Bicompartmental decompressive craniectomy: Report of two cases

A recent study of randomized controlled trials showed favorable outcomes with use of decompressive craniectomy in managing and treating uncontrolled intracranial pressures accompanied with cerebral edema due to trauma. We present the details of bicompartmental decompressive craniectomy on two patients who presented with severe head trauma of supra- and infratentorial pathologies. The surgical management techniques and long-term follow-up are discussed in detail

Clinoidal meningioma associated with an internal carotid artery aneurysm

Coexistence of primary brain neoplasms with intracranial aneurysms is rare but presents a diagnostic and therapeutic challenge to healthcare providers. We describe the case of a 60-year-old woman who had a left internal carotid artery aneurysm with a small ipsilateral clinoidal meningioma. The meningioma was an unexpected finding encountered during the surgery for aneurysmal clipping. Both the lesions were dealt with simultaneously

Prospective validation of a blood ordering protocol for elective spine arthrodesis and its impact on cost reduction

Background: On the basis of an institutional audit, the authors published an individual patient-based protocol for preoperative arrangement of blood products in patients undergoing elective spine arthrodesis. The present study was conducted for the prospective validation of the proposed protocol in reducing cross match to transfusion ratio, and its implications on overall cost.Methods: This cross-sectional study was conducted over 1 year (2012). All adult patients who underwent elective spinal arthrodesis were included and prospectively observed. The actual transfusion index was calculated for individual patients with the formula C1/T, where C1 is the number of units of packed RBCs cross matched and T is the number of actual transfusions. C1/T was then compared with a theoretical transfusion index C2/T for the same group of patients, C2 being the number derived from calculating the number of units of packed RBCs that would have been ordered for individual patient according to the protocol. The cost difference between C1/T and C2/T was analyzed.Results: A total of 125 patients were included. A total of 435 units of packed RBCs were ordered (C1), out of which only 108 units were transfused (T), yielding a C1/T of 4.02. The C2 for the same group of patients was 188 units of packed RBCs and the C2/T was thus calculated to be 1.74. Implementation of the protocol would reduce per patient cost from Pakistani Rupees (PKR) 6676.8 ± 4125.8 to 4700.8 ± 1712.86, with a P \u3c 0.001 and an overall reduction of 30%.Conclusion: Cross match to transfusion ratio and blood ordering related cost are both significantly reduced with the application of institutional cross-match protocol

Paediatric traumatic brain injury: presentation

Abstract Traumatic brain injury (TBI) is the leading cause of morbidity and mortality in children worldwide. This study was conducted to report the presentation, management, outcomes and prognostic indicators in a large series of patients from a tertiary care centre in a developing country. It is a review of prospectively collected data of paediatric patients with TBI admitted at our centre between July 2010 and December 2013. A total of 291 patients with a mean age of 7.2±5.0 years were dichotomised into survivors and non-survivors, and variables were compared between the two groups. The mean post-resuscitation Glasgow coma scale (GCS) score was 11.6±3.9, mean Marshall Score was 2.26±0.95 and the mean revised trauma score at presentation was 10.58±1.7. Younger age, lower GCS score after resuscitation, lower revised trauma score, absent cisterns on imaging, associated subarachnoid haemorrhage (SAH) and intraventricular haemorrhage (IVH) and a lower Marshall score were associated with higher mortality

Paediatric traumatic brain injury: Presentation, prognostic indicators and Outcome analysis from a tertiary care center in a developing country

Traumatic brain injury (TBI) is the leading cause of morbidity and mortality in children worldwide. This study was conducted to report the presentation, management, outcomes and prognostic indicators in a large series of patients from a tertiary care centre in a developing country. It is a review of prospectively collected data of paediatric patients with TBI admitted at our centre between July 2010 and December 2013. A total of 291 patients with a mean age of 7.2±5.0 years were dichotomised into survivors and non-survivors, and variables were compared between the two groups. The mean post-resuscitation Glasgow coma scale (GCS) score was 11.6±3.9, mean Marshall Score was 2.26±0.95 and the mean revised trauma score at presentation was 10.58±1.7. Younger age, lower GCS score after resuscitation, lower revised trauma score, absent cisterns on imaging, associated subarachnoid haemorrhage (SAH) and intraventricular haemorrhage (IVH) and a lower Marshall score were associated with higher mortality

Comparative Bony Union Time Analysis of Dynamic Hip Screw and Proximal Femoral Plate Implants

Objective: To determine the comparative and effective applicability of the Dynamic Hip Screw (DHS), and proximal femoral plate (PFP) in terms of the rapid bony union and complications for treating unstable pertrochanteric fractures. Methodology: This comparative study was conducted at the Department of Orthopedic surgery, Pakistan Institute of Medical Sciences, Islamabad during a period of 8 months from August 2016 to April 2017. Patients ages of 45 to 90 years, with close fresh unstable pertrochanteric fractures (one week) and of either gender were included. All the patients were divided into two groups. Patients in group A underwent PFP treatment and patients of group B underwent DHS treatment. Patients were followed up after 6 weeks and then every 2 weekly afterwards for a total period of 3 months for assessment of bony union both clinically and radiologically. The data was collected on a pre-structured Performa, and analysis was done using SPSS version 26. Results: A total of 84 patients were analysed, and average age of the patients in the PFP group was 66.57 ± 11.71 years and in the DHS group was 70.14 ± 9.03 years. Females were found in majority in both groups. No union was found till six weeks in both groups, while on 2nd month followup, union was found significantly high 19.0% in cases of the PFP group, compared to the 2.4% in the DHS group (p-0.014). On 2.5th months the union rate was significantly higher 59.5% in the PFP group, compared to the 7.1% DHS group (p-0.014), while on the 3rd month followup the union was almost in all cases in both groups (p-0.557) and the overall average union duration was significantly lower in PFP group compared to the DHS (p-0.001). Conclusion: The proximal femoral plate technique for treating unstable pertrochanteric fractures was observed to be more effective in terms of significant rapid bony union with minimum complications compared to the Dynamic Hip Screw (DHS)

Providing care beyond the hospital: Perspective of a tertiary care hospital from a developing country

Background: Neurorehabilitation is an important aspect of continuing care for neurosurgical patients with functional disability. In developing countries, where formal home nursing frequently is unavailable, ensuring care after discharge is a difficult task. Training attendants to provide nursing care is an alternate option. In this study, we compared the outcomes of patients nursed by family members versus those looked after by a professional nurse.Methods: This was a retrospective observational study conducted at the Aga Khan University Hospital Karachi. The study consisted of 2 groups. Group 1 (consisting of patients cared for by a professional nurse) included 94 patients and group 2 (patients cared for by family members) included 102. All these patients had activity of daily living score of ≥3. Glasgow Outcomes Scale score, time to decannulation, development/worsening of bedsores, and mortality were recorded and compared between the groups at follow-up.Results: The study included 196 patients. Traumatic brain injury was the most common diagnosis. Nursing requirements were similar between the 2 groups and included tracheostomy care, percutaneous endoscopic gastrostomy tube care, peripherally inserted central catheter line care, care of patients with no bone flap, and log-rolling. The outcomes of the 2 groups were comparable and included bedsore development/worsening of grade, Glasgow Outcomes Scale score at follow-up, time to decannulation, and 30-day mortality.Conclusions: There was no statistically significant difference in outcomes of patients nursed by family members compared with the patients looked after by professional nurses

Collagen pre-strain discontinuity at the bone—Cartilage interface

The bone-cartilage unit (BCU) is a universal feature in diarthrodial joints, which is mechanically-graded and subjected to shear and compressive strains. Changes in the BCU have been linked to osteoarthritis (OA) progression. Here we report existence of a physiological internal strain gradient (pre-strain) across the BCU at the ultrastructural scale of the extracellular matrix (ECM) constituents, specifically the collagen fibril. We use X-ray scattering that probes changes in the axial periodicity of fibril-level D-stagger of tropocollagen molecules in the matrix fibrils, as a measure of microscopic pre-strain. We find that mineralized collagen nanofibrils in the calcified plate are in tensile pre-strain relative to the underlying trabecular bone. This behaviour contrasts with the previously accepted notion that fibrillar pre-strain (or D-stagger) in collagenous tissues always reduces with mineralization, via reduced hydration and associated swelling pressure. Within the calcified part of the BCU, a finer-scale gradient in pre-strain (0.6% increase over ~50μm) is observed. The increased fibrillar pre-strain is linked to prior research reporting large tissue-level residual strains under compression. The findings may have biomechanical adaptative significance: higher in-built molecular level resilience/damage resistance to physiological compression, and disruption of the molecular-level pre-strains during remodelling of the bone-cartilage interface may be potential factors in osteoarthritis-based degeneration

Global, regional, and national burden of disorders affecting the nervous system, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background Disorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021. Methods We estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined. Findings Globally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378–521), affecting 3·40 billion (3·20–3·62) individuals (43·1%, 40·5–45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7–26·7) between 1990 and 2021. Age-standardised rates of deaths per 100 000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6–38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5–32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7–2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer. Interpretation As the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed. Funding Bill & Melinda Gates Foundation

Global, regional, and national burden of disorders affecting the nervous system, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BackgroundDisorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021.MethodsWe estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined.FindingsGlobally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378–521), affecting 3·40 billion (3·20–3·62) individuals (43·1%, 40·5–45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7–26·7) between 1990 and 2021. Age-standardised rates of deaths per 100 000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6–38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5–32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7–2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer.InterpretationAs the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed