Reverse Lid Swinging Approach: A Case Series.

In this report, the authors describe the reverse lid swinging approach, which comprises lateral canthotomy, superior lateral cantholysis to free the upper eyelid, and an incision at the superonasal conjunctival fornix for orbital exposure. Four patients underwent orbitotomy using the reverse lid swinging approach for orbital tumor removal (n = 3) or orbital abscess drainage (n = 1). All 4 operations were uneventful, with no optic nerve dysfunction or extraocular dysmotility over the follow-up period. Satisfactory cosmesis was achieved with no visible external scar in all cases. The reverse lid swinging approach provides easy access to medial orbital lesions as demonstrated in the present case series.

Measurement and Management of QT Interval Prolongation for General Physicians.

One of the more challenging aspects of ECG interpretation is measurement and interpretation of the QT interval. This interval represents the time taken for the ventricles to completely repolarise after activation. Abnormal prolongation of the QT interval can lead to torsades de pointes, a form of potentially life-threatening polymorphic ventricular tachycardia (VT). Detection of a prolonged QT interval is essential as this can be a reversible problem, particularly in the context of the use of a variety of commonly prescribed medications in the hospital setting. Automated ECG printouts cannot be relied upon to diagnose QT interval prolongation; thus, the onus is on the clinician to identify it. This is a difficult task, as the normal QT interval is typically measured relative to the heart rate. Therefore, the QT interval often requires "correction" for the current heart rate, in order to correctly stratify the risk of torsades de pointes. A wealth of correctional formulae have been derived, but none has proven superior. We present an approach to the ECG in this context, and a step-by-step guide to manually measuring and correcting the QT interval, and an approach to management in common hospital-based clinical scenarios.

Minimalistic strategy for coronary sinus lead implant: A single tool capable of electrophysiological mapping, pressure measurement, and angiography.

BACKGROUND: Left ventricular (LV) lead implantation for cardiac resynchronization therapy (CRT) may be confounded by contrast load during attempted cannulation and lead dislodgement during guiding catheter splitting. An LV lead implant system with a steerable single catheter that completely avoids the use of guiding catheters when needed, acquires atrioventricular electrograms, measures intracardiac pressures, permits CS angiography, and has the ability to direct a coronary angioplasty wire that will lead the final delivery of LV lead into a CS tributary, may help limit contrast use and avoid lead dislodgement at CS guide sheath removal. METHODS AND RESULTS: In this article as a proof of concept, we describe the use of this minimalist technique as a first line approach in six patients who had standard indications for CRT. The LV lead was successfully implanted in a target vein in all patients without acute complications. Contrast was not used in half the group and the LV lead was successfully implanted without guiding catheter in four patients. The implantation technique evolved through the series and in the final patient, no guiding sheath or contrast was used. Postimplant lead positions on chest X-ray and lead parameters were stable in all patients at follow-up. CONCLUSION: In proof of concept paper, we describe a technique of LV lead implantation potentially without the use of contrast and standard CS guiding catheters. Once familiar, this approach may provide a less complicated strategy.

The importance of aspirin, catheterization accuracy, and catheter design in external ventricular drainage-related hemorrhage: a multicenter study of 1002 procedures.

BACKGROUND: External ventricular drainage (EVD) is the commonest neurosurgical procedure performed in daily neurosurgical practice, but relatively few studies have investigated the incidence and risk factors of its related hemorrhagic complications. METHODS: This was a multicenter retrospective review of consecutive EVD procedures. Patients 18 years or older who underwent EVD and had a routine postoperative computed tomography (CT) scan performed within 24 hours were included. EVD-related hemorrhage was defined as new intracranial hemorrhage immediately adjacent or within the ventricular catheter trajectory. The volume of hemorrhage and the position of the catheter tip were assessed. A review of patient-, disease-, and surgery-related factors including the ventricular catheter design utilized was conducted. The Bonferroni correction was applied to the alpha level of significance (0.05) for multivariable analysis. RESULTS: Nine hundred sixty-two patients underwent 1002 EVD performed by neurosurgeons in the operating theater. Sixteen percent (154) of patients were on aspirin before the procedure. Thirty-four percent (333) of patients had intracerebral hemorrhage, 25% (251) had aneurysmal subarachnoid hemorrhage and 16% (158) had traumatic brain injury. The mean duration from EVD to the first postoperative CT scan was 20 ± 4 h. EVD-related hematomas were detected after 81 procedures with a per-catheter risk of 8.1%. Mean hematoma volume was 1.2 ± 3.3 ml. Most were less than 1 ml (grade I, 79%, 64), 1 to 15 ml (grade II) in 20% (16) and a single clot larger than 15 ml (grade III, 1%) were detected. Clinically significant hemorrhage that resulted in catheter occlusion occurred in 1.7% (17) of procedures. Most catheters (62%, 625) were optimally placed, i.e., its tip being within the ipsilateral frontal horn or third ventricle. Three non-antibiotic-impregnated ventricular catheter designs were used with 55% (550) being the 2.2-mm Integra™ catheter, 14% (137) being the 2.8-mm Medtronic™ catheter, and 31% (315) being the 3.1-mm Codman™ catheter. Independent significant predictors for EVD-related hemorrhage were the preoperative prescription of aspirin (adjusted OR 1.94; 95% CI 1.10-3.44), catheter malposition (aOR 1.99; 95% CI 1.22-3.23), and use of the 2.8-mm Medtronic™ catheter (aOR 4.22; 95% CI 2.39-7.41). CONCLUSIONS: The per-catheter risk of hemorrhage was 8.1%, but the incidence of symptomatic hemorrhage was low. The only patient risk factor was aspirin intake. This is the first study to evaluate and establish an association between catheter malposition and catheter design with EVD-related hemorrhage.

BioMonitor 2 Pilot Study: Early Experience With Implantation of the Biotronik BioMonitor 2 Implantable Cardiac Monitor.

BACKGROUND: The BioMonitor 2 Pilot Study assessed the implantation procedure, the sensing amplitude and the remote monitoring transmission success rate of the second generation implantable cardiac monitor, the BioMonitor 2 (Biotronik, Berlin, Germany). METHODS: This was a prospective, multi-centre, single-arm, non-randomised study involving seven operators in five sites across Australia. Data were collected at implantation, during clinic visits at 1 week and 1 month post-implantation, and through wireless remote monitoring. RESULTS: Thirty patients with indications for long-term cardiac monitoring underwent successful insertion of a study device. The median implantation time was 9 minutes (interquartile range (IQR) 5-14 mins). The mean R-wave amplitude at 1 week was 0.75±0.39mV and remained stable over the follow-up period. Within 1 day, 97% of the patients connected to the remote monitoring network and daily messages were transmitted on 93.8% of all study days. Seventy-six per cent of patients transmitted at least one subcutaneous ECG (sECG), with a median number of sECGs per patient of seven (IQR 3-37) within 28 days. CONCLUSIONS: The results of the BioMonitor 2 Pilot study confirm the excellent sensing amplitudes afforded by this new device and the utility of the implantation tools and technique. Patient compliance with and the transmission success rate of the home monitoring system were excellent.

Prognostic Significance of Peri-procedural Myocardial Infarction in the Era of High Sensitivity Troponin: A Validation of the Joint ACCF/AHA/ESC/WHF Universal Definition of Type 4a Myocardial Infarction with High Sensitivity Troponin T.

AIMS: This study aims to validate the joint ACCF/AHA/ESC/WHF Universal Definition of peri-procedural myocardial infarction (PMI) with high sensitivity troponin T (hsTnT). METHODS: A retrospective cohort study encompassing patients admitted to our institution between May 2012 and April 2013 was performed. RESULTS: 630 patients underwent percutaneous coronary interventions during the study period. Among them, 459 patients met the inclusion criteria and were eligible for analyses. 76.9% of these patients were male, while the mean age was 68.6. PMI was observed in 4.3% of the patients based on the Universal Definition. The predictors of PMI were chronic kidney disease (OR: 3.0, p=0.026), family history of cardiovascular disease (OR: 2.7, p=0.043) and use of IIb/IIIa inhibitors (OR 4.2, p=0.01). MACE was reported in 4.4% of the patients at 12 months, and was significantly and independently associated with PMI (OR 7.3, p=0.003) in a multivariate model which accounted for lesion complexity, patients' baseline clinical information, dual-antiplatelet status at follow-up and various procedural characteristics. The post-procedural hsTnT was much higher in those who suffered MACE than those who did not (156 v.s. 43 ng/L, p<0.001). CONCLUSION: PMI as defined by the current Universal Definition using hsTnT is an independent predictor of adverse clinical outcome at 12 months in patients undergoing PCI. Accordingly, PMI remains a clinically relevant factor in current practice and should be considered a key outcome measure in clinical trials and a potential target for therapy.

A randomized-controlled trial of a digital, small incentive-based intervention for working adults with short sleep.

STUDY OBJECTIVES: We evaluated the efficacy of a digitally delivered, small and scalable incentive-based intervention program on sleep and wellbeing in short-sleeping, working adults. METHODS: A 22-week, parallel-group, randomized-controlled trial was conducted on 21-40 y participants gifted with FitbitTM devices to measure sleep for ≥2 years, as part of a broader healthy lifestyle study. About 225 short sleepers (141 males; average time-in-bed, TIB < 7h) were randomly assigned in a 2:1 ratio to Goal-Setting or Control groups. The Goal-Setting group received health vouchers (~USD 0.24) for meeting each sleep goal (i.e. increasing weeknight TIB by 30 min/sleeping before midnight).The study spanned three phases: (1) 2-week Baseline, (2) 10-week Intervention, and (3) 10-week Follow-Up. Wellbeing questionnaires were administered on Weeks 1-2, 11-12, and 21-22. RESULTS: Baseline weeknight TIB (mean ±â€…SD) was 387 ±â€…43 min (Goal-Setting) and 399 ±â€…44 min (Control), while bedtime was 00:53 ±â€…01:13 (Goal-Setting), and 00:38 ±â€…00:56 (Control). No difference in sleep outcomes was observed at study endpoints, but exploratory week-by-week analysis showed that on Weeks 3-5, TIB in the Goal-Setting group increased (9-18 min; ps < 0.05) while on Week 5, bedtimes shifted earlier (15 min; p < 0.01) compared to Baseline. Morning sleepiness was reduced in the Goal-Setting group (mean[SEM] = -3.17(1.53); p = 0.04) compared to Baseline, although between-group differences were not significant (p = 0.62). Main barriers to sleeping longer were work hours (35%), followed by leisure activities (23%) and family commitments (22%). CONCLUSION: Our program resulted in encouraging subjective sleep improvements and short-term sleep extension, but sustained transformation of sleep will probably require structural measures to overcome significant obstacles to sleep. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04878380 (hiSG Sleep Health Study (hiSG-SHS); https://clinicaltrials.gov/ct2/show/NCT04878380).

Action Potential Morphology Accurately Predicts Proarrhythmic Risk for Drugs With Potential to Prolong Cardiac Repolarization.

BACKGROUND: Drug-induced or acquired long QT syndrome occurs as a result of the unintended disruption of cardiac repolarization due to drugs that block cardiac ion channels. These side effects have been responsible for the withdrawal of a range of drugs from market and are a common reason for termination of the development of new drugs in the preclinical stage. Existing approaches to risk prediction are expensive and overly sensitive meaning that recently there have been renewed efforts, largely driven by the comprehensive proarrhythmic assay initiative, to develop more accurate methods for allocation of proarrhythmic risk. METHODS: In this study, we aimed to quantify changes in the morphology of the repolarization phase of the cardiac action potential as an indicator of proarrhythmia, supposing that these shape changes might precede the emergence of ectopic depolarizations that trigger arrhythmia. To do this, we describe a new method of quantifying action potential morphology by measuring the radius of curvature of the repolarization phase both in simulated action potentials, as well as in action potentials measured from induced pluripotent stem cell-derived cardiomyocytes. Features derived from the curvature signal were used as inputs for logistic regressions to predict proarrhythmic risk. RESULTS: Optimal risk classifiers based on morphology were able to correctly classify risk to drugs in the comprehensive proarrhythmic assay initiative panels with very high accuracy (0.9375) and outperformed conventional metrics based on action potential duration at 90% repolarization, triangulation, and charge movement (qNet). CONCLUSIONS: Analysis of action potential morphology in response to proarrhythmic drugs improves prediction of torsadogenic risk. Furthermore, morphology metrics can be measured directly from the action potential, potentially eliminating the burden of undertaking complex screens of potency and drug-binding kinetics against multiple cardiac ion channels. As such, this method has the potential to improve and streamline regulatory assessment of proarrhythmia in preclinical drug development.

Working-from-home persistently influences sleep and physical activity 2 years after the Covid-19 pandemic onset: a longitudinal sleep tracker and electronic diary-based study.

Objective: Working from home (WFH) has become common place since the Covid-19 pandemic. Early studies observed population-level shifts in sleep patterns (later and longer sleep) and physical activity (reduced PA), during home confinement. Other studies found these changes to depend on the proportion of days that individuals WFH (vs. work from office; WFO). Here, we examined the effects of WFH on sleep and activity patterns in the transition to normality during the later stages of the Covid-19 pandemic (Aug 2021-Jan 2022). Methods: Two-hundred and twenty-five working adults enrolled in a public health study were followed for 22 weeks. Sleep and activity data were collected with a consumer fitness tracker (Fitbit Versa 2). Over three 2-week periods (Phase 1/week 1-2: August 16-29, 2021; Phase 2/week 11-12: October 25-November 7, 2021; Phase 3/week 21-22: January 3-16, 2022), participants provided daily Fitbit sleep and activity records. Additionally, they completed daily phone-based ecological momentary assessment (EMA), providing ratings of sleep quality, wellbeing (mood, stress, motivation), and information on daily work arrangements (WFH, WFO, no work). Work arrangement data were used to examine the effects of WFH vs. WFO on sleep, activity, and wellbeing. Results: The proportion of WFH vs. WFO days fluctuated over the three measurement periods, mirroring evolving Covid restrictions. Across all three measurement periods WFH days were robustly associated with later bedtimes (+14.7 min), later wake times (+42.3 min), and longer Total Sleep Time (+20.2 min), compared to WFO days. Sleep efficiency was not affected. WFH was further associated with lower daily step count than WFO (-2,471 steps/day). WFH was associated with higher wellbeing ratings compared to WFO for those participants who had no children. However, for participants with children, these differences were not present. Conclusion: Pandemic-initiated changes in sleep and physical activity were sustained during the later stage of the pandemic. These changes could have longer term effects, and conscious effort is encouraged to harness the benefits (i.e., longer sleep), and mitigate the pitfalls (i.e., less physical activity). These findings are relevant for public health as hybrid WHF is likely to persist in a post-pandemic world.

Effects of E'Jiao on Skeletal Mineralisation, Osteocyte and WNT Signalling Inhibitors in Ovariectomised Rats.

E'Jiao is a traditional Chinese medicine derived from donkey skin. E'Jiao is reported to suppress elevated bone remodelling in ovariectomised rats but its mechanism of action is not known. To bridge this research gap, the current study aims to investigate the effects of E'Jiao on skeletal mineralisation, osteocyte and WNT signalling inhibitors in ovariectomised rats. Female Sprague-Dawley rats (3 months old) were ovariectomised and supplemented with E'Jiao at 0.26 g/kg, 0.53 g/kg and 1.06 g/kg, or 1% calcium carbonate (w/v) in drinking water. The rats were euthanised after two months of supplementation and their bones were collected for Fourier-transform infrared spectroscopy, histomorphometry and protein analysis. Neither ovariectomy nor treatment affected the skeletal mineral/matrix ratio, osteocyte number, empty lacunar number, and Dickkopf-1 and sclerostin protein levels (p > 0.05). Rats treated with calcium carbonate had a higher Dickkopf-1 level than baseline (p = 0.002) and E'Jiao at 0.53 g/kg (p = 0.002). In conclusion, E'Jiao has no significant effect on skeletal mineralisation, osteocyte and WNT signalling inhibitors in ovariectomised rats. The skeletal effect of E'Jiao might not be mediated through osteocytes.

The Role of Artificial Intelligence and Machine Learning in Clinical Cardiac Electrophysiology.

In recent years, numerous applications for artificial intelligence (AI) in cardiology have been found, due in part to large digitized data sets and the evolution of high-performance computing. In the discipline of cardiac electrophysiology (EP), a number of clinical, imaging, and electrical waveform data are considered in the diagnosis, prognostication, and management of arrhythmias, which lend themselves well to automation through AI. But equally relevant, AI offers a unique opportunity to discover novel EP concepts and improve clinical care through its inherent, hierarchical tenets of self-learning. In this review we focus on the application of AI in clinical EP and summarize state-of-the art, large, clinical studies in the following key domains: (1) electrocardiogram-based arrhythmia and disease classification; (2) atrial fibrillation source detection; (3) substrate and risk assessment for atrial fibrillation and ventricular tachyarrhythmias; and (4) predicting outcomes after cardiac resynchronization therapy. Many are small, single-centre, proof-of-concept investigations, but they still show ground-breaking performance of deep learning, a subdomain of AI, which surpasses traditional statistical analysis. Larger studies, for instance classifying arrhythmias from electrocardiogram recordings, have further provided external validation of their high accuracy. Ultimately, the performance of AI is dependent on the quality of the input data and the rigour of algorithm development. The field is still nascent and several barriers will need to be overcome, including prospective validation in large, well labelled data sets and more seamless information technology-based data collection/integration, before AI can be adopted into broader clinical EP practice. This review concludes with a discussion of these challenges and future work.

Indocyanine Green-Assisted Endoscopic Transorbital Excision of Lateral Orbital Apex Cavernous Hemangioma.

Orbital apex lesions posed operative difficulties to neurosurgeons and ophthalmologists due to limited surgical corridor and close vicinity to cranial nerves and arteries. Lateral orbital apex lesions were traditionally operated via the transcranial route by neurosurgeons. Recently, only a handful of reports have described the use of endoscope alone for excision of lateral orbital apex lesion. Our group, with both endoscopic skull base neurosurgeons and oculoplastic surgeons, has adopted the endoscopic transorbital approach for orbital apex lesions. We also used an indocyanine green (ICG) endoscope to aid identification and dissection of orbital apex cavernous hemangioma, which otherwise can be difficult to differentiate from surrounding intraconal recti muscles. Video 1 captured the first reported case of excision of lateral orbital apex cavernous hemangioma via endoscopic transorbital approach, using a zero-degree ICG endoscope. This was a 64-year-old Chinese woman who presented with right eye painless blurring of vision with visual acuity of 0.6 and right relative afferent pupillary defect. Fundoscopic examination showed absence of right optic disc swelling, and automated visual field testing confirmed a superior and infratemporal visual field defect in the right eye. On magnetic resonance imaging, there was a 1-cm oval mass that was hypointense on T1-weighted and hyperintense on T2-weighted images, with slow enhancement, suggestive of cavernous hemangioma. Optical coherence tomography of the retinal nerve fiber layer showed evidence of subtle right nerve fiber layer thinning. Right endoscopic transorbital excision of the tumor was performed with an ICG-assisted endoscope. Lateral skin crease incision was followed by crescent-shaped superolateral orbital rim removal. Superior and inferior orbital fissures were identified after stripping off the periorbita. The meningoorbital band was divided to release the orbital apex from the middle fossa dura. The greater wing of sphenoid bone was drilled with a 3-mm high-speed diamond burr under irrigation to create space for dissection. Injection of ICG resulted in delayed enhancement of the lesion at around 1 minute and 30 seconds, in contrast to rapid enhancement of surrounding recti muscles at around 30 seconds. Incision of periorbita was guided by ICG enhancement of lesion. The tumor was dissected from the lateral rectus and superior division of oculomotor nerve and was excised en bloc. The supraorbital rim was reconstructed with 2 miniplates. Pathology confirmed the diagnosis of cavernous hemangioma. Postoperatively, the patient had good recovery, with right eye visual acuity of 0.8 and resolution of the relative afferent pupillary defect.

A Factorial Analysis on Visual Outcomes of Transsphenoidal Surgery for Pituitary Macroadenoma.

Objective Sellar lesions are possible reversible causes of vision loss. This study is to provide quantitative objective measurement of efficacy of surgery for non-functioning pituitary adenoma and discuss different factors that could affect visual outcome of non-functioning pituitary adenoma. Method This is a single centre, retrospective study conducted at a tertiary neurosurgery referral centre. 108 cases of sellar tumors which underwent surgery during the 3-year period from early June 2015 to late May 2018 were reviewed. Pituitary adenoma that were non-functioning and without apoplexy at initial presentation were selected for the study. We have analyzed the correlation of different factors with the visual outcome, including the extent of vertical decompression in terms of change in tumor height post operation and the extent of lateral decompression in terms of change in Knosp grading. Visual outcome was represented by the visual impairment score (VIS), an integrated measurement of visual acuity and visual field deficit. Results Preoperative absolute tumor height and supracarotid height correlated with preoperative VIS scale ( p ≤ 0.01). Absolute Knosp grading correlates significantly with VA ( p = 0.001) and VF ( p ≤ 0.001) of that particular eye. Although most patients had an objective improvement in visual acuity (VA) (88%) and visual field (VF) (99%) after operation, a larger reduction in tumor height and successful Knosp downgrading after surgery is associated with better VIS improvement. ( p = 0.025) Change in supracarotid height shows trend in correlating with change in VIS ( p = 0.084). Conclusion Height of tumor measured from genu of cavernous ICA correlates better with visual outcome than absolute tumor height. The extent of both vertical and lateral decompression of non-functioning pituitary adenoma are important determinants that lead to better visual outcome. As endoscopic approach is able to achieve a greater degree of lateral decompression, it is a preferred approach in pituitary surgery to achieve a better visual outcome.

Minimum number of nights for reliable estimation of habitual sleep using a consumer sleep tracker.

Study Objectives: To determine the minimum number of nights required to reliably estimate weekly and monthly mean sleep duration and sleep variability measures from a consumer sleep technology (CST) device (Fitbit). Methods: Data comprised 107 144 nights from 1041 working adults aged 21-40 years. Intraclass correlation (ICC) analyses were conducted on both weekly and monthly time windows to determine the number of nights required to achieve ICC values of 0.60 and 0.80, corresponding to "good" and "very good" reliability thresholds. These minimum numbers were then validated on data collected 1-month and 1-year later. Results: Minimally, 3 and 5 nights were required to obtain "good" and "very good" mean weekly total sleep time (TST) estimates, while 5 and 10 nights were required for monthly TST estimates. For weekday-only estimates, 2 and 3 nights were sufficient for weekly time windows while 3 and 7 nights sufficed for monthly time windows. Weekend-only estimates of monthly TST required 3 and 5 nights. TST variability required 5 and 6 nights for weekly time windows, and 11 and 18 nights for monthly time windows. Weekday-only weekly variability required 4 nights for both "good" and "very good" estimates while monthly variability required 9 and 14 nights. Weekend-only estimates of monthly variability required 5 and 7 nights. Error estimates made using data collected 1-month and 1-year later with these parameters were comparable to those associated with the original dataset. Conclusions: Studies should consider the metric, measurement window of interest, and desired reliability threshold to decide on the minimum number of nights required to assess habitual sleep using CST devices.

A Mini Review on Osteoporosis: From Biology to Pharmacological Management of Bone Loss.

Osteoporosis refers to excessive bone loss as reflected by the deterioration of bone mass and microarchitecture, which compromises bone strength. It is a complex multifactorial endocrine disease. Its pathogenesis relies on the presence of several endogenous and exogenous risk factors, which skew the physiological bone remodelling to a more catabolic process that results in net bone loss. This review aims to provide an overview of osteoporosis from its biology, epidemiology and clinical aspects (detection and pharmacological management). The review will serve as an updated reference for readers to understand the basics of osteoporosis and take action to prevent and manage this disease.

The protean manifestations of central nervous system IgG4-related hypertrophic pachymeningitis: a report of two cases.

BACKGROUND: IgG4-related hypertrophic pachymeningitis is a relative newly recognized and rare manifestation of IgG4-related disease, an immune-mediated fibroinflammatory tumefactive disorder. Fewer than 80 patients have been reported in the literature, and it can mimic common neurosurgical conditions. We describe the clinical presentation of two patients that were initially considered to have a subdural collection, tuberculous meningitis, and a cervical spinal meningioma, but were eventually diagnosed with this disease. CASE PRESENTATION: Two ethnic Chinese men, 86 and 62 years old, experienced a 4-week history of headache. Both patients had a history of autoimmune disease, namely glomerulonephritis and Grave's disease, respectively. Magnetic resonance brain imaging revealed diffuse dural thickening with the latter patient exhibiting homogeneous and intense gadolinium-contrast enhancement. Since the 86-year-old patient also had progressive bilateral visual loss, giant cell arteritis was suspected and a 2-week course of glucocorticoid therapy was prescribed, but his symptoms failed to improve. The 62-year-old patient also had accompanying low-grade fever and was treated empirically as having tuberculous meningitis although there were no confirmatory microbiological findings. This patient further developed right hemiparesis, and additional imaging revealed a C4/5 intradural-extramedullary contrast-enhancing lesion resembling a meningioma causing cord compression. Both patients underwent neurosurgical intervention with the former undergoing a dural biopsy and the latter having the cervical lesion resected. The final diagnosis was IgG4-related hypertrophic pachymeningitis with the hallmark histological features of lymphoplasmacytic infiltration of IgG4+ plasma cells, storiform fibrosis, and obliterative phlebitis. In addition, their serum IgG4 levels were elevated (i.e., > 135 mg/dL). Both patients received at least 6 months of glucocorticoid therapy while the latter also had azathioprine. Their symptoms improved significantly and recurrent lesions were not detected on follow-up imaging. CONCLUSIONS: A high index of suspicion for this condition is suggested when a male patient with a history of autoimmune disease and compatible radiological findings, experiences subacute headache that is disproportionate to the degree of dural involvement. Neurosurgeons should consider early meningeal biopsy to establish a definitive histological diagnosis in order for early effective immunosuppressive treatment to be initiated and to avoid unnecessary morbidity.

COVID-19-related mobility reduction: heterogenous effects on sleep and physical activity rhythms.

STUDY OBJECTIVES: Mobility restrictions imposed to suppress transmission of COVID-19 can alter physical activity (PA) and sleep patterns that are important for health and well-being. Characterization of response heterogeneity and their underlying associations may assist in stratifying the health impact of the pandemic. METHODS: We obtained wearable data covering baseline, incremental mobility restriction, and lockdown periods from 1,824 city-dwelling, working adults aged 21-40 years, incorporating 206,381 nights of sleep and 334,038 days of PA. Distinct rest-activity rhythm (RAR) profiles were identified using k-means clustering, indicating participants' temporal distribution of step counts over the day. Hierarchical clustering of the proportion of days spent in each of these RAR profiles revealed four groups who expressed different mixtures of RAR profiles before and during the lockdown. RESULTS: Time in bed increased by 20 min during the lockdown without loss of sleep efficiency, while social jetlag measures decreased by 15 min. Resting heart rate declined by ~2 bpm. PA dropped an average of 42%. Four groups with different compositions of RAR profiles were found. Three were better able to maintain PA and weekday/weekend differentiation during lockdown. The least active group comprising ~51% of the sample, were younger and predominantly singles. Habitually less active already, this group showed the greatest reduction in PA during lockdown with little weekday/weekend differences. CONCLUSION: In the early aftermath of COVID-19 mobility restriction, PA appears to be more severely affected than sleep. RAR evaluation uncovered heterogeneity of responses to lockdown that could associate with different outcomes should the resolution of COVID-19 be protracted.

Novel Wavelength-Specific Blue Light-Emitting Headlamp for 5-Aminolevulinic Acid Fluorescence-Guided Resection of Glioblastoma.

OBJECTIVE: Extent of resection of glioblastoma is an important predictor for overall survival, and 5-aminolevulinic acid fluorescence-guided surgery can improve outcomes. However, the technique requires the installation of a blue light module on operative microscopes and may be cost prohibitive. A novel and economical blue light-emitting headlamp was designed, and its clinical utility was explored. METHODS: A remote-controlled dual light emitting diode headlamp system was constructed with 1 diode emitting white light and the other blue. Spectrographic analysis of the blue light emitted from a commercial operative microscope and the headlamp was performed. A comparative evaluation of the 2 illumination systems was conducted for 3 patients who underwent craniotomy for glioblastoma resection. Histologic examination of the fluorescing tissue detected by the headlamp was performed, and the extent of resection was assessed by postoperative day 1 magnetic resonance imaging. RESULTS: Spectrography of blue light emitted from the headlamp system was wavelength specific with a single emission peak at 416 nm and a linewidth of 35 nm. In contrast, blue light from the microscope (peak: 426 nm) had a wider linewidth of 54 nm and was not wavelength specific with additional infrared radiation detected. Gross or near-total resection of contrast-enhancing glioblastoma was performed for all 3 patients. Intraoperatively, comparable tumor fluorescence was observed under microscope and headlamp blue light illumination. Histologic examination of tissue fluorescing under headlamp blue light confirmed the presence of glioblastoma. CONCLUSIONS: This novel proof-of-concept blue light-emitting headlamp device may offer an opportunity for institutions with limited resources to implement 5-aminolevulinic acid fluorescence-guided glioblastoma resections.

Instantaneous VO2 from a wearable device.

We present a method for calculating instantaneous oxygen uptake (VO2) through the use of a non-invasive and non-obtrusive (i.e. without a face mask) wearable device, together with its clinical evaluation against a standard technique based upon expired gas calorimetry. This method can be integrated with existing wearable devices, we implemented it in the "Device for Reliable Energy Expenditure Monitoring" (DREEM). The DREEM comprises a single lead electrocardiogram (ECG) device combined with a tri-axial accelerometer and is worn around the waist. Our clinical evaluation tests the developed method against a gold standard for VO2, expired gas calorimetry, using an ethically approved protocol comprising active exercise and sedentary periods. The study was performed on 42 participants from a wide sample population including healthy people, athletes and an at-risk health group including persons affected by obesity. We developed an algorithm combining heart rate (HR) and the integral of absolute acceleration (IAA), with results showing a correlation of r = 0.93 for instantaneous VO2, and r = 0.97 for 3 min mean VO2, this is a considerably improved estimation of VO2 in comparison to methods utilising HR and IAA independently.

Coronary artery stenting in acute coronary syndrome associated with giant cell arteritis.

Coronary vasculitis is a rare but devastating complication of giant cell arteritis, otherwise known as temporal arteritis. Originally named for its propensity to attack the superficial temporal arteries, it is now recognized that it commonly involves a number of medium and large arteries throughout the body. Here we describe two cases of giant cell arteritis affecting the coronary arteries, one discovered at post-mortem and one which was successfully treated with immunosuppressive therapy and drug-eluting coronary stents. .