Aids to improve understanding of statistical risk in patients consenting for surgery and interventional procedures: A systematic review.

BACKGROUND: Informed consent is an essential process in clinical decision-making, through which healthcare providers educate patients about benefits, risks, and alternatives of a procedure. Statistical risk information is difficult to communicate and the effectiveness of aids aimed at supporting this type of communication is uncertain. This systematic review aims to study the impact of risk communication adjuncts on patients' understanding of statistical risk in surgery and interventional procedures. METHODS: A systematic search was performed across Medline, Embase, PsycINFO, Scopus, and Web of Science until July 2021 with a repeated search in September 2022. RCTs and observational studies examining risk communication tools (e.g., information leaflets and audio-video) in adult (age >16) patients undergoing a surgical or interventional procedure were included. Primary outcomes included the objective assessment of statistical risk recall. Secondary outcomes included patient attitudes with respect to statistical information. Due to the study heterogeneity, a narrative synthesis was performed. RESULTS: A total of 4348 articles were identified, and following abstract and full-text screening 14 articles, including 9 RCTs, were included. The total number of adult patients was 1513. The most common risk communication tool used was written information (n = 7). Most RCTs (7/9, 77.8%) showed statistically significant improvements in patient understanding of statistical risk in the intervention group. Quality assessment found some concerns with all RCTs. CONCLUSION: Risk communication tools appear to improve recall of statistical risk. Additional prospective trials comparing various aids simultaneously are warranted to determine the most effective method of improving understanding.

The initial intracranial pressure spike phenomenon.

BACKGROUND: Elective use of intraparenchymal intracranial pressure (ICP) monitoring is a valuable resource in the investigation of hydrocephalus and other cerebrospinal fluid disorders. Our preliminary study aims to investigate ICP changes in the immediate period following dural breach, which has not yet been reported on. METHOD: This is a prospective cohort study of patients undergoing elective ICP monitoring, recruited between March and May 2022. ICP readings were obtained at opening and then at 5-min intervals for a 30-min duration. RESULTS: Ten patients were recruited, mean age 45 years, with indications of a Chiari malformation (n = 5), idiopathic intracranial hypertension (n = 3) or other ICP-related pathology (n = 2). Patients received intermittent bolus sedation (80%) vs general anaesthesia (20%). Mean opening pressure was 22.9 mmHg [± 6.0], with statistically significant decreases present every 5 min, to a total reduction of 15.2 mmHg at 20 min (p = < 0.0001), whereafter the ICP plateaued with no further statistical change. DISCUSSION: Our results highlight an intracranial opening pressure 'spike' phenomenon. This spike was 15.2 mmHg higher than the plateau, which is reached at 20 min after insertion. Several possible causes exist which require further research in larger cohorts, including sedation and pain response. Regardless of causation, this study provides key information on the use of ICP monitoring devices, guiding interpretation and when to obtain measurements.

ICP during head movement: significance of the venous system.

BACKGROUND: It is thought that the internal jugular veins (IJV) are the primary route for cranial venous outflow in supine position and the vertebral venous plexus when upright. Previous studies have noted a greater increase in intracranial pressure (ICP) when subjects turn their head in one direction compared to the other, but no clear cause had been investigated. We hypothesised that in the supine position, head turning and consequently obstructing the IJV draining the dominant transverse sinus (TVS) would lead to a greater rise in ICP compared to turning to the non-dominant side. METHODS: A prospective study in a large-volume neurosurgical centre. Patients undergoing continuous ICP monitoring as part of their standard clinical management were recruited. Immediate ICP was measured in different head positions (neutral, rotated to the right and left) when supine, seated, and standing. TVS dominance was established by consultant radiologist report on venous imaging. RESULTS: Twenty patients were included in the study, with a median age of 44 years. Venous system measurements revealed 85% right-sided vs 15% left-sided dominance. Immediate ICP rose more when head turning from neutral to the dominant TVS (21.93mmHg ± 4.39) vs non-dominant side (16.66mmHg ± 2.71) (p= <0.0001). There was no significant relationship in the sitting (6.08mmHg ± 3.86 vs 4.79mmHg ± 3.81, p = 0.13) or standing positions (8.74mmHg ± 4.30 vs 6.76mmHg ± 4.14, p =0.07). CONCLUSION: This study has provided further evidence that the transverse venous sinus to internal jugular system pathway is the likely primary venous drainage when supine; and quantified its effect when head turning on ICP. It may guide patient-specific nursing care and advice.

Comparing computer-assisted learning activities for learning clinical neuroscience: a randomized control trial.

BACKGROUND: Computer-assisted learning has been suggested to improve enjoyment and learning efficacy in medical education and more specifically, in neuroscience. These range from text-based websites to interactive electronic modules (eModules). It remains uncertain how these can best be implemented. To assess the effects of interactivity on learning perceptions and efficacy, we compared the utility of an eModule using virtual clinical cases and graphics against a Wikipedia-like page of matching content to teach clinical neuroscience: fundamentals of stroke and cerebrovascular anatomy. METHODS: A randomized control trial of using an interactive eModule versus a Wikipedia-like page without interactivity was performed. Participants remotely accessed their allocated learning activity once, for approximately 30 min. The primary outcome was the difference in perceptions on enjoyability, engagement and usefulness. The secondary outcome was the difference in learning efficacy between the two learning activities. These were assessed using a Likert-scale survey and two knowledge quizzes: one immediately after the learning activity and one repeated eight weeks later. Assessments were analysed using Mann-Whitney U and T-tests respectively. RESULTS: Thirty-two medical students participated: allocated evenly between the two groups through randomisation. The eModule was perceived as significantly more engaging (p = 0.0005), useful (p = 0.01) and enjoyable (p = 0.001) by students, with the main contributing factors being interactivity and clinical cases. After both learning activities, there was a significant decrease between the first and second quiz scores for both the eModule group (-16%, p = 0.001) and Wikipedia group (-17%, p = 0.003). There was no significant difference in quiz scores between the eModule and Wikipedia groups immediately afterwards (86% vs 85%, p = 0.8) or after eight weeks (71% vs 68%, p = 0.7). CONCLUSION: Our study shows that increased student satisfaction associated with interactive computer-assisted learning in the form of an eModule does not translate into increased learning efficacy as compared to using a Wikipedia-like webpage. This suggests the matched content of the passive webpage provides a similar learning efficacy. Still, eModules can help motivate self-directed learners and overcome the perceived difficulty associated with neuroscience. As computer assisted learning continues to rapidly expand among medical schools, we suggest educators critically evaluate the usage and cost-benefit of eModules.

Pharmacological venous thromboembolism prophylaxis in elective cranial surgery: a systematic review of time of initiation, regimen and duration.

INTRODUCTION: Pharmacological prophylaxis of venous thromboembolism (VTE) requires nuanced decision-making to balance the risk of VTE against haemorrhage. This problem is compounded in neurosurgical patients, in whom postoperative intracranial haemorrhage (ICH) may be catastrophic, compared to non-neuraxial bleeding in other types of surgery. Current major guidelines recommend caution when using pharmacological prophylaxis in elective cranial surgery, but incorporate low-quality evidence and lack precise guidance on timing and duration of anticoagulation. METHODS: We aimed to answer the following questions for patients undergoing elective cranial surgery: (1) when is the optimal time to initiate postoperative anticoagulation, and (2) how long should postoperative anticoagulation be continued for? In this systematic review, we screened randomised and non-randomised studies reporting original data on pharmacological VTE prophylaxis in elective cranial surgery. Outcomes of interest were VTE and ICH. RESULTS: Three retrospective, single-centre observational studies met eligibility criteria, with a total of 923 participants. Meta-analysis was not performed due to a high risk of bias across all studies. Through narrative synthesis, we found that patients who developed VTE were significantly more likely to receive their first postoperative dose at a later time (mean: 144 vs. 29 h, p = .04). Shorter courses of anticoagulation (<7 days) were associated with significantly lower ICH rates (p = .03) compared to longer courses (>21 days). CONCLUSION: The limited evidence favours earlier initiation and shorter courses of thromboprophylactic anticoagulation. These findings are specific to patients undergoing surgery for meningioma or glioma and may not apply to other populations. Randomised controlled trials or robustly designed observational studies are necessary to establish a clearer evidence base.

LATCH Score at Discharge: A Predictor of Weight Gain and Exclusive Breastfeeding at 6 Weeks in Term Healthy Babies.

OBJECTIVES: World Health Organization recommends exclusive breastfeeding (EBF) for 6 months after birth. However, problems with the baby failing to latch properly are common in the postpartum period contributing to breastfeeding cessation. The aim of the study was to evaluate the utility of LATCH score to predict EBF and weight gain at 6 weeks postpartum along with an optimum LATCH score cutoff. PATIENTS AND METHODS: This prospective cohort study was conducted in India. Ninety-three mother-infant dyads at term gestation were enrolled. Two LATCH score assessments were done by a lactation consultant: first within 24 hours of birth and second at discharge. Mothers with low LATCH scores were counselled before discharge. EBF rate and weight gain velocity were analyzed at 6 weeks. RESULTS: LATCH score ≥6 at discharge has the highest sensitivity (92.1%) and specificity (66.7%) for predicting EBF at 6 weeks postpartum (RR, 95% CI; 5.63 [4.32-12.65], P = 0.0003). Receiver operating characteristic (ROC) of LATCH score at discharge and EBF at 6 weeks had an area under the curve of 0.785 with a cutoff ≥5.5, showing the highest sensitivity of 93.6% with a false-positive rate of 30.1%. LATCH score >6 at discharge was significantly associated with higher EBF rate (RR, 95% CI; 0.61 [0.39-0.94]) and appropriate weight gain (≥ 20 grams/day) at 6 weeks of age (RR, 95% CI; 0.44 [0.25-0.75]). After counselling, the LATCH score significantly improved at discharge in mothers (n = 62) with an initial score <6 (P < 0.001). CONCLUSION: LATCH score is a simple tool to identify mothers who require breastfeeding support and counselling before discharge from the hospital to prevent early breastfeeding cessation.

Stability of the Initial Diagnosis of Autism Spectrum Disorder by DSM-5 in Children: A Short-Term Follow-Up Study.

BACKGROUND: Assessing the stability of the diagnosis of autism spectrum disorder (ASD) in children is important. Only few such studies have been reported from India. We aimed to assess the stability after 18-30 months, of an initial diagnosis of ASD based on DSM-5, in children ≤ 5 years of age using Autism Diagnostic Observation Schedule, 2nd Edition (ADOS-2). METHODS: A total of 125 children with ASD diagnosed by DSM-5 at ≤ 5 years of age were followed up at 18-30 months using ADOS-2, which is considered as the 'gold-standard' observational assessment for diagnosing ASD and hence suitable for confirming the stability of the diagnosis. RESULTS: Similar to previous studies from developed countries, the stability of ASD diagnosis was 80%. There was no significant correlation between gender, socioeconomic status and the stability of the final diagnosis. All the children continued to have some developmental difficulties mainly in the domain of language, attention or social communication. CONCLUSION: Our results suggest that DSM-5 can be used for the initial diagnosis ASD to initiate early intervention for children with this condition in resource-limited set-ups. Adequately powered prospective studies with long-term follow-up are needed to confirm our findings.

GWAS identifies population-specific new regulatory variants in FUT6 associated with plasma B12 concentrations in Indians.

Vitamin B12 is an important cofactor in one-carbon metabolism whose dysregulation is associated with various clinical conditions. Indians have a high prevalence of B12 deficiency but little is known about the genetic determinants of circulating B12 concentrations in Indians. We performed a genome-wide association study in 1001 healthy participants in the Pune Maternal Nutrition Study (PMNS), replication studies in 3418 individuals from other Indian cohorts and by meta-analysis identified new variants, rs3760775 (P = 1.2 × 10-23) and rs78060698 (P = 8.3 × 10-17) in FUT6 to be associated with circulating B12 concentrations. Although in-silico analysis replicated both variants in Europeans, differences in the effect allele frequency, effect size and the linkage disequilibrium structure of credible set variants with the reported variants suggest population-specific characteristics in this region. We replicated previously reported variants rs602662, rs601338 in FUT2, rs3760776, rs708686 in FUT6, rs34324219 in TCN1 (all P < 5 × 10-8), rs1131603 in TCN2 (P = 3.4 × 10-5), rs12780845 in CUBN (P = 3.0 × 10-3) and rs2270655 in MMAA (P = 2.0 × 10-3). Circulating B12 concentrations in the PMNS and Parthenon study showed a significant decline with increasing age (P < 0.001), however, the genetic contribution to B12 concentrations remained constant. Luciferase reporter and electrophoretic-mobility shift assay for the FUT6 variant rs78060698 using HepG2 cell line demonstrated strong allele-specific promoter and enhancer activity and differential binding of HNF4α, a key regulator of expression of various fucosyltransferases. Hence, the rs78060698 variant, through regulation of fucosylation may control intestinal host-microbial interaction which could influence B12 concentrations. Our results suggest that in addition to established genetic variants, population-specific variants are important in determining plasma B12 concentrations.

Dietary pattern regulates fatty acid desaturase 1 gene expression in Indian pregnant women to spare overall long chain polyunsaturated fatty acids levels.

The aim of this study was to determine if the dietary pattern of pregnant women has any compensatory effect on the fatty acid desaturase (FADS) gene expression, thus enhancing the conversion of precursors to long chain polyunsaturated fatty acids (LCPUFA) to spare the overall LCPUFA levels. The dietary intake of plant-based precursor polyunsaturated fatty acids (PUFA) influences circulating levels of LCPUFA. We hypothesized that low LCPUFA diets during pregnancy would compensate by higher expression of FADS genes to enhance the conversion of precursors to LCPUFA to spare the overall LCPUFA levels. Seventy-five pregnant women were enrolled during the last trimester of pregnancy based on the eligibility and exclusion criteria. Maternal LCPUFA in plasma, expression of FADS1 and FADS2 genes, FADS2 Indel genotype status and neonate birth weight were studied.In the vegetarian group (n = 25), plasma α-linolenic acid (ALA) but not linoleic acid (LA) was significantly lower (p < 0.05) than the non-vegetarian group (n = 50). No significant differences were found for arachidonic acid (AA) or docosahexaenoic acid (DHA) levels. FADS1 expression was significantly higher in the vegetarian group compared to the non-vegetarian group. There was no significant difference in the birth weight of the neonates between two groups. No significant correlation was observed between FADS2 Indel genotype and birth weight. Our small sample size study demonstrated an increase FADS1expression during pregnancy in vegetarian pregnant women that may have contributed to the maintenance of AA, eicosapentaenoic acid and DHA levels thereby ensuring that the overall LCPUFA levels of the neonate is not compromised.

Fragile X Syndrome with Congenital Diaphragmatic Hernia.

The authors present a case of Fragile X syndrome (FXS) in siblings from an Indian family with no developmental delay in previous generations. The boy presented with developmental delay, autistic features and defiant behaviours that raised clinical suspicion. He also had congenital diaphragmatic hernia (CDH). Social anxiety and difficulty in making friends were the subtle features in his sister with dull normal intelligence. FXS was confirmed by clinical features and DNA testing. Intervention was initiated for both the siblings. Screening siblings in FXS is important. CDH can be associated with FXS.

Factors Associated with Time to Full Feeds in Preterm Very Low Birth Weight Infants.

BACKGROUND: Feeding intolerance prolongs time to full feeds (TFFs) in preterm infants. We studied factors associated with TFF in preterm infants on standardized feeding regimen (SFR) and routine probiotic supplementation (RPS). METHODS: This is a prospective cohort study of preterm infants ≤1500 g. Pearson's correlation, Mann-Whitney test and multivariate analysis were used. RESULTS: In total, 37 of 304 admitted infants died before reaching full feeds. Median (interquartile range) gestation, birth weight and TFF were 31.4 (30-33.05) weeks, 1210 (1066-1400) g and 11 (8-15) days, respectively. Gestation and birthweight were inversely correlated with TFF, whereas low Apgar's, sepsis, patent ductus arteriosus (PDA) and respiratory distress syndrome were directly correlated with TFF. Growth-restricted infants had significantly shorter TFF vs. appropriate for gestational age infants, probably because of higher gestation. On multivariate analysis gestation, sepsis and PDA were significant predictors of TFF. CONCLUSION: In preterm infants managed with SFR and RPS, gestation had inverse correlation with TFF, whereas sepsis and PDA had direct correlation with TFF.

Higher glucose, insulin and insulin resistance (HOMA-IR) in childhood predict adverse cardiovascular risk in early adulthood: the Pune Children's Study.

AIMS/HYPOTHESIS: The Pune Children's Study aimed to test whether glucose and insulin measurements in childhood predict cardiovascular risk factors in young adulthood. METHODS: We followed up 357 participants (75% follow-up) at 21 years of age who had undergone detailed measurements at 8 years of age (glucose, insulin, HOMA-IR and other indices). Oral glucose tolerance, anthropometry, plasma lipids, BP, carotid intima-media thickness (IMT) and arterial pulse wave velocity (PWV) were measured at 21 years. RESULTS: Higher fasting glucose, insulin and HOMA-IR at 8 years predicted higher glucose, insulin, HOMA-IR, BP, lipids and IMT at 21 years. A 1 SD change in 8 year variables was associated with a 0.10-0.27 SD change at 21 years independently of obesity/adiposity at 8 years of age. A greater rise in glucose-insulin variables between 8 and 21 years was associated with higher cardiovascular risk factors, including PWV. Participants whose HOMA-IR measurement remained in the highest quartile (n = 31) had a more adverse cardiovascular risk profile compared with those whose HOMA-IR measurement remained in the lowest quartile (n = 28). CONCLUSIONS/INTERPRETATION: Prepubertal glucose-insulin metabolism is associated with adult cardiovascular risk and markers of atherosclerosis. Our results support interventions to improve glucose-insulin metabolism in childhood to reduce cardiovascular risk in later life.

Improving risk communication: a proof-of-concept randomised control trial assessing the impact of visual aids for neurosurgical consent.

Introduction: Informed consent is a fundamental component in the work-up for surgical procedures. Statistical risk information pertaining to a procedure is by nature probabilistic and challenging to communicate, especially to those with poor numerical literacy. Visual aids and audio/video tools have previously been shown to improve patients' understanding of statistical information. In this study, we aimed to explore the impact of different methods of risk communication in healthy participants randomized to either undergo the consent process with visual aids or the standard consent process for lumbar puncture. Material and methods: Healthy individuals above 18 years old were eligible. The exclusion criteria were prior experience of the procedure or relevant medical knowledge, lack of capacity to consent, underlying cognitive impairment and hospitalised individuals. After randomisation, both groups received identical medical information about the procedure of a lumbar puncture in a hypothetical clinical scenario via different means of consent. The control group underwent the standard consent process in current clinical practice (Consent Form 1 without any illustrative examples), whereas the intervention group received additional anatomy diagrams, the Paling Palette and the Paling perspective scale. Anonymised questionnaires were received to evaluate their perception of the procedure and its associated risks. Results: Fifty-two individuals were eligible without statistically significant differences in age, sex, professional status and the familiarity of the procedure. Visual aids were noted to improve the confidence of participants to describe the risks by themselves (p = 0.009) and participants in the intervention group felt significantly less overwhelmed with medical information (p = 0.028). The enhanced consent process was found to be significantly more acceptable by participants (p = 0.03). There was a trend towards greater appropriateness (p = 0.06) and it appeared to have "good" usability (median SUS = 76.4), although this also did not reach statistical significance (p = 0.06). Conclusion: Visual aids could be an appropriate alternative method for medical consent without being inferior regarding the understanding of the procedure, its risks and its benefits. Future studies could possibly compare or incorporate multiple interventions to determine the most effective tools in a larger scale of population including patients as well as healthy individuals.

The Impact of Intracranial Pressure Telesensors: An Observational Propensity-Matched Control Analysis of Service Demand and Costs.

BACKGROUND AND OBJECTIVES: Implantable telemetric intracranial pressure (ICP) sensors (telesensors) enable routine, noninvasive ICP feedback, aiding clinical decision-making and attribution of pressure-related symptoms in patients with cerebrospinal fluid shunt systems. Here, we aim to explore the impact of these devices on service demand and costs in patients with adult hydrocephalus. METHODS: We performed an observational propensity-matched control study, comparing patients who had an MScio/Sensor Reservoir (Christoph Miethke, GmbH & Co) against those with a nontelemetric reservoir inserted between March 2016 and March 2018. Patients were matched on demographics, diagnosis, shunt-type, and revision status. Service usage was recorded with frequencies of neurosurgical admissions, outpatient clinics, scans, and further surgical procedures in the 2 years before and after shunt insertion. RESULTS: In total, 136 patients, 73 telesensors, and 63 controls were included in this study (48 matched pairs). Telesensor use led to a significant decrease in neurosurgical inpatient admissions, radiographic encounters, and procedures including ICP monitoring. After multivariate adjustment, the mean cumulative saving after 2 years was £5236 ($6338) in telesensor patients (£5498 on matched pair analysis). On break-even analysis, cost-savings were likely to be achieved within 8 months of clinical use, postimplantation. Telesensor patients also experienced a significant reduction in imaging-associated radiation (4 mSv) over 2 years. CONCLUSION: The findings of this exploratory study reveal that telesensor implantation is associated with reduced service demand and provides net financial savings from an institutional perspective. Moreover, telesensor patients required fewer appointments, invasive procedures, and had less radiation exposure, indicating an improvement in both their experience and safety.

Diffusion magnetic resonance imaging in preterm brain injury.

INTRODUCTION: White matter injury and abnormal maturation are thought to be major contributors to the neurodevelopmental disabilities observed in children and adolescents who were born preterm. Early detection of abnormal white matter maturation is important in the design of preventive, protective, and rehabilitative strategies for the management of the preterm infant. Diffusion-weighted magnetic resonance imaging (d-MRI) has become a valuable tool in assessing white matter maturation and injury in survivors of preterm birth. In this review, we aim to (1) describe the basic concepts of d-MRI; (2) evaluate the methods that are currently used to analyse d-MRI; (3) discuss neuroimaging correlates of preterm brain injury observed at term corrected age; during infancy, adolescence and in early adulthood; and (4) explore the relationship between d-MRI measures and subsequent neurodevelopmental performance. METHODS: References for this review were identified through searches of PubMed and Google Scholar before March 2013. RESULTS: The impact of premature birth on cerebral white matter can be observed from term-equivalent age through to adulthood. Disruptions to white matter development, identified by d-MRI, are related to diminished performance in functional domains including motor performance, cognition and behaviour in early childhood and in later life. CONCLUSION: d-MRI is an effective tool for investigating preterm white matter injury. With advances in image acquisition and analysis approaches, d-MRI has the potential to be a biomarker of subsequent outcome and to evaluate efficacy of clinical interventions in this population.

Bubble CPAP versus ventilator CPAP in preterm neonates with early onset respiratory distress--a randomized controlled trial.

UNLABELLED: Bubble continuous positive airway pressure (BCPAP) is a low cost nasal CPAP delivery system with potential benefits to developing nations. OBJECTIVE: To compare the efficacy and safety of BCPAP with ventilator-derived CPAP (VCPAP) in preterm neonates with respiratory distress. METHODS: In a randomized controlled trial, preterm neonates with Silverman-Anderson score ≥ 4 and oxygen requirement >30% within first 6 h of life were randomly allocated to BCPAP or VCPAP. Proportion of neonates with success or failure was compared. RESULTS: In all, 47 of 57 (82.5%) neonates from BCPAP group and 36 of 57 (63.2%) neonates from the VCPAP group completed CPAP successfully (p = 0.03). Neonates who failed CPAP had higher Silverman-Anderson score (p < 0.01), lower arterial to alveolar oxygenation ratio (p < 0.05) and needed surfactant more frequently (p < 0.01). CONCLUSION: BCPAP has higher success rate than VCPAP for managing preterm neonates with early onset respiratory distress, with comparable safety.

Moving towards a unified classification of glioblastomas utilizing artificial intelligence and deep machine learning integration.

Glioblastoma a deadly brain cancer that is nearly universally fatal. Accurate prognostication and the successful application of emerging precision medicine in glioblastoma relies upon the resolution and exactitude of classification. We discuss limitations of our current classification systems and their inability to capture the full heterogeneity of the disease. We review the various layers of data that are available to substratify glioblastoma and we discuss how artificial intelligence and machine learning tools provide the opportunity to organize and integrate this data in a nuanced way. In doing so there is the potential to generate clinically relevant disease sub-stratifications, which could help predict neuro-oncological patient outcomes with greater certainty. We discuss limitations of this approach and how these might be overcome. The development of a comprehensive unified classification of glioblastoma would be a major advance in the field. This will require the fusion of advances in understanding glioblastoma biology with technological innovation in data processing and organization.