Assessment of impaired cerebral autoregulation and its correlation with neurological outcome in aneurysmal subarachnoid hemorrhage: A prospective and observational study.

Background: Cerebral autoregulation (CA) is crucial for the maintenance of cerebral homeostasis. It can be assessed by measuring transient hyperemic response ratio (THRR) using transcranial Doppler (TCD). We aimed at assessing the incidence of impaired CA (ICA) and its correlation with the neurological outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods: One hundred consecutive patients with aSAH scheduled for aneurysmal clipping were enrolled in this prospective and observational study. Preoperative and consecutive 5-day postoperative THRR measurements were taken. Primary objective of the study was to detect the incidence of ICA and its correlation with vasospasm (VS) postclipping, and neurological outcome at discharge and 1, 3, and 12 months was secondary objectives. Results: ICA (THRR < 1.09) was observed in 69 patients preoperatively, 74 patients on the 1st and 2nd postoperative day, 76 patients on 3rd postoperative day, and 78 patients on 4th and 5th postoperative day. Significant VS was seen in 13.4% and 61.5% of patients with intact THRR and deranged THRR, respectively (P < 0.000). Out of 78 patients who had ICA, 42 patients (53.8%) at discharge, 60 patients (76.9%) at 1 month, 54 patients (69.2%) at 3 month, and 55 patients (70.5%) at 12 months had unfavorable neurological outcome significantly more than those with preserved CA. Conclusion: Incidence of ICA assessed in aSAH patients varies from 69% to 78% in the perioperative period. The deranged CA was associated with significantly poor neurological outcome. Therefore, CA assessment using TCD-based THRR provides a simple, noninvasive bedside approach for predicting neurological outcome in aSAH.

High throughput Luminex beads based multiplex assay for identification of six major bacterial pathogens of mastitis in dairy animals.

Introduction: Bovine mastitis is caused by over 150 different microorganisms. Specific identification and quantification of multiple bacteria in a single milk sample becomes essential for rapid intervention. Methods: In the present study a Luminex beads based multiplex assay emphasizing on the precise identification of six major bacterial pathogens of mastitis was developed. Assay was developed in two triplex sets, triplex 1 comprised of Streptococcus agalactiae, Streptococcus dysgalactiae and Streptococcus uberis while triplex 2 consisted of Staphylococcus aureus, E. coli and Klebsiella pneumoniae. Results: The analytical sensitivity was 10 6 copies per reaction mixture for all the six bacteria. A 100% analytical specificity was observed for simultaneous detection of these bacteria. Clinical milk samples from 100 bovine quarters were tested for validation. Discussion: The analytical sensitivity was similar to the findings reported earlier in real time PCR multiplex assay targeting the DNA of the 11 most common bacterial species or groups in mastitis. The analytical specificity of the optimized assay was 100% similar to reported earlier for simultaneous detection of Mycoplasma spp. and for seven entric viruses of humans.The developed assay indicates a concept proof of a rapid, cost effective high throughput diagnostic tool for identification of major bacteria causing mastitis.

Studies on immunopathological changes induced by commercial IBD live vaccines in poultry birds.

Intermediate plus live strain infectious bursal disease virus (IBDV) vaccines are used to control IBDV endemic infections in India. In the present study, immunopathological changes induced by commercial infectious bursal disease live vaccines with different immunization regimes were compared. A total of days old 108 Cobb broiler chicks were randomly divided into five groups with 24 chicks each in groups I, II, III and 18 chicks each in group IV and V. Group I served as control I (no immunization) and group II and III chicks were immunized with a single dose of vaccines 1 and 2 on 17th day of age (DOA), respectively. The group IV and V chicks were immunized with vaccines 1 and 2, respectively with primary dose on 17th DOA followed by booster dose on 24th DOA. Both intermediate plus live vaccines produced gross and histopathological lesions in lymphoid organs (bursa of Fabricius, thymus, spleen and caecal tonsils). Increased CD4 + , CD8 + T cells in affected bursa of Fabricius was evidenced by immunohistochemistry. Further, up-regulation in relative mRNA expression of IFN-γ, IL-1ß and IL-6 were observed in bursa of Fabricius of treated birds, with maximum alteration particularly on 14th day post single immunization and 7th day post booster immunization. The findings suggest that single immunization regime on the 17th day of age showed immunization equivalent to booster immunization with lesser lesions, therefore, may be practiced and promoted in the field conditions for the better economic returns and animal welfare.

Controlled arachnoid opening to aid endoscopic trans-sphenoidal extrarachnoidal dissection of pituitary macroadenoma.

OBJECTIVES: The arachnoid often bulges prematurely during surgical excision of large pituitary tumors obscuring the deeper regions and crevices preventing total excision. Pushing the arachnoid may not be helpful and may tear it inadvertently and extensively leading to complications. We have described controlled arachnoid opening in large pituitary macroadenomas during the final stages of excision to gain access to the hidden portions and compared our results to the conventional technique. PATIENTS AND METHODS: Patients with pituitary macroadenoma of Hardy's III and KNOSP II in whom arachnoid had bulged prematurely were considered for study. They were grouped temporally. In first group (n = 12), the arachnoid was pushed to retrieve the tumor and in the second group (n = 10) it was punctured to aid resection. The extent of resection was assessed on postoperative scans, and complications in both groups, were noted. RESULTS: In the first group where arachnoid was pushed to retrieve tumor, Gross Total Resection (GTR) could be achieved in 5 patients. Inadvertent large arachnoid tear occurred in 3 patients of which, 2 developed CSF Rhinorrhoea. No patient had neurovascular injury.In the second group, GTR could be achieved in all without any added complications. CONCLUSION: Deliberate needle puncture and controlled drainage of CSF from arachnoid that bulges prematurely while endoscopic Transsphenoidal surgery for large pituitary tumors is a safe and effective method to gain access to the hidden portions of tumor to achieve GTR.

Phosphorylation of ß-catenin at Serine552 correlates with invasion and recurrence of non-functioning pituitary neuroendocrine tumours.

Non-functioning pituitary tumours (NF-PitNETs) are common intracranial benign neoplasms that can exhibit aggressive behaviour by invading neighbouring structures and, in some cases, have multiple recurrences. Despite resulting in severe co-morbidities, no predictive biomarkers of recurrence have been identified for NF-PitNETs. In this study we have used high-throughput mass spectrometry-based analysis to examine the phosphorylation pattern of different subsets of NF-PitNETs. Based on histopathological, radiological, surgical and clinical features, we have grouped NF-PitNETs into non-invasive, invasive, and recurrent disease groups. Tumour recurrence was determined based on regular clinical and radiological data of patients for a mean follow-up of 10 years (SD ± 5.4 years). Phosphoproteomic analyses identified a unique phosphopeptide enrichment pattern which correlates with disease recurrence. Candidate phosphorylated proteins were validated in a large cohort of NF-PitNET patients by western blot and immunohistochemistry. We identified a cluster of 22 phosphopeptides upregulated in recurrent NF-PitNETs compared to non-invasive and invasive subgroups. We reveal significant phosphorylation of the ß-catenin at Ser552 in recurrent and invasive NF-PitNETs, compared to non-invasive/non-recurrent NF-PitNET subgroup. Moreover, ß-catenin pSer552 correlates with the recurrence free survival among 200 patients with NF-PitNET. Together, our results suggest that the phosphorylation status of ß-catenin at Ser552 could act as potential biomarker of tumour recurrence in NF-PitNETs.

Challenges in Brain-Death Certification in India.

The determination of Brain Death (BD)/Death by neurological criteria (DNC) is now widely accepted among various international societies following the World Brain Death project recommendation. As per the World Brain Death project, ancillary testing should be performed when standard brain-death examination components are inconclusive or cannot be performed. BD was defined legally in 1994 under the Transplantation of Human Organs Act (THOA). However, even after 27 years of the formulated law, there are no guidelines in the THOA regarding the determination of BD using ancillary tests. The present brief report describes two instances where ancillary tests like four-vessel angiography and transcranial doppler-aided brain-death certification were done. It is the first available literature from our country where ancillary tests aided in confirmation of BD when the standard clinical components of DNC could not be performed.

Setting up a Neurosurgical Skills Laboratory and Designing Simulation Courses to Augment Resident Training Program.

Background: The surgical skill practice in neurosurgery is being compromised in the recent past owing to the duty time constraint, patient safety concerns, and medico-legal issues. Surgical practice outside the operating room is essential to enhance a resident's operative skills and to gain confidence. Objective: To discuss the experience of establishing an 'in-house neurosurgery skills laboratory' and various training sessions conducted with cadaveric and non-cadaveric simulation modules. Methods: A skills laboratory was set up in the existing resident teaching hall with nine workstations. Each station has been equipped with an operating table, surgeon's chair, basic microscope, endoscope, high-speed drill system, and a suction machine. Vascular anastomosis, high-speed drilling, and basic neuroendoscopy were planned on low-cost non-cadaveric modules. Craniotomy and various surgical approaches were designed on cadaveric modules obtained from the anatomy department. Result: A total of 18 residents in divided groups during their initial three semesters had participated in the non-cadaveric simulation courses. Twenty-six residents had participated and 12 sessions were conducted on the cadaveric modules. Three workshops were conducted and 20 residents and faculty members from five other institutions had participated in the cadaveric hands-on training session. Conclusion: A well-equipped skills laboratory provides an opportunity for the residents to acquire operative expertise in a similar atmosphere to that of the operating theater. A structured program comprising various operative practice sessions should be incorporated into the resident training program.

Limited Invasive Protocol: Optimizing Diagnostic Modalities in Corticotropin Mediated Cushing Syndrome.

BACKGROUND: To limit the role of bilateral inferior petrosal sinus sampling (BIPSS) in distinguishing between Cushing disease (CD) and ectopic Cushing syndrome (ECS), recent reports have proposed a noninvasive approach based on a combination of biochemical testing and radiological imaging as an alternative to the conventional invasive strategy (CIS). However, this strategy requires further validation. The current study aimed to evaluate 2 limited invasive protocols (LIP-1 and LIP-2) in limiting the role of BIPSS while maintaining a diagnostic accuracy similar to that of CIS. METHODS: This was a single-center study conducted on individuals with corticotropin-dependent Cushing syndrome. The LIPs were based on performing high-dose dexamethasone suppression (>50% cut-off in first [LIP-1] and >80% in second [LIP-2]) and magnetic resonance imaging of the sella in all individuals and selective use of computed tomography of the chest and abdomen before BIPSS. These LIPs were evaluated for limiting the use of BIPSS, their accuracy, and cost in comparison to CIS. RESULTS: Of the 206 individuals, 114 (97 of CD and 21 of ECS) were eligible for the current study. Using LIP-1, LIP-2, and CIS, BIPSS could have been avoided in 62.3%, 35.9%, and 25.4% of individuals, respectively. The positive predictive value for CD using LIP-1 and LIP-2 was 98.9% and 100%, respectively. The cost per patient evaluated using LIP-1, LIP-2, and CIS was $602.21, $966.81, and $1107.78, respectively. CONCLUSION: LIPs represent an equally accurate, less invasive, and more cost-effective alternative to the CIS for distinguishing between CD and ECS.

Virulence and antimicrobial resistance gene profiles of Staphylococcus aureus associated with clinical mastitis in cattle.

Staphylococcus aureus (S. aureus) is the most prevalent microorganism associated with mastitis in cattle, which harbours several virulence factors and antibiotic resistance genes. The present study aimed to characterize S. aureus isolated from mastitic milk of the cattle for antibiotic resistance (blaZ and mecA), haemolysins (hla and hlb) and enterotoxins (sea, seb, sec, and sed) genes. A total of 69 staphylococci were isolated and phenotypically characterized for haemolytic properties on 5% sheep blood agar medium. Out of 69 isolates, 55 (79.71%) were identified as S. aureus by polymerase chain reaction assay. Among S. aureus, the majority of the isolates harboured the gene blaZ (92.73%), followed by coa (89.09%), hlb (60%) and hla (49.09%). Gene mecA responsible for methicillin resistance was detected in 23.64% of S. aureus isolates. Enterotoxin genes seb (9.09%), sec (1.82%) and sed (7.27%) responsible for food poisoning were detected at a comparatively lower rate and none of the S. aureus strain was found positive for sea. Additionally, antimicrobial susceptibility study of S. aureus against 18 antimicrobial discs showed maximum resistance to oxytetracycline, penicillin, and fluoroquinolone groups, contrarily, we observed maximum sensitivity to methicillin and cefuroxime antimicrobials. The high occurrence rate of S. aureus harbouring genes for virulence factors and antimicrobial resistance needs appropriate strategies to control the pathogen spread to the human population.

Studies on intra-ocular vaccination of adult cattle with reduced dose Brucella abortus strain-19 vaccine.

Brucella abortus vaccines play a central role in bovine brucellosis control with tremendous success worldwide for decades. The study was aimed to evaluate the efficacy of reduced dose (5.0 × 10 9 cfu) of S19 vaccine in adult cattle and its shedding in the milk of vaccinated cattle using molecular techniques. The OIE recommended tests (RBPT, SAT, and iELISA) for brucellosis screening in cattle were used. Seronegative cattle (n = 90) of different age groups (young, old heifers & milking cows, n = 30 each) were selected for the vaccine trials. Antibody titers were recorded at 7th, 21st, 30th, 60th, 90th and 120th days post-vaccination (DPV) to monitor the immune responses following vaccination and at 150th, 180th, 210th and 240th DPB following booster-dose to an intraocular group. The humoral immune responses observed by RBPT and ELISA, proved that antibody titers persisted in s/c group compared to the i/o group in all categories. The IFN-γ stimulation (CMI) due to reduced dose vaccination was noticed early as 30th in all groups and declined after 90th DPV, with higher IFN-γ stimulation among the s/c group. The Bcsp31 and IS711 targeted PCR detected the presence of Brucella DNA in milk samples (n = 120) from the vaccinated cows (n = 30) and confirmed by qPCR (TaqMan assay) at 30th, 60th, 90th and 120th DPV. A Significant number, 70% (7/10) was detected in s/c by qPCR. BCSP31 sequence was deposited at NCBI GenBank (accession no. MK881173-6). PCR and qPCR techniques could provide a reliable diagnosis of brucellosis from milk. The intraocular route remains the safer route for vaccinating adult cattle than subcutaneous.

Impact of Stellate Ganglion Block in the Management of Cerebral Vasospasm: A Prospective Interventional Study.

Background: Stellate ganglion block (SGB) causes blockage of sympathetic nerve activity, which may lead to intracerebral vessel dilatation and relieve cerebral vasospasm in patients of aneurysmal subarachnoid hemorrhage (aSAH). Objective: The aim of this study was to evaluate the efficacy and safety of SGB to relieve cerebral vasospasm on clinicoradiological parameters. Materials and Methods: We prospectively included 20 patients with clinical and angiographic evidence of vasospasm post aneurysmal clipping. Cerebral blood flow velocity and Lindegaard ratio were assessed using transcranial Doppler (TCD). Location of vasospasm, vessel diameter, vasospasm severity, parenchymal filling time, and venous sinus filling time were assessed on digital subtraction angiography (DSA). Patients received ultrasound-guided SGB with 10 mL of 0.5% bupivacaine on the ipsilateral side of the vasospasm. After 30 minutes, the neurological status, TCD, and DSA parameters were reevaluated. Results: After SGB, there was statistically significant reduction in the middle cerebral artery (MCA) peak systolic velocity (P = 0.005), mean flow velocity (P = 0.025), and Lindegaard ratio (P = 0.022) on TCD. We observed significant dilatation in the mean vessel diameter measured at the mid-M1 segment of MCA (P = 0.003) and mid-A1 segment of ACA (P = 0.002) on DSA. The mean parenchymal filling time and mean venous sinus filling time decreased nonsignificantly after SGB (P = 0.163/0.104). Neurological improvement was observed in five (25%) patients. Conclusion: SGB has positive clinicoradiological influence in the management of cerebral vasospasm of large vessels. However, its effect on cerebral microvasculature is limited and needs a larger database for further analysis.

Outcomes in pituitary adenoma causing acromegaly following endoscopic endonasal transsphenoidal surgery.

Objectives: The objectives of the study were to study the analysis of outcomes after endoscopic endonasal transsphenoidal surgery (EETSS) in acromegaly in terms of surgical complications, clinical improvement, endocrinological remission, achievement of prognostically critical growth hormone (GH) level, and requirement of additional treatment. Materials and Methods: The study included 28 acromegaly patients, who underwent EETSS. A 2010 consensus criterion was used for defining remission. Assessment of prognostically critical GH level (random value <2.5 ng/ml), the extent of resection and additional treatment, was done at post-operative week (POW) 12. Results: All adenomas were macroadenomas; with a mean volume of 16.34 cm3 (range, 0.4-99 cm3). Most adenomas had high-grade extensions. Most common suprasellar, infrasellar, anterior, and posterior extension grades were 3 (n = 13), 1 (n = 16), 1 (n = 14), and 0 (n = 20), respectively. Knosp Grade 3 was common on both sides (right, n = 9 and left, n = 8). One patient had already been operated on with EETSS, 1.5 years back from current surgery. Sixteen patients were on hormonal support, preoperatively. Four patients died during follow-up. Post-operative common complications were diabetes insipidus (DI, n = 18), cerebrospinal fluid rhinorrhea (n = 10), surgical site hematoma (n = 3), meningitis (n = 3), hydrocephalus (n = 2), and syndrome of inappropriate antidiuretic hormone (n = 1). The mean hospital stay was 11.62 days and 12.17 months were the mean follow-up period. At 12 POW, no improvement was seen in body enlargement and visual complaints, but all other complaints improved significantly except perspiration. Adenomas were decreased in all extensions except posterior and mean adenoma volume was reduced from 16.34 cm3 to 2.92 cm3 after surgery. Sub-total resection (STR, n = 10), near-total resection (NTR, n = 7), gross-total resection (GTR, n = 5), and partial resection (PR, n = 2) were achieved. Endocrinological remission and prognostically critical GH levels were attained in 29.17% (n = 7) and 66.67% (n = 16), respectively. NTR, GTR, STR, and PR were associated with 57.14%, 40%, 10%, and 0% endocrinological remission, respectively. Additional treatment was required in a total of 17 patients, three in GTR, nine in STR, three in NTR, and two in PR. Ten were treated with Gamma Knife radiosurgery along with medical treatment and seven with medical treatment alone. Conclusion: A successful EETSS can reduce adenoma volume to achieve clinical improvement, endocrinologic remission, and prognostically critical GH level with some complications related to surgery. Pre-operative larger volume and higher extension grades affect these outcomes adversely.

Head injury care in a low- and middle-income country tertiary trauma center: epidemiology, systemic lacunae, and possible leads.

BACKGROUND: Although head injury (HI) from low- and middle-income countries (LMIC) heavily contributes to the global disease burden, studies are disproportionately less from this part of the world. Knowing the different epidemiological characteristics from high-income nations can target appropriate prevention strategies. This study aims to provide a comprehensive overview of the clinico-epidemiological data of HI patients, focusing on the existing challenges with possible solutions from a developing nation's perspective. METHODS: This is a prospective, registry-based, observational study of HI in an Indian tertiary trauma-care center over 4 years. Various clinico-epidemiological parameters, risk factors, and imaging spectrum were analyzed in a multivariate model to identify the challenges faced by LMIC and discuss pragmatic solutions. RESULTS: The study included a large-volume cohort of 14,888 patients. Notably, half of these patients belonged to mild HI, despite most were referred (90.3%) cases. Only one-third (30.8%) had severe HI. Less than a third reached us within 6 h of injury. Road traffic accidents (RTA) accounted for most injuries (61.1%), especially in the young (70.9%). Higher age, males, RTA, helmet non-usage, drunken driving, systemic injuries, and specific imaging features had an independent association with injury severity. CONCLUSIONS: The study represents the much-needed, large-volume, epidemiological profile of HI from an LMIC, highlighting the suboptimal utilization of peripheral healthcare systems. Strengthening and integrating these facilities with the tertiary centers in a hub and enhanced spoke model, task sharing design, and efficient back-referrals promise effective neurotrauma care while avoiding overburden in the tertiary centers. Better implementation of road safety laws also has the potential to reduce the burden of HI.

Effectiveness of dietary diabetes insipidus bundle on the severity of postoperative fluid imbalance in pituitary region tumours: A randomized controlled trial.

AIM: To test the effectiveness of nurse-led dietary diabetes insipidus (DI) bundle on the severity of postoperative fluid imbalance in pituitary region tumours. DESIGN: Blinded randomized controlled trial. METHODS: Patients aged 18-65 operated for sellar-suprasellar tumours in an Indian tertiary care centre were enrolled through total enumeration sampling and underwent randomization with allocation concealment during Sep 2018-Feb 2019. Pre-operative DI, postoperative ventilation, renal failure or decompensated diabetes mellitus were excluded. Patients in the intervention group received a nurse-led DI bundle (validated by three Delphi rounds) with four dietary components: intake of only water during thirst and avoidance of the following-added salt, high-protein foods and caffeinated drinks. Treating clinicians and the investigator assessing outcome were blinded about enrolment. Urine output, serum sodium, vasopressin requirement and hospital stay were assessed as primary outcomes. The outcome measures were monitored daily till the 6th postoperative day. Analyses were performed on 'intention-to-treat' basis, irrespective of compliance. Independent t-test and Chi-square test were used. RESULTS: Of the initial 63 patients, 50 fulfilling criteria were randomized to two groups and assessed over six days yielding 150 patient-days per group. There were no significant baseline differences between groups. The mean daily urine output was significantly lower in the DI bundle group than in control, both overall and among endonasal operated pituitary adenomas [3000.09(462.7) vs. 4095.71(896.4)ml & 2987.14(419.5) vs. 4064.73(1051)ml], with the greatest difference on the second postoperative day. Though hypernatraemia in controls became most prominent during days 2-3 and resolved in a week, it was significantly lower in the intervention group (12.7% vs. 30.7% overall, 11.4% vs. 29.4% endonasal adenomas). The need for vasopressin analogues and hospital stay were also significantly lower with DI bundle (p < 0.001). CONCLUSION: This is probably the first ever report of dietary DI bundle among operated pituitary patients, which seem to flatten the DI trend with significant benefits in polyuria, hypernatraemia, vasopressin requirement and hospital stay. TRIAL REGISTRATION: CTRI/2018/07/015127 of ICMR. IMPACT: The nurse-led dietary DI bundle has effectively reduced the severity of DI among operated pituitary patients with significant benefits in polyuria, hypernatraemia, vasopressin requirement and hospital stay. Its implementation is simple and easy to carry out, especially in resource-constrained institutions, where continuous monitoring and repeated serum sodium estimation are difficult.

Posterior pituitary tumours: patient outcomes and determinants of disease recurrence or persistence.

OBJECTIVE: Posterior pituitary tumours (PPTs) are rare neoplasms with the four recognised subtypes unified by thyroid transcription factor -1 (TTF-1) expression, according to the 2017 WHO classification. Though traditionally defined as low-grade neoplasms, a substantial proportion of them show recurrence/persistence following surgery. METHODS: We selected patients with PPTs in our cohort of 1760 patients operated for pituitary tumours over the past 10 years (2010-2019). The clinical, radiological, hormonal, histopathological profiles and long-term outcomes of the three cases identified (two pituicytomas and one spindle cell oncocytoma, SCO) were analysed. Following a literature review, data of all published cases with documented TTF-1 positive pituicytomas and SCOs were analysed to determine the predictors of recurrence/persistence in these tumours. RESULTS: Patients presented with compressive features or hypogonadism. Two had sellar-suprasellar masses. One had a purely suprasellar mass with a pre-operative radiological suspicion of pituicytoma. Two were operated by transsphenoidal surgery and one transcranially guided by neuronavigation. Histopathology confirmed spindle cells in a storiform arrangement and low Ki67 index. Immunohistochemistry showed positive TTF-1, S-100 expression and variable positivity for EMA, vimentin and GFAP. Re-evaluation showed recurrence/persistence in two patients. A literature review of recurrent/persistent pituicytoma (n = 17) and SCO (n = 9) cases revealed clinical clues (headache for pituicytomas, male gender for SCO), baseline tumour size (≥20.5 mm with sensitivity exceeding 80%) and longer follow-up duration as determinants of recurrence/persistence. CONCLUSION: PPTs are rare sellar masses with quintessential TTF-1 positivity. Recurrent/persistent disease following surgery is determined by greater tumour size at baseline and duration of follow-up. This warrants intensive and long-term surveillance in these patients.

Multidimensional dynamic healthcare personnel (HCP)-centric model from a low-income and middle-income country to support and protect COVID-19 warriors: a large prospective cohort study.

OBJECTIVES: Healthcare personnel (HCP) are at an increased risk of acquiring COVID-19 infection especially in resource-restricted healthcare settings, and return to homes unfit for self-isolation, making them apprehensive about COVID-19 duty and transmission risk to their families. We aimed at implementing a novel multidimensional HCP-centric evidence-based, dynamic policy with the objectives to reduce risk of HCP infection, ensure welfare and safety of the HCP and to improve willingness to accept and return to duty. SETTING: Our tertiary care university hospital, with 12 600 HCP, was divided into high-risk, medium-risk and low-risk zones. In the high-risk and medium-risk zones, we organised training, logistic support, postduty HCP welfare and collected feedback, and sent them home after they tested negative for COVID-19. We supervised use of appropriate personal protective equipment (PPE) and kept communication paperless. PARTICIPANTS: We recruited willing low-risk HCP, aged <50 years, with no comorbidities to work in COVID-19 zones. Social distancing, hand hygiene and universal masking were advocated in the low-risk zone. RESULTS: Between 31 March and 20 July 2020, we clinically screened 5553 outpatients, of whom 3012 (54.2%) were COVID-19 suspects managed in the medium-risk zone. Among them, 346 (11.4%) tested COVID-19 positive (57.2% male) and were managed in the high-risk zone with 19 (5.4%) deaths. One (0.08%) of the 1224 HCP in high-risk zone, 6 (0.62%) of 960 HCP in medium-risk zone and 23 (0.18%) of the 12 600 HCP in the low-risk zone tested positive at the end of shift. All the 30 COVID-19-positive HCP have since recovered. This HCP-centric policy resulted in low transmission rates (<1%), ensured satisfaction with training (92%), PPE (90.8%), medical and psychosocial support (79%) and improved acceptance of COVID-19 duty with 54.7% volunteering for re-deployment. CONCLUSION: A multidimensional HCP-centric policy was effective in ensuring safety, satisfaction and welfare of HCP in a resource-poor setting and resulted in a willing workforce to fight the pandemic.

The collateral fallout of COVID19 lockdown on patients with head injury from north-west India.

BACKGROUND: The COVID19 lockdown has altered the dynamics of living. Its collateral fallout on head injury care has not been studied in detail, especially from low- and middle-income countries, possibly overwhelmed more than developed nations. Here, we analyze the effects of COVID19 restrictions on head injury patients in a high-volume Indian referral trauma center. METHODS: From the prospective trauma registry, clinico-epidemiological and radiological parameters of patients managed during 190 days before and 190 days during COVID19 phases were studied. As an indicator of care, the inpatient mortality of patients with severe HI was also compared with appropriate statistical analyses. RESULTS: Of the total 3372 patients, there were 83 head injury admissions per week before COVID19 restrictions, which decreased to 33 every week (60% drop) during the lock phases and stabilized at 46 per week during the unlock phases. COVID19 restrictions caused a significant increase in the proportion of patients arriving directly without resuscitation at peripheral centers and later than 6 h of injury. Though the most common mechanism was vehicular, a relative increase in the proportion of assaults was noted during COVID19. There was no change in the distribution of mild, moderate, and severe injuries. Despite a decrease in the percentage of patients with systemic illnesses, severe head injury mortality was significantly more during the lock phases than before COVID19 (59% vs. 47%, p = 0.02). CONCLUSIONS: COVID19 restrictions have amplified the already delayed admission among patients of head injury from north-west India. The severe head injury mortality was significantly greater during lock phases than before COVID19, highlighting the collateral fallout of lockdown. Pandemic control measures in the future should not ignore the concerns of trauma emergency care.

Differential independent impact of the intraoperative use of navigation and angled endoscopes on the surgical outcome of endonasal endoscopy for pituitary tumors: a prospective study.

Despite widespread popularity of navigation and angled endoscopes in endonasal endoscopy, there are hardly few studies on their efficacy with the extent of resection or retreatment. This is probably the first study to assess the independent impact of these adjuncts among pituitary tumors. Patients with pituitary tumors undergoing endonasal endoscopy were prospectively studied for their demographics, clinico-radiological features, intraoperative use of navigation, and angled endoscopes, in relation to gross total resection (GTR), near total resection (NTR), endocrine remission, and retreatment. Pertinent statistical analyses were performed. Among a total of 139 patients, navigation and angled endoscopes could be used in 54 and 48 patients, respectively, depending upon their availability rather than chosen as per the case. There was no significant difference in baseline characteristics in relation to their use. The surgeon's perception of immediate benefit was noted among 51.9% while using navigation. The use of angled endoscopes towards the end of resection could help with additional tumor removal in 62.5% of patients. Overall, the use of navigation resulted in a significantly higher GTR (80.8% vs. 59.7%, OR 2.83, p = 0.01), a higher GTR/NTR (86.5% vs. 70.8%, OR 2.65, p = 0.04), and a lower retreatment rate (7.7% vs. 20.8%, OR 3.15, p = 0.05) than the others. In functioning tumors with cavernous sinus invasion, navigation had significantly increased remission rates (69.2% vs. 0%, p = 0.03). The use of angled endoscopes yielded a significantly higher GTR/NTR (91.7% vs. 70.6%, p = 0.04) and a lower retreatment rate (0% vs. 15.7%, p = 0.05) among only non-functioning adenomas. In multivariate analyses, the use of neuronavigation had a significant association with both GTR and retreatment rates (p values 0.005 and 0.02 respectively), independent of other confounding factors. The elective intraoperative use of navigation has a significant independent impact on the extent of resection and retreatment overall. While navigation results in better remission rates among functioning tumors with cavernous sinus invasion, angled endoscopy has a significant association with surgical outcomes in non-functioning tumors.

Molecular Imaging Targeting Corticotropin-releasing Hormone Receptor for Corticotropinoma: A Changing Paradigm.

BACKGROUND: Corticotrophin-releasing hormone (CRH) is the major regulator of adrenocorticotrophic hormone (ACTH) secretion from the anterior pituitary and acts via CRH-1 receptors (CRH-1R). Corticotropinoma though autonomous, still retain their responsiveness to CRH and hence, we hypothesize that in vivo detection of CRH-1 receptors on pituitary adenoma using Gallium-68 (68Ga)-tagged CRH can indicate the functionality of adenoma, and combining it with positron emission tomography-computed tomography (PET-CT) can provide requisite anatomical information. METHODS: Subjects with ACTH-dependent Cushing's syndrome (CS) (n = 27, 24 with Cushing's disease [CD], 3 with ectopic CS [ECS]) underwent 68Ga CRH PET-CT. Two nuclear medicine physicians read these images for adenoma delineation and superimposed them on magnetic resonance imaging (MRI) sella. The information provided was used for intraoperative navigation and compared with operative and histopathological findings. FINDINGS: 68Ga CRH PET-CT correctly delineated corticotropinoma in all the 24 cases of CD, including the 10 cases with adenoma size < 6mm (4 cases were negative on MRI). Corticotropinoma location on 68Ga CRH PET fusion images with MRI were concordant with operative findings and were further confirmed on histopathology. There was no tracer uptake in the pituitary in 2 patients with ECS, while, in another, the diffuse uptake in pituitary suggested ectopic CRH production. CONCLUSION: 68Ga CRH PET-CT represents a novel, noninvasive molecular imaging, targeting CRH receptors that not only delineate corticotropinoma and provides the surgeon with valuable information for intraoperative tumor navigation, but also helps in differentiating a pituitary from an extra-pituitary source of ACTH-dependent CS. FUNDING: None.