Prognostic factors and outcomes in WHO Grade 1 and Grade 2 intracranial meningiomas - 5 year institutional experience.

BACKGROUND: Meningiomas are the most frequent primary intracranial tumour. While histological grade and grade of excision are established predictors of recurrence, nuances such as the role of radical excision of dural attachment and postoperative radiotherapy in intermediate-risk groups remain unanswered. METHOD: This report presented data from 451 WHO Grade 1 and 248 WHO Grade 2 intracranial meningiomas operated between 2010 and 2015, analysing their clinical and radiological features and surgical details. Outcomes were assessed among 352 WHO Grade 1 and 208 WHO Grade 2 meningiomas, studying the effect of extent of resection and use of radiotherapy. Kaplan Meier analysis was used to determine differences in survival by extent of resection and use of postoperative radiotherapy in the treatment of WHO Grade 1 and 2 meningiomas. RESULTS: The mean age of the cohort was 46.3 years, with a female predominance. On univariate analysis, gender, WHO grade, and Simpson grade were significant predictors of recurrence. On multivariate analysis, WHO grade and Simpsons grade remained significant predictors of recurrence. Recurrence was significantly associated with poor performance status and mortality. Postoperative radiation significantly improved progression-free survival among Grade 2 meningioma that underwent gross total resection (GTR), but not among WHO Grade 1 and 2 meningioma after subtotal resection (STR). CONCLUSION: WHO Grade and Simpson grade are independent predictors of recurrence among meningiomas. Irrespective of Grade, gross total resection must be effected when possible, and postoperative radiotherapy may be recommended in Grade 2 meningioma.

Suprasellar multiple Neurocysticercal (NCC) cyst presenting with visual loss.

Suprasellar cysticercosis is a rare entity. Only a few cases are reported in the literature.1 Clinically, present with visual loss and endocrinopathy and radiologically mimic craniopharyngioma, cystic pituitary adenoma, and Rathke cleft cyst.2 We present the case of a 34-year-old lady with a history of diminution of vision for two months. On examination, her visual acuity was 6/9 bilaterally, per the Snellen chart. The visual field showed incomplete temporal hemianopia in the right eye and a severely depressed field in the left eye. She was evaluated with magnetic resonance imaging of the brain, which showed multiple well-defined enhancing cystic lesions in the suprasellar cistern splaying the optic chiasm. EITB testing was not done due to the lack of availability at our center. She underwent left pterional craniotomy and excision of the cysts. Multiple cysts were noted during surgery, and all were dissected from the surrounding structures. However, there was a spillage of cystic contents during excision, and they are not associated with any adverse reactions, unlike hydatid cysts.3 She recovered well. Histopathology suggestive of cysticercal cyst, no scolexes. As per IDSA non, non-operated subarachnoid neurocysticercosis requires prolonged antiparasitic agents along with steroids.4 She received six weeks of albendazole 15mg/kg/day and steroids tapered over three weeks. At two years of follow-up, her visual acuity improved to 6/6 with a normal visual field. Follow-up MRI showed complete removal of all cysts with no relapse. Early surgery is safe and effective. Visual outcome depends on the timing of the diagnosis and prompt intervention.

Pediatric shunt failure: finding predictability in the sea of uncertainty.

OBJECTIVE: Shunt malfunction is a complication that can have devastating implications. In this study, the authors aimed to evaluate the rate of shunt revision in a single institution over 5 years and to determine the factors associated with shunt revision in the pediatric population. METHODS: This retrospective report assimilated data from all patients ≤ 18 years old who underwent shunt surgery between January 2015 and April 2021 at the authors' institute with a minimum of 3 months of follow-up. Patient data regarding demographic characteristics, indications, clinical status, point of entry, operative and CSF findings, revision interval, and cause of failure were collected. RESULTS: Between January 2015 and April 2021, 1112 pediatric patients underwent initial shunt surgery at the authors' institute, among whom 934 patients met the inclusion criteria. Ninety-five patients underwent revision (shunt revision rate 10.2%). The cohort comprised 562 male and 368 female patients (no sex was recorded in 4 cases), with infratentorial tumors (37.8%) being the most common indication for the shunt. Multivariate analyses revealed that younger patient age, right-sided shunt, single surgeon, and shunt placement done in the evening and night were significantly associated with shunt failure. Among all the factors analyzed, female sex had the greatest risk of early shunt failure (OR 2.90 [95% CI 1.09-8.16], p = 0.037). The presence of prior external ventricular drainage was associated with an increased risk of multiple revisions (OR 6.67 [95% CI 1.60-32.52], p = 0.012). The most common cause of failure was obstruction, usually at the cranial end. The most common cause of distal failure was malposition of the abdominal end. CONCLUSIONS: This study identifies various factors associated with shunt failure. Various goal-directed strategies toward modifiable risk factors can significantly improve shunt survival.

Three-Year Experience and Outcomes of Near-Early Internal Fixation for Femoral Neck Fractures in Pediatric Trauma Patients: A Retrospective Study.

Background The fractured neck of the femur in children is commonly caused by high-energy trauma, and despite its low incidence, complications are more frequent. Delayed presentation is not unusual in developing countries. The interval between injury and surgery is thought to be a critical factor in determining outcomes. This study aims to evaluate the effectiveness of "near early" internal fixation (24-72 hours) for fractured neck of the femur in children. Methods This is a retrospective observational study that analyzed complete case records from a period of seven years. Cases were classified according to the Delbet classification and outcomes were assessed using the Ratliff criteria with a minimum follow-up of three years. Results The study included 24 male and 11 female patients, with an average age of 11.28 years. The most common cause of injury was road traffic accidents. The fracture distribution in the study population was as follows: Delbet type II in 18 patients, Delbet type III in 10 patients, and Delbet type IV in seven patients. In our study, all patients underwent near-early fixation, meaning their fractures were fixed within 24-72 hours of injury. The average time for the clinical-radiological union was 8 weeks, and the most common complication was premature physeal fusion, followed by osteonecrosis. Conclusion In developing countries, where patients often experience delayed referrals and lack of awareness, near-early fixation (24-72 hours) of a fractured neck of the femur in children is a crucial option that holds significant value.

Gamma Knife Radiosurgery in Partially Embolised Arteriovenous Malformations: Management Dilemmas and Outcomes.

Introduction: The role of Gamma Knife radiosurgery (GKRS) in partially embolized arteriovenous malformations (AVMs) has always remained a subject of debate. The aim of this study was to evaluate the efficacy of GKRS in partially embolized AVMs and to analyze factor that influence its obliteration. Methods: This was a retrospective study from a single institute performed over a period of 12 years (2005-2017). It included all patients who underwent GKRS for partially embolized AVMs. Demographic characteristics, treatment profiles, and clinical and radiological data were obtained during treatment and follow-up. Obliteration rates and factors affecting the same were sought and analyzed. Results: A total of 46 patients with a mean age of 30 years (range: 9-60 years) were included in the study. Follow-up imaging was available for 35 patients either by digital subtraction angiography (DSA) or magnetic resonance imaging (MRI). We found complete AVM obliteration in 21 patients (60%): one had near total obliteration (>90% obliteration), 12 had subtotal obliteration (<90%), and one had no change in the volume following GKRS. Following embolization alone, an average of 67% of the AVM volume was obliterated which resulted in an average 79% final obliteration rate after Gamma Knife radiosurgery. Mean duration to complete obliteration was found to be 3.45 years (range: 1-10 years). There was a significant difference (P = 0.04) in the mean interval between embolization and GKRS among cases with complete obliteration (12 months) and those with incomplete obliteration (36 months). There was no significant difference (P = 0.49) in the average obliteration rate between the ARUBA-eligible unruptured AVMs (79.22%) and ruptured AVMs (79.04%). Bleeding after GKRS during the latency period had a negative impact on obliteration (P = 0.05). Other factors like age, sex, Spetzler-Martin (SM)-grade, Pollock Flickinger score (PF-score), nidus volume, radiation dose, or presentation before embolization had no significant influence on obliteration. Three patients had permanent neurological deficits after embolization and none after radiosurgery. Six out of nine patients (66%) presenting with seizures were seizure-free after the treatment. Hemorrhage was noted in three patients following combined treatment and were managed non-surgically. Conclusion: Obliteration rates in partially embolized AVM after Gamma Knife are inferior when compared to Gamma Knife alone; moreover with volume staging and/or dose staging being increasingly plausible due to the new ICON machine, embolization may be completely replaced. However we have shown that in complicated and carefully chosen AVMs, embolization followed by GKRS is a valid modality of management. This study represents a real-world picture of individualized AVM treatment depending on patient choices and resources available.

Clinical Characteristics and Early Outcomes of Hospitalized COVID-19 Patients with End-Stage Kidney Disease in Saudi Arabia.

BACKGROUND: The prognosis of the novel coronavirus disease 2019 (COVID-19) may be poor in patients with end-stage kidney disease (ESKD). Limited information is available on the clinical characteristics and outcomes of such patients in Arab countries. The present study aimed to address this gap. METHODS: This retrospective cohort study included 101 patients with ESKD who were hospitalized for COVID-19 between May 1, 2020 and December 31, 2020 at King Fahad Central Hospital (single center), Jazan Province, Saudi Arabia. Chi-square test, independent samples t-test, Mann-Whitney U-test, and Cox regression were performed in the statistical analysis. RESULTS: Of the 101 hospitalized COVID-19 patients with ESKD, 20 patients died (19.8%). Patients aged ≥ 65 years had a significant mortality risk. Mortality was higher in male patients (70%) than in female patients (30%). The most common comorbidities were hypertension (88%), diabetes mellitus (47%), and heart disease (17%). The presence of diabetes and cardiovascular diseases along with ESKD increased the mortality risk [relative risk (RR) = 6.5 and RR = 3.8, respectively]. The most frequently reported clinical symptoms were fever (50%), shortness of breath (41%), and cough (35%). In total, 17% of the patients were admitted to the intensive care unit and required mechanical ventilation. Most patients had bilateral lung infiltrates (88%). Hemoglobin levels and platelet counts were significantly lower in the deceased patients than in the surviving ones. Moreover, compared with the surviving patients, higher degree of lymphocytopenia, neutrophilia, ferritin, D-dimer, blood urea nitrogen, and aspartate transaminase were detected in the deceased patients. Septic shock (20%) and respiratory failure (19%) were the most prevalent complications resulting in death. CONCLUSION: COVID-19 patients with ESKD have an increased risk of poor outcomes and mortality. The mortality risk increases with an increase in age and the presence of other comorbidities, such as diabetes and cardiovascular disease. Elevated levels of inflammatory markers correlate with disease severity and are associated with in-hospital mortality in this population.

Tetrad of Split Cord Malformation I with Neuroenteric Cyst, Dermoid Cyst, and Thickened Filum Terminale in a 2-Year-Old Child: A Case Report.

INTRODUCTION: Split cord malformations (SCMs) are developmental anomalies that are associated with a number of congenital defects. However, a combination of SCM I with a neuroenteric cyst (NEC) is extremely rare, and only 11 cases have been described in the literature. To the best of authors' knowledge, the combination of the above two with dermoid cyst and thickened filum terminale has never been reported in the literature. CASE PRESENTATION: We present a case of the above combination in a 2-year-old child who underwent microsurgical excision of all 4 pathologies and complete recovery. CONCLUSION: NEC and dermoid should be considered in the differential diagnosis when imaging reveals cystic pathology along with SCM. Expeditious surgical repair resulted in an outstanding functional outcome at 1-year follow-up.

Comparison of intra articular NSAID (ketorolac) injection versus hyaluronic acid injection for the mean decrease of pain score (according to UCLA shoulder rating scale) in the management of adhesive capsulitis.

Adhesive capsulitis is painful condition, associated with gradual loss of active and passive shoulder motion that has a disabling capability. In this study we compared the short term outcome by measuring the mean decrease of pain in adhesive capsulitis using University of California Los-Angeles (UCLA) shoulder rating scale after intra-articular Non-Steroidal Anti Inflammatory Drug (NSAID) Ketorolac and Hyaluronic acid injection. This Randomized controlled trial was carried out using non probability consecutive sampling technique from 1st November 2015 to 30th April 2016. Total 160 patients with adhesive capsulitis for six months' age between 18 to 70 years were taken and randomly divided into two equal groups by computer allocation method. The 80 patients in Group A received Intra-articular (NSAID) Ketorolac injection while patients in Group B were given Intra-articular Hyaluronic acid. Pain score for both the groups were recorded using UCLA shoulder rating scale before treatment and then at follow up after a period of 4 weeks. Out of total 160 cases, 47.5% (n=38) in Group A and 45% (n=36) in Group B were male whereas 52.5% (n=42) in Group A and 55% (n=44) in Group B were females. Most commonly affected age group with 40% (n=32) participants was aged between 51 - 60 years. Mean age of Group A was 37.87±1.027 and in Group B was 45.37±5.743. Interestingly 60% (n=48) of Group A and 55% (n=44) of Group B had involvement of the right shoulder. Pre-treatment UCLA pain score was calculated to be 14.90±4.969 in Group-A and 15.16±5.578 in Group-B. Final post treatment UCLA score was 26.67±2.331 in Group A and 21.72±3.838 in Group B. The mean decrease of pain in Adhesive capsulitis using UCLA rating scale was significantly better in NSAID group as compared to Hyaluronic acid group.

The association of health literacy, numeracy and graph literacy with frailty.

BACKGROUND: Frailty is a state of vulnerability to stressors which may result in high mortality, morbidity, and health-care utilization in older adults. Whether health literacy, graph literacy and numeracy are associated with frailty is unknown. AIM: To assess the association of health literacy, numeracy and graph literacy with frailty in male veterans. METHODS: This is a retrospective study of 470 cognitively intact, non-depressed veterans who completed evaluations of health literacy, numeracy and graph literacy at Miami VA facility in 2012. A 43-item frailty index was created as a proportion of all potential variables (demographics, comorbidities, number of medications, laboratory tests, and activities of daily life). Odds ratios and 95% confidence intervals were calculated by multinomial logistic regression models with frailty status (robust, prefrail and frail) as the outcome variable, and with health literacy, numeracy, and graph literacy scores as independent variables. Age, race, ethnicity, education, socio-economic status, and comorbidities were considered as covariates. RESULTS: Patients were 100% male, 40% White, 82% non-Hispanic, mean age was 56.8 years. The proportion of robust, pre-frail and frail was 10.0%, 61.3% and 28.7%, respectively. Neither health literacy nor objective nor subjective numeracy was associated with frailty after adjustment for covariates. In contrast, higher graph literacy scores were associated with a lower risk for frailty (p = .015) even after adjusting known risk factors for frailty. DISCUSSION AND CONCLUSION: Neither health literacy nor numeracy is associated with frailty. Higher graph literacy score is associated with a lower risk for frailty even after adjusting for known risk factors for frailty.

Cosmetic Outcome of Cranioplasty After Decompressive Craniectomy-An Overlooked Aspect.

BACKGROUND: Cranioplasty (CP) is an obligatory surgery after decompressive craniectomy (DC). The primary objective is to protect the brain from external injury and prevent syndrome of trephined. In a government hospital, such cases pose a significant burden to a trauma center. Because of this reason, cosmetic outcome is never taken into account for the CP. We present results of CP performed at our hospital. METHODS: This is a retrospective review of the cases of CP performed over the past 3 years at our hospital. The cosmetic outcome was divided into 3 grades: 1-good symmetrical, 2-irregularities, 2a-elevated and 2b depressed, and 3-bad cosmetic outcome requiring reoperation. RESULTS: A total of 133 patients with acute brain injury underwent CP during the study period. The outcome was good in 74 (55.6%) and bad, requiring reoperation, in 2 (1.5%) cases. Various types of the CP materials like autologous bone flap, titanium mesh, and customized titanium plates were used. Methods of fixation were threads or miniplates and screws. In univariate analysis, cerebral venous thrombosis as an indication for DC, use of autologous bone flap, and fixation with thread were associated with poor outcome. However, in multivariate analysis only the method of implant fixation was associated with poor outcome. It was found that if screws and plates are used for fixation of bone flap, the chances of bad outcome are reduced by 74.6%. CONCLUSIONS: The cosmetic outcome is overlooked for CP. The bone flap fixation has to be rigid for a good outcome.

Evaluation of diphenhydramine in talc induced type 2 diabetes mellitus in Wistar rats.

Evaluation of diphenhydramine in talc induced type 2 diabetes mellitus was done in Wistar rats. Oral administration of Talc (10mg/kg)carried out for 21days increased the levels of serum glutamate pyruvate transaminase (SGPT), glutamate oxaloacetate transaminase (SGOT), serum creatinine, blood glucose, urea, uric acid and triglycerides (TGs), but when the animals were treated with diphenhydramine (DPH), the levels of the aforementioned biochemical parameters decreased significantly (p<0.0001). The level of serum cholesterol and high density lipoprotein (HDL) was found to be reduced in Diabetes Mellitus (DM) control and when it was treated with DPH control animals, these makers increased significantly. The study done on DM and Diphenhydramine suggests that Talc increases the blood glucose level at a dose of 10mg/kg (0.14gm) and Diphenhydramine (1mg/kg)reduces the increased blood glucose level. These finding simply that diphenhydramine may be useful in the management of talc induced diabetes.

Antibiotic prophylaxis in hip surgery: A comparision of two vs. three doses of cefuroxime.

OBJECTIVE: To compare the efficacy of two-dose regime with a three-dose regime of cefuroxime in the prevention of post-operative wound infection in hip surgery patients and to determine the most effective regime of antibiotic prophylaxis for such patients. METHODS: The prospective, comparative, multi-centre cohort study was conducted from January 1998 to June 1998 at Dundee Royal Infirmary and attached district hospitals (Stirling Royal Infirmary and Falkirk Royal Infirmary). It comprised patients who had hip surgery i.e. fracture fixation, hemiarthroplasty or total hip replacement. Patients were assigned to two groups. Group A patients received cefuroxime 750mg at induction of anaesthesia and 750mg at the end of the procedure, while Group B patients received 1.5gm of cefuroxime at the induction of anaesthesia, followed by 750mg 8 and 16 hours after the operation. Patients were assessed post-operatively daily according to the ASEPSIS wound scoring system during the hospital stay. RESULTS: There were 280 patients in the study, with 140(50%) in each of the two groups. In Group A 60(43%) patients required fracture fixation, the rate of wound infection was 2(3.3%), 40(28.5%) required hemiarthroplasty and the rate of wound infection was 1(2.5%) and 40(28.5%) required total hip replacement and the rate of wound infection was zero. In Group B, the corresponding numbers were 1/60 (1.6%), 1/40 (2.5%) and zero. No evidence of minor, moderate or severe wound infection was observed in 272(97%) patients regardless of the group. The most frequent pathogens were Staphylococcus aureus in 3(1%) patients and Staphylococcus epidermidis in 2(0.7%). CONCLUSIONS: There was no significant difference in the prevalence of wound infection between the patients who had received two or three doses of cefuroxime.

Why is hepatocellular carcinoma less attributable to viral hepatitis in Yemen?

The hepatitis B virus (HBV) and the hepatitis C virus (HCV) are still public health problems in Yemen, with older individuals having much higher prevalence than younger generations. However, research on the prevalence of viral hepatitis in association with hepatocellular cancer (HCC) has not yet been undertaken in Yemen. The aim of this study was to determine the prevalence of HBV and HCV infection among HCC patients and to estimate the risk of these infections being associated with the development of HCC. A cross-sectional study was conducted on patients attending oncology outpatient in Sana'a, Yemen, through the period 2008-mid 2010 with confirmed diagnosis of HCC. A total of 88 cases were studied thoroughly with different investigations such as CT-scan, ultrasound, tumour marker, alpha-feto-protein and histopathological biopsy. A structured questionnaire was also applied and physical examination done to assess the general condition of the patients. Statistical package (SPSS version 16) was used for analysis of the data. The mean age of the cases was 61.2 years (± 12.6) with half over 60 years. There were fewer male patients (36%) compared to females and most (97%) only had basic /no formal education. Seventy nine (89%) were diagnosed as HCC cases with histopathological biopsy while the rest were diagnosed by ultrasound, CT scan, tumour marker, and alpha-feto-protein. Around one-third of the subjects were positive for HBsAg and HCV antibodies. Multivariate analysis showed infection with HCV and use of smoking was associated with HCC diagnosis. Although an association was observed between the occurrence of HCC and viral hepatitis (either HBV or HCV) and cigarette smoking, but the rate of viral infection was lower than what has been reported elsewhere.

Steel slag: a waste industrial by-product as an alternative sustainable green building material in construction applications--an attempt for solid waste management.

This investigation explores the possibility of utilizing granular slag as an alternative to fine aggregate (natural sand) in construction applications like masonry and plastering. Construction industry utilizes large volume of fine aggregate in all the applications which has resulted into shortage of good quality naturally available fine aggregate. Use of granular slag serves two fold purposes, i.e. waste utilisation as well as alternative eco-friendly green building material for construction. The investigation highlights comparative study of properties with partial and full replacement of fine aggregate (natural sand) by granular slag in cement mortar applications (masonry and plastering). For this purpose, cement mortar mix proportions from 1:3, 1:4, 1:5 & 1:6 by volume were selected for 0, 25, 50, 75 & 100% replacement levels with w/c ratios of 0.60, 0.65, 0.70 & 0.72 respectively. Based on the study results, it could be inferred that replacement of natural sand with granular slag from 25 to 75% increased the packing density of mortar which resulted into reduced w/c ratio, increased strength properties of all mortar mixes. Hence, it could be recommended that the granular slag could be effectively utilized as fine aggregate in masonry and plastering applications in place of conventional cement mortar mixes using natural sand.

Quality of life among breast cancer patients in Yemen.

OBJECTIVE: The objective of this study is to determine the quality of life among breast cancer patients in Yemen based on socio-demographic and clinical characteristics. METHODOLOGY: This study was designed as a cross-sectional study. The data collected from 106 female breast cancer patients who were chosen for recruitment from the outpatient in National Oncology Centre (NOC), Sana'a, Yemen from November 2008 to June 2011. Questionnaires were distributed to the patients during their visit to the outpatient clinics in the center. The instrument of this study consists of two parts: Socio-demographic and the Functional Assessment of Cancer Therapy-Breast (FACT-B) questionnaire. Regarding data analysis, means and SD of subscales were evaluated for descriptive purpose. Analysis of variance (ANOVA) was performed to compare the three groups regarding QOL subscales. Whereas, independent t-test was performed for comparing two groups regarding QOL subscales. Multiple linear regression using backward analysis was performed to obtain the final model for each domain. The final model was chosen depending on R2 and the p value of the model. A p value less than 0.05 is considered statistically significant. RESULTS: A total number of 106 breast cancer patients were participated in this study. The majority of them were uneducated, unemployed with normal weight and had middle income (60.4%; 95.3%; 59.4%, 46.2%; respectively). As for clinical characteristics of the study participants; the majority of them had had no family history of breast cancer, have been diagnosed at least 2 years, were diagnosed at grade 3 and size of tumor greater than 2 cm (88.7%, 66.0%, 35.8%, 73.6%; respectively). The majority of them underwent mastectomy, radiotherapy, chemotherapy and tamoxifen therapy (85.8%, 63.2%, 94.3% and 62.3%; respectively). For univariate analysis, the present study has identified several factors includes family monthly income, BMI, educational status, years after diagnosis, histological grade radiotherapy and surgery that influence the QOL of breast cancer patients in Yemen. For multivariate analysis, years after diagnosis, family monthly income and radiotherapy were significantly associated with total QOL of the breast cancer patients (p=0.01, p=0.023, p=0.039; respectively). CONCLUSION: Family monthly income, BMI, educational status, years after diagnosis, histological grade radiotherapy and surgery were significantly influence the QOL of breast cancer patients in Yemen, in univariate analysis. For multivariate analysis, years after diagnosis, family monthly income and radiotherapy were significantly associated with total QOL of the breast cancer patients.

Ischemic colitis or melanosis coli: a case report.

BACKGROUND: Melanosis Coli is described as black or brown discolouration of the mucosa of the colon. Its a benign condition, which arises from anthraquinone laxative abuse and has no symptoms of its own. The main importance of diagnosing Melanosis Coli correctly lies in the fact that if its extensive, there may be difficulty in differentiating it from ischemic colitis. CASE PRESENTATION: We present a case of extensive Melanosis Coli involving the whole of large bowel that appeared gangrenous. A sub total colectomy was performed on presumed diagnosis of ischemic bowel. CONCLUSION: This report reminds the clinicians that extensive Melanosis Coli may mimic ischemic colitis and thus must be considered as a differential diagnosis.