Though Raney clips are the most popular and effective in maintaining hemostasis, their high cost and nonreusability become deterrents for routine use in resource-stricken environments. METHODS: We have compared stationery binder clips of different sizes with Raney clips on the parameters of effectiveness, availability, and cost. Binder clips were also used in intraoperative settings for scalp hemostasis. The comparative efficacy, additional usage of cautery, and need for sterilization are also discussed. RESULTS: We describe our experience with simple stationery metal binder clips in maintaining effective hemostasis in a cost-effective manner. The 25-mm size binder clip exerts same force as a Raney clip without any tissue injury. Practical application revealed effective scalp hemostasis up to blood pressure of 150 mm Hg. CONCLUSIONS: Stationery binder clips are a cost-effective, ready-to-use alternative for standard Raney clips.

Changing Hands: Why Being Ambidextrous Is a Trait That Needs to Be Acquired and Nurtured in Neurosurgery.

OBJECTIVE: The aim of this article is examine the issue of ambidexterity under the neurosurgical lens and demonstrate its need, its validity, and its advantages to neurosurgery as a whole. METHODS: Inspiration can be derived from extraordinary circumstances that shaped ordinary people into legends. There have been instances in history where highly skilled professionals relying on hand motor skills had the misfortune of having to relearn their skill set with the other, less dominant hand. RESULTS: We as neurosurgeons have always been ahead of the curve. It is only natural for us to understand the need and advantages of using both our hands with equal dexterity. Whether ambidexterity is an inherited trait or one that can be taught and, if practiced, mastered has been controversial. CONCLUSION: These remarkable individuals from history demonstrate that if one is willing to practice without ego and one has the right motivation, one can use both hands with equal dexterity.

From Conversation to Transformation: Mens' Perspective on Strange Nuances of Neurosurgical Practice for Women in India.

BACKGROUND: In India, men outnumber women in neurosurgery by a wide margin. At the graduation party of our woman colleague, we recalled the experiences of the past few years. It led to a transforming experience for the authors, who have hitherto only held the "mens' perspective." METHODS: Societal pressures of marriage, profession, family, and culture on women in India emerge readily in this conversational piece. A comparison with "obstetrics and gynecology" in which women dominate is drawn to better describe the idiosyncrasies of Indian society. The meaning of discrimination and equality is examined in terms of neurosurgical training for women. RESULTS: At present, the price of becoming a doctor in India is the youth of the kid and uncertainties in the career because of gruesome competition at each level, without any incentives. CONCLUSIONS: Conversation itself is one of the greatest forces for changing the situation and how this conversation can be taken forward to transform a "culture of discrimination" to a "culture of acceptance."

Arteries Paving the Way for Centrifugal Excision of Anterior Clinoidal Meningioma.

The anterior clinoidal meningiomas often engulf/encase or compress the internal carotid artery (ICA) and its branches, the optic nerve (ON), and structures passing through the superior orbital fissure (SOF). The transsylvian route of excising a tumor poses difficulty in exposing and safeguarding encased vessels. In addition, it may jeopardize the bulging brain and stretched veins, especially in large tumors. The objective is to present an operative video to demonstrate the technique of "centrifugal opening" and removal of anterior clinoidal meningiomas. The ICA, ON, and SOF are exposed after extradural anterior clinoidectomy. The dural base is devascularized and incised radially. Cuts start proximally from these neurovascular structures. The tumor is then debulked and removed by tracing these structures from proximal to distal. The arachnoid and veins are preserved. Early identification of the ICA, ON, and SOF provides better control and allows preservation of these structures despite their engulfment, encasement, or compression. The perforators and arteries are skeletonized in a stepwise manner to achieve maximal safe resection. Even with brain edema, the arachnoid and adjacent veins can be preserved. The technique was used by the authors in >15 cases with good outcome. Thus the discussed technique imparts better control of neurovascular structures with minimal handling of adjacent brain and veins, thereby allowing a more aggressive resection.