Access to reperfusion therapy and mortality outcomes in patients with ST-segment elevation myocardial infarction under universal health coverage in Thailand.

BACKGROUND: Evidence on access to reperfusion therapy for patients with ST-segment elevation myocardial infarction (STEMI) and associated mortality in developing countries is scarce. This study determined time trends in the nationally aggregated reperfusion and mortality, examined distribution of percutaneous coronary intervention (PCI) utilization across provinces, and assessed the reperfusion-mortality association in Thailand that achieved universal health coverage in 2002. METHODS: Data on hospitalization with STEMI in 2011-2017 of 69,031 Universal Coverage Scheme (UCS) beneficiaries were used for estimating changes in the national aggregates of % reperfusion and mortality by a time-series analysis. Geographic distribution of PCI-capable hospitals and PCI recipients was illustrated per provinces. The reperfusion-mortality association was determined using the propensity-score matching of individual patients and panel data analysis at the hospital level. The exposure is a presence of PCI or thrombolysis. Outcomes are all-cause mortality within 30 and 180 days after an index hospitalization. RESULTS: In 2011-2017, the PCI recipients increased annually 5.7 percentage (%) points and thrombolysis-only recipients decreased 2.2% points. The 30-day and 180-day mortalities respectively decreased annually 0.20 and 0.27% points among the PCI recipients, and they increased 0.79 and 0.59% points among the patients receiving no reperfusion over the same period. Outside Bangkok, the provinces with more than half of the patients receiving PCI increased from 4 provinces of PCI-capable hospitals in 2011 to 37 provinces, which included the neighboring provinces of the PCI-capable hospitals in 2017. Patients undergoing reperfusion had lower 30-day and 180-day mortalities respectively by 19.6 and 21.1% points for PCI, and by 14.1 and 15.1% points for thrombolysis only as compared with no reperfusion. The use of PCI was associated with decreases in 30-day and 180-day mortalities similarly by 5.4-5.5% points as compared with thrombolysis only. A hospital with 1% higher in the recipients of PCI had lower mortalities within 30 and 180 days by approximately 0.21 and 0.20%, respectively. CONCLUSIONS: Patients with STEMI in Thailand experienced increasing PCI access and the use of PCI was associated with lower mortality compared with thrombolysis only. This is an evidence of progress toward a universal coverage of high-cost and effective health care.

The Relationships between Asterion, the Transverse-Sigmoid Junction, the Superior Nuchal Line and the Transverse Sinus in Thai Cadavers: Surgical Relevance.

Background: Anatomical localization of the venous sinuses in the posterior cranial fossa is important to preventing inadvertent venous sinus injury during surgical approaches to the area. Identification of surface landmarks related to these structures is useful in planning such approaches. Objective: To identify the positions of the asterion and the superior nuchal line for localization of the venous sinus in the posterior fossa. Material and Method: Twenty fresh cadaveric heads, yielding 40 sides, were used. The vessels were injected with colored silicone. The soft tissues were removed to expose the posterior cranium, from inion to the foramen magnum and laterally to the mastoid process. Using digital calipers, the relationship of asterion to the transverse-sigmoid sinus junction was determined and the distance from the highest superior nuchal line to the nearest transverse sinus was measured. Results: Asterion was located in 82.5% of the cadavers on the right side and 85.0% on the left side. The most common asterion position was at the junction of the transverse and sigmoid sinuses (67.5%), of which 5.0% were superior to the transverse-sigmoid junction, 2.5% inferior to the transverse-sigmoid junction and 7.5% medial to the transverse-sigmoid junction, at the transverse sinus. The superior nuchal line was identified in all cadavers. The most common position was inferior to the transverse sinus (60.0%) at an average distance of 8.55 mm 35.0% were at the same level as the transverse sinus and 5.0% were superior to the transverse sinus at an average distance of 2.14 mm. Conclusion: A burr hole inferior-medial to asterion can expose the posterior fossa dura with the least risk. The superior nuchal line is always identifiable and relatively close to the transverse sinus. A burr hole more than 3 mm inferior to the superior nuchal line can expose the posterior fossa dura with the least risk.

Pineal calcification is associated with symptomatic cerebral infarction.

BACKGROUND: Pineal calcification and low melatonin have been shown to be risk factors for stroke in animal studies; however, there are limited clinical data on the association of pineal calcification and stroke in humans. METHODS: All computed tomographic (CT) scans of the brains of patients >15 years of age during the year 2011 at a university teaching hospital were retrospectively reviewed. Patient medical charts were used to obtain the risk factors for stroke, including diabetes, hypertension, dyslipidemia, age, and sex. Cerebral infarction was identified by having clinical syndromes of stroke and a positive CT scan. Patients with embolic or hemorrhagic stroke were excluded. Pineal calcification was evidenced by the CT scans. The association of various stroke risk factors and cerebral infarction were calculated using logistic regression analysis. RESULTS: A total of 1614 patients were included, and symptomatic cerebral infarction was identified in 620 patients (38.4%). Regarding stroke risk factors in symptomatic cerebral infarction patients, the majority of patients were male (356 [57.4%]), >50 years of age (525 [84.7%]), and had hypertension (361 [58.2%]); some had diabetes (199 [32.1%]) and dyslipidemia (174 [28.1%]). Pineal calcification was found in 1081 patients (67.0%), with a male:female ratio of 1.5:1. Significant factors related to cerebral infarction by univariate logistic regression were age >50 years, hypertension, diabetes, dyslipidemia, and pineal calcification. Pineal calcification as a risk factor for cerebral infarction had an adjusted odds ratio of 1.35 (95% confidence interval 1.05-1.72). CONCLUSIONS: Pineal calcification may be a potential new contributor to cerebral infarction.

A dot-ELISA test using a Gnathostoma spinigerum recombinant matrix metalloproteinase protein for the serodiagnosis of human gnathostomiasis.

Gnathostomiasis caused by Gnathostoma spinigerum, is a hazardous food- borne helminthic zoonosis, and is endemic especially in developing countries in Asia. Definitive diagnosis, relying upon identification of worms from human tissues or body, is rarely accomplished. Consequently, sensitive supporting tools such as serological tests have been used widely. But these methods are time con- suming, need sophisticated equipment and are impractical in some settings. In the present study a dot enzyme-linked immunosorbent assay (dot-ELISA), using C. spin igerum recombinant matrix metalloproteinase protein as the antigen, was developed and assessed using sera of gnathostomiasis and other parasitosis pa- tients as well as healthy controls. The accuracy, sensitivity, specificity, positive and negative predictive values were 97.4%, 100%, 96.1%, 92.9%, and 100%, respectively. The dot-ELISA appears to be a suitable rapid test for diagnostic purpose as well as epidemiological studies.

Detection of Gnathostoma spinigerum antibodies in sera of non-traumatic subarachnoid hemorrhage patients in Thailand.

Gnathostoma spinigerum can cause subarachnoid hemorrhage (SAH). The detection of specific antibodies in serum against G. spinigerum antigen is helpful for diagnosis of neurognathostomiasis. There is limited data on the frequency of G. spinigerum infection in non-traumatic SAH. A series of patients diagnosed as non-traumatic SAH at the Srinagarind Hospital, Khon Kaen University, Thailand between January 2011 and January 2013 were studied. CT or MR imaging of the brain was used for diagnosis of SAH. Patients were categorized as aneurysmal subarachnoid hemorrhage (A-SAH) or non-aneurysmal subarachnoid hemorrhage (NA-SAH) according to the results of cerebral angiograms. The presence of specific antibodies in serum against 21- or 24-kDa G. spinigerum antigen was determined using the immunoblot technique. The detection rate of antibodies was compared between the 2 groups. Of the 118 non-traumatic SAH patients for whom cerebral angiogram and immunoblot data were available, 80 (67.8%) patients had A-SAH, whereas 38 (32.2%) had NA-SAH. Overall, 23.7% were positive for specific antibodies against 21- and/or 24-kDa G. spinigerum antigen. No significant differences were found in the positive rate of specific antibodies against G. spinigerum in both groups (P-value=0.350).

A recombinant matrix metalloproteinase protein from Gnathostoma spinigerum for serodiagnosis of neurognathostomiasis.

Neurognathostomiasis is a severe form of human gnathostomiasis which can lead to disease and death. Diagnosis of neurognathostomiasis is made presumptively by using clinical manifestations. Immunoblotting, which recognizes antigenic components of molecular mass 21 kDa and 24 kDa in larval extracts of Gnathostoma spinigerum (Gs 21/24), has high sensitivity and specificity for diagnosis of neurognathostomiasis. However, only very small amounts of the Gs 21/24 antigens can be prepared from parasites harvested from natural or experimental animals. To overcome this problem, we recently produced a recombinant matrix metalloproteinase (rMMP) protein from G. spinigerum. In this study, we evaluated this rMMP alongside the Gs 21/24 antigens for serodiagnosis of human neurognathostomiasis. We studied sera from 40 patients from Srinagarind Hospital, Khon Kaen University, Thailand, with clinical criteria consistent with those of neurognathostomiasis, and sera from 30 healthy control adults from Thailand. All sera were tested for specific IgG antibodies against both G. spinigerum crude larval extract and rMMP protein using immunoblot analysis. The sensitivity and specificity for both antigenic preparations were all 100%. These results show that G. spinigerum rMMP protein can be used as an alternative diagnostic antigen, in place of larval extract, for serodiagnosis of neurognathostomiasis.

Supramastoid crest, safety landmark for craniotomy?

BACKGROUND: Bony landmarks are important in identifying and avoiding various structures, and thus, decreasing surgical morbidity. Knowledge of frontal bone was studied to help surgeons with safe craniotomy as temporooccipital region study was rare. OBJECTIVE: To identify usefulness of supramastoid crest and relationship to venous and Labbe's vein. MATERIAL AND METHOD: Twenty fresh cadaveric heads, the vessels were injected with colorized silicone, were studied on both sides, yielded 40 sides. The relationship of the supramastoid crest to the transverse, sigmoid sinus, Labbe's vein was also determined and measured. The following distances were measured utilizing the digital caliper for all measurements. RESULTS: Supramastoid crest was found in all cadavers (100%) and skull opened along supramastoid crest 100% safe from injury to venous sinus. Anterior border of supramastoid crest was close in relation to middle cranialfossa floor, 85% on right side and 90% on left side and the same level of middle cranial. The authors defined supramastoid point with turning of supramastoid crest and found distance from supramastoid point to nearest venous sinuse (always transverse sinus) 1.0-22.41 mm in range and average 12.94 mm on right side and 11.87 mm on left side. The last distance, from supramastoid point to nearest Labbe's vein, was measured and found to be 5.94-24.97 mm in range and average 17.23 mm on both sides. CONCLUSION: Supramastoid crest is bony landmark and easy to identify in the adult cadaver and craniotomy along supramastoid crest and always safe from injuring the venous sinus and Labbe s vein. 87.5% anterior border of supramastoid crest is the same level for middle cranial fossa floor.

Hypoimmunoglobulinemia and protein C deficiency in a girl with Jacobsen syndrome: a case report.

Jacobsen syndrome is a rare contiguous gene syndrome caused by partial deletion of the long arm of chromosome 11. The typical clinical manifestations include physical growth retardation, mental retardation,facial dysmorphisms, congenital heart disease, thrombocytopenia, or pancytopenia. A Thai-Australian girl was born with multiple abnormalities. Typical features and her karyotype, 46, XX, del(ll) (q23-qter), confirmed Jacobson syndrome. She had many uncommon findings including upslanting palpebral fissures, tortuousity of retinal vessels and hypogammaglobulinemia. In addition, this case also presented with protein C deficiency, which has not been reported previously in Jacobsen syndrome. The patient was treated with phototherapy, intravenous antibiotic injection, and platelet transfusion in neonatal period. Cranioplasty was performed for prevention of the increased intracranial pressure at three months of age. Surgical correction for strabismus was in the treatment plan.

Cerebral angiographic findings in patients with non-traumatic subarachnoid hemorrhage.

BACKGROUND: Even though ruptured intracranial aneurysm is a major cause of non-traumatic subarachnoid hemorrhage (SAH), non-aneurysmal SAH has a good prognosis with few neurologic complications. The gold standard for detecting the vascular pathology is digital subtraction cerebral angiography (DSA). OBJECTIVE: The primary objective of the present study was to clarify cerebral angiographic findings in patients with non-traumatic subarachnoid hemorrhage (SAH); to define the incidence of nonaneurysmal SAH. The secondary aim was to review the clinical data of all of the patients diagnosed with non-traumatic SAH in order to determine the associated etiology. MATERIAL AND METHOD: This retrospective, descriptive study, was conducted at Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, between January 2005 and November 2010. The authors reviewed the medical records, cranial computed tomography (CT) and DSA of patients with non-traumatic SAH. The DSA findings were assessed and the correlation with clinical data and CT pattern determined. RESULTS: The author included and analyzed the records of 118 non-traumatic SAH patients (66 females, 52 males). The DSA discovered vascular lesions in 62.6% of cases (57.6% aneurysm, 4.2% arteriovenous malformation (AVM) and 0.8% Moyamoya disease). A total of 76 aneurysms were found in 68 cases. The location of the aneurysms included: 35.5% anterior communicating artery, 17.1% posterior communicating artery, 15.7% middle cerebral artery, 11.8% internal carotid artery 2.6% basilar artery, 1.3% vertebrobasillar junction and 10.5% others. The prevalence of nonaneurysmal SAH was 42.4% (50/118). In the multivariate analysis, hypertension was the factor most strongly associated with aneurysmal SAH on the DSA (p = 0.029). The location of SAH on Sylvian fissure was most frequently associated with the cause of aneurysms. In another way, tentorial cerebelli SAH was most commonly associated with a non-aneurysm cause. CONCLUSION: The present study revealed that the major cause of non-traumatic SAH is cerebral aneurysm. The factors associated with aneurysmal SAH included: hypertension and Sylvian fissure SAH. Tentorial cerebelli SAH was most commonly associated with a non-aneurysm cause.

Cost-effectiveness analysis of endovascular coiling and neurosurgical clipping for aneurysmal subarachnoid hemorrhage in Thailand.

BACKGROUND: For patients with aneurysmal subarachnoid hemorrhage (aSAH), the Universal Coverage Scheme in Thailand covers the full costs of surgical and endovascular procedures except for those of embolization coils and assisting devices. Costs and effectiveness were compared between endovascular coiling and neurosurgical clipping to inform reimbursement policy decisions. METHODS: Costs and quality-adjusted life years (QALYs) were compared between coiling and clipping using the decision tree and Markov models. Mortality and functional outcomes of clipping were derived from national and hospital databases, and relative efficacies of coiling were obtained from meta-analyses of randomized controlled trials. Risks of rebleeding were abstracted from the International Subarachnoid Aneurysm Trial. Costs of the primary treatments, retreatments and follow-up care as well as utilities were obtained from hospital-based data. Non-health and indirect costs were abstracted from standard cost lists. RESULTS: Coiling and clipping contributed 10.59 and 9.28 QALYs to patients aged in their 50s. Under the societal and healthcare perspectives, the incremental costs incurred by coiling compared with clipping were US$1923 and $4343, respectively, which were equal to the incremental cost-effectiveness ratio of US$1470 and $3321 per QALY gained, respectively. Coiling became a cost-saving option when the costs of coil devices were reduced by 65.7%. At the country's cost-effectiveness threshold of US$5156, the probability of coiling being cost-effective was 71.3% and 65.6%, under the societal and healthcare perspectives, respectively. CONCLUSION: Endovascular treatment for aSAH is cost-effective and this evidence supports coverage by national insurance.

Rapid assessment of Opisthorchis viverrini IgG antibody in serum: A potential diagnostic biomarker to predict risk of cholangiocarcinoma in regions endemic for opisthorchiasis.

BACKGROUND: Opisthorchiasis is caused by an infection with fish-borne liver flukes of the genus Opisthorchis. Opisthorchiasis frequently leads to chronic inflammation in the biliary tract and is classified as a group 1 biological carcinogen by the International Agency for Research on Cancer: a definitive risk for cholangiocarcinoma (CCA). METHODS: We used the rapid immunochromatographic test (ICT) to detect anti-Opisthorchis viverrini IgG and IgG4 subclass antibodies in sera of patients with CCA. The ICT kits were developed based on soluble antigens excreted and secreted by O. viverrini adult worms. RESULTS: ICT indicated sera was positive for IgG and IgG4 antibodies, respectively, in 22 (61.1%) and 15 (41.6%) participants of the 36 study participants diagnosed with CCA (P > 0.05). Our study also included groups with other cancers and with liver cirrhosis, where the IgG ICT and IgG4 ICT kits were 27.7% (13/47) and 25.5% (12/47) positive, respectively (P > 0.05). Neither total the IgG ICT nor the IgG4 ICT yielded positive results in a control group of 20 healthy participants. Moreover, the percentage positivity rate using the ICT for total IgG between the CCA group and the other cancers and liver cirrhosis group was significantly different (P < 0.05). By contrast, no significant difference between these groups was apparent in the ICT for IgG4 antibody. The CCA group was 6.53 times more likely to have positive anti-O. viverrini IgG antibody (odds ratio 6.53, P < 0.001) and 3.27 times more likely to have positive anti-O. viverrini IgG4 antibody (odds ratio 3.27, P = 0.010) than the non-CCA group. CONCLUSION: This information is of potential value for the development of a diagnostic biomarker to predict risk for O. viverrini infection-associated CCA.

Evaluation of total immunoglobulin G and subclass antibodies in an enzyme-linked immunosorbent assay for serodiagnosis of human amebic liver abscess.

Background: Amebic liver abscess (ALA) caused by Entamoeba histolytica is usually diagnosed based on its clinical symptoms, medical imaging abnormalities of the liver, and serological tests, the most common being the enzyme-linked immunosorbent assay (ELISA). For more than three decades, no investigation has evaluated the diagnostic performance of immunoglobulin G (IgG) subclasses in the serodiagnosis of ALA. Herein, we assessed the efficiencies of anti-amebic IgG and IgG subclasses for diagnosing ALA. Methods: A serological ELISA-based test was performed to assess its diagnostic performance using a total of 330 serum samples from ALA patients (n = 14), healthy individuals (n = 40), and patients with other diseases (n = 276). Results: ELISA targeting the total IgG antibody to E. histolytica antigen exhibited 100% sensitivity 95% CI [76.8-100.0] and 97.8% specificity 95% CI [95.5-99.1], whereas the assay targeting IgG1 showed the same sensitivity (100% 95% CI [76.8-100.0]) and a slightly higher specificity (99.1% 95% CI [97.3-99.8]). The other IgG subclasses (IgG2, IgG3, and IgG4) displayed a lower sensitivity and specificity. The sensitivity and specificity did not significantly differ between tests measuring total IgG and IgG1 (Exact McNemar's test; p > 0.05), with a concordance of 98.2%, represented by a Cohen's kappa of 0.83 (p < 0.001), indicating almost perfect agreement. Conclusion: ELISA targeting IgG1 can provide valuable information to clinicians in differentiating ALA from other parasitic diseases, cancers, cirrhosis, and viral hepatitis. However, enzyme-conjugated anti-human total IgG is cheaper than anti-human IgG subclasses. Therefore, we suggest that total IgG-based ELISA is sufficient for the routine serodiagnosis of human ALA and possibly other clinical manifestations of invasive amebiasis.

Ventriculoperitoneal shunt failure in pediatric patients: an analysis of a national hospitalization database in Thailand.

OBJECTIVE: Shunt failure is common among patients undergoing ventriculoperitoneal shunting for treatment of hydrocephalus. The present study examined long-term shunt failure and associated risk factors in pediatric patients by using a national hospitalization database of Thailand. METHODS: Patients 17 years or younger who had been admitted to 71 public hospitals in 2012-2017 for first-time ventriculoperitoneal shunting for diseases with known etiology and discharged alive were followed through 2019 to ascertain shunt failure. Shunt survivals were calculated using Kaplan-Meier estimates and time to failure was analyzed to identify risk factors for the first failure by using Cox proportional hazards regression. Differences in risks of subsequent failures with respect to place in the order of failures (i.e., first, second, third) were determined using a cumulative hazard function. RESULTS: Over a median follow-up of 29.9 months, shunt failure occurred in 33.7% of 2072 patients (median age 8.8 months), with a higher proportion in patients < 1 year than in patients 1-17 years (37.8% vs 28.9%, p < 0.001), and ranged from 26.1% of those having posttraumatic hydrocephalus to 35.9% of those having infectious diseases. The shunt failure rates at 3, 6, and 12 months were 11.5%, 19.0%, and 25.2%, respectively. Patients < 1 year had a higher risk of the first failure than patients 1-17 years (hazard ratio 1.45, 95% CI 1.20-1.76). Among those with shunt failure, 35.8% had multiple failures and 52.9% failed within 180 days after the index shunting. The cumulative hazard of subsequent failure was consistently higher than that of an earlier failure regardless of age and etiology, and the cumulative hazard of the second failure in the patients with 180-day failure was higher than that in the patients in whom shunts failed beyond 180 days. CONCLUSIONS: Shunt failure occurred more frequently in younger pediatric patients. Much attention should be placed on the initial shunt operation so as to mitigate the failure risk. Close follow-up was crucial once patients had developed the failure, because the risk of subsequent failure was more likely than an earlier one among those with multiple failures.

What are the strongest indicators of intracerebral hemorrhage in mild traumatic brain injury?

BACKGROUND: Although there are eight factors known to indicate a high risk of intracranial hemorrhage (ICH) in mild traumatic brain injury (TBI), identification of the strongest of these factors may optimize the utility of brain CT in clinical practice. This study aimed to evaluate the predictors of ICH based on baseline characteristics/mode of injury, indications for brain CT, and a combination of both to determine the strongest indicator. METHODS: This was a descriptive, retrospective, analytical study. The inclusion criteria were diagnosis of mild TBI, high risk of ICH, and having undergone a CT scan of the brain. The outcome of the study was any type of ICH. Stepwise logistic regression analysis was used to find the strongest predictors according to three models: (1) injury pattern and baseline characteristics, (2) indications for CT scan of the brain, and (3) a combination of models 1 and 2. RESULTS: There were 100 patients determined to be at risk of ICH based on indications for CT of the brain in patients with acute head injury. Of these, 24 (24.00%) had ICH. Model 1 found that injury due to motor vehicle crash was a significant predictor of ICH, with an adjusted OR (95% CI) of 11.53 (3.05 to 43.58). Models 2 and 3 showed Glasgow Coma Scale (GCS) score of 13 to 14 after 2 hours of observation and open skull or base of skull fracture to be independent predictors, with adjusted OR (95% CI) of 11.77 (1.32 to 104.96) and 5.88 (1.08 to 31.99) according to model 2. DISCUSSION: Open skull or base of skull fracture and GCS score of 13 to 14 after 2 hours of observation were the two strongest predictors of ICH in mild TBI. LEVEL OF EVIDENCE: III.

Prognostic factors and clinical nomogram predicting survival in high-grade glioma.

BACKGROUND: Genomic-based tools have been used to predict poor prognosis high-grade glioma (HGG). As genetic technologies are not generally available in countries with limited resources, clinical parameters may be still necessary to use in predicting the prognosis of the disease. This study aimed to identify prognostic factors associated with survival of patients with HGG. We also proposed a validated nomogram using clinical parameters to predict the survival of patients with HGG. METHODS: A multicenter retrospective study was conducted in patients who were diagnosed with anaplastic astrocytoma (WHO III) or glioblastoma (WHO IV). Collected data included clinical characteristics, neuroimaging findings, treatment, and outcomes. Prognostic factor analysis was conducted using Cox proportional hazard regression analysis. Then, we used the significant prognostic factors to develop a nomogram. A split validation of nomogram was performed. Twenty percent of the dataset was used to test the performance of the developed nomogram. RESULTS: Data from 171 patients with HGG were analyzed. Overall median survival was 12 months (interquartile range: 5). Significant independent predictors included frontal HGG (hazard ratio [HR]: 0.62; 95% confidence interval [CI]: 0.40-0.60), cerebellar HGG (HR: 4.67; 95% CI: 0.93-23.5), (HR: 1.55; 95% CI: 1.03-2.32; reference = total resection), and postoperative radiotherapy (HR: 0.18; 95% CI: 0.10-0.32). The proposed nomogram was validated using nomogram's predicted 1-year mortality rate. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the curve of our nomogram were 1.0, 0.50, 0.45, 1.0, 0.64, and 0.75, respectively. CONCLUSION: We developed a nomogram for individually predicting the prognosis of HGG. This nomogram had acceptable performances with high sensitivity for predicting 1-year mortality.

Appropriate Blood Pressure in Cerebral Aneurysm Clipping for Prevention of Delayed Ischemic Neurologic Deficits.

BACKGROUND: Delayed ischemic neurologic deficit (DNID) is a problem after cerebral aneurysm clipping. Intraoperative hypotension seems to be indicated as a risk factor, but it remains a controversial issue with varying low-blood pressure levels accepted. METHODS: A retrospective, hospital-based, case-control study was performed with patients who received general anesthesia for cerebral aneurysm clipping. 42 medical record charts were randomly selected and matched 1 : 2 (1 case with DNID : 2 controls without DNID) based on the type of general anesthetic techniques and severity of subarachnoid hemorrhage. The optimal cutoff points of hemodynamic response were calculated by the area under the curve. RESULTS: Data suggested that the optimal cutoff points for lowest blood pressure for prevention of DNID should be systolic blood pressure (SBP) of 95 mmHg (sensitivity of 78.6%; specificity of 53.6%), diastolic blood pressure (DBP) of 50 mmHg (sensitivity of 71.4%; specificity of 67.9%), and mean arterial pressure (MAP) of 61.7 mmHg (sensitivity of 85.7%; specificity of 35.7%). Furthermore, the optimal cutoff point mean difference baseline blood pressure was recommended as Δ SBP of 36 mmHg (sensitivity of 85.7%; specificity of 60.7%), Δ DBP of 27 mmHg (sensitivity of 92.9%; specificity of 71.4%), and Δ MAP of 32 mmHg (sensitivity of 92.9%; specificity of 85.7%). No significant difference between DNID and non-DNID groups was found for end-tidal carbon dioxide (ETCO2) and has poor diagnostic value for predicting DNID. CONCLUSION: To prevent DNID, we recommend that optimal blood pressure should not be lower than 95 for SBP, 50 for DBP, and 61.7 mmHg for MAP. Additionally, we suggest that Δ SBP, Δ DBP, and Δ MAP should be less than 36, 27, and 32 mmHg, respectively.

Prognostic Factors and Nomogram Predicting Survival in Diffuse Astrocytoma.

Background Prognosis of low-grade glioma are currently determined by genetic markers that are limited in some countries. This study aimed to use clinical parameters to develop a nomogram to predict survival of patients with diffuse astrocytoma (DA) which is the most common type of low-grade glioma. Materials and Methods Retrospective data of adult patients with DA from three university hospitals in Thailand were analyzed. Collected data included clinical characteristics, neuroimaging findings, treatment, and outcomes. Cox's regression analyses were performed to determine associated factors. Significant associated factors from the Cox regression model were subsequently used to develop a nomogram for survival prediction. Performance of the nomogram was then tested for its accuracy. Results There were 64 patients with DA with a median age of 39.5 (interquartile range [IQR] = 20.2) years. Mean follow-up time of patients was 42 months (standard deviation [SD] = 34.3). After adjusted for three significant factors associated with survival were age ≥60 years (hazard ratio [HR] = 5.8; 95% confidence interval [CI]: 2.09-15.91), motor response score of Glasgow coma scale < 6 (HR = 75.5; 95% CI: 4.15-1,369.4), and biopsy (HR = 0.45; 95% CI: 0.21-0.92). To predict 1-year mortality, sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the curve our nomogram was 1.0, 0.50, 0.45, 1.0, 0.64, and 0.75, respectively. Conclusions This study provided a nomogram predicting prognosis of DA. The nomogram showed an acceptable performance for predicting 1-year mortality.

Are full-face helmets the most effective in preventing head and neck injury in motorcycle accidents? A meta-analysis.

Motorcycles are the most common type of vehicle involved in traffic deaths in developing countries. Although helmets can provide protection against injury, there is limited evidence available regarding which type of helmet best protects against head and neck injuries in this setting. This review was conducted based on articles in the PubMed, Scopus, and Web of Science databases. We compared full-face helmets with other types of helmet with regard to head and neck injury prevention in road accidents involving motorcyclists. Of 702 studies, six were eligible with a total of 6,529 participants. When compared with partial and open helmets, the odds ratio of full-face helmets was 0.356 (95% CI of 0.280, 0.453) and 0.636 (95% CI of 0.453, 0.894), respectively, for reduction of head and neck injuries. In conclusion, full-face helmets reduced head and neck injuries in motorcycle accidents to a greater extent than other types of helmet. Policy makers should recommend that motorcyclists use full-face helmets.

Results of a Preventive Rebleeding Protocol in Patients with Ruptured Cerebral Aneurysm: A Retrospective Cohort Study.

OBJECTIVE: In 2015, a protocol to prevent rebleeding was implemented to improve the outcome of patients with ruptured intracranial aneurysm. We performed a single-center retrospective analysis to compare the outcomes of pre/post using protocol. METHODOLOGY: Over a 3-year period, 208 patients with ruptured cerebral aneurysm were treated at our institution. The protocol for preventing rebleeding was initiated in 2015. We compared the two cohorts between the group of patients before initiating the protocol (n = 104) and after initiating the protocol (n = 104). We analyzed the protocol for preventing rebleeding which consisted of absolute bed rest, adequate pain control, avoiding stimuli (R), keeping euvolemia (E), preoperative systolic blood pressure <160 mmHg and within 140-180 mmHg after definite treatment (S), a short course (<72 h) of intravenous transaminic acid, and aneurysm treatment as early as possible (T). Outcomes are presented as in-hospital rebleeding, delayed cerebral ischemia (DCI), and proportion of unfavorable outcomes (score of 4-6 on a modified Rankin scale at 6 and 12 months). RESULTS: Postprotocol, there was a reduction in the incidence of in-hospital rebleeding from 6.7% to 2.8% (P = 0.20, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.10-1.63) and in the proportion of patients who presented with good WFNS grades (1-3) with unfavorable clinical outcomes at 12 months from 27.0% to 12.8% (P = 0.03, OR = 0.40, 95% CI = 0.17-0.95). The DCI experienced a significant reduction from 44.2% to 7.7% (P < 0.001, OR = 0.10, 95% CI = 0.04-0.23), and their 180-day mortality rate in good WFNS grades patients decreased from 16.3% to 8.8% (hazard ratio 0.80, 95% CI = 0.28-2.28). CONCLUSION: Ruptured cerebral aneurysm patients benefit from this protocol due to its ability to reduce the incidence of DCI and reduce unfavorable outcome on good WFNS grade patients.

Preoperative MRI evaluation of meningioma consistency: A focus on detailed architectures.

OBJECTIVES: Meningioma is one of the most common primary intracranial tumors. Diagnosis by imaging is not difficult. However evaluation of tumor consistency is an important factor affecting the surgical outcomes. The purpose of our study is to discover the relationship of different findings on pre-operative MRI, with a focus on detailed architectures, and different degrees of intra-operative stiffness of meningioma. Consistency of meningioma is also analyzed in compression to semi-quantitative pathological grading of fibrosis. PATIENTS AND METHODS: Sixty patients who underwent pre-operative MRI and primary surgery at our hospital were included in prospective fashion. Pre-operative MRI parameters, including general data and detailed internal architectures, were recorded. Intra-operative grading of tumor consistency was performed by the neurosurgeon. Pathological report according to WHO 2007 was performed with additional semi-quantitative grading of fibrosis. This study is focused on correlation of operative grade and MRI findings. RESULTS: Meningioma with hard consistency shows significant correlation with several features including en plaque appearance (p = 0.0427), higher ADC value (p = 0.0046) and ratio (p = 0.0016), absent of prominent enhanced rim (p = 0.0306), absent of enostotic spur (p = 0.0040) and absent of vascular core (p = 0.0133) in univariate analysis but no significant correlation is found in multivariate analysis in all except ADC ratio. Higher ADC ratio increase relative risk of hard consistency of meningioma by a factor of 41.22 (ORs = 41.22; 95%CI = 1.19-1426.24, P = 0.04). Good to very good inter-rater agreements are found. No significant correlation between tumor consistency and WHO grading was shown (p = 0.606). However, near significant p-value (p = 0.055) is found with increase degree of fibrosis in pathology as increase degree of tumor consistency. CONCLUSION: We found that en plaque appearance, higher ADC value and ADC ratio, absent of prominent capsular enhancement and absent of vascular core were suggestive of hard consistency in univariate analysis but not independent factors. Additionally, semi-quantitative pathological grading of fibrosis showed near significant correlation with tumor consistent.