Multidisciplinary neurosurgical rounds incorporating antimicrobial stewardship. Are they of benefit?

Background: In an era of increasing antimicrobial resistance, appropriate antimicrobials are essential to optimise patient outcomes. In 2017, antimicrobial use prevalence (AMU) on the two neurosurgical wards in our tertiary teaching hospital varied from 23% on ward A to 33% on ward B with 67% and 100% 'appropriate' prescriptions, respectively. In July 2018, a weekly antimicrobial stewardship multidisciplinary round led by a senior neurosurgery registrar commenced, attended by the antimicrobial stewardship team (AST). Research question: This report evaluates whether a multi-disciplinary approach on neurosurgical prescribing was beneficial, specifically in reducing AMU. Materials and methods: The following data was collected on AST rounds for 30 weeks in total from August 2018 to July 2019: number of patients on antimicrobials, appropriateness and stewardship actions. A questionnaire was distributed to neurosurgical doctors on two occasions to canvass opinions and attitudes on antimicrobial prescribing. Results: 1716 prescriptions were reviewed (mean 57.2 per week). Of these 321 (18.7%) included antimicrobial prescriptions; 200 on ward A (19.8%), and 121 on ward B (17%), representing a decrease in AMU from 2017. The majority of antimicrobial prescriptions, 271 (84.4%) were deemed appropriate. Stewardship actions were taken in 215 (67%) prescriptions.Fifteen questionnaires were completed by neurosurgical doctors. The majority, 87%, stated the AST round was helpful overall. 93% indicated that informal training on the AST round was a source of education in antibiotic prescribing. Discussion and conclusion: The weekly AST round provided a timely opportunity for multidisciplinary discussion, implementation of antimicrobial stewardship actions and opportunistic antimicrobial stewardship education.

Concurrent management of suppurative intracranial complications of sinusitis and acute otitis media in children.

OBJECTIVE: Intracranial complications of sinusitis and acute otitis media (AOM) are rare but life-threatening events. In children with suppurative intracranial complications, concurrent neurosurgical and otolaryngological (ORL) intervention has been recommended to optimize outcomes. The aim of this study was to investigate outcomes following concurrent neurosurgical and ORL intervention. METHODS: A retrospective cohort study of children undergoing neurosurgical intervention for intracranial complications of sinusitis or AOM in two neurosurgical centres in Ireland was conducted. RESULTS: 65 children were identified. Mean age was 11.9 years. The most prevalent symptoms were headache, pyrexia, altered level of consciousness, facial swelling, and vomiting. Subdural empyema (n = 24, 36.9%) and extradural abscess (n = 17, 26.2%) were the most common complications. 54 underwent same admission ORL intervention; 47 (87%) were performed concurrently or earlier. For rhinogenic infections, 35 (64.8%) underwent endoscopic sinus surgery (ESS), 13 (24.1%) underwent frontal sinus trephine, and 5 (9.3%) underwent maxillary sinus washout alone. For otogenic infections, 10 (90.9%) underwent mastoidectomy and 7 (63.6%) underwent tympanostomy tube placement. 19 (29.2%) had post-operative neurological deficits, of which 2 (3.1%) were permanent. Streptococcus intermedius was the most common pathogen (n = 30, 46.2%). Concurrent intervention reduced the prevalence of residual collection (p = 0.018) and the need for revision neurosurgical intervention (p = 0.039) for sinogenic complications. The same trends did not achieve statistical significance for the otogenic group. Mortality was 0%. CONCLUSION: Intracranial complications of sinusitis and AOM are best managed in a specialist centre with multidisciplinary input. Concurrent ORL and neurosurgical intervention reduces abscess recurrence and requirement for revision neurosurgery in sinogenic complications and should represent the standard of care. ESS is the ORL modality of choice in experienced hands.

Primary External Ventricular Drains in the Management of Open Myelomeningocele Repairs in the Neonatal Setting in Ireland

Aim The aim of this study is to outline the role of primary external ventricular drains (EVD) in the management of open myelomeningoceles in the neonatal setting in Ireland. Methods Retrospective cohort study involving all infants who underwent open myelomeningocele repair in a teritary centre in Ireland between January 2009 and April 2016. Medical charts and laboratory data was reviewed on all infants meeting the inclusion criteria. Results One hundred and forty-three neonates underwent open myelomeningocele repair in the 6.5 year period. EVD were inserted at the time of primary wound closure in 19 cases (13%). EVD were used to aid in wound closure and as a primary method of cerebrospinal fluid (CSF) diversion. They remained in place for a median of 8 days, ranging from 1-22 days. All EVD, apart from one, in our series were replaced by a ventricular-peritoneal (VP) shunt at some stage. Conclusion EVD were used in 13% of cases of open myelomeningocele repairs from Jan 2009-Apr 2016 as a primary measure to aid in management. Compared to the cohort in whom an EVD was not inserted at the time of surgery, there was a decrease in the rate of infections. However, there was an increased rate of wound dehiscence/leak and a later need for VP shunt insertion.

A Review Of Referral Patterns For Sagittal Synostosis In Ireland: 2008-2013.

Sagittal synostosis (SS) is the commonest form of craniosynostosis. Children with sagittal synostosis in Ireland are treated in the National Paediatric Craniofacial Centre (NPCC) in Temple Street Children's University Hospital. This retrospective study analysed the correlation between referral patterns to the unit and age at operation. The notes of 81 patients referred over a 5-year period (April 2008 - April 2013) to the NPCC with non-syndromic SS were reviewed and demographics and referral information were recorded. Of 81 patients reviewed, 60 (74%) were referred before 6 months of age, while 21 (26%) had late referrals. Neonatologists referred 100% of infants before 6 months, paediatricians referred 71%, and GPs 64%. Later referral was associated with a more complex referral pathway, including multiple-steps of referral and unnecessary investigations. Improved clinician knowledge and emphasis on the importance of early referral may lead to a reduction in late referrals.

Interpretive analysis of 85 systematic reviews suggests that narrative syntheses and meta-analyses are incommensurate in argumentation.

Using Toulmin's argumentation theory, we analysed the texts of systematic reviews in the area of workplace health promotion to explore differences in the modes of reasoning embedded in reports of narrative synthesis as compared with reports of meta-analysis. We used framework synthesis, grounded theory and cross-case analysis methods to analyse 85 systematic reviews addressing intervention effectiveness in workplace health promotion. Two core categories, or 'modes of reasoning', emerged to frame the contrast between narrative synthesis and meta-analysis: practical-configurational reasoning in narrative synthesis ('what is going on here? What picture emerges?') and inferential-predictive reasoning in meta-analysis ('does it work, and how well? Will it work again?'). Modes of reasoning examined quality and consistency of the included evidence differently. Meta-analyses clearly distinguished between warrant and claim, whereas narrative syntheses often presented joint warrant-claims. Narrative syntheses and meta-analyses represent different modes of reasoning. Systematic reviewers are likely to be addressing research questions in different ways with each method. It is important to consider narrative synthesis in its own right as a method and to develop specific quality criteria and understandings of how it is carried out, not merely as a complement to, or second-best option for, meta-analysis. © 2016 The Authors. Research Synthesis Methods published by John Wiley & Sons Ltd.

Is the endoscopic third ventriculostomy success score an appropriate tool to inform clinical decision-making?

INTRODUCTION: The endoscopic third ventriculostomy success score (ETVSS) is a model, which provides each patient with a prediction of the outcome of endoscopic third ventriculostomy. The objective of this study was to determine if there is clinical value to the use of the ETVSS in the decision for ETV. METHODS: Prospectively collected data on all ETV procedures with the Republic of Ireland in children ≤16 years of age, totalling 112, from 2008 to 2014 was analysed. The percentage chance of success at six months was retrospectively calculated according to the ETVSS. A multivariable model, comprising the risk factors from the ETVSS - age, aetiology and previous shunt - was created and its performance compared to that of the ETVSS. RESULTS: The ETVSS achieved an AUC of 0.61 (95% CI: 0.49-0.71) with a sensitivity and specificity of 50% and 76%, respectively, at its optimal cutoff. The ETVSS was not significantly well calibrated in this cohort and there was a limited net benefit on decision curve analysis in comparison with the strategy of performing ETV in all patients. The multivariable model achieved an AUC of 0.67 (95% CI: 0.56-0.78), was well calibrated and was associated with a superior net benefit over that of the ETVSS. CONCLUSION: The ETVSS represents the future of patient risk stratification with an easy to use, individualised approach for each patient. The ETVSS has performed adequately in this study. However, through the addition of novel risk factors, the continuous updating of the model and recalibration where needed, the ETVSS can become a tool that the paediatric neurosurgeon cannot do without.

Thinking outside the shunt-sterile CSF malabsorption in pilocytic astrocytomas: case series and review of the literature.

INTRODUCTION: Ventriculoperitoneal (VP) shunt insertion is the most common cerebrospinal fluid (CSF) diversionary procedure used for the treatment of chronic hydrocephalus. Sterile CSF ascites is a rare complication of VP shunt insertion. This can arise from either an overproduction of CSF or inadequate filtration of CSF at the level of the peritoneum. By either mechanism, the development of CSF ascites requires an intact VP shunt. OBJECTIVE: The authors discuss two paediatric cases diagnosed with suprasellar pilocytic astrocytomas treated with platinum-based chemotherapy, who subsequently developed sterile CSF ascites. We review the literature with regard to CSF malabsorption and discuss it as a contributing factor to shunt malfunction. CONCLUSION: CSF malabsorption with resultant ascites is a rare complication of VP shunting with many etiologies. Two common predisposing factors included the use of platinum-based chemotherapeutic agents, as well as the specific neuropathology. Further analysis of these two entities is needed in order to elucidate their role in contributing to the development of CSF ascites in this patient cohort.

Cranial fasciitis located at the temporal region in a 2-year-old girl.

INTRODUCTION: Cranial fasciitis is an exceedingly rare, benign, fibroblastic tumour of the skull of young children. It was first described in 1980 by Lauer and Enzinger as a subset of nodular fasciitis. There are fewer than 55 cases described in the literature. CASE REPORT: We describe the presentation of a 2-year-old girl with a rapidly growing left temporal lesion, initially treated as an intramuscular haemangioma with propanolol. Following failure of response to this management, radiological and histological investigations indicated cranial fasciitis, and multidisciplinary surgery was undertaken via a bicoronal incision. Gross total resection was carried out, and the lesion was found to be adherent to but not infiltrating the dura. The petrous bone and zygomatic arch appeared destroyed, leaving a large temporal bony defect. This was repaired with a split calvarial graft from the outer table of the right parietal bone. DISCUSSION: Histology confirmed a diagnosis of cranial fasciitis. She had an uneventful post-operative course and was discharged home well. A CT scan 8 months post-operatively showed no residual lesion and it was noted that the reconstruction had fully integrated and the zygomatic arch had reformed.

Mashed-muscle and oxidised regenerated cellulose (Surgicel) hammock: a quick and effective way to repair frontal air sinus.

The authors describe a simple modification of the traditional muscle-packing technique to seal exposed frontal air sinus during neurosurgical, ENT and facio-maxillary trauma and elective procedures. Oxidised cellulose hammock is used to effectively hold the muscle piece in place to seal the sinus.

The effects of practice with MP3 players on driving performance.

This study examined the effects of repeated iPod interactions on driver performance to determine if performance decrements decreased with practice. Nineteen younger drivers (mean age=19.4, range 18-22) participated in a seven session study in the University of Calgary Driving Simulator (UCDS). Drivers encountered a number of critical events on the roadways while interacting with an iPod including a pedestrian entering the roadway, a vehicle pullout, and a lead vehicle braking. Measures of hazard response, vehicle control, eye movements, and secondary task performance were analyzed. Increases in perception response time (PRT) and collisions were found while drivers were performing the difficult iPod tasks, which involved finding a specific song within the song titles menu. Over the course of the six experimental sessions, driving performance improved in all conditions. Difficult iPod interactions significantly increased the amount of visual attention directed into the vehicle above that of the baseline condition. With practice, slowed responses to driving hazards while interacting with the iPod declined somewhat, but a decrement still remained relative to the baseline condition. The multivariate results suggest that access to difficult iPod tasks while vehicles are in motion should be curtailed.

Matrix metalloproteinases 2 and 9 in human atherosclerotic and non-atherosclerotic cerebral aneurysms.

Matrix metalloproteinases 2 and 9 (MMP 2 and -9) have been implicated in the pathogenesis of atherosclerosis and aneurysm formation. The goal of the study was to establish the role of these metalloproteinases in both human atherosclerotic and non-atherosclerotic cerebral aneurysms. Eleven cerebral aneurysms (four atherosclerotic, seven non-atherosclerotic) were immunohistochemically stained for MMP 2 and -9. As controls, atherosclerotic and normal Circle of Willis arteries were similarly immunostained. All specimens were retrieved at autopsy and were paraffin-embedded. In order to evaluate the real MMP 2 and -9 activities, gelatin zymography was also performed in only two available specimens of non-atherosclerotic intracranial aneurysms, because of the relative unavailability of fresh intracranial aneurysm tissue (i.e. reluctance to excise the aneurysm fundus at surgery). Our data establish that MMP 2 and -9 were expressed minimally or not at all in normal Circle of Willis arteries but were strongly expressed in medial smooth muscle cells of atherosclerotic Circle of Willis arteries. In the aneurysm group, both MMP 2 and -9 were strongly expressed in the atherosclerotic aneurysms, but MMP 2 alone was detected in the non-atherosclerotic aneurysms. Zymography revealed a weak enzyme activity correlating to MMP 9 standard recombinant protein. MMP 2 activity was not demonstrated in either specimen. This study shows that the expression of MMP 2 and -9 is associated with atherosclerosis, be it in aneurysmal or non-aneurysmal cerebral vessels but MMP 2 appears to be specifically expressed in aneurysms devoid of atherosclerosis perhaps suggesting a pathogenic role for MMP 2 in the alteration of the extracellular matrix of cerebral arteries during aneurysm formation.

The impact of antithrombotic therapy on neurosurgical emergency referral load.

The authors sought to determine the impact of antithrombotic therapy on emergency referrals at one neurosurgical centre. All emergency telephone referrals over a 90 day period were carefully documented with particular attention paid to current antithrombotic medications and their indication. Details regarding age, gender, diagnosis, radiological findings and treatment were also recorded. 713 emergency referrals were documented in the data collection period. 174 (24.4%) patients presented with intracranial or spinal haemorrhage and 75 (43.1%) of these were on antithrombotic therapy, ranging in age from 46-94 years (mean 71.1 years) with 29 (31.8%) on warfarin, 43 (47.2%) on aspirin and 15 (16.4%) on clopidogrel alone or in combination with another antithrombotic agent. 17 (22.6%) had no documented indication for antithrombotic therapy (all of these were on aspirin therapy) and 9 (31%) of those on warfarin had an INR in excess of 3.5 on presentation. Almost one quarter of those on antithrombotic therapy who presented with a haemorrhagic complication had no obvious indication for such therapy. One third of those on warfarin were over anticoagulated.

Craniotomy with prosthetic heart valves: a clinical dilemma.

The authors report two cases of spontaneous intracranial haemorrhage after elective craniotomy for resection of cerebral tumour. Both patients had mechanical aortic valve prostheses and were on regular warfarin therapy. In both cases, warfarin therapy was discontinued 5 days prior to surgery and unfractionated heparin administered intravenously until 12 h before surgery. Both patients were re-anticoagulated with subcutaneous low molecular weight heparin within the first week postcraniotomy-both developed life-threatening intracranial haemorrhage requiring urgent evacuation. The authors emphasize the risk of re-anticoagulation without postoperative imaging and the disadvantages of therapeutic dose, low molecular weight heparin in the postoperative period.

Preoperative cervical traction in cases of cranial settling with halo ring and Mayfield skull clamp.

Rheumatoid cervical myelopathy presents one of the most daunting challenges in neurological surgery. Preoperative cervical traction can help to distract the dens from the brainstem prior to performing occipitocervical fusion in cases of cranial settling. Valuable millimetres gained in preoperative traction can be lost in placing the patient in the prone position after removing the halo to allow application of the Mayfield skull clamp. The authors have found that traction can be adequately maintained during surgery by applying the Mayfield skull clamp with skull pins to the halo ring itself.

The relationships between organizational and individual variables to on-the-job driver accidents and accident-free kilometres.

Highway fatalities are the leading cause of fatal work injuries in the US, accounting for approximately 1 in 4 of the 5900 job-related deaths during 2001. The present study focused on the contribution of organizational factors and driver behaviours to on-the-job driving accidents in a large Western Canadian corporation. A structural equation modelling (SEM) approach was used which allows researchers to test a complex set of relationships within a global theoretical framework. A number of scales were used to assess organizational support, driver errors, and driver behaviours. The sample of professional drivers that participated allowed the recording of on-the-job accidents and accident-free kilometres from their personnel files. The pattern of relationships in the fitted model, after controlling for exposure and social desirability, provides insight into the role of organizational support, planning, environment adaptations, fatigue, speed, errors and moving citations to on-the-job accidents and accident-free kilometres. For example, organizational support affected the capacity to plan. Time to plan work-related driving was found to predict accidents, fatigue and adaptations to the environment. Other interesting model paths, SEM limitations, future research and recommendations are elaborated.

'Plunging' during burr hole craniostomy: a persistent problem amongst neurosurgeons in Britain and Ireland.

The inadvertent 'plunging' of an instrument into the cranial cavity is a feared complication of drilling a burr hole and while anecdotes abound, little is known about the extent or the consequences of this problem. A survey by anonymous postal questionnaire of 304 neurosurgeons in Britain and Ireland was conducted to analyse the extent of this complication. Of respondents, 65.6% had experienced 'plunging', 22.3% having 'plunged' at least twice, indicating a high prevalence of this complication. The Cushing perforator was implicated by most. 'Plunging' carried a 12% risk of death or permanent neurological morbidity. The authors analyse the prevalence and significance of this preventable complication, and discuss various options available to minimize its occurrence.

Symmetric inertial-confinement-fusion-capsule implosions in a double-z-pinch-driven hohlraum.

An inertial-confinement-fusion (ICF) concept using two 60-MA Z pinches to drive a cylindrical hohlraum to 220 eV has been recently proposed. The first capsule implosions relevant to this concept have been performed at the same physical scale with a lower 20-MA current, yielding a 70+/-5 eV capsule drive. The capsule shell shape implies a polar radiation symmetry, the first high-accuracy measurement of this type in a pulsed-power-driven ICF configuration, within a factor of 1.6-4 of that required for scaling to ignition. The convergence ratio of 14-21 is to date the highest in any pulsed-power ICF system.

Visual search for traffic signs: the effects of clutter, luminance, and aging.

Latency and eye movement measures were used to examine the effects of aging, clutter, and luminance on visual search for traffic signs embedded in digitized images of driving scenes. Initially 14 older and 14 younger observers classified daytime and nighttime traffic scenes as containing low or high amounts of clutter. Next, an independent sample of 14 younger and 14 older participants searched for traffic signs contained within these scenes. Errors were more common among the elderly. Search efficiency declined with increased clutter and with aging. However, relative to the young, older adults did not suffer disproportionately as a result of increased clutter. The methods developed might be profitably employed to assess sign conspicuity and sign acquisition during driving.