Social media for dissemination and public engagement in neurosurgery-the example of Brainbook.

BACKGROUND: Public engagement has become one of the most effective tools in gaining feedback and perspectives from members of the public, involving patients with decisions, and inspiring young people to carry the medical profession forwards. Brainbook is a multi-platform, social media-based resource that was created specifically to enhance public engagement in neurosurgery and results from one of its case discussions will be reported in this paper. METHODS: A Brainbook case was created in collaboration with the NIHR Global Health Research Group on Neurotrauma and presented over 3 days (23-25 February 2018). YouTube videos were created depicting the management of an acute subdural haematoma using patient interviews, medical illustration, consultant-led discussion and operative footage. Content was shared across all Brainbook social media platforms and analytics were gathered through social media applications. RESULTS: Over a 72-hour time period, and across multiple social media accounts, 101,418 impressions were achieved (defined as penetrance onto individual media feeds and total views of the content), with active discussion on social media. CONCLUSIONS: Neurosurgical content published across multiple social media outlets represents an encouraging and exciting potential for global engagement across multiple audiences. Social media can be an effective method of not only disseminating neurosurgical knowledge, but activating and engaging the public, allied healthcare professionals, medical students and neurosurgeons.

First line fertility treatment strategies regarding IUI and IVF require clinical evidence.

The advent of intracytoplasmic sperm injection (ICSI) has contributed to a significant growth in the delivery of assisted conception technique, such that IVF/ICSI procedures are now recommended over other interventions. Even the UK National Institute for Health Care Excellence (NICE) guidelines controversially recommends against intrauterine insemination (IUI) procedures in favour of IVF. We reflect on some of the clinical, economic, financial and ethical realities that have been used to selectively promote IVF over IUI, which is less intrusive and more patient friendly, obviates the need for embryo storage and has a global application. The evidence strongly favours IUI over IVF in selected couples and national funding strategies should include IUI treatment options. IUI, practised optimally as a first line treatment in up to six cycles, would also ease the pressures on public funds to allow the provision of up to three IVF cycles for couple who need it. Fertility clinics should also strive towards ISO15189 accreditation standards for basic semen diagnosis for male infertility used to triage ICSI treatment, to reduce the over-diagnosis of severe male factor infertility. Importantly, there is a need to develop global guidelines on inclusion policies for IVF/ICSI procedures. These suggestions are an ethically sound basis for constructing the provision of publicly funded fertility treatments.

Semen characteristics in consecutive ejaculates with short abstinence in subfertile males.

This study reports the favourable semen characteristics of 73 subfertile oligozoospermic men with short abstinence periods up to 40 min. Semen characteristics were compared between initial and consecutive ejaculate showing improved semen parameters: progressive grade A spermatozoa, morphology and sperm concentration. Median concentrations in initial and consecutive ejaculates were 10 million/ml and 17 million/ml, respectively. The second sample had a higher median normal morphology (7% versus 6%, P < 0.001). The median of non-progressive spermatozoa (Grade C) was significantly lower in the consecutive sample than the initial sample (0% versus 5%, P < 0.01). Medians for slow progression spermatozoa (B grade) and immotile spermatozoa (D grade) were lower in the consecutive samples (20% versus 13%, P < 0.01 and 60% versus 50%, P < 0.001, respectively). The median for rapid motility (Grade A) was significantly higher in the consecutive sample than the first (30% versus 5%, P < 0.001). Overall median progressive motility as benchmarked by the WHO 2010 criteria was significantly higher in the consecutive sample (43% versus 25%, P < 0.001). Semen analyses of consecutive semen samples collected 30 min (mean) apart in oligozoospemic men should be checked routinely for diagnostic purposes and for managing potential subfertility treatment.

Myxopapillary ependymoma: correlation of clinical and imaging features with surgical resectability in a series with long-term follow-up.

STUDY DESIGN: Retrospective case series. OBJECTIVES: The objective of this study is to identify imaging and intraoperative characteristics that may predict surgical resection for myxopapillary ependymoma (MPE). The diffuse involvement in the conus-filum region makes complete resection challenging. The preoperative characteristics that may estimate the extent of resection has not been reported. SETTING: Toronto, Canada. METHODS: All MPE cases between 1972 and 2005 at a single institution were identified and reexamined by a neuropathologist. Neurological outcomes (Frankel scale), clinical features, operative findings, pre and postoperative imaging results were reviewed. RESULTS: A total of 18 operations were performed on 15 MPE patients (8 females/7 males; age range: 18-71 years). Median postoperative follow-up was 56 months. Three patients (17%) developed tumor regrowth requiring reoperations. Preoperative magnetic resonance imaging (MRI; in 14/18 procedures) determined that tumors involved the conus in 70% of cases, which was significantly associated with intraoperative findings (P=0.02). Complete microsurgical resection was accomplished in 4 out of 7 cases where conus was not involved, but in only 1 out of 10 cases with conus involvement (P=0.056). The degree of conus involvement in one case was unclear. None of patients with total surgical resection developed recurrence. All patients survived at long-term follow-up. CONCLUSION: Our series is the first to correlate MPE involvement to conus medullaris on preoperative MRI with intraoperative findings, and examine its significance on surgical resectability. This information could guide clinicians in preoperative planning and advising patients on treatment options and potential risks/benefits. MRI is very sensitive (100%) and moderately specific (67%) in detecting direct anatomical contact between conus and MPE tumors.

Observer accuracy and reproducibility of visual estimation of blood loss in obstetrics: how accurate and consistent are health-care professionals?

OBJECTIVES: To evaluate the observer accuracy and intra-observer test-retest reliability of visual estimation of blood loss by midwives and obstetricians. METHODS: This was a prospective, single-blinded observational study conducted at a London teaching hospital. The accuracy of visually estimating five maternity pads that had been soaked with 25, 50, 100, 150 and 200 ml of blood was assessed. The reproducibility in estimating the same volume (two sets of pads soaked with 50, 100, 150 and 200 ml of blood randomly placed at separate stations) was evaluated by asking participants to visually estimate these volumes. RESULTS: Although there is a tendency to overestimate, the mean percentage difference (estimated-actual volumes) was not significantly different among consultants, trainees and midwives. Visual estimations were especially inaccurate with smaller volumes, which could be overestimated by up to 540%. Test-retest reliability was poor for the larger volumes but statistically acceptable for the smaller volumes, although the difference between the two estimates of the same volume could be as much as 300%. CONCLUSIONS: Visual estimations were inaccurate by health-care professionals who have a tendency to overestimate. Experience did not appear to have a confounding effect on accuracy. Further training in visual assessment skills is necessary in order to improve the clinicians' estimation.

Inhibition of trypsin and chymotrypsin by thiols. Biphasic kinetics of reactivation and inhibition induced by sodium periodate addition.

Biphasic kinetic data were obtained when trypsin (EC 3.4.21.4) which had previously been complexed with a thiol-containing inhibitor (present in Ehrlich ascites tumour cells) was incubated with incremental additions of periodate. At low concentrations of periodate the trypsin was re-activated whilst at higher concentrations of periodate the trypsin was irreversibly inhibited. This biphasic reactivation followed by inhibition was also demonstrated when trypsin was first inhibited by dithiothreitol and followed by incremental addition of periodate. Similar results were obtained with chymotrypsin (EC 3.4.21.1). Incremental additions of either dithiothreitol or periodate caused inhibition of both these enzymes. The biphasic kinetic data can be explained in terms of reduction and oxidation of a significant disulphide bond in both trypsin and chymotrypsin which can be cleaved by thiols in a disulphide exchange reaction [1]. This bond is thought to maintain the active centres of each of these enzymes in a conformation sterically favourable for enzymic cleavage of specific peptide bonds in the protein substrates (polymeric collagen fibrils and casein) employed in this study.

Inhibition properties of Sepharose-bound trypsin and a protease on the surface of Ehrlich ascites tumour cells.

Ehrlich ascites cells have been shown to possess a protease with beta-naphthylamidase activity located on the surface of these cells. This enzyme is protected from the inhibitory action of protein inhibitors of trypsin (EC 3.4.21.4) in free solution, but is inhibited by high concentrations of active site-directed inhibitors of trypsin. We believe the protection against inhibition is provided by the location of this protease on the cell surface. We employed a model system of trypsin coupled to Sepharose to demonstrate the protective action of an inert surface, resulting in a marked reduction in inhibition of trypsin-Sepharose, compared to trypsin in free solution, when exposed to both high and low molecular weight inhibitors. This cell protease has been shown to play a role in activation of the zymogen of collagenase exported by tumour cells. This role may have important implications for tumour cell invasion of the intercellular matrix.

Biphasic kinetics of metal ion reactivation of trypsin-thiol complexes.

This report describes biphasic kinetic data obtained when trypsin was inhibited by a thiol-containing inhibitor present in Ehrlich ascites tumour cells and then subjected to addition of Hg2+, Cu2+ or Ag+. This resulted in an initial re-activation of the trypsin, followed by inhibition of the enzyme with the addition of higher concentrations of these ions. The significance of these observations is 2-fold: (i) help to elucidate the mechanism of metal ion activation of latent enzymes, and (ii) also indicate that, in certain circumstances, the concentration of added metal ion determines whether the metal acts as an activator or an inhibitor of enzyme activity.

Intracerebral rhabdoid and papillary meningioma with leptomeningeal spread and rapid clinical progression.

OBJECTIVE AND IMPORTANCE: Rhabdoid meningioma (RM) is a relatively new, Grade III tumor entity according to the latest WHO classification. We report rhabdoid and partly papillary, highly anaplastic, intracerebral meningioma with diffuse leptomeningeal spread and distant SCF metastasis to the cervical cord. CLINICAL PRESENTATION: This 27-year-old female was admitted to the hospital with radiological findings suggestive of a primary brain tumor or a metastasis. After subtotal resection and during radiotherapy, follow-up MRI revealed recurrence, metastasis to meninges at the high cervical level, and diffuse basal leptomeningeal enhancement indicating infiltrating tumor. She died approximately 3 months after onset of symptoms. RESULTS: Histological examination revealed rhabdoid and papillary meningioma with high proliferation rate (80% of MIB1-positive cells), necrosis and extensive brain invasion. It was positive for vimentin and S-100 protein, showed focal epithelial membrane antigen expression and accumulation of intermediate filaments on ultrastructural examination. The recurrent tumor diffusely infiltrated leptomeninges and subarachnoid space. CONCLUSION: This is a rare example of mixed, rhabdoid and papillary variant of meningioma, located entirely within the brain parenchyma and accompanied by a fulminant clinical course. The combination of the histological anaplasia with the highest reported proliferation rate, and loss of the cohesion of neoplastic cells led to diffused infiltration of the leptomeninges and metastasis to the spinal cord.

Natural history of fetal hydronephrosis diagnosed on mid-trimester ultrasound.

OBJECTIVES: Renal tract dilatation is a common finding in routine prenatal ultrasound. However, there is no consensus as to the criteria used for differentiating pathological from physiological dilatation. The aim of this study was to evaluate the natural history and postnatal outcome of fetal hydronephrosis in an unselected obstetric population. DESIGN: This was a prospective study of fetal hydronephrosis, detected at 18-23 weeks' gestation, in a routine obstetric population. Fetal hydronephrosis was diagnosed as 'mild' if the antero-posterior renal pelvic diameter (APRPD) measured >or = 4 mm and as 'moderate/severe' if the APRPD measured > or = 7 mm or if there was associated calyceal dilatation. The postnatal outcome of fetuses with persistent hydronephrosis (> or = 10 mm in the third trimester) was determined from a postal questionnaire. RESULTS: During the study period, 11 465 women underwent an anomaly scan at 18-23 weeks of gestation. Fetal hydronephrosis was identified in 2.3% (268/11 465) of women. Mild hydronephrosis was present in 80.6% (216/268) and moderate/severe hydronephrosis in 19.4% (52/268). The hydronephrosis resolved in the antenatal or early neonatal period in 88% of fetuses. None of the fetuses with mild hydronephrosis and approximately one in three fetuses with persistent moderate/severe hydronephrosis required postnatal surgery. Overall, only one in every 1000 total births in the study population required postnatal urological surgery. CONCLUSIONS: The current study highlights the natural history of antenatally detected hydronephrosis. Mild fetal hydronephrosis appears to be associated with an excellent prognosis and probably represents the group with physiological renal pelvic dilatation. Moderate/severe fetal hydronephrosis is associated with poorer outcome and is perhaps the group that will need more intense follow up both antenatally and postnatally.

A trypsin-like neutral protease on Ehrlich ascites cell surfaces: its role in the activation of tumour-cell zymogen of collagenase.

Ehrlich ascites cells in mice have been shown to have a cell-surface trypsin-like neutral protease (TLNP) with proteolytic and beta-naphthylamidase activity. This activity is inhibited by low-mol.-wt inhibitors of trypsin but not by 11 high-mol.-wt inhibitors of trypsin in free solution. We believe that lack of inhibition is due to protection given to the enzyme by the chemical environment of the cell surface. These cells were demonstrated to export a collagenase zymogen which has been shown to be activated by the cell-surface TLNP. When this protease was completely inhibited by low-mol.-wt inhibitors of trypsin, chymotrypsin was used to activate the collagenase zymogen exported by Ehrlich ascites cells. Examination of the products of collagenolysis at 15 degrees C demonstrated the expected 3/4- and 1/4-length alpha-chain fragments derived from monomeric collagen, confirming that collagenase was one of the enzymes responsible for lysis of the collagen fibrils in the test system.

A randomized, controlled trial comparing effect of oral misoprostol and intravenous syntocinon on intra-operative blood loss during cesarean section.

BACKGROUND: Oxytocics are routinely used in an attempt to prevent excessive blood loss during cesarean section. Misoprostol, a potent uterotonic agent, has been reported to be useful in the prevention and treatment of postpartum hemorrhage by several investigators but its use during cesarean section has not been described. The objective of this study was to randomly compare the effectiveness of oral misoprostol with intravenous syntocinon on blood loss during elective cesarean sections under regional anesthesia. METHODS: Sixty pregnant women were randomized either to receive misoprostol 400 micrograms orally or syntocinon 10 IU intravenously during cesarean section. The primary outcome measure was intra-operative blood loss as estimated by physicians, and by values of preoperative and postoperative hemoglobin concentration and hematocrit. Demographic characteristics of the subjects and outcomes were compared using chi-square test for categorical and two-sample t-test for continuous data. RESULTS: Baseline characteristics in terms of age, body weight, parity, gestational age and indications for cesarean section were similar in both groups. The estimated blood loss was 545 ml (CI 476-614) in misoprostol group and 533 ml (CI 427-639) in syntocinon group (p = 0.85). Differences in preoperative and postoperative hemoglobin and hematocrit values were also similar in both groups. Two women in the misoprostol group and three in the syntocinon group (p=0.64) required additional oxytocics. One patient in each group required blood transfusion. No serious side effects were noted in either group. CONCLUSION: Oral misoprostol appears to be safe and as effective as intravenous syntocinon in reduction of intra-operative blood loss during elective cesarean section under regional anesthesia and merits further investigation.