Prospective, multicentre study of external ventricular drainage-related infections in the UK and Ireland

Objectives External ventricular drain (EVD) insertion is a common neurosurgical procedure. EVD-related infection (ERI) is a major complication that can lead to morbidity and mortality. In this study, we aimed to establish a national ERI rate in the UK and Ireland and determine key factors influencing the infection risk. Methods A prospective multicentre cohort study of EVD insertions in 21 neurosurgical units was performed over 6 months. The primary outcome measure was 30-day ERI. A Cox regression model was used for multivariate analysis to calculate HR. Results A total of 495 EVD catheters were inserted into 452 patients with EVDs remaining in situ for 4700 days (median 8 days; IQR 4–13). Of the catheters inserted, 188 (38%) were antibiotic-impregnated, 161 (32.5%) were plain and 146 (29.5%) were silver-bearing. A total of 46 ERIs occurred giving an infection risk of 9.3%. Cox regression analysis demonstrated that factors independently associated with increased infection risk included duration of EVD placement for ≥8 days (HR=2.47 (1.12–5.45); p=0.03), regular sampling (daily sampling (HR=4.73 (1.28–17.42), p=0.02) and alternate day sampling (HR=5.28 (2.25–12.38); p\u3c0.01). There was no association between catheter type or tunnelling distance and ERI. Conclusions In the UK and Ireland, the ERI rate was 9.3% during the study period. The study demonstrated that EVDs left in situ for ≥8 days and those sampled more frequently were associated with a higher risk of infection. Importantly, the study showed no significant difference in ERI risk between different catheter types

Inter-observer agreement in interpreting intraoperative ultrasonography during brain tumour surgery

BACKGROUND: Intraoperative ultrasonography (iUS) is a powerful technology that is being increasingly utilized for brain tumour surgery. However, ultrasonography has been documented to be observer dependent in a range of healthcare settings. Here we objectively assess the degree of inter-observer variability in iUS for brain tumour surgery. METHODS: Nine images taken from routinely collected iUS videos from brain tumour surgery were presented to 18 neurosurgeons (5 consultants, 7 senior fellows, 6 residents). This included three tumour types [metastasis, high-grade (HGG) and low-grade glioma (LGG)] at three operative stages (before, during and near resection completion). Using 3D Slicer, observers segmented what they deemed to be tumour. Digital Image Correlation Engine Similarity Coefficients (DSC) were calculated to examine inter-observer variability. RESULTS: A total of 1,377 DSCs were calculated between 18 observers across 9 images. Metastasis had the highest DSC (0.72 ± 0.32), followed by HGG (0.64 ± 0.33) and LGG (0.58 ± 0.25; p < 0.00001). As the resection progressed, the degree of inter-observer agreement broke down. Before resection the DSC was 0.87 ± 0.11; during resection (0.74 ± 0.17) and at completion (0.32 ± 0.27; p < 0.00001). The trend of decreasing agreement as the resection progressed held across tumour types. Observers reported increasing difficulty with iUS interpretation as the resection proceeded and there was statistically significant (p = 0.014) negative correlation (−0.775) between DSC and difficulty rating of the segmentation. CONCLUSION: Here we demonstrate significant inter-observer variability in iUS for brain tumour surgery. The degree of variability is tumour-type and operative stage dependent. This work adds weight to the value of building machine learning augmented iUS for brain tumour surgery

Post-concussion symptom burden and dynamics: Insights from a digital health intervention and machine learning

Individuals who sustain a concussion can experience a range of symptoms which can significantly impact their quality of life and functional outcome. This study aims to understand the nature and recovery trajectories of post-concussion symptomatology by applying an unsupervised machine learning approach to data captured from a digital health intervention (HeadOn). As part of the 35-day program, patients complete a daily symptom diary which rates 8 post-concussion symptoms. Symptom data were analysed using K-means clustering to categorize patients based on their symptom profiles. During the study period, a total of 758 symptom diaries were completed by 84 patients, equating to 6064 individual symptom ratings. Fatigue, sleep disturbance and difficulty concentrating were the most prevalent symptoms reported. A decline in symptom burden was observed over the 35-day period, with physical and emotional symptoms showing early rates of recovery. In a correlation matrix, there were strong positive correlations between low mood and irritability (r = 0.84), and poor memory and difficulty concentrating (r = 0.83). K-means cluster analysis identified three distinct patient clusters based on symptom severity. Cluster 0 (n = 24) had a low symptom burden profile across all the post-concussion symptoms. Cluster 1 (n = 35) had moderate symptom burden but with pronounced fatigue. Cluster 2 (n = 25) had a high symptom burden profile across all the post-concussion symptoms. Reflecting the severity of the clusters, there was a significant relationship between the symptom clusters for both the Rivermead (p = 0.05) and PHQ-9 (p = 0.003) questionnaires at 6-weeks follow-up. By leveraging digital ecological momentary assessments, a rich dataset of daily symptom ratings was captured allowing for the identification of symptom severity clusters. These findings underscore the potential of digital technology and machine learning to enhance our understanding of post-concussion symptomatology and offer a scalable solution to support patients with their recovery

Subarachnoid haemorrhage with negative initial neurovascular imaging: a systematic review and meta-analysis

Abstract: Background: In patients with spontaneous subarachnoid haemorrhage (SAH), a vascular cause for the bleed is not always found on initial investigations. This study aimed to systematically evaluate the delayed investigation strategies and clinical outcomes in these cases, often described as “non-aneurysmal” SAH (naSAH). Methods: A systematic review was performed in concordance with the PRISMA checklist. Pooled proportions of primary outcome measures were estimated using a random-effects model. Results: Fifty-eight studies were included (4473 patients). The cohort was split into perimesencephalic naSAH (PnaSAH) (49.9%), non-PnaSAH (44.7%) and radiologically negative SAH identified on lumbar puncture (5.4%). The commonest initial vascular imaging modality was digital subtraction angiography. A vascular abnormality was identified during delayed investigation in 3.9% [95% CI 1.9–6.6]. There was no uniform strategy for the timing or modality of delayed investigations. The pooled proportion of a favourable modified Rankin scale outcome (0–2) at 3–6 months following diagnosis was 92.0% [95% CI 86.0–96.5]. Complications included re-bleeding (3.1% [95% CI 1.5–5.2]), hydrocephalus (16.0% [95% CI 11.2–21.4]), vasospasm (9.6% [95% CI 6.5–13.3]) and seizure (3.5% [95% CI 1.7–5.8]). Stratified by bleeding pattern, we demonstrate a higher rate of delayed diagnoses (13.6% [95% CI 7.4–21.3]), lower proportion of favourable functional outcome (87.2% [95% CI 80.1–92.9]) and higher risk of complications for non-PnaSAH patients. Conclusion: This study highlights the heterogeneity in delayed investigations and outcomes for patients with naSAH, which may be influenced by the initial pattern of bleeding. Further multi-centre prospective studies are required to clarify optimal tailored management strategies for this heterogeneous group of patients

Operating theatre related syncope in medical students: a cross sectional study

<p>Abstract</p> <p>Background</p> <p>Observing surgical procedures is a beneficial educational experience for medical students during their surgical placements. Anecdotal evidence suggests that operating theatre related syncope may have detrimental effects on students' views of this. Our study examines the frequency and causes of such syncope, together with effects on career intentions, and practical steps to avoid its occurrence.</p> <p>Methods</p> <p>All penultimate and final year students at a large UK medical school were surveyed using the University IT system supplemented by personal approach. A 20-item anonymous questionnaire was distributed and results were analysed using the Statistical Package for Social Sciences, version 15.0 (Chicago, Illinois, USA).</p> <p>Results</p> <p>Of the 630 clinical students surveyed, 77 responded with details of at least one near or actual operating theatre syncope (12%). A statistically significant gender difference existed for syncopal/near-syncopal episodes (male 12%; female 88%), p < 0.05. Twenty-two percent of those affected were graduate entry medical course students with the remaining 78% undergraduate. Mean age was 23-years (range 20 – 45). Of the 77 reactors, 44 (57%) reported an intention to pursue a surgical career. Of this group, 7 (9%) reported being discouraged by syncopal episodes in the operating theatre. The most prevalent contributory factors were reported as hot temperature (n = 61, 79%), prolonged standing (n = 56, 73%), wearing a surgical mask (n = 36, 47%) and the smell of diathermy (n = 18, 23%). The most frequently reported measures that students found helpful in reducing the occurrence of syncopal episodes were eating and drinking prior to attending theatre (n = 47, 61%), and moving their legs whilst standing (n = 14, 18%).</p> <p>Conclusion</p> <p>Our study shows that operating theatre related syncope among medical students is common, and we establish useful risk factors and practical steps that have been used to prevent its occurrence. Our study also highlights the detrimental effect of this on the career intentions of medical students interested in surgery. Based on these findings, we recommend that dedicated time should be set aside in surgical teaching to address this issue prior to students attending the operating theatre.</p

Knowledge of medical law amongst doctors of internal diseases

Objectives: In Poland, 95% of medical personnel had not received legal education before they completed their studies. Having been given these facts, we have started questioning legal awareness of people providing medical services. Aim of the study: The study aimed at evaluating the knowledge of allergists and pulmonologists. Material and Methods: The group consisting of 328 allergists and/or pulmonologist completed the questionnaire. Results: The participants possess the best knowledge in providing information to patients about their health status (CV1). Sixty nine % of responders replied correctly, and the difference was significant (p < 0.001) in comparison with next aspect referring to the principles of providing medical services following guidelines created by think-tanks and also possibilities to take autonomous decisions by physicians (CV2). The correct answers in relation to CV2 were given by 57% of responders. The third compared aspect was physicians' awareness of patients' right to giving a consent or refusal before undertaking the medical procedure CV3. Only 55% of physicians gave correct answers and the difference was significant compared to CV1 (p < 0.001) as well as CV2 (p < 0.05). Younger doctors showed to have better knowledge than their older colleagues (p < 0.05). Working in urban workplaces proved to be more associated with better knowledge than in rural ones (p < 0.05). Discussion: Insufficient knowledge results in a low quality of provided services and puts the doctors at risk of being liable. The rates indicate that doctors are not aware of the fact that only legal regulations are binding, while standards not published by the Minister of Health are not legally valid. Half of the respondents have the wrong belief that the opinions expressed by experts make the doctor feel exempt from liability. Probably there are specialities, like occupational medicine which are specially linked with awareness of valid legal rules

More questions than answers to the diagnosis and management of cauda equina syndrome—Authors’ reply

No abstract available

The management and outcome for patients with chronic subdural hematoma: A prospective, multicenter, observational cohort study in the United Kingdom

OBJECTIVESymptomatic chronic subdural hematoma (CSDH) will become an increasingly common presentation in neurosurgical practice as the population ages, but quality evidence is still lacking to guide the optimal management for these patients. The British Neurosurgical Trainee Research Collaborative (BNTRC) was established by neurosurgical trainees in 2012 to improve research by combining the efforts of trainees in each of the United Kingdom (UK) and Ireland's neurosurgical units (NSUs). The authors present the first study by the BNTRC that describes current management and outcomes for patients with CSDH throughout the UK and Ireland. This provides a resource both for current clinical practice and future clinical research on CSDH.METHODSData on management and outcomes for patients with CSDH referred to UK and Ireland NSUs were collected prospectively over an 8-month period and audited against criteria predefined from the literature: NSU mortality &lt; 5%, NSU morbidity &lt; 10%, symptomatic recurrence within 60 days requiring repeat surgery &lt; 20%, and unfavorable functional status (modified Rankin Scale score of 4–6) at NSU discharge &lt; 30%.RESULTSData from 1205 patients in 26 NSUs were collected. Bur-hole craniostomy was the most common procedure (89%), and symptomatic recurrence requiring repeat surgery within 60 days was observed in 9% of patients. Criteria on mortality (2%), rate of recurrence (9%), and unfavorable functional outcome (22%) were met, but morbidity was greater than expected (14%). Multivariate analysis demonstrated that failure to insert a drain intraoperatively independently predicted recurrence and unfavorable functional outcome (p = 0.011 and p = 0.048, respectively). Increasing patient age (p &lt; 0.00001), postoperative bed rest (p = 0.019), and use of a single bur hole (p = 0.020) independently predicted unfavorable functional outcomes, but prescription of high-flow oxygen or preoperative use of antiplatelet medications did not.CONCLUSIONSThis is the largest prospective CSDH study and helps establish national standards. It has confirmed in a real-world setting the effectiveness of placing a subdural drain. This study identified a number of modifiable prognostic factors but questions the necessity of some common aspects of CSDH management, such as enforced postoperative bed rest. Future studies should seek to establish how practitioners can optimize perioperative care of patients with CSDH to reduce morbidity as well as minimize CSDH recurrence. The BNTRC is unique worldwide, conducting multicenter trainee-led research and audits. This study demonstrates that collaborative research networks are powerful tools to interrogate clinical research questions.Society of British Neurological Surgeons. PJH supported by NIHR Research Professorship and NIHR Cambridge Biomedical Research Centre.This is the author accepted manuscript. It is permanently embargoed to comply with the publisher’s copyright terms. The final version is available via https://doi.org/10.3171/2016.8.JNS1613