Comparison of Decompressive Craniectomy Versus Craniotomy for Evacuation of Subdural Hemorrhage: A Systematic Review and Meta-Analysis.

INTRODUCTION: Acute subdural hemorrhage (ASDH) from traumatic brain injury is a life-threatening situation, often requiring surgical intervention. This meta-analysis is done to update the literature regarding the choice of procedure for the treatment of ASDH. METHODS: PubMed, Scopus, and Cochrane were searched from the year 2000 up to September 2023. Randomized controlled trials and observational studies were included. The odds ratio with 95% confidence interval (CI) mean difference and standardized mean difference were calculated for dichotomous and continuous outcomes, respectively. RESULTS: A total of 14 studies comprising 4686 patients were included in the analysis. Pooled Glasgow Outcome Scale/Extended Glasgow Outcome Scale scores were compared based on their means, with the craniotomy (CO) group having better mean scores than decompressive craniectomy (DC) (standardized mean difference -0.37, 95% CI -0.68 to -0.06, P = 0.02). The risk for poor outcomes was statistically greater in the DC group compared to the CO group (1.32, 95% CI 1.05-1.66, P value = 0.02). There were fewer residual subdural hematoma cases in the DC group as compared to CO (odds ratio 0.40, 95% CI 0.22-0.73, P value < 0.005). CONCLUSIONS: Our meta-analysis showed that the ASDH patients had better functional outcomes when treated with CO as compared to DC. However, there were fewer odds of residual subdural hematoma with DC.

Oncological Outcomes of Sub-Lobar Resection Versus Lobectomy for Stage I Non-Small Cell Lung Cancer.

INTRODUCTION: Although lobectomy has been the treatment of choice for early-stage non-small cell lung cancer (NSCLC), sub-lobar resection (i.e., segmentectomy or wedge resection) has emerged as an alternative over time due to its ability to preserve additional lung function. This meta-analysis explores the survival outcomes of sub-lobar resection versus lobectomy in patients with stage I NSCLC (tumor size: ≤2 cm). MATERIAL AND METHODS: We conducted a systematic search of PubMed, EMBASE, and the Cochrane Library from inception up to July 28, 2023. The hazard ratios and odds ratios for overall survival (OS), disease-free survival (DFS), and mortality were calculated using the random effects model. RESULTS: A total of 27 studies, comprising 10,449 patients, were included. Sub-lobar resection demonstrated comparable OS and DFS to that of lobectomy. Similarly, there was no significant risk of mortality associated with any of the groups. However, the subgroup analysis according to patient selection (intentional, compromised, not specified, and both [intentional and compromised]) showed that the patients in the compromised subgroup had a poor DFS with sub-lobar resection as compared to lobectomy (hazard ratio: 1.52, confidence interval: 1.14-2.02, P = 0.004). Additionally, there was no significant difference in OS, DFS, or overall mortality in the results stratified by surgical procedure or patient selection. CONCLUSIONS: The patients with stage I NSCLC who underwent sub-lobar resection showed a significantly worse DFS and OS in the "compromised group." However, there was no overall significant difference in OS, DFS, or mortality in the sub-lobar resection group as compared to lobectomy.

Safety and efficacy of Withania somnifera for anxiety and insomnia: Systematic review and meta-analysis.

OBJECTIVE: Despite the historical neurological use of Withania somnifera, limited evidence supports its efficacy for conditions like anxiety and insomnia. Given its known anti-stress properties, this review evaluated its safety and efficacy for anxiety and insomnia. METHODS: We searched Medline, Cochrane Library, and Google Scholar until August 2023 for randomized controlled trials (RCTs) comparing W. somnifera to placebo in patients with anxiety and/or insomnia. Outcome measures included changes in anxiety levels via the Hamilton Anxiety Scale (HAM-A), Sleep Onset Latency (SOL), Total Sleep Time (TST), Wake After Sleep Onset (WASO), Total Time in Bed (TIB), Sleep Efficiency (SE), and Pittsburgh Sleep Quality Index (PSQI) score. We utilized a random-effect model for pooling Mean Differences (MD) with a 95% Confidence Interval (CI). Heterogeneity was assessed through sensitivity and subgroup analysis, and the quality of RCTs was evaluated using the Cochrane revised risk of bias tool. RESULTS: Pooled results from five RCTs (n = 254) demonstrated that W. somnifera significantly reduced HAM-A scores (MD = -5.96; [95% CI -10.34, -1.59]; P = 0.008; I2 = 98%), as well as sleep parameters such as SOL, TST, PSQI, and SE, but not WASO and TIB. CONCLUSION: While W. somnifera extracts yielded promising results, further research with larger sample sizes is needed to confirm its effects on anxiety and insomnia.

The role of angiotensin receptor blockers in treating epilepsy: a review.

Epilepsy is a chronic brain disease with a global prevalence of 70 million people. According to the World Health Organization, roughly 5 million new cases are diagnosed every year. Anti-seizure drugs are the treatment of choice. However, in roughly one third of the patients, these drugs fail to produce the desired effect. As a result, finding novel treatments for epilepsy becomes inevitable. Recently, angiotensin receptor blockers have been proposed as a treatment to reduce the over-excitation of neurons in epilepsy. For this purpose, we conducted a review using Medline/PubMed and Google Scholar using the relevant search terms and extracted the relevant data in a table. Our review suggests that this novel approach has a very high potential to treat epilepsy, especially in those patients who fail to respond to conventional treatment options. However, more extensive and human-based trials should be conducted to reach a decisive conclusion. Nevertheless, the use of ARBs in patients with epilepsy should be carefully monitored keeping the adverse effects in mind.

Development of palliative care clinical practice guidelines and referral care pathways for primary care practitioners in Pakistan.

BACKGROUND: Despite a large burden of life-limitingillness, there exists a dearth of services of palliative care in Pakistan. International guidelines have questionable applicability in Pakistan due to the socioeconomic differences. We generated a protocol describing the process of developing comprehensive palliative care guidelines and palliative care referral pathways for primary care practitioners to adopt in Pakistan. METHODS: A GRADE-ADOLOPMENT approach with modification has been employed to create guidelines for a Pakistani context. The "National Comprehensive Cancer Network Guidelines Insights: Palliative Care, Version 2.2021" was used as the source guideline. Recommendations from the source guideline were reviewed by two local palliative care specialists to either "Adopt," "Adapt" or "Exclude". The finalized recommendations were incorporated into the local palliative care guideline. Clinical diagnosis and referral pathways were made from the finalized guideline. Any gaps in management found in the pathways were filled by taking existing recommendations from other credible guidelines. RESULTS: Twenty-seven recommendations were adopted without modification. No recommendations were deemed to be adapted and 15 were excluded. The referral care pathways created were reflective of the local guideline and included elements of initial assessment, preliminary management, reassessment, and referral. 6 additional recommendations were made. CONCLUSION: The described clinical practice guidelines and primary care clinical referral pathways will aid to standardize palliative care provision in Pakistan. These can be used by other resource constrained settings to develop guidelines within their own local context.

Antibiotic Prophylaxis for Upper Gastrointestinal Bleed in Liver Cirrhosis; Less May Be More.

INTRODUCTION: Administration of antibiotics in patients with cirrhosis and upper gastrointestinal bleeding has been shown to improve outcomes. Little is known regarding optimum duration of prophylactic antibiotics. Seven days of antibiotics are generally recommended but very few studies have compared antibiotic duration to clinical outcomes in current available scientific literature. The goal of our study was to study the effect of shorter antibiotic duration on patient outcomes. METHODS: We conducted a retrospective cohort study of patients with cirrhosis presenting with upper GI bleeding at our institute from 2010 to 2018. Patients were divided into three cohorts based on duration of antibiotic administration for prophylaxis: 1-3 days of antibiotics, 4-6 days of antibiotics and 7 days or more of antibiotics. Rates of infection diagnosis within 30 days, rebleeding, and mortality were compared between the three groups with Chi square, Fisher Exact and Kruskall-Wallace tests. Multivariable analysis was conducted to evaluate independent risk factors for infection. RESULTS: Medical charts of 980 patients with cirrhosis and upper GI bleeding during the study period were reviewed. A total of 303 with upper gastrointestinal bleeding were included in the final sample, of these 243 patients received antibiotics for prophylaxis and were included for analysis. Seventy-seven patients received antibiotic therapy for 3 days or less, 69 patients for 4-6 days, and 97 patients longer than 6 days. The three groups were well matched in demographic and clinical variables. Twenty-seven patients developed infections within 30 days of bleeding. MELD-Na score at presentation and presence of ascites were associated with infection within 30 days. Rates of infection were not statistically different between the three antibiotic groups (p = 0.78). In the thirty days following the GI bleed, pneumonia was the most diagnosed infection (eleven patients) followed by urinary tract infections (eight patients). Four patients developed spontaneous bacterial peritonitis and three were diagnosed with bacteremia. There was no difference in time to infection (Kruskall Wallace test p = 0.75), early re-bleeding (p = 0.81), late re-bleeding (p = 0.37) and in-hospital mortality (p = 0.94) in the three groups. Six patients in the cohort developed C. Difficile infection; no patient in the short antibiotic group developed C. Difficile infection. CONCLUSION: Short course of antibiotics for prophylaxis (3 days) appears safe and adequate for prophylaxis in patients with cirrhosis with upper gastrointestinal bleeding if there is no active infection.

Addressing rural health disparity with a novel hospital sleep apnea screening: Precision of a high-resolution pulse oximeter in screening for sleep-disordered breathing.

PURPOSE: High-resolution pulse oximetry (HRPO) may offer a low-cost and simple screening option for sleep-disordered breathing (SDB) that could be vitally important in rural areas with limited healthcare resources and specialty care. Our team hypothesized that application of this technology to a broad cohort of rural dwelling hospitalized individuals would demonstrate congruence similar to previous urban studies comparing HRPO to portable sleep monitors. METHODS: This retrospective study was conducted at West Virginia University Hospital and compared indices obtained from HRPO with those obtained from a type III portable sleep monitor (PM) on the same night. RESULTS: A total of 365 individuals underwent evaluation. The mean oxygen desaturation index (18.8 ± 19.3 events/h) from the HRPO was slightly higher than the mean respiratory event index (16.0 ± 18.1 events/h, p ≤ 0.001) from the PM. ROC curves were developed for thresholds of apnea severity predicted by the screening program. The AUC values for all three thresholds exceeded 0.92 and for a respiratory event index (REI) of ≥ 30 was 0.965. Indices from the PM and HRPO demonstrated agreement in those individuals with screening suggestive of moderate to severe disease. CONCLUSION: This study demonstrates that use of HRPO in screening for SDB in hospitalized patients from rural communities is as accurate as PM and may serve as a simple cost-effective tool to address sleep health disparities in these regions with significant health inequity. Our data extend previous findings by applying HRPO to a larger hospitalized cohort with highly prevalent cardiopulmonary disease.

Antimicrobial resistance: more than 70 years of war between humans and bacteria.

Development of antibiotic resistance in bacteria is one of the major issues in the present world and one of the greatest threats faced by mankind. Resistance is spread through both vertical gene transfer (parent to offspring) as well as by horizontal gene transfer like transformation, transduction and conjugation. The main mechanisms of resistance are limiting uptake of a drug, modification of a drug target, inactivation of a drug, and active efflux of a drug. The highest quantities of antibiotic concentrations are usually found in areas with strong anthropogenic pressures, for example medical source (e.g., hospitals) effluents, pharmaceutical industries, wastewater influents, soils treated with manure, animal husbandry and aquaculture (where antibiotics are generally used as in-feed preparations). Hence, the strong selective pressure applied by antimicrobial use has forced microorganisms to evolve for survival. The guts of animals and humans, wastewater treatment plants, hospital and community effluents, animal husbandry and aquaculture runoffs have been designated as "hotspots for AMR genes" because the high density of bacteria, phages, and plasmids in these settings allows significant genetic exchange and recombination. Evidence from the literature suggests that the knowledge of antibiotic resistance in the population is still scarce. Tackling antimicrobial resistance requires a wide range of strategies, for example, more research in antibiotic production, the need of educating patients and the general public, as well as developing alternatives to antibiotics (briefly discussed in the conclusions of this article).

Reduced risk of post ERCP pancreatitis in statin users.

BACKGROUND: One of the most feared complications of endoscopic retrograde cholangiopancreatography (ERCP), with an incidence of 3.5 to 15%, is post ERCP pancreatitis (PEP). Given the role of statins in the reduction of systemic and pancreatic intraluminal inflammation, we hypothesized that the use of statins may lower the risk of PEP. METHODS: A retrospective cohort study of all patients undergoing ERCP at West Virginia University during the years 2016 and 2017 was performed. Possible association of collected variables with PEP was assessed with Univariate tests and multivariable logistic regression analyses. RESULTS: A total of 1162 ERCPs were included. Mean age was 60.12 years (SD: 17.5). 51.3% of the participants were female. Two hundred and sixty-three participants underwent more than one ERCP during the study period. Seven hundred and ninety-nine ERCPs (78.8%) were conducted in participants who were not taking a statin medication at the time of ERCP, while 363 participants were on statin medications at the time of ERCP; 118 and 245 participants were taking high dose statins (atorvastatin 40-80 mg or rosuvastatin 20 mg), and low/medium dose statins (all other statin regimens) at the time of the procedure, respectively. The overall incidence of PEP in the cohort was 7.3%. In the non-statin and statin groups, 9.5 and 3.4% of participants developed PEP, respectively. On univariate analysis, young age, no statin use, history of PEP, and endoscopic sphincterotomy were found to be significantly associated with the development of PEP. In a binary logistic regression model, young age (P = 0.033), history of PEP (P = 0.0001, OR 2.41, 95% CI: 1.05-5.51) and endoscopic sphincterotomy (P = 0.038, OR 2.85, 95% CI: 1.7-4.78) were found to be associated with increased risk of PEP. Statin usage was found to be protective against PEP, (OR 0.35, 95% CI: 0.18-0.69). CONCLUSION: Chronic statin usage is protective against post ERCP pancreatitis, and our findings suggest a potential role of these drugs as prophylactic agents. Randomized controlled trials are needed to establish any potential clinical application.

Independent association of obstructive sleep apnea with Barrett's esophagus.

BACKGROUND AND AIM: Current guidelines suggest screening at-risk groups of patients for Barrett's esophagus (BE), a precursor to esophageal cancer. Although BE and obstructive sleep apnea (OSA) have common risk factors, including elevated body mass index and gastroesophageal reflux disease (GERD), the relationship between these two conditions has not been well established. METHODS: Retrospectively, all patients who had undergone a polysomnography and esophagogastroduodenoscopy at West Virginia University Hospital from 2013 to 2018 were identified and divided into groups on the basis of the presence or absence of OSA. Clinical course and procedure reports were reviewed to identify relevant variables. RESULTS: One thousand ninety-one patients met inclusion criteria; 60.9% were female, and mean age of participants was 53.5 years. Univariate analysis revealed that male gender, age, diagnosis of OSA, severity of OSA, and a clinical diagnosis of GERD were associated with BE (P values < 0.05). Multiple logistic regression incorporating age, sex, clinical diagnosis of GERD, smoking history, body mass index, Helicobacter pylori status, and presence of hiatal hernia was utilized. Patients with OSA had an increased risk of BE than had those without OSA (P < 0.001, odds ratio 3.26 [1.72-6.85]). The risk increased with increasing severity of OSA, categorized in apnea-hypopnea index increments of 10. CONCLUSION: Obstructive sleep apnea is associated with BE, a relationship that is independent of other known risk factors. Additionally, this risk increases with increasing severity of OSA. Future efforts should determine if patients with severe OSA need to be screened for BE due to its potential for causing esophageal cancer.

Disseminated strongyloidiasis in an immunocompetent male: A Case Report.

Strongyloidiasis is a human parasitic disease caused by infection of Strongyloidesstercoralis. It can manifest from asymptomatic eosinophilia in an immunocompetent host and disseminate the disease in the immunocompromised ones. The inconsistency of eosinophilia and low sensitivity of a standard microscopic stool examination makes it difficult to diagnose the disease. We report a case of chronic strongyloidiasis who, despite being immunocompetent, developed dissemination. The patient was a 30-years-old male who presented with diarrhoea, vomiting, high-grade fever and dyspnoea. On examination, he was pale, oedematous and had ascites with systolic murmurs in tricuspid area. After a fullworkup for differentials, biopsy confirmed the diagnosis of strongyloidiasis. Echocardiogram revealed vegetations on mitral and tricuspid valves and regurgitation through the valves, which confirmed dissemination to endocardium. A course of Ivermectin 9 mg daily for two weeks eradicated the infection in time. In conclusion, awareness for physicians and the use of various diagnostic methods like serology, endoscopy and biopsy should be considered for high risk patients.

Assessment and comparison of sleep patterns among medical and non-medical undergraduates of Karachi: A cross-sectional study - SPECIAL REPORT.

To assess and compare patterns, habits and quality of sleep in undergraduate medical and non-medical students. The cross-sectional study was conducted from February to March, 2018, at Dow Medical College, Karachi, and Pakistan Air Force-Karachi Institute of Economics and Technology. Data was collected by self-reported questionnaires. Sleep quality of individuals was assessed using Pittsburg Sleep Quality Index. Data was analysed using SPSS 21. Of the 245 subjects, 137(55%) were medical students and 108(45%) were non-medical. Overall, 101(41.2%) subjects aid 8 hours of sleep was sufficient for them; 153(62.4%) reported daytime sleeping; and 168(68.5%) did not take naps. The duration of nap was >30 minutes in 118(48%) students. Factors affecting sleep were cited as electronic media 132(53.9%), caffeine 42(17.1%) and stress 126(51.4%). Of the total, 161(65.7%) subjects had poor sleep quality. There was no significant difference between medical and non-medical students (p>0.05). Majority of medical and non-medical undergraduate students were poor sleepers.

Letter to the Editor: Increasing incidence of Parkinson's disease in patients with epilepsy: A Nationwide Cohort Study.

We have read with a great deal of interest the article by Hwang et al. (1) and appreciate the authors'' commendable efforts. The article was intelligently written and provides a significant insight into the study carried out by the authors. We greatly acknowledge the brief concepts the authors have shared regarding Parkinson's disease and epilepsy, which are without doubt an asset to the field of neurology. The study has laid a good foundation for future related studies. The article mentions epilepsy as an uncommon comorbidity of Parkinson's disease and the transition of a non-epilepsy brain to an epilepsy brain. It is also mentioned that PD is a progressive neurodegenerative disorder of dopaminergic neurons in the substantia nigra, and the incidence of the two diseases. However, as we assess the article in depth, we have found some shortcomings that would have enhanced the sense and purpose of the study.

Bilateral renal lymphangiectasia: Literature review of a rare entity.

Renal lymphangiectasia (RL) is a rare condition in which lymphatic vessels are dilated giving rise to cyst formation in peripelvic, perirenal and intrarenal locations. Knowledge about RL is limited and based upon individual case reports. This can be genetic or acquired. There is no significant association with any gender or age. It can be manifested as focal or diffuse forms and can be unilateral or bilateral. Most of the cases present with abdominal or flank pain. The diagnosis is based on radiological imaging. Due to rarity of diseases, it has potential to be misdiagnosed as other cystic disease of kidneys. The treatment is mainly conservative but prolonged follow up for associated complications like hypertension and renal vein thrombosis is required. We have presented a case of bilateral renal lymphangiectasia with the review of available literature.

Delay in the Diagnosis of Pediatric Brain Tumors in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: Vague symptoms and a lack of pathognomonic features hinder the timely diagnosis of pediatric brain tumors (PBTs). However, patients in low- and middle-income countries (LMICs) must also bear the brunt of a multitude of additional factors contributing to diagnostic delays and subsequently affecting survival. Therefore, this study aims to assess these factors and quantify the durations associated with diagnostic delays for PBTs in LMICs. METHODS: A systematic review of extant literature regarding children from LMICs diagnosed with brain tumors was conducted. Articles published before June 2023 were identified using PubMed, Google Scholar, Scopus, Embase, Cumulative Index to Nursing and Allied Health Literature, and Web of Science. A meta-analysis was conducted using a random-effects model through R Statistical Software. Quality was assessed using the Newcastle Ottawa Scale. RESULTS: A total of 40 studies including 2483 patients with PBT from 21 LMICs were identified. Overall, nonspecific symptoms (62.5%) and socioeconomic status (45.0%) were the most frequently reported factors contributing to diagnostic delays. Potential sources of patient-associated delay included lack of parental awareness (45.0%) and financial constraints (42.5%). Factors contributing to health care system delays included misdiagnoses (42.5%) and improper referrals (32.5%). A pooled mean prediagnostic symptomatic interval was calculated to be 230.77 days (127.58-333.96), the patient-associated delay was 146.02 days (16.47-275.57), and the health care system delay was 225.05 days (-64.79 to 514.89). CONCLUSION: A multitude of factors contribute to diagnostic delays in LMICs. The disproportionate effect of these factors is demonstrated by the long interval between symptom onset and the definitive diagnosis of PBTs in LMICs, when compared with high-income countries. While evidence-based policy recommendations may improve the pace of diagnosis, policy makers will need to be cognizant of the unique challenges patients and health care systems face in LMICs.

The role of hydrogels in the management of brain tumours: a narrative review.

Conventional therapeutic techniques for brain tumours have limitations and side effects, necessitating the need for alternative treatment options. MRI-monitored therapeutic hydrogel systems show potential as a non-surgical approach for brain tumour treatment. Hydrogels have unique physical and chemical properties that make them promising for brain tumour treatment, including the ability to encapsulate therapeutic agents, provide sustained and controlled drug release, and overcome the blood-brain barrier for better penetration. By combining hydrogel systems with MRI techniques, it is possible to develop therapeutic approaches that provide real-time monitoring and controlled release of therapeutic agents. Surgical resection remains important, but there is a growing need for alternative approaches that can complement or replace traditional methods. The objective of this comprehensive narrative review is to evaluate the potential of MRI-monitored therapeutic hydrogel systems in non-surgical brain tumour treatment.

Governance Challenges to the Neurosurgical Care of Brain Tumors in Low- and Middle-Income Countries: A Systematic Review.

BACKGROUND: Low- and middle-income countries (LMICs) often struggle to provide adequate neurosurgical care due to poor governance and institutional efforts, making access to care difficult. Therefore, our review of literature aims to identify gaps in government, national, and institutional efforts to combat barriers to neurosurgical care of brain tumors in LMICs, to inform future policy and action planning. METHODS: A comprehensive literature search was conducted using PubMed, Scopus, Google Scholar, and CINAHL without language restrictions from inception to October 20, 2022. After screening and data extraction, a thematic analysis based on the National Surgical, Obstetric, and Anesthesia Plan (NSOAP) systematically identified and classified notable themes, which were then quantified and presented as percentages. RESULTS: A total of 12 studies were included in the final analysis. The review highlighted some of the barriers to providing surgical care of brain tumors in LMICs, including political instability (14%), inadequate national budget for health care (43%), poor government support (14%), lack of support of hospital management (14%), and no coverage under national insurance plans (14%). Strategies that can be implemented to address the barriers include strengthening the local health system (17%), advocating for health ministry support (33%), developing national treatment guidelines (17%), making neurosurgery a part of the national surgical plan (17%), fostering collaborations across various levels of government (17%), changing national insurance policy to include neurosurgical care (17%), and advocating for more resources and changes in global care (33%). CONCLUSIONS: Effective governance plays a critical role in addressing challenges as it shapes the availability of resources and policies that affect the quality of care provided. Our study outlines key challenges and strategies reported within literature in an attempt to drive government attention and thereby policy to support the neurosurgical care of brain tumors, particularly in the developing world.