Perceptions of Indian neurosurgeons about medicolegal issues and malpractice suits.

OBJECTIVE: Despite the rising trend of medicolegal challenges in India, there is an absolute dearth of literature from India on this issue. The authors conducted a survey, to their knowledge a first of its kind, to assess the perceptions of Indian neurosurgeons about the medicolegal challenges faced in everyday practice. METHODS: An anonymous online survey performed using Google Forms was widely circulated among neurosurgeons practicing in India via email and social media platforms. The questionnaire consisted of 38 questions covering the various aspects of medicolegal issues involved in neurosurgery practice. RESULTS: A total of 221 survey responses were received, out of which 214 responses were included in the final analysis, barring 7 responders who had no work experience in India. The respondents were categorized according to their working arrangements and work experience. Out of all of the respondents, 20 (9.3%) had ≥ 1 malpractice suits filed against them. More than 90% of the respondents believed that malpractice suits are on the rise in India. Almost half of the respondents believed the advent of teleconsultation is further compounding the risk of malpractice suits, and 66.4% of respondents felt that they were inadequately trained during residency to deal with medicolegal issues. Most respondents (88.8%) felt that neurosurgeons working in the government sector had lesser chances of facing litigations in comparison to those working in the private sector. The practice of obtaining video proof of consent was more commonly reported by respondents working in freelancing and private settings (45.1%) and those with multiple affiliations (61.3%) compared to respondents practicing in government settings (22.8%) (p < 0.001). Neurosurgeons working in the private sector were more likely to alter management and refer sick patients to higher-volume treatment centers to avoid malpractice suits than their government counterparts (p = 0.043 and 0.006, respectively). The practices pertaining to legal preparedness were also found to be significantly higher among the respondents from the private sector (p < 0.001). CONCLUSIONS: This survey highlights the apprehensions of neurosurgeons in India with regard to rising malpractice suits and the subsequent increase of defensive neurosurgical practices, especially in the private sector. A stronger legal framework for providing for quick redress of patient complaints, while deterring frivolous malpractice suits, can go a long way to allay these fears. There is a dire need for systematic training of neurosurgeons regarding legal preparedness, which should begin during residency.

Human neural stem cell grafts modify microglial response and enhance axonal sprouting in neonatal hypoxic-ischemic brain injury.

BACKGROUND AND PURPOSE: Hypoxic-ischemic (HI) brain injury in newborn infants represents a major cause of cerebral palsy, development delay, and epilepsy. Stem cell-based therapy has the potential to rescue and replace the ischemic tissue caused by HI and to restore function. However, the mechanisms by which stem cell transplants induce functional recovery are yet to be elucidated. In the present study, we sought to investigate the efficacy of human neural stem cells derived from human embryonic stem cells in a rat model of neonatal HI and the mechanisms enhancing brain repair. METHODS: The human neural stem cells were genetically engineered for in vivo molecular imaging and for postmortem histological tracking. Twenty-four hours after the induction of HI, animals were grafted with human neural stem cells into the forebrain. Motor behavioral tests were performed the fourth week after transplantation. We used immunocytochemistry and neuroanatomical tracing to analyze neural differentiation, axonal sprouting, and microglia response. Treatment-induced changes in gene expression were investigated by microarray and quantitative polymerase chain reaction. RESULTS: Bioluminescence imaging permitted real time longitudinal tracking of grafted human neural stem cells. HI transplanted animals significantly improved in their use of the contralateral impeded forelimb and in the Rotorod test. The grafts showed good survival, dispersion, and differentiation. We observed an increase of uniformly distributed microglia cells in the grafted side. Anterograde neuroanatomical tracing demonstrated significant contralesional sprouting. Microarray analysis revealed upregulation of genes involved in neurogenesis, gliogenesis, and neurotrophic support. CONCLUSIONS: These results suggest that human neural stem cell transplants enhance endogenous brain repair through multiple modalities in response to HI.

Temporary internal distraction as an aid to correction of severe scoliosis.

BACKGROUND: Halo traction is a well-recognized adjunct for correcting severe complex rigid scoliotic curves, but it is associated with complications and is contraindicated in the presence of fixed cervical instability, kyphosis, or stenosis. In addition, halo traction often requires prolonged hospital stays and is not welcomed by all families. These limitations led to consideration of temporary internal distraction as an alternative. METHODS: We retrospectively reviewed the records of children in whom severe scoliosis had been treated with temporary internal distraction. Our goals were to (1) assess whether the use of temporary internal distraction can aid in the correction of severe scoliosis and (2) identify complications associated with temporary internal distraction and compare them with those associated with halo traction. The mean preoperative curve was 104 degrees . All patients underwent initial posterior release of the rigid portion of the spine (with six also having anterior release) and placement of spinal instrumentation under distraction during spinal cord monitoring. Of the ten patients, four had one distraction procedure (i.e., the initial surgery [or first distraction] followed by definitive fusion and the remaining six had two distraction procedures (i.e., the initial surgery [or first distraction] followed by the second distraction) followed by definitive fusion. After distraction, all patients underwent posterior spinal fusion with definitive dual-rod fixation. The amount of correction was determined by measuring the curve on plain radiographs made preoperatively, after each internal distraction procedure, after definitive fusion, and at the time of final follow-up. RESULTS: Curve correction after use of internal distraction, and before definitive fusion, averaged 53% (from 104 degrees to 49 degrees ) (range, 39% [from 70 degrees to 43 degrees ] to 79% [from 70 degrees to 15 degrees ]). This method facilitated safe, gradual deformity correction in all ten patients. The mean time between the initial procedure and the definitive fusion was 2.4 weeks. The mean final curve correction was 80% (from 104 degrees to 20 degrees ) (range, 73% [from 131 degrees to 35 degrees ] to 91% [from 110 degrees to 10 degrees ]). No neurologic deficits or infections resulted. CONCLUSIONS: Temporary internal distraction is a viable alternative approach to maximizing curve correction in patients undergoing spinal fusion for severe scoliosis. LEVEL OF EVIDENCE: Therapeutic Level IV.

Diagnosis and treatment of common fractures in children: femoral shaft fractures and supracondylar humeral fractures.

Femoral shaft fractures and supracondylar elbow fractures are two of the most common major pediatric injuries managed by the general orthopedic surgeon. Therapeutic choices frequently are influenced by many factors, including associated injuries, fracture type, and the child's age, social situation, and economic issues. Nonsurgical management of femoral shaft fractures has been a preferred and cost-effective treatment for most age groups, but recently the use of surgical techniques has gained popularity with the overall goal of rapid mobilization of the child. Supracondylar elbow fractures are diagnostically challenging and can result in severe acute and long-term complications. An understanding of fracture presentation, anatomic detail, and surgical applications will optimize the chances for successful outcomes.

Adolescent idiopathic scoliosis: modern management guidelines.

Adolescent idiopathic scoliosis (AIS), a structural lateral curvature of the spine of uncertain etiology, is the most common cause of spinal deformity in adolescents. In its most severe form, AIS is characterized by progressive spinal curvature that may lead to a permanent deformity. Thus, the goal of treatment is early detection and prevention of progression. This article provides a review of general spinal anatomy relevant to AIS and its etiology, describes several proposed methods of classifying curves in AIS, delineates the natural history of AIS, and discusses the nonoperative and operative treatment options.

Comparative case study of two biomedical research collaboratories.

BACKGROUND: Working together efficiently and effectively presents a significant challenge in large-scale, complex, interdisciplinary research projects. Collaboratories are a nascent method to help meet this challenge. However, formal collaboratories in biomedical research centers are the exception rather than the rule. OBJECTIVE: The main purpose of this paper is to compare and describe two collaboratories that used off-the-shelf tools and relatively modest resources to support the scientific activity of two biomedical research centers. The two centers were the Great Lakes Regional Center for AIDS Research (HIV/AIDS Center) and the New York University Oral Cancer Research for Adolescent and Adult Health Promotion Center (Oral Cancer Center). METHODS: In each collaboratory, we used semistructured interviews, surveys, and contextual inquiry to assess user needs and define the technology requirements. We evaluated and selected commercial software applications by comparing their feature sets with requirements and then pilot-testing the applications. Local and remote support staff cooperated in the implementation and end user training for the collaborative tools. Collaboratory staff evaluated each implementation by analyzing utilization data, administering user surveys, and functioning as participant observers. RESULTS: The HIV/AIDS Center primarily required real-time interaction for developing projects and attracting new participants to the center; the Oral Cancer Center, on the other hand, mainly needed tools to support distributed and asynchronous work in small research groups. The HIV/AIDS Center's collaboratory included a center-wide website that also served as the launch point for collaboratory applications, such as NetMeeting, Timbuktu Conference, PlaceWare Auditorium, and iVisit. The collaboratory of the Oral Cancer Center used Groove and Genesys Web conferencing. The HIV/AIDS Center was successful in attracting new scientists to HIV/AIDS research, and members used the collaboratory for developing and implementing new research studies. The Oral Cancer Center successfully supported highly distributed and asynchronous research, and the collaboratory facilitated real-time interaction for analyzing data and preparing publications. CONCLUSIONS: The two collaboratory implementations demonstrated the feasibility of supporting biomedical research centers using off-the-shelf commercial tools, but they also identified several barriers to successful collaboration. These barriers included computing platform incompatibilities, network infrastructure complexity, variable availability of local versus remote IT support, low computer and collaborative software literacy, and insufficient maturity of available collaborative software. Factors enabling collaboratory use included collaboration incentives through funding mechanism, a collaborative versus competitive relationship of researchers, leadership by example, and tools well matched to tasks and technical progress. Integrating electronic collaborative tools into routine scientific practice can be successful but requires further research on the technical, social, and behavioral factors influencing the adoption and use of collaboratories.

Synthesis, analytical analysis, and medicinal aspect of novel benzimidazoles and their metal complexes.

Benzimidazole and their metal analogs that can act as multimodal agent and have non-peptidic CCK-B receptor antagonist were synthesized and characterized on the basis of spectroscopic techniques such as FT-IR, NMR, FAB-MS and also evaluated for biologic efficacy. The ligands showed binding to most of the organs, known to express CCK receptors in biodistribution studies. Cholecystokinin (CCK1 and CCK2) receptor binding affinities of these analogs (IC50) are 0.802 ± 0.007 for compound C and 0.326 ± 0.012 for compound D in rat pancreatic acini. These studies have provided a new template for further development of novel agents for various related diseases.

The anatomic suitability of the C2 vertebra for intralaminar and pedicular fixation: a computed tomography study.

BACKGROUND CONTEXT: Several methods have been used to stabilize the atlantoaxial joint, including the use of C2 pedicle and laminar screws. No report has used computed tomography (CT) angiograms to compare the risk to the vertebral artery or assess the suitability for each fixation technique. PURPOSE: To compare the suitability of C2 pedicle versus laminar screws using CT angiograms. STUDY DESIGN: We retrospectively evaluated the anatomic dimensions of the C2 lamina and pedicle in 50 patients using CT angiograms. METHODS: We retrospectively reviewed the last 50 patients admitted who underwent CT angiograms of the head and neck. Data recorded included the pedicle length and width and the laminar length and width. Vertebral artery anatomy was also assessed to determine if an aberrant location would preclude pedicle fixation. RESULTS: Mean pedicle length and width were 15.5±3.5 and 4.7±1.7 mm, respectively, with 24% of patients having anatomy that would preclude 3.5-mm pedicle screw fixation. The mean lamina length and width were 25.2±3.6 and 5.5±1.4 mm, and more than 90% of patients could tolerate a 3.5-mm C2 laminar screw. CONCLUSION: Preoperative CT angiography or noncontrast CT is an excellent method to delineate the anatomy at C2 to determine the suitability for pedicle or intralaminar fixation. In cases where vertebral artery anatomy precludes C2 pedicle fixation, more than 90% of patients may be a candidate for C2 intralaminar fixation.

An anatomic study of the S2 iliac technique for lumbopelvic screw placement.

STUDY DESIGN: An anatomic study conducted on cadaveric specimens. OBJECTIVES: The objectives of the study were (1) to determine course of S2 lumbopelvic screws with reference to the articular cartilage of the sacroiliac joint, (2) to determine the length and trajectory of screws placed using anatomic placement techniques, and (3) to determine vital structures at risk using this technique. SUMMARY OF BACKGROUND DATA: Multiple techniques exist for fixation distal to S1 including alar screws, iliac post bolts, and transiliac rods. Distal fixation is crucial in adult deformity surgery when fusion to the sacrum is indicated. METHODS: Five female and 5 male cadaveric specimens were instrumented with S1 promontory screws and S2 iliac lumbopelvic screws. The specimens then underwent computed tomography scanning to determine structures at risk, cortical violations, and characteristics of screws placed. The sacroiliac joints were opened to examine articular cartilage penetration. RESULTS: Articular violation occurred in 60% of screws placed. Average length was 84 mm. No vital structures were at risk from screw placement. No intrapelvic cortical violations occurred. CONCLUSION: S2 iliac technique is a potential option for distal fixation in spine surgery. Biomechanical and clinical data are required to fully evaluate the potential of this technique.

Functional engraftment of the medial ganglionic eminence cells in experimental stroke model.

Currently there are no effective treatments targeting residual anatomical and behavioral deficits resulting from stroke. Evidence suggests that cell transplantation therapy may enhance functional recovery after stroke through multiple mechanisms. We used a syngeneic model of neural transplantation to explore graft-host communications that enhance cellular engraftment.The medial ganglionic eminence (MGE) cells were derived from 15-day-old transgenic rat embryos carrying green fluorescent protein (GFP), a marker, to easily track the transplanted cells. Adult rats were subjected to transient intraluminal occlusion of the medial cerebral artery. Two weeks after stroke, the grafts were deposited into four sites, along the rostro-caudal axis and medially to the stroke in the penumbra zone. Control groups included vehicle and fibroblast transplants. Animals were subjected to motor behavioral tests at 4 week posttransplant survival time. Morphological analysis demonstrated that the grafted MGE cells differentiated into multiple neuronal subtypes, established synaptic contact with host cells, increased the expression of synaptic markers, and enhanced axonal reorganization in the injured area. Initial patch-clamp recording demonstrated that the MGE cells received postsynaptic currents from host cells. Behavioral analysis showed reduced motor deficits in the rotarod and elevated body swing tests. These findings suggest that graft-host interactions influence the fate of grafted neural precursors and that functional recovery could be mediated by neurotrophic support, new synaptic circuit elaboration, and enhancement of the stroke-induced neuroplasticity.

Staged pelvic closure of extreme pubic diastasis in the exstrophy-epispadias complex.

PURPOSE: Staged pelvic closure has been shown to be beneficial in achieving pubic approximation in children with the exstrophy-epispadias complex. We have continued to use this procedure in children with extreme pelvic diastasis and have updated our experience. MATERIALS AND METHODS: We performed closure of the pelvis in 15 patients 12 months to 14 years old presenting with a pubic diastasis of at least 8 cm (range 8 to 16). Of the patients 14 had cloacal exstrophy and 1 had classic exstrophy. Two patients with cloacal exstrophy and the patient with classic exstrophy had prior complete dehiscence at primary closure, and 1 patient with cloacal exstrophy had partial dehiscence. The technique involved bilateral innominate and vertical iliac osteotomy, and placement of a bony fixator with interfragmentary pins. The fixator was gradually closed, and soft tissue and pelvic ring closure occurred 2 to 3 weeks later. In 9 of the 15 patients an interpubic stainless steel plate was used to keep the pubis in apposition at the time of bladder closure. RESULTS: At a mean followup of 5.5 years (range 6 months to 14 years) closure was successful in all 15 patients. One patient (age 12 months) had loosening of the pin between stages, which was salvaged with pin replacement. One patient had ureteral obstruction from hematoma after pin placement without direct pressure from the pins or bone. None of the patients had dehiscence or prolapse. CONCLUSIONS: This technique of staged pelvic closure can be used in the setting of primary or secondary pelvic reconstruction in patients presenting with extreme pelvic diastasis. The gradual reduction in diastasis allows gradual stretching of the soft tissues. It converts a major reconstruction challenge into 2 well tolerated components. However, the procedure is not recommended in children younger than 1 year due to the possibility of the pins loosening during diastasis reduction.