Awake brain tumor resection during pregnancy: Decision making and technical nuances

The co-occurrence of primary brain tumor and pregnancy poses unique challenges to the treating physician. If a rapidly growing lesion causes life-threatening mass effect, craniotomy for tumor debulking becomes urgent. The choice between awake craniotomy versus general anesthesia becomes complicated if the tumor is encroaching on eloquent brain because considerations pertinent to both patient safety and oncological outcome, in addition to fetal wellbeing, are involved. A 31-year-old female at 30 weeks gestation with twins presented to our hospital seeking awake craniotomy to resect a 7 × 6 × 5 cm left frontoparietal brain tumor with 7 mm left-to-right subfalcine herniation on imaging that led to word finding difficulty, dysfluency, right upper extremity paralysis, and right lower extremity weakness. She had twice undergone tumor debulking under general anesthesia during the same pregnancy at an outside hospital at 16 weeks and 28 weeks gestation. There were considerations both for and against awake brain tumor resection over surgery under general anesthesia. The decision-making process and the technical nuances related to awake brain tumor resection in this neurologically impaired patient are discussed. Awake craniotomy benefits the patient who harbors a tumor that encroaches on the eloquent brain by allowing a greater extent of resection while preserving the language and sensorimotor function. It can be successfully done in pregnant patients who are neurologically impaired. The patient should be motivated and well informed of the details of the process. A multidisciplinary and collaborative effort is also crucial

Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report

Background Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define—for the first time—the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally. Methods and findings The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries—who only made up 21% of the total attendees. Conclusions To track global progress towards timely access to quality SAO care, these indicators—at the basic level—should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.publishedVersio

Counting Chickens when they Hatch: Timing and the Effects of Aid on Growth

Recent research yields widely divergent estimates of the cross-country relationship between foreign aid receipts and economic growth. We re-analyse data from the three most influential published aid-growth studies, strictly conserving their regression specifications, with sensible assumptions about the timing of aid effects and without questionable instruments. All three research designs show that increases in aid have been followed on average by increases in investment and growth. The most plausible explanation is that aid causes some degree of growth in recipient countries, although the magnitude of this relationship is modest, varies greatly across recipients and diminishes at high levels of aid. Economists have spent decades debating, without resolution, the cross-country relationship between foreign aid receipts and economic growth. Some find that aid robustly causes positive economic growth on average. Others cannot distinguish the average effect from zero. Still others find an effect only in certain countries, such as those with good policies or governance. Wearied readers of this literature would be right to wonder what produces diverse findings from apparently the same aid and growth data. Here, we show that two traits of previous research help to explain why different studies reach different conclusions. Both traits relate to how these studies treat the timing of causal relationships between aid and growth. First, the most cited research has focused on measuring the effect of aggregate aid on contemporaneous growth, while many aid-funded projects can take a long time to influence growth. Funding for a new road might affect economic activity in short order, funding for a vaccination campaign might only affect growth decades later and humanitarian assistance may never affect growth. Second, because current growth is likely to affect current aid, these studies require a strategy to disentangle correlation from causation. They have tended to rely on instrumental variables but the instruments that have been used are of questionable validity and strength. When these issues are addressed, the divergence in empirical findings is greatly reduced. We show this by stepwise altering the research design of the three most influential papers in the aid and growth literature. We hold all else constant: we begin b

Mandatory Sentencing

Sentencing Matters is a new series of incidental research papers prepared by members of the secretariat of the Sentencing Advisory Council as part of the Council’s statutory function of conducting research and disseminating information on sentencing matters. Mandatory Sentencing is the first in the series and has been authored by Dr Adrian Hoel, Legal Policy Officer, and Dr Karen Gelb, Senior Criminologist. The views expressed in this paper are those of the authors and do not necessarily reflect the views of the Council or its individual members. Mandatory sentencing is a controversial issue that creates significant debate and divisions both in the community and in government. It has been implemented, in Australia and around the world, in various forms including ‘three strikes’ legislation and, in an attenuated form, as presumptive minimum sentences and standard non-parole periods. The goal of these legislative initiatives has been to increase consistency in sentencing and to improve public confidence in the courts by ensuring that sentences properly reflect community views. Periodically calls arise for the introduction of mandatory sentences in Victoria. This research paper examines what mandatory sentencing is and considers how mandatory sentencing fits within a spectrum of sentencing schemes, ranging from wholly discretionary systems and structured discretionary systems through systems with standard minimum non-parole periods to systems with greater degrees of prescription. The purpose of the paper is to consider the aims of mandatory sentencing, and to assess whether various schemes that have been adopted elsewhere have been successful in achieving those aims. The paper also examines the economic and social costs of mandatory sentencing. The paper concludes, on the basis of existing research, that mandatory and other prescriptive schemes are unlikely to achieve their aims. To the extent that such schemes achieve some of their aims, the research indicates that they are achieved at a high economic and social cost