Unveiling the axonal connectivity between the precuneus and temporal pole: Structural evidence from the cingulum pathways.

Neuroimaging studies have consistently demonstrated concurrent activation of the human precuneus and temporal pole (TP), both during resting-state conditions and various higher-order cognitive functions. However, the precise underlying structural connectivity between these brain regions remains uncertain despite significant advancements in neuroscience research. In this study, we investigated the connectivity of the precuneus and TP by employing parcellation-based fiber micro-dissections in human brains and fiber tractography techniques in a sample of 1065 human subjects and a sample of 41 rhesus macaques. Our results demonstrate the connectivity between the posterior precuneus area POS2 and the areas 35, 36, and TG of the TP via the fifth subcomponent of the cingulum (CB-V) also known as parahippocampal cingulum. This finding contributes to our understanding of the connections within the posteromedial cortices, facilitating a more comprehensive integration of anatomy and function in both normal and pathological brain processes. PRACTITIONER POINTS: Our investigation delves into the intricate architecture and connectivity patterns of subregions within the precuneus and temporal pole, filling a crucial gap in our knowledge. We revealed a direct axonal connection between the posterior precuneus (POS2) and specific areas (35, 35, and TG) of the temporal pole. The direct connections are part of the CB-V pathway and exhibit a significant association with the cingulum, SRF, forceps major, and ILF. Population-based human tractography and rhesus macaque fiber tractography showed consistent results that support micro-dissection outcomes.

Functional and union outcome of combined column tibial plateau fracture treated with hybrid external fixator.

Objective: To determine the combined column tibial plateau fracture treated with a hybrid external fixator in terms of knee functionality, union outcome and complications. METHODS: The quasi-experimental study was conducted at the Department of Orthopaedic Surgery, Mayo Hospital, Lahore, Pakistan, from July 5, 2019, to December 31, 2021, and comprised patients of either gender aged 20-50 years who presented with 2-column or 3-column fractures of proximal tibia classified according to the 3-column classification system after being diagnosed using radiographs and three-dimensional computed tomography scan. Knee function, union and complications, like neural, vascular, infection, delayed union, nonunion, malunion and implant failure, were evaluated. The Knee Society Score was used to assess knee function, and modified Rasmussen score for the union, while complications were assessed clinically on the 2nd, 6th, 12th, 16th, 24th, 36th weeks and one year post-operatively. Data was analysed using SPSS 26. RESULTS: Of the 113 patients, 91(80.53%) were males and 22(19.47%) were females. The overall mean age was 35.56±9.00 years. From the 12th week to the 24th week 45(39.83%) patients had good and 59(52.21%) patients had excellent functional outcomes. Union outcome in the 16th and 24th week was good in 57(50.44%) patients and excellent in 47(41.59%) patients. No neurovascular injury was observed. Superficial pin tract infection was observed in 21(18.6%) cases that healed with wound debridement and antibiotics. No delayed union, malunion and implant failure was observed. CONCLUSIONS: Good to excellent functional and union outcomes with minimum complications were observed with the hybrid external fixator.

Impact of emotional intelligence in resolving clinical conflicts among postgraduate residents of surgery.

Background & Objective: Emotional intelligence (EI) can become a vital tool for resolving clinical conflicts (CC) in surgery. The postgraduate residents focus on the technical skills and undermine the soft skills required for their better training. Our aim was to determine the EI of postgraduate resident (PGR) years one & two in General and Orthopedic Surgery. The CC in their workplace and how they use their EI to resolve these conflicts. Methods: This mixed-method study was conducted from March 10, 2019 to May 28, 2020 at Departments of General and Orthopedic Surgery, Mayo Hospital, Lahore. The study was conducted in two phases 1 & 2. In Phase-1, one hundred PGR years one & two were administered the Mayor-Salovey-Caruso Emotional Intelligence test (MSCEIT) to measure EI. In phase-2, semi-structured in-depth interviews of 10 PGRs five with high and five with low EI were conducted to determine the CC and use of EI to resolve the CC at the workplace. A thematic analysis was done. Results: Out of 100 PGR, the mean EI score was 46.25±14.8 with a maximum score of 75.4, and a minimum score of 18.16 (p-value =0.775). Ninety-one (91%) have not improving EI, and 09 (09%) have considered developing EI. Five themes in four settings, including emergency, ward, elective operation theatre, and outpatient department (OPD) were determined. The emerged themes for the CC were nepotism, gender biases, burnout, lack of professionalism, and toxic culture. The following were CC management strategies: self-study, deceit, gender affinity, performing attention-attaining work, aggrieved reaction and being disgruntled when alone. Conclusion: None of the PGR was emotionally intelligent in overall grades, as well as a particular aspect of MSCEIT.

Isolation of lectin from Musa acuminata for its antibiofilm potential against Methicillin-resistant Staphylococcus aureus and its synergistic effect with Enterococcus species.

Methicillin resistant Staphylococcus aureus (MRSA) is an emerging pathogen posing a considerable burden on the healthcare system due to its involvement in skin and soft tissue infections (SSTIs). Lectins are carbohydrate binding proteins found ubiquitously in animals, plants and microorganisms. Extraction and isolation of proteins from Musa acuminata were performed by using Affinity chromatography with Sephadex G 75 to determine antibiofilm activity against MRSA. Enterococcus strains obtained from dairy products, beans and vegetables were also screened for its potential to inhibit growth and biofilm formation of MRSA by using 96 well microtiter plates. Synergistic effect of cell free supernatant of Enterococcus with proteins from ripe banana were also tested. BanLec was successfully isolated and appeared as 15 KDa band after SDS-PAGE (15%) while multiple bands of unbound protein fractions were observed. The unbound fractions showed inhibition of planktonic cells and biofilm but BanLec exhibited no significant effect. The CFS of Enterococcus faecium (LCM002), Enterococcus lactis (LCM003) and Enterococcus durans (LCM004 and LCM005) displayed antagonistic effects against pathogen. The synergistic effect of CFS from E. lactis (LCM003) and unbound proteins showed inhibition of biofilm and pathogenic growth. This study demonstrates the use of Enterococcus species and plant proteins against pathogens and results suggested that it can inhibit the growth of resistant strains of Staphylococcus aureus and their synergistic effect has opened new ways to tackle emerging resistance. Furthermore, after assessment of Enterococcus as probiotics, this could be used in food industries as well as in treatment of severe skin infections.

Preoperative Frailty Predicts Worse Outcomes after Microvascular Decompression for Trigeminal Neuralgia, Hemifacial Spasm, and Glossopharyngeal Neuralgia: A Multicenter Analysis of 1,473 Patients from a Prospective Surgical Registry.

INTRODUCTION: Microvascular decompression (MVD) is an efficacious neurosurgical intervention for patients with medically intractable neurovascular compression syndromes. However, MVD may occasionally cause life-threatening or altering complications, particularly in patients unfit for surgical operations. Recent literature suggests a lack of association between chronological age and surgical outcomes for MVD. The Risk Analysis Index (RAI) is a validated frailty tool for surgical populations (both clinical and large database). The present study sought to evaluate the prognostic ability of frailty, as measured by RAI, to predict outcomes for patients undergoing MVD from a large multicenter surgical registry. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database (2011-2020) was queried using diagnosis/procedure codes for patients undergoing MVD procedures for trigeminal neuralgia (n = 1,211), hemifacial spasm (n = 236), or glossopharyngeal neuralgia (n = 26). The relationship between preoperative frailty (measured by RAI and 5-factor modified frailty index [mFI-5]) for primary endpoint of adverse discharge outcome (AD) was analyzed. AD was defined as discharge to a facility which was not home, hospice, or death within 30 days. Discriminatory accuracy for prediction of AD was assessed by computation of C-statistics (with 95% confidence interval) from receiver operating characteristic (ROC) curve analysis. RESULTS: Patients undergoing MVD (N = 1,473) were stratified by RAI frailty bins: 71% with RAI 0-20, 28% with RAI 21-30, and 1.2% with RAI 31+. Compared to RAI score 19 and below, RAI 20 and above had significantly higher rates of postoperative major complications (2.8% vs. 1.1%, p = 0.01), Clavien-Dindo grade IV complications (2.8% vs. 0.7%, p = 0.001), and AD (6.1% vs. 1.0%, p < 0.001). The rate of primary endpoint was 2.4% (N = 36) and was positively associated with increasing frailty tier: 1.5% in 0-20, 5.8% in 21-30, and 11.8% in 31+. RAI score demonstrated excellent discriminatory accuracy for primary endpoint in ROC analysis (C-statistic: 0.77, 95% CI: 0.74-0.79) and demonstrated superior discrimination compared to mFI-5 (C-statistic: 0.64, 95% CI: 0.61-0.66) (DeLong pairwise test, p = 0.003). CONCLUSIONS: This was the first study to link preoperative frailty to worse surgical outcomes after MVD surgery. RAI frailty score predicts AD after MVD with excellent discrimination and holds promise for preoperative counseling and risk stratification of surgical candidates. A risk assessment tool was developed and deployed with a user-friendly calculator: https://nsgyfrailtyoutcomeslab.shinyapps.io/microvascularDecompression.

Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet? A systematic review.

Failure to rescue (FTR) is a standardized patient safety indicator (PSI-04) developed by the Agency for Healthcare Research and Quality (AHRQ) to assess the ability of a healthcare team to prevent mortality following a major complication. However, FTR rates vary and are impacted by non-modifiable individual patient characteristics such as baseline frailty. This raises concerns regarding the validity of FTR as an objective quality metric, as not all patients have the same baseline frailty level, or physiological reserve, to recover from major complications. Literature from other surgical specialties has identified flaws in FTR and called for risk-adjusted metrics. Currently, knowledge of factors influencing FTR and its subsequent implementation in neurosurgical patients are limited. The present review assesses trends in FTR utilization to assess how FTR performs as an objective neurosurgery quality metric. This review then proposes how FTR may be best modified to optimize use in neurosurgical patients. A PubMed search was performed to identify articles published until August 9, 2023. Studies that reported FTR as an outcome in patients undergoing neurosurgical procedures were included. A qualitative assessment was performed using the Newcastle Ottawa Scale (NOS). The initial search revealed 1232 citations. After a title and abstract screen, followed by a full text screen, 12 studies met criteria for inclusion. These articles measured FTR across a total of 764,349 patients undergoing neurosurgical procedures. Five studies analyzed FTR with regard to hospital characteristics, and three studies utilized patient characteristics to predict FTR. All studies were considered high quality based on the NOS. Modifications in criteria to measure FTR are necessary since FTR depends on patient characteristics like frailty. This would allow for the incorporation of risk-adjusted FTR metrics that would aid in clinical decision making in neurosurgical patients.

Improving preoperative prediction of surgery duration.

BACKGROUND: Operating rooms (ORs) are one of the costliest units in a hospital, therefore the cumulative consequences of any kind of inefficiency in OR management lead to a significant loss of revenue for the hospital, staff dissatisfaction, and patient care disruption. One of the possible solutions to improving OR efficiency is knowing a reliable estimate of the duration of operations. The literature suggests that the current methods used in hospitals, e.g., a surgeon's estimate for the given surgery or taking the average of only five previous records of the same procedure, have room for improvement. METHODS: We used over 4 years of elective surgery records (n = 52,171) from one of the major metropolitan hospitals in Australia. We developed robust Machine Learning (ML) approaches to provide a more accurate prediction of operation duration, especially in the absence of surgeon's estimation. Individual patient characteristics and historic surgery information attributed to medical records were used to train predictive models. A wide range of algorithms such as Extreme Gradient Boosting (XGBoost) and Random Forest (RF) were tested for predicting operation duration. RESULTS: The results show that the XGBoost model provided statistically significantly less error than other compared ML models. The XGBoost model also reduced the total absolute error by 6854 min (i.e., about 114 h) compared to the current hospital methods. CONCLUSION: The results indicate the potential of using ML methods for reaching a more accurate estimation of operation duration compared to current methods used in the hospital. In addition, using a set of realistic features in the ML models that are available at the point of OR scheduling enabled the potential deployment of the proposed approach.

Preoperative frailty and 30-day mortality after resection of brain metastases: a multicenter surgical registry analysis of 11,038 patients.

OBJECTIVE: Surgery plays a key role in the management of brain metastases. Stratifying surgical risk and individualizing treatment will help optimize outcomes because there is clinical equipoise between radiation and resection as treatment options for many patients. Here, the authors used a multicenter database to assess the prognostic utility of baseline frailty, calculated with the Risk Analysis Index (RAI), for prediction of mortality within 30 days after surgery for brain metastasis. METHODS: The authors pooled patients who had been surgically treated for brain metastasis from the American College of Surgeons National Surgical Quality Improvement Program database (2012-2020). The authors studied the relationship between preoperative calculated RAI score and 30-day mortality after surgery for brain metastasis by using linear-by-linear proportional trend tests and binary logistic regression. The authors calculated C-statistics (with 95% CIs) in receiver operating characteristic (ROC) curve analysis to assess discriminative accuracy. RESULTS: The authors identified 11,038 patients who underwent brain metastasis resection with a median (interquartile range) age of 62 (54-69) years. The authors categorized patients into four groups on the basis of RAI: robust (RAI 0-20), 8.1% of patients; normal (RAI 21-30), 9.2%; frail (RAI 31-40), 75%; and severely frail (RAI ≥ 41), 8.1%. The authors found a positive correlation between 30-day mortality and frailty. RAI demonstrated superior predictive discrimination for 30-day mortality as compared with the 5-factor modified frailty index (mFI-5) on ROC analysis (C-statistic 0.65, 95% CI 0.65-0.66). CONCLUSIONS: The RAI frailty score accurately estimates 30-day mortality after brain metastasis resection and can be calculated online with an open-access software tool: https://nsgyfrailtyoutcomeslab.shinyapps.io/BrainMetsResection/. Accordingly, RAI can be utilized to measure surgical risk, guide treatment options, and optimize outcomes for patients with brain metastases. RAI has superior discrimination for predicting 30-day mortality compared with mFI-5.

Thirty-day outcomes for suboccipital decompression in adults with Chiari malformation type I: a frailty-driven perspective from the American College of Surgeons National Surgical Quality Improvement Program.

OBJECTIVE: When indicated, patients with symptomatic Chiari malformation type I (CM-I) may benefit from suboccipital decompression (SOD). Although SOD is considered a lower-risk neurosurgical procedure, preoperative risk assessment and careful surgical patient selection remain critical. The objectives of the present study were twofold: 1) describe 30-day SOD outcomes for CM patients with attention to the impact of preoperative frailty and 2) design a predictive model for the primary endpoint of nonhome discharge (NHD). METHODS: There were 1015 CM-I patients who underwent SOD in the 2011-2020 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, as specified by diagnostic and procedural codes (Current Procedural Terminology code 61343). Descriptive statistics were used to analyze total cohort baseline demographics, preoperative comorbidities, and postoperative outcomes within 30 days of surgery. Univariate cross-tabulation was used to compare baseline demographics and preoperative characteristics across the NHD and home discharge (HD) cohorts. Receiver operating characteristic (ROC) curve analysis was used to assess the discriminative ability of the revised Risk Analysis Index (RAI-rev) on NHD. RESULTS: The study cohort had a median age of 36 years, and 80.6% of patients were female. Race distribution was categorized as White (69.9%), Black (16.6%), and other groups (13.6%). The most common preoperative comorbidities were active smoking (24.4%), hypertension (19.2%), and diabetes mellitus (4.7%). The primary outcome of NHD occurred in 4.6% of patients (n = 47). Increasing frailty (measured by the RAI-rev) was associated with a stepwise increase in the rate of NHD: 2.3% for RAI-rev scores 0-10, 5.8% for RAI-rev scores 11-15, 7.6% for RAI-rev scores 16-20, 18.2% for RAI-rev scores 21-25, and 77.8% for RAI-rev scores ≥ 26 (p < 0.001). Other preoperative factors associated with NHD included older age, nonelective surgery, diabetes, hypertension, and elevated creatinine (all p < 0.01). The other most common 30-day complications included unplanned readmission (9.3%), unplanned reoperation (5.3%), return to the operating room (5.8%), Clavien-Dindo grade IV (life-threatening) (1.5%), organ space surgical site infection (SSI) (1.5%), superficial SSI (1.4%), and reoperation for a CSF leak (1.1%). Surgical mortality (within 30 days) was extremely rare (1/1015, 0.1%). ROC curve analysis demonstrated that RAI-rev predicted NHD with significant discriminatory accuracy among CM-I patients who received SOD treatment (C-statistic 0.731, 95% CI 0.648-0.814). CONCLUSIONS: This decade-long analysis of a multicenter surgical registry provides internationally representative, modern rates of 30-day outcomes after suboccipital decompression (with or without duraplasty) for adult CM-I patients. Preoperative frailty assessment with the RAI-rev may help identify higher-risk surgical candidates.

Frailty as a Superior Predictor of Dysphagia and Surgically Placed Feeding Tube Requirement After Anterior Cervical Discectomy and Fusion Relative to Age.

Frailty is a measure of physiological reserve that has been demonstrated to be a discriminative predictor of worse outcomes across multiple surgical subspecialties. Anterior cervical discectomy and fusion (ACDF) is one of the most common neurosurgical procedures in the United States and has a high incidence of postoperative dysphagia. To determine the association between frailty and dysphagia after ACDF and compare the predictive value of frailty and age. 155,300 patients with cervical stenosis (CS) who received ACDF were selected from the 2016-2019 National Inpatient Sample (NIS) utilizing International Classification of Disease, tenth edition (ICD-10) codes. The 11-point modified frailty index (mFI-11) was used to stratify patients based on frailty: mFI-11 = 0 was robust, mFI-11 = 1 was prefrail, mFI-11 = 2 was frail, and mFI-11 = 3 + was characterized as severely frail. Demographics, complications, and outcomes were compared between frailty groups. A total of 155,300 patients undergoing ACDF for CS were identified, 33,475 (21.6%) of whom were frail. Dysphagia occurred in 11,065 (7.1%) of all patients, and its incidence was significantly higher for frail patients (OR 1.569, p < 0.001). Frailty was a risk factor for postoperative complications (OR 1.681, p < 0.001). Increasing frailty and undergoing multilevel ACDF were significant independent predictors of negative postoperative outcomes, including dysphagia, surgically placed feeding tube (SPFT), prolonged LOS, non-home discharge, inpatient death, and increased total charges (p < 0.001 for all). Increasing mFI-11 score has better prognostic value than patient age in predicting postoperative dysphagia and SPFT after ACDF.

A discrete event simulation for improving operating theatre efficiency.

BACKGROUND: Increasing demand in healthcare services has posed excessive burden on healthcare professionals and hospitals with finite capacity. Operating theatres are critical resources within hospitals that can become bottlenecks in patient flow during high demand conditions. There are substantial costs associated with running operating theatres that include keeping professional staff ready, maintaining operating theatres and equipment, environmental services and cleaning of operating theatres and recovery rooms, and these costs can increase if theatres are not used efficiently. In addition to cost, operating theatre inefficiency can result in surgery cancelations and delays, and eventually, poor patient outcomes, which can be exacerbated under the increase in demand. METHODS: The allocation of surgeries to operating theatres is explored using a simulation model for patients admitted to inpatient beds and sent for surgery. We proposed a discrete event simulation (DES) to model incoming flow to operating theatres of a major metropolitan hospital. We assessed how changing the configuration of surgery at the target hospital affects Key Performance Indicators relating to theatre efficiency. In particular, the model was used to assess impacts of six different scenarios by defining new/hypothetical theatre case-mix, opening and closing times of theatres, turnaround (changeover) time, and repurposing the theatres. Target performance metrics included theatre utilisation, pre-operative length-of-stay, average reclaimable time, the percentage of total theatre time in a year that could be reclaimed, and patient waiting time. A web-based application was developed that allows testing user-defined scenarios and interactive analysis of the results. RESULTS: Extending the opening hours of operating theatres by 1 hour almost halved the number of deferred electives as well as over-run cases but at the expense of reduced theatre utilisation. A one-hour reduction in opening hours resulted in 10 times more deferred elective cases and a negligible increase in theatre utilisation. Reducing turnaround time by 50% had positive effects on theatre management: increased utilisation and less deferred and over-run elective cases. Pooling emergency theatres did not affect theatre utilisation but resulted in a considerable reduction in average wait time and the proportion of the delayed emergency cases. CONCLUSIONS: The developed DES-based simulation model of operating theatres along with the web-based user interface provided a useful interrogation tool for theatre management and hospital executive teams to assess new operational strategies. The next step is to embed simulation as ongoing practices in theatre planning workflow, allowing operational managers to use the model outputs to increase theatre utilisation, and reduce cancellations and schedule changes. This can support hospitals in providing services as efficiently and effectively as possible.

RIS-Enabled Secret Key Generation for Secured Vehicular Communication in the Presence of Denial-of-Service Attacks.

Wireless communication has become an integral part of modern vehicles. However, securing the information exchanged between interconnected terminals poses a significant challenge. Effective security solutions should be computationally inexpensive, ultra-reliable, and capable of operating in any wireless propagation environment. Physical layer secret key generation has emerged as a promising technique, which leverages the inherent randomness of wireless-channel responses in amplitude and phase to generate high-entropy symmetric shared keys. The sensitivity of the channel-phase responses to the distance between network terminals makes this technique a viable solution for secure vehicular communication, given the dynamic behavior of these terminals. However, the practical implementation of this technique in vehicular communication is hindered by fluctuations in the communication link between line-of-sight (LoS) and non-line-of-sight (NLoS) conditions. This study introduces a key-generation approach that uses a reconfigurable intelligent surface (RIS) to secure message exchange in vehicular communication. The RIS improves the performance of key extraction in scenarios with low signal-to-noise ratios (SNRs) and NLoS conditions. Additionally, it enhances the network's security against denial-of-service (DoS) attacks. In this context, we propose an efficient RIS configuration optimization technique that reinforces the signals received from legitimate users and weakens the signals from potential adversaries. The effectiveness of the proposed scheme is evaluated through practical implementation using a 1-bit RIS with 64×64 elements and software-defined radios operating within the 5G frequency band. The results demonstrate improved key-extraction performance and increased resistance to DoS attacks. The hardware implementation of the proposed approach further validated its effectiveness in enhancing key-extraction performance in terms of the key generation and mismatch rates, while reducing the effect of the DoS attacks on the network.

Frailty and outcomes in lacunar stroke.

BACKGROUND: Lacunar strokes (LS) are ischemic strokes of the small perforating arteries of deep gray and white matter of the brain. Frailty has been associated with greater mortality and attenuated response to treatment after stroke. However, the effect of frailty on patients with LS has not been previously described. OBJECTIVE: To analyze the association between frailty and outcomes in LS. METHODS: Patients with LS were selected from the National Inpatient Sample (NIS) 2016-2019 using the International Classification of Disease, 10th edition (ICD-10) diagnosis codes. The 11-point modified frailty scale (mFI-11) was used to group patients into severely frail and non-severely frail cohorts. Demographics, clinical characteristics, and complications were defined. Health care resource utilization (HRU) was evaluated by comparing total hospital charges and length of stay (LOS). Other outcomes studied were discharge disposition and inpatient death. RESULTS: Of 48,980 patients with LS, 10,830 (22.1%) were severely frail. Severely frail patients were more likely to be older, have comorbidities, and pertain to lower socioeconomic status categories. Severely frail patients with LS had worse clinical stroke severity and increased rates of complications such as urinary tract infection (UTI) and pneumonia (PNA). Additionally, severe frailty was associated with unfavorable outcomes and increased HRU. CONCLUSION: Severe frailty in LS patients is associated with higher rates of complications and increased HRU. Risk stratification based on frailty may allow for individualized treatments to help mitigate adverse outcomes in the setting of LS.

Dog bite management practices by general practitioners; where are we standing in ASIA; a narrative review.

Rabies is an infectious viral disease endemic worldwide and is fatal after the onset of clinical symptoms. In 99% of cases, dogs contribute to infectious viral transmission in humans. It causes approximately 10,000 deaths per year, mainly in Asia and Africa, with 95% of deaths occurring in Asia alone. Currently, the number of dog bite cases reported in Pakistan is alarming. Such cases are first seen mostly by general practitioners. The current narrative review was planned to assess the knowledge, attitude and practices of general practitioners as reported in the literature from different countries published between July 2016 and February 2021 regarding dog bite management. Articles were searched using Google, Google Scholar, Ovid, Eric and PubMed databases. Keywords used included rabies, dog bite, general practitioners, medical officers, knowledge, attitude and practices. A total of 7 studies comprising 875 participants were included. Because of the increasing human population, a growing number of dogs and a lack of concerted efforts for the control of disease, the burden of human deaths as a result of rabies will continue to escalate.

Prevalence and severity of restless leg syndrome in patients with spinal cord injuries.

OBJECTIVE: To determine the prevalence of restless leg syndrome in patients with spinal cord injury using a consensus criterion. METHODS: The cross-sectional study was conducted from November 29, 2018, to February 28, 2021 at the departments of Neurology and Orthopaedic Surgery, King Edward Medical University, Mayo Hospital, Lahore, Pakistan, and comprised patients of either gender aged 18-80 years having spinal cord injuries. All the patients were interviewed using a 10-item questionnaire, and were assessed using the five-point consensus criteria of the International Restless Leg Syndrome Study Group. Data was analysed using SPSS 20. RESULTS: Of the 253 patients, 128(50.6%) were males and 125(49.4%) were females. The overall mean age was 38.6±14.2 years. Restless leg syndrome was present in 116(45.8%) patients, and 64(55.2%) of them were males (p>0.05). The mean duration of the symptoms was 18.9±16.9 months. Causes of spinal cord injury included metastasis 28(11.1%) multiple sclerosis 32(12.6%), neuromyelitis optica spectrum disorders 68(26.9%), tuberculous spondylitis 85(33.6%), trauma 24(9.5%) and viral myelitis 16(6.3%). CONCLUSIONS: Restless leg syndrome was prevalent in less than half the patients having spinal cord injury. It was more prevalent in males compared to females, but the difference was not significant.

Preoperative frailty measured by risk analysis index predicts complications and poor discharge outcomes after Brain Tumor Resection in a large multi-center analysis.

PURPOSE: To evaluate the independent effect of frailty, as measured by the Risk Analysis Index-Administrative (RAI-A) for postoperative complications and discharge outcomes following brain tumor resection (BTR) in a large multi-center analysis. METHODS: Patients undergoing BTR were queried from the National Surgical Quality Improvement Program (NSIQP) for the years 2015 to 2019. Multivariable logistic regression was performed to evaluate the independent associations between frailty tools (age, 5-factor modified frailty score [mFI-5], and RAI-A) on postoperative complications and discharge outcomes. RESULTS: We identified 30,951 patients who underwent craniotomy for BTR; the median age of our study sample was 59 (IQR 47-68) years old and 47.8% of patients were male. Overall, increasing RAI-A score, in an overall stepwise fashion, was associated with increasing risk of adverse outcomes including in-hospital mortality, non-routine discharge, major complications, Clavien-Dindo Grade IV complication, and extended length of stay. Multivariable regression analysis (adjusting for age, sex, BMI, non-elective surgery status, race, and ethnicity) demonstrated that RAI-A was an independent predictor for worse BTR outcomes. The RAI-A tiers 41-45 (1.2% cohort) and > 45 (0.3% cohort) were ~ 4 (Odds Ratio [OR]: 4.3, 95% CI: 2.1-8.9) and ~ 9 (OR: 9.5, 95% CI: 3.9-22.9) times more likely to have in-hospital mortality compared to RAI-A 0-20 (34% cohort). CONCLUSIONS AND RELEVANCE: Increasing preoperative frailty as measured by the RAI-A score is independently associated with increased risk of complications and adverse discharge outcomes after BTR. The RAI-A may help providers present better preoperative risk assessment for patients and families weighing the risks and benefits of potential BTR.

Rapid exponential increase in neurosurgery departmental scholarly output following an intensive research initiative.

There has been extensive research into methods of increasing academic departmental scholarly activity (DSA) through targeted interventions. Residency programmes are responsible for ensuring sufficient scholarly opportunities for residents. We sought to discover the outcomes of an intensive research initiative (IRI) on DSA in our department in a short-time interval. IRI was implemented, consisting of multiple interventions, to rapidly produce an increase in DSA through resident/medical student faculty engagement. We compare pre-IRI (8 years) and post-IRI (2 years) research products (RP), defined as the sum of oral presentations and publications, to evaluate the IRI. The study was performed in 2020. The IRI resulted in an exponential increase in DSA with an annual RP increase of 350% from 2017 (3 RP) to 2018 (14 RP), with another 92% from 2018 (14 RP) to 2019 (27 RP). RP/year exponentially increased from 2.1/year to 10.5/year for residents and 0.5/year to 10/year for medical students, resulting in a 400% and 1900% increase in RP/year, respectively. The common methods in literature to increase DSA included instituting protected research time (23.8%) and research curriculum (21.5%). We share our department's increase in DSA over a short 2-year period after implementing our IRI. Our goal in reporting our experience is to provide an example for departments that need to rapidly increase their DSA. By reporting the shortest time interval to achieve exponential DSA growth, we hope this example can support programmes in petitioning hospitals and medical colleges for academic support resources.

Divergent roles of astrocytic versus neuronal EAAT2 deficiency on cognition and overlap with aging and Alzheimer's molecular signatures.

The excitatory amino acid transporter 2 (EAAT2) is the major glutamate transporter in the brain expressed predominantly in astrocytes and at low levels in neurons and axonal terminals. EAAT2 expression is reduced in aging and sporadic Alzheimer's disease (AD) patients' brains. The role EAAT2 plays in cognitive aging and its associated mechanisms remains largely unknown. Here, we show that conditional deletion of astrocytic and neuronal EAAT2 results in age-related cognitive deficits. Astrocytic, but not neuronal EAAT2, deletion leads to early deficits in short-term memory and in spatial reference learning and long-term memory. Neuronal EAAT2 loss results in late-onset spatial reference long-term memory deficit. Neuronal EAAT2 deletion leads to dysregulation of the kynurenine pathway, and astrocytic EAAT2 deficiency results in dysfunction of innate and adaptive immune pathways, which correlate with cognitive decline. Astrocytic EAAT2 deficiency also shows transcriptomic overlaps with human aging and AD. Overall, the present study shows that in addition to the widely recognized astrocytic EAAT2, neuronal EAAT2 plays a role in hippocampus-dependent memory. Furthermore, the gene expression profiles associated with astrocytic and neuronal EAAT2 deletion are substantially different, with the former associated with inflammation and synaptic function similar to changes observed in human AD and gene expression changes associated with inflammation similar to the aging human brain.

Preoperative risk model for perioperative stroke after intracranial tumor resection: ACS NSQIP analysis of 30,951 cases.

OBJECTIVE: Perioperative and/or postoperative cerebrovascular accidents (PCVAs) after intracranial tumor resection (ITR) are serious complications with devastating effects on quality of life and survival. Here, the authors retrospectively analyzed a prospectively maintained, multicenter surgical registry to design a risk model for PCVA after ITR to support efforts in neurosurgical personalized medicine to risk stratify patients and potentially mitigate poor outcomes. METHODS: The National Surgical Quality Improvement Program database was queried for ITR cases (2015-2019, n = 30,951). Patients with and without PCVAs were compared on baseline demographics, preoperative clinical characteristics, and outcomes. Frailty (physiological reserve for surgery) was measured by the Revised Risk Analysis Index (RAI-rev). Logistic regression analysis was performed to identify independent associations between preoperative covariates and PCVA occurrence. The ITR-PCVA risk model was generated based on logit effect sizes and assessed in area under the receiver operating characteristic curve (AUROC) analysis. RESULTS: The rate of PCVA was 1.7% (n = 532). Patients with PCVAs, on average, were older and frailer, and had increased rates of nonelective surgery, interhospital transfer status, diabetes, hypertension, unintentional weight loss, and elevated BUN. PCVA was associated with higher rates of postoperative reintubation, infection, thromboembolic events, prolonged length of stay, readmission, reoperation, nonhome discharge destination, and 30-day mortality (all p < 0.001). In multivariable analysis, predictors of PCVAs included RAI "frail" category (OR 1.7, 95% CI 1.2-2.4; p = 0.006), Black (vs White) race (OR 1.5, 95% CI 1.1-2.1; p = 0.009), nonelective surgery (OR 1.4, 95% CI 1.1-1.7; p = 0.003), diabetes mellitus (OR 1.5, 95% CI 1.1-1.9; p = 0.002), hypertension (OR 1.4, 95% CI 1.1-1.7; p = 0.006), and preoperative elevated blood urea nitrogen (OR 1.4, 95% CI 1.1-1.8; p = 0.014). The ITR-PCVA predictive model was proposed from the resultant multivariable analysis and performed with a modest C-statistic in AUROC analysis of 0.64 (95% CI 0.61-0.66). Multicollinearity diagnostics did not detect any correlation between RAI-rev parameters and other covariates (variance inflation factor = 1). CONCLUSIONS: The current study proposes a novel preoperative risk model for PCVA in patients undergoing ITR. Patients with poor physiological reserve (measured by frailty), multiple comorbidities, abnormal preoperative laboratory values, and those admitted under high acuity were at highest risk. The ITR-PCVA risk model may support patient-centered counseling striving to respect goals of care and maximize quality of life. Future prospective studies are warranted to validate the ITR-PCVA risk model and evaluate its utility as a bedside clinical tool.

Daily surgery caseload prediction: towards improving operating theatre efficiency.

BACKGROUND: In many hospitals, operating theatres are not used to their full potential due to the dynamic nature of demand and the complexity of theatre scheduling. Theatre inefficiencies may lead to access block and delays in treating patients requiring critical care. This study aims to employ operating theatre data to provide decision support for improved theatre management. METHOD: Historical observations are used to predict long-term daily surgery caseload in various levels of granularity, from emergency versus elective surgeries to clinical specialty-level demands. A statistical modelling and a machine learning-based approach are developed to estimate daily surgery demand. The statistical model predicts daily demands based on historical observations through weekly rolling windows and calendar variables. The machine learning approach, based on regression algorithms, learns from a combination of temporal and sequential features. A de-identified data extract of elective and emergency surgeries at a major 783-bed metropolitan hospital over four years was used. The first three years of data were used as historical observations for training the models. The models were then evaluated on the final year of data. RESULTS: Daily counts of overall surgery at a hospital-level could be predicted with approximately 90% accuracy, though smaller subgroups of daily demands by medical specialty are less predictable. Predictions were generated on a daily basis a year in advance with consistent predictive performance across the forecast horizon. CONCLUSION: Predicting operating theatre demand is a viable component in theatre management, enabling hospitals to provide services as efficiently and effectively as possible to obtain the best health outcomes. Due to its consistent predictive performance over various forecasting ranges, this approach can inform both short-term staffing choices as well as long-term strategic planning.