Evaluation of a novel approach to recognising community-acquired paediatric sepsis at ED triage by combining an electronic screening algorithm with clinician assessment.

OBJECTIVE: We report the utilisation and impact of a novel triage-based electronic screening tool (eST) combined with clinical assessment to recognise sepsis in paediatric ED. METHODS: An electronic sepsis screening tool was implemented in the paediatric EDs of two large UK secondary care hospitals between June 2018 and January 2019. Patients eligible for screening were children < 16 years of ages excluding those with minor injuries or who were brought directly to resuscitation. Subsequently, a retrospective evaluation was performed to determine the performance of the tool alone and in combination with clinical assessment after triage, to identify septic patients, using sensitivity, specificity, positive, negative predictive values (PPV and NPV) and likelihood ratios. RESULTS: 19 912 children were triaged during the study period, of whom 90 (0.45%) were classified as having sepsis. 99% of all eligible patients were screened. The eST alerted for 2651 (13.3%) patients. After immediate physician assessment, 151 were treated for sepsis in the ED, of whom 70 had a final diagnosis of sepsis. Eight patients who were not thought to be septic returned with sepsis within 24 hours. The eST showed a sensitivity of 86.7% (95% CI 77.5% to 92.6%), specificity 87.0% (95% CI 86.5% to 87.5%), PPV 2.94% (95% CI 2.35% to 3.68%), NPV 99.9% (95% CI 99.8% to 99.9%) which improved with combined clinical assessment to a sensitivity of 90.0% (95% CI 81.4% to 95.0%), specificity 99.4 (95% CI 99.3% to 99.5%), PPV 42.0 (95% CI 35.0% to 49.3%) and NPV 99.9% (95% CI 99.9% to 99.9%). CONCLUSION: Utilisation of a novel triage-based eST allowed sepsis screening in over 99% of eligible patients. The screening tool showed good accuracy to recognise sepsis at triage in the ED, which was augmented further by combining it with clinician assessment. The screening tool requires further refinement through multicentre evaluation to avoid missing sepsis cases.

Intraoperative neurophysiological monitoring in paediatric Chiari surgery-help or hindrance?

INTRODUCTION: The role of intraoperative neurophysiological monitoring (IONM) during surgery for Chiari I malformation has not been fully elucidated. Questions remain regarding its utility as an adjunct to foramen magnum decompression surgery, specifically, does IONM improve the safety profile of foramen magnum decompression surgery and can IONM parameters help in intraoperative surgical decision-making. This study aimed to describe a single institution experience of IOM during paediatric Chiari I surgery. METHODS: The methodology comprised a retrospective review of prospectively collected electronic neurosurgical departmental operative database. Inclusion criteria were children under 16 years of age who had undergone foramen magnum decompression for Chiari I malformation with IONM. In addition to basic demographic data, details pertaining to presenting features and post-operative outcomes were obtained. These included primary symptoms of Chiari I malformation and indications for surgery. MRI findings, including the presence of syringomyelia on pre-and post-operative imaging, were reviewed. Details of the surgical technique for each patient were recorded. Only patients with either serial brainstem auditory evoked potential (BAEP) and/or upper limb somatosensory evoked potential (SSEP) recordings were included. Two time points were used for the purposes of analysing IONM data; initial baseline before skin incision and final at the time of skin closure. RESULTS: Thirty-seven children underwent foramen magnum decompression (FMD) with IONM. Mean age was 10.5 years (range 1-16 years) with a male:female ratio 13:24. The commonest clinical features on presentation included headaches (15) and scoliosis (13). Twenty-four patients had evidence of associated syringomyelia (24/37 = 64.9%). A reduction in the SSEP latency was observed in all patients. SSEP amplitude was more variable, with a decrease seen in 18 patients and an increase observed in 12 patients. BAEP recordings decreased in 13 patients and increased in 4 patients. There were no adverse neurological events following surgery; the primary symptom was resolved or improved in all patients at 3-month follow-up. Resolution or improvement in syringomyelia was observed in 19/24 cases. CONCLUSIONS: Our data shows that FMD for Chiari malformation (CM) is associated with changes in SSEPs and BAEPs. However, we did not identify a definite link between clinical outcomes and IONM, nor did syrinx outcome correlate with IONM. There may be a role for IONM in CM surgery but more robust data with better-defined parameters are required to further understand the impact of IONM in CM surgery.

Personalizing Deep Brain Stimulation Therapy for Parkinson's Disease With Whole-Brain MRI Radiomics and Machine Learning.

Background Deep brain stimulation (DBS) is a well-recognised treatment for advanced Parkinson's disease (PD) patients. Structural brain alterations of the white matter can correlate with disease progression and act as a biomarker for DBS therapy outcomes. This study aims to develop a machine learning-driven predictive model for DBS patient selection using whole-brain white matter radiomics and common clinical variables. Methodology A total of 120 PD patients underwent DBS of the subthalamic nucleus. Their therapy effect was assessed at the one-year follow-up with the Unified Parkinson's Disease Rating Scale-part III (UPDRSIII) motor component. Radiomics analysis of whole-brain white matter was performed with PyRadiomics. The following machine learning methods were used: logistic regression (LR), support vector machine, naïve Bayes, K-nearest neighbours, and random forest (RF) to allow prediction of clinically meaningful UPRDSIII motor response before and after. Clinical variables were also added to the model to improve accuracy. Results The RF model showed the best performance on the final whole dataset with an area under the curve (AUC) of 0.99, accuracy of 0.95, sensitivity of 0.93, and specificity of 0.97. At the same time, the LR model showed an AUC of 0.93, accuracy of 0.88, sensitivity of 0.84, and specificity of 0.91. Conclusions Machine learning models can be used in clinical decision support tools which can deliver true personalised therapy recommendations for PD patients. Clinicians and engineers should choose between best-performing, less interpretable models vs. most interpretable, lesser-performing models. Larger clinical trials would allow to build trust among clinicians and patients to widely use these AI tools in the future.

Preoperative embolisation of choroid plexus tumours in children: part I-does the reduction of perioperative blood loss affect the safety of subsequent surgery?

OBJECTIVE: Operative management of choroid plexus tumours is hindered by excessive bleeding and significant CSF production. Our aim was to assess whether the use of preoperative embolisation would increase the safety of surgery by reducing the perioperative blood loss and achieve higher rates of resection of the tumour. METHODS: Between 1996 and 2009, 30 patients (mean age 2.25 years) with choroid plexus tumours (24 papillomas, 6 carcinomas) were treated. Fifteen of them underwent preoperative super-selective embolisation of the feeding vessels with histoacryl glue. The perioperative blood loss as a percentage of estimated blood volume loss (EBV) was recorded together with mortality and morbidity of the two groups (embolised, EMB+ vs. not, EMB-). RESULTS: The embolisation was successful in 13/15 (86.6 %) patients. This manoeuvre rendered the tumour relatively avascular making the operative field "less hazardous" as reported by the surgeon. In addition, higher gross total resection rate was achieved (100 vs. 41 %; p = 0.001) at the first operative attempt in the EMB+ group. The percentage EBV loss was 96 % in EMB- group vs. 224 % in EMB+ group (p = 0.038). CONCLUSION: Our observations with regards to preoperative embolisation of choroid plexus tumours show an acceptable safety profile for the endovascular technique. At the same time, it renders the operative treatment of the tumours safer by reducing perioperative blood loss resulting in a high gross total resection rate. In summary, we suggest that preoperative embolisation is a useful adjunct that should be considered prior to surgical resection in managing these patients.

Pre-operative embolisation of choroid plexus tumours in children. Part II. Observations on the effects on CSF production.

OBJECTIVE: Choroid plexus tumours are one of the few causes of hydrocephalus secondary to increased CSF production. Operative treatment aided by pre-op embolisation is being used in our institution as a primary option of treatment. Our aim was firstly to quantify the effects of embolisation on CSF production and secondly to assess whether the use of pre-operative embolisation would lead to reduction of CSF production thus reducing the need for CSF diversion procedures in the perioperative and long term. METHODS: From 1996 till 2009, 30 patients (mean age, 2.25 years) underwent surgical treatment for 24 choroid plexus papillomas and 6 choroid plexus carcinomas. Thirteen underwent pre-operative super-selective embolisation of the feeding vessels with Histoacryl glue. The need for CSF diversion-external ventricular drain (EVD)/shunt-was recorded together with the daily CSF production between the two groups (embolised: EMB+ vs. not embolised: EMB-) RESULTS: The embolisation was successful in 13 of 15 (86.6 %) patients. The average post-op daily CSF production between the EMB+ and EMB- groups was (67 vs. 135 ml/day; p = 0.005). EVD days in situ post-operatively was 7.9 vs. 12.1 (p = 0.033). However, the need for permanent CSF diversion was similar in both groups (five vs. six). CONCLUSION: We have established the safety of pre-operative embolisation as an adjunct to operative treatment of choroid plexus tumours. As we expected, this technique, by removing the tumour's blood supply, reduces the rate of CSF production. This has had a positive impact on the post-operative management of these patients. We cannot say the same for the need of permanent CSF diversion in our study.

Predicting impact of Deep Brain Stimulation on Non-motor symptoms of Parkinson's disease.

This is the largest study on Radiomics analysis looking into the impact of Deep Brain Stimulation on Non-Motor Symptoms (NMS) of Parkinson's disease. Preoperative brain white matter radiomics of 120 patients integrated with clinical variables were used to predict the DBS effect on NMS after 1 year from the surgery. Patients were classified "suboptimal" vs "good" based on a 10% or more improvement in NMS score. The combined Radiomics-Clinical Random Forrest (RF) model achieved an AUC of 0.96, Accuracy of 0.91, Sensitivity of 0.94 and Specificity of 0.88. The Youden's index showed optimal threshold for the RF of 0.535. The confusion matrix of the RF classifier gave a TPR of 0.92 and a FPR of 0.03. This corresponds to a PPV of 0.93 and a NPV of 0.93. The predictive models can be easily interpreted and after careful large-scale validation be integrated in assisting clinicians and patients to make informed decisions.Clinical Relevance- This paper shows the lesser studied positive impact of Deep Brain Stimulation on Non motor symptoms of Parkinson's disease while allows clinicians to predict non responders to the therapy.

Postoperative Magnetic Resonance Imaging (MRI) Scans for the Surgical Resection of Cranial Glial Tumors According to National Institute of Health and Care Excellence (NICE) Guidelines: A Single-Center Experience.

Background Glial tumours are the most common central nervous system (CNS) neoplastic lesions. They occur in 7 per 100,000 individuals in the United Kingdom (UK) and are categorized into astrocytomas, oligodendrogliomas, and glioblastomas in the adult population. The World Health Organization (WHO) has created a classification system in order to better categorise these lesions, placing them in a range from grade I to grade IV. The higher the grade, the poorer the prognosis. The National Institute of Health and Care Excellence (NICE) in the United Kingdom recommends that all surgical resections of glial brain tumours are followed by a postoperative magnetic resonance imaging (MRI) scan within a 72-hour to establish a baseline for further management. Objective We present a retrospective analysis that assessed the compliance rate with NICE guidelines among patients who underwent surgical resection of glial lesions at the Department of Neurosurgery, Queens Hospital Romford, between January 2022 and September 2023. Materials and methods A retrospective analysis was conducted on 136 glial tumour resections that were performed during the period between January 2022 and September 2023. The total time between the end of the operation and the MRI scan was calculated in hours for each procedure. This was analyzed into two groups with respect to compliance with the NICE guidelines, which are within 72 hours and after 72 hours. The non-compliant group was then further investigated regarding the reason for the delay. The cost related to delays was also determined by discussion with the hospital's finance department. Results All of the procedures were followed by a post-operative MRI scan but only 88% were within the timeframe recommended by NICE guidelines. The amount of delay was calculated in hours and the reasons for these delays were identified. We created two categories for delay: requesting delays and radiology department-related delays with an almost equivalent number of delays resulting from each category. This delay has resulted in approximately £19,845 of extra costs for inpatient stays. Conclusion A retrospective analysis at Queens Hospital, Romford, found good compliance with NICE guidelines for post-operative MRI scans in glial lesion resections from January 2022 to September 2023. Eighty-eight per cent of patients received scans within 72 hours, crucial for baseline assessment. A 12% non-compliance rate revealed areas for improvement, causing £19,845 in extra costs due to longer inpatient stays. Expediting scans to 36 hours could save around £30,876 annually and reduce complications like infections and thromboembolism. Proposed strategies include dedicated MRI slots and policy adjustments for MRI requests.

Delayed caroticocavernous fistula after stent-assisted coil embolization of intracavernous carotid aneurysm: should we manage conservatively?

Constructive endovascular techniques remain the mainstay for the treatment of cavernous carotid aneurysms due to their efficacy. However, they do harbor risks of complications, such as thromboembolic events, arterial injuries, and vessel occlusions. A 58-year-old lady presented with delayed caroticocavernous fistula (CCF) 1 month after stent-assisted coil embolization of a cavernous carotid aneurysm (CCA). Following this, her caroticocavernous fistula resolved spontaneously with no further intervention. Our case demonstrates a unique presentation of a CCF as a delayed complication of stent-assisted coil embolization of CCA and the spontaneous resolution of the CCF. Symptomatic CCFs are commonly treated as an emergency in many institutions and the question arises as to whether we should adopt a conservative policy in the light of this case report.

Combining Device-Aided Therapies in Parkinson's Disease: A Case Series and a Literature Review.

BACKGROUND: Deep brain stimulation (DBS), levodopa-carbidopa intestinal gel (LCIG) and subcutaneous apomorphine infusion are device-aided therapies (DATs) for advanced Parkinson's disease (PD). We present a case series from the Cretan PD Registry who required 2 DATs for optimal management along with a systematic review of similar studies. CASES: From 2009 to 2020, we retrospectively studied all PD patients who were simultaneously treated with 2 DATs. Six patients on DBS required an infusion treatment for persisting or re-emergent fluctuations because of disease progression. Two patients on LCIG infusion received DBS as a levodopa-sparing strategy because of drug-induced complications. Fluctuations and quality of life improved in all patients. LITERATURE REVIEW: We identified 4 case series, 1 prospective and 1 retrospective study that included a total of 50 DBS-treated patients who required an infusion therapy. Improvement in motor outcomes, assessed in different ways, was a constant finding. CONCLUSIONS: Selected PD patients on 1 DAT may experience additional benefit from a second DAT, for several reasons along the course of their disease. Although infusion therapies optimize dopaminergic drug delivery in fluctuating DBS-treated patients, DBS added on LCIG treatment has an additive symptomatic effect that allows levodopa dose reduction in patients with drug-induced side effects.

Effects of phosphodiesterase-5 inhibitors on Leydig cell secretory function in oligoasthenospermic infertile men: a randomized trial.

OBJECTIVE: to evaluate the effects of phosphodiesterase-5 inhibitors (PDE5-i) on Leydig cell secretory function (LCSF). PATIENTS AND METHODS: in all, 75 men with oligoasthenospermia were treated daily for 12 weeks with either vardenafil (23 men, group A), sildenafil (25 men, group B) or l-carnitine (26 men, group C); a further group of 22 men with oligoasthenospermia (group D) received no treatment. Serum levels of insulin-like-3 peptide (INSL3) were evaluated before and after the end of the treatment in each of groups A, B and C, respectively. Serum INSL3 levels were measured in each participant of group D before and after the 12-week experimental period. RESULTS: within group A and B, the peripheral serum mean INSL3 concentration, sperm concentration, percentage of motile spermatozoa, and percentage of morphologically normal spermatozoa were significantly greater after PDE5-i treatment than before. CONCLUSION: we suggest that PDE5-i enhances LCSF, as the mean INSL3 concentration was significantly greater after PDE5-i administration than before, within groups A and B. This enhancement in LCSF might contribute to the increase in sperm concentration and sperm motility after administration of PDE5-i.

Wound breakdown secondary to silk granuloma 20 years after craniotomy.

We describe a rare case of a foreign body granuloma associated with silk suture material in a 36-year-old patient 20 years after craniotomy for traumatic subdural haematoma. The use of silk in neurosurgery is discussed.

Current Surgical Options for Patients with Epilepsy.

Surgery for epilepsy dates back to 1886 and has undergone significant developments. Today it is considered a key treatment modality in patients who are resistant to pharmacological intervention. It improves seizure control, cognition and quality of life. New technologies, advances in surgical technique and progress in scientific research underlie the expansion of surgery in epilepsy treatment. Effectiveness of surgical treatment depends on several factors including the type of epilepsy, the underlying pathology and the localisation of the epileptogenic zone. Timely referral to an experienced epilepsy surgery centre is important to allow the greatest chance of seizure control and to minimise associated morbidity and mortality. Following referral, patients undergo thorough presurgical investigation to evaluate their suitability for surgery. The commonest form of epilepsy treated by surgery is mesial temporal lobe sclerosis and there is Class I evidence for the medium-term efficacy of temporal lobe resection from two randomised control trials. Various other forms of epilepsy are now considered for resective and neuromodulatory surgical intervention due to favourable results. In this article, the authors review the current status of surgical treatment for epilepsy including the presurgical evaluation of patients, surgical techniques and the future directions in epilepsy surgery.

Antiepileptic Treatment Strategy in Vascular Malformations.

BACKGROUND: Antiepileptic treatment strategy plays an important role in the management of intracranial vascular malformations. The intracranial vascular malformations can be divided into cavernous hemangiomas, arteriovenous malformations, developmental venous anomalies and capillary telangiectasias. Seizures and hemorrhage are among their most common clinical manifestations. OBJECTIVE: The aim of this article is to review the current literature on the antiepileptic treatment in the setting of intracranial vascular malformations and offer an updated view on when antiepileptic drug treatment should be employed for each type of vascular malformation. METHODS AND MATERIALS: Current literature has been reviewed on cavernous malformations, arteriovenous malformations, developmental venous anomalies and capillary telangiectasias. Epidemiological features, epileptogenesis, clinical presentation and antiepileptic treatment have been analyzed. RESULTS: A variety of treatment modalities exist for the management of intracranial vascular malformations, including antiepileptic treatment, microsurgery, radiosurgery and embolization. The decision-making process is different for each type of intracranial vascular malformation. Moreover, a plethora of other clinical factors needs to be taken into consideration during the decision-making process, such as the patient's age and comorbidities, the risk of hemorrhage the need for definitive treatment of the malformation, the seizure rates after the definitive treatment, the efficacy and side effects profile of antiepileptic drugs. CONCLUSION: Antiepileptic treatment strategy is a multifactorial decision that should be individualized and ideally be made by multidisciplinary teams.

Quality-of-Life after Anterior Skull Base Surgery: A Systematic Review.

Background Improved treatment and survival of patients with skull base tumors has made the assessment of quality-of-life (QoL) in this population increasingly important. This article provides a comprehensive systematic review pertaining to QoL assessment in adults undergoing anterior skull base surgery. Methods We performed a literature search using the electronic databases of Ovid Medline and Embase. Additional articles were identified through a search using the phrase anterior skull base. Further articles were sought through hand-searching relevant journals and reference lists of identified articles. Results Our search strategy identified 29 articles for inclusion in our systematic review, with considerable variation between studies in population characteristics, methodological design and quality, follow-up length, and outcome assessment. The most commonly used QoL tools were the Karnofsky Performance Status and the Anterior Skull Base Questionnaire. QoL following anterior skull base surgery appears to improve beyond preoperative levels in the months after surgery. For patients undergoing endoscopic skull base surgery, the gain in QoL appears to be greater and may manifest earlier, with no clear long-term deleterious effect on sinonasal outcomes compared with open surgery. Conclusions QoL after anterior skull base surgery in adults appears to improve within several months of surgery, but earlier and to a larger extent if the endoscopic approach is used. Given the relative paucity and heterogeneity of anterior skull base tumors, large-scale prospective multicentre studies utilizing valid and reliable multidimensional QoL tools are required. This may result in improved patient care, by understanding patients' needs better and facilitating the provision of reliable outcome data for clinical trials.

Endovascular treatment of ruptured intracranial aneurysms during pregnancy: is this the best way forward? Case report and review of the literature.

OBJECTIVE AND IMPORTANCE: Subarachnoid haemorrhage in pregnancy has traditionally been treated by surgical clipping however lately cases of successful coiling have been reported. Nevertheless, the long-term outcome of coiling is not well known in pregnant women. Mortality due to rebleeding of an incompletely treated aneurysm remains high. Only 15 cases of successful endovascular coiling during pregnancy have been reported so far. CLINICAL PRESENTATION: We report the case of a pregnant woman who presented with aneurysmal subarachnoid hemorrhage (WFNS Grade III) due to rupture of a right posterior communicating artery aneurysm. INTERVENTION: The patient underwent endovascular coiling successfully followed by an elective caesarian section and delivery of a healthy baby. However, during the course of a 2-year follow up the patient had suffered two relapses of the coiled aneurysm which required additional treatment. These events have affected her choice of extending her family. CONCLUSION: The small risk of recurrence and the potential impact on future pregnancies should be explicitly communicated to patients in cases of endovascular coiling.