The safety of early pharmacological venous thromboembolism prophylaxis in patients with traumatic intracranial haemorrhage: a systematic review and meta-analysis.

INTRODUCTION: In patients with traumatic intracranial haemorrhage (tICH) there is significant risk of both venous thromboembolism (VTE) and haemorrhage progression. There is a paucity of literature to inform the timing of pharmacological thromboprophylaxis (PTP) initiation. AIM: This meta-analysis aims to summarise the current literature on the timing of PTP initiation in tICH. METHODS: This meta-analysis followed the Methodological Expectations of Cochrane Intervention Reviews checklist and the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Following the literature search, studies were matched against the criteria for inclusion. Data from included studies was pooled, analysed using random-effect analysis and presented as forest plots of risk ratios, except one result reported as difference of means. The ROBINS-I tool was used to assess the risk of bias in the studies. The GRADE approach was taken to assess the quality of included studies. Heterogeneity of studies was assessed using Tau∧2. Funnel plots were generated and used in conjunction with Harbord's test and Rucker's arcsine to assess for small-study effect including publication bias. RESULTS: A total of 9927 ICH patients who received PTP were included from 15 retrospective observational cohort studies, 4807 patients received early PTP, the remaining 5120 received late PTP. The definition of early was dependent on the study but no more than 72-hours after admission. The mean age of the included cohort was 45.3 (std dev ±9.5) years, and the proportion of males was 71%. Meta-analysis indicated that there was a significant difference between early and late groups for the rate of VTE (RR, 0.544; p = 0.000), pulmonary embolus (RR, 0.538; p = 0.004), deep vein thrombosis (RR, 0.484; p = 0.000) and the intensive care unit length of stay (difference of means, -2.021; 95% CI, -2.250, -1.792; p = 0.000; Tau∧2 = 0.000), favouring the early group. However, the meta-analysis showed no significant difference between the groups for the rate of mortality (RR, 1.008; p = 0.936), tICH progression (RR, 0.853; p = 0.157), and neurosurgical intervention (RR, 0.870; p = 0.480). CONCLUSION: These findings indicated that early PTP appears to be safe and effective in patients with tICH.

Incidence and Risk Factors of Surgical Site Infection After Cranial Surgery for Patients with Brain Tumors: A Systematic Review and Meta-analysis.

BACKGROUND: Surgical site infections after craniotomy (SSI-CRANs) are a serious adverse event given the proximity of the wound to the central nervous system. SSI-CRANs are associated with substantial patient morbidity and mortality. Despite the importance and recognition of this event in other surgical fields, there is a paucity of evidence in the neurosurgical literature devoted to SSI-CRAN specifically in patients after brain tumor surgery. METHODS: Systematic searches of Medline, Embase, and Cochrane Central were undertaken. The primary outcome was the incidence of SSI-CRAN at 30 and 90 days. Secondary outcomes were risk factors for SSI-CRAN. RESULTS: Thirty-seven studies reporting 91,907 patients with brain tumors who underwent cranial surgery were included in the meta-analysis. Pooled incidence of SSI-CRAN at 30 and 90 days was 4.03% (95% CI: 2.94%-5.28%, I2 = 97.3) and 6.17% (95% CI: 3.16%-10.07%, I2 = 97.3), respectively. Specifically, incidence of SSI-CRAN following surgery for posterior fossa tumors was the highest at 9.67% (95% CI: 5.98%-14.09%, I2 = 75.5). Overall pooled incidence of readmission within 30 days and reoperation due to SSI-CRAN were 13.9% (95% CI: 12.5%-15.5%, I2 = 0.0) and 16.3% (95% CI: 5.4%-31.3%, I2 = 72.9), respectively. Risk factors for SSI-CRAN included reintervention (risk ratio [RR] 1.58, 95% CI: 1.22-2.04, I2 = 0.0), previous radiotherapy (RR 1.69, 95% CI: 1.20-2.38, I2 = 0.0), longer duration of operation (mean difference 64.18, 95% CI: 3.96-124.40 minutes, I2 = 90.3) and cerebrospinal fluid (CSF) leaks (RR 14.26, 95% CI: 2.14-94.90, I2 = 73.2). CONCLUSIONS: SSI-CRAN affects up to 1 in 14 patients with brain tumors. High-risk groups include those with reintervention, previous radiotherapy, longer duration of operation, and CSF leaks. Further prospective studies should focus on bundles of care that will reduce SSI-CRAN.

To assess the safety of laparoscopy in patients with CSF catheters draining distally into the abdomen.

PURPOSE: This study evaluates the safety of laparoscopic procedures in patients with cerebrospinal fluid (CSF) catheters draining distally into the abdomen. METHODS: A systematic search across PubMed, Scopus, and Ovid databases using pertinent keywords yielded 47 relevant papers, encompassing 197 cases, for analysis. RESULTS: In the pediatric cohort (n = 129), male (49.6%) and female (34.1%) cases were reported, while gender remained unspecified in 16.3%. Shunt indications included unspecified (126 cases) and Meningomyelocele (3 cases). Laparoscopic procedures encompassed gastric (72.1%), urologic (21.7%), and other (6.2%) indications. Peri-operative shunt management included subcostal incision and clamping (1), ICP monitoring and drainage (2), and distal shunt flow confirmation (1). The prevalent complication was mechanical obstruction (10.1%), followed by pseudocyst formation (1.5%) and infection (2.3%). In the adult cohort (n = 61), males (60.6%) and females (39.3%) with a median age of 55 years were observed. Management strategies encompassed sponge packing and mobilization (11), distal shunt flow confirmation (2), shunt clamping (3), Transcranial Doppler monitoring (2), and no manipulation (30). Shunt infection emerged as the primary complication (2). Overall, 24 patients encountered VP shunt-related complications post-laparoscopy. CONCLUSION: This study underscores the safety of laparoscopic interventions in patients with ventriculoperitoneal or lumboperitoneal shunts when facilitated by interdisciplinary cooperation. A meticulous preoperative assessment for shunt track localization, intraoperative visualization of shunt tip with CSF flow, vigilant perioperative anesthetic monitoring, and shunt dysfunction surveillance are crucial for favorable outcomes in laparoscopic procedures for these patients.

Does Preoperative Neutrophil-Lymphocyte Ratio Predict Patient-Reported Pain and Functional Outcomes at 12 Months After Lumbar Fusion?

BACKGROUND: Preoperative neutrophil-lymphocyte ratio (NLR) has been described in various fields to predict pain outcomes, but its prognostic utility for pain/functional outcomes after spine surgery is unclear. OBJECTIVE: To determine the relationship between preoperative NLR and pain/functional outcomes at 12 months after lumbar fusion. METHODS: We performed a single-center retrospective study of 53 patients who underwent lumbar fusion and collected demographic data including age, sex, body mass index, smoking status, spinal levels operated, and preoperative NLR. Visual analog scale (VAS) for back and leg pain and Oswestry Disability Index (ODI) at baseline and 12 months after lumbar fusion were also collected. The outcome measures were the occurrence of a clinically important improvement in VAS and ODI scores at 12 months. Binary logistic regression was used to estimate the associations of demographic factors and NLR with improvement in VAS and ODI scores. A P value of <0.05 was considered statistically significant. RESULTS: There were no statistically significant associations between preoperative NLR and improvement in VAS or ODI scores. A unit increase in baseline VAS back pain score was associated with a 56% increase in the odds of improvement in back pain (OR: 1.56, 95% CI: 1.04-2.35, P = 0.03). Compared to male patients, female patients had 12 times greater odds of an improvement in leg pain (OR: 12.0, 95% CI: 1.3-110, P = 0.03). CONCLUSION: Preoperative NLR does not predict patient-reported pain/functional outcomes at 12 months after lumbar fusion. Large-scale prospective multicenter studies are warranted to confirm our findings.

Preoperative lymphocyte percentage and neutrophil-lymphocyte ratio are useful predictors of 30-day postoperative complications after lumbar fusion.

Background: Lymphocyte percentage/count, platelet-lymphocyte ratio (PLR), and neutrophil-lymphocyte ratio (NLR) have shown prognostic significance in patients with cancer, stroke, and following cardiac surgery. However, the utility of these blood parameters for assessing the 30-day postoperative risk for lumbar fusion complications has not been established. Methods: In this single-center-single-surgeon retrospective series, 77 consecutive patients underwent one- or two-level lumbar fusion. Lymphocyte percentage/count, PLR, and NLR were investigated as predictors of 30-day postoperative complications. Results: Ten of 77 patients had postoperative complications. A unit increase in NLR and lymphocyte percentage was significantly associated with a 23% increase and 7% decrease, respectively, in the odds of a complication occurring. Preoperative NLR ≥ 2.32 and lymphocyte percentage ≤ 29.5% significantly discriminated between the "complication" and "no-complication" groups. Conclusion: Patients with a preoperative lymphocyte percentage of ≤29.5% and/or NLR ≥2.32 should be closely monitored as high-risk groups susceptible to 30-day postoperative complications after lumbar fusion.

Structural and Functional Properties of Subsidiary Atrial Pacemakers in a Goat Model of Sinus Node Disease.

BACKGROUND: The sinoatrial/sinus node (SAN) is the primary pacemaker of the heart. In humans, SAN is surrounded by the paranodal area (PNA). Although the PNA function remains debated, it is thought to act as a subsidiary atrial pacemaker (SAP) tissue and become the dominant pacemaker in the setting of sinus node disease (SND). Large animal models of SND allow characterization of SAP, which might be a target for novel treatment strategies for SAN diseases. METHODS: A goat model of SND was developed (n = 10) by epicardially ablating the SAN and validated by mapping of emergent SAP locations through an ablation catheter and surface electrocardiogram (ECG). Structural characterization of the goat SAN and SAP was assessed by histology and immunofluorescence techniques. RESULTS: When the SAN was ablated, SAPs featured a shortened atrioventricular conduction, consistent with the location in proximity of atrioventricular junction. SAP recovery time showed significant prolongation compared to the SAN recovery time, followed by a decrease over a follow-up of 4 weeks. Like the SAN tissue, the SAP expressed the main isoform of pacemaker hyperpolarization-activated cyclic nucleotide-gated channel 4 (HCN4) and Na+/Ca2+ exchanger 1 (NCX1) and no high conductance connexin 43 (Cx43). Structural characterization of the right atrium (RA) revealed that the SAN was located at the earliest activation [i.e., at the junction of the superior vena cava (SVC) with the RA] and was surrounded by the paranodal-like tissue, extending down to the inferior vena cava (IVC). Emerged SAPs were localized close to the IVC and within the thick band of the atrial muscle known as the crista terminalis (CT). CONCLUSIONS: SAN ablation resulted in the generation of chronic SAP activity in 60% of treated animals. SAP displayed development over time and was located within the previously discovered PNA in humans, suggesting its role as dominant pacemaker in SND. Therefore, SAP in goat constitutes a promising stable target for electrophysiological modification to construct a fully functioning pacemaker.

A sexy approach to pacemaking: differences in function and molecular make up of the sinoatrial node.

BACKGROUND: Functional properties of the sinoatrial node (SAN) are known to differ between sexes. Women have higher resting and intrinsic heart rates. Sex determines the risk of developing certain arrhythmias such as sick sinus syndrome, which occur more often in women. We believe that a major contributor to these differences is in gender specific ion channel expression. METHODS: qPCR was used to compare ion channel gene expression in the SAN and right atrium (RA) between male and female rats. Histology, immunohistochemistry and signal intensity analysis were used to locate the SAN and determine abundance of ion channels. The effect of nifedipine on extracellular potential recording was used to determine differences in beating rate between sexes. RESULTS: mRNAs for Cav1.3, Kir3.1, and Nkx2-5, as well as expression of the L-Type Ca²âº channel protein, were higher in the female SAN. Females had significantly higher intrinsic heart rates and the effect of nifedipine on isolated SAN preparations was significantly greater in male SAN. Computer modelling using a SAN cell model demonstrated a higher propensity of pacemaker-related arrhythmias in females. CONCLUSION: This study has identified key differences in the expression of Cav1.3, Kir3.1 and Nkx2-5 at mRNA and/or protein levels between male and female SAN. Cav1.3 plays an important role in the pacemaker function of the SAN, therefore the higher intrinsic heart rate of the female SAN could be caused by the higher expression of Cav1.3. The differences identified in this study advance our understanding of sex differences in cardiac electrophysiology and arrhythmias.