ANTI-NMDA ENCEPHALITIS IN THE ACUTE SETTING

Background: Encephalitis associated with antibodies targeted against the N-methyl-D-aspartate (NMDA) receptor is increasingly recognised as a major cause of an acute presentation of organic psychosis. Misdiagnosis and subsequent inappropriate referral to psychiatric services is common and avoidable. This review focuses on addressing this issue in the acute setting. Methods: The authors present a review of existing literature relating to the pathophysiology and presentation of anti-NMDA receptor encephalitis, prior to proposing a management pathway avoiding delays to treatment incurred through misdiagnosis or inappropriate referral. Conclusions: Acute care physicians should have a low threshold for suspecting anti-NMDA receptor encephalitis in any patient presenting with acute psychosis in the context of non-specific coryzal and constitutional symptoms in whom infective causes have been excluded. The presence of pleocytosis and reduced protein in routine CSF analysis should further raise suspicion, and samples should be sent for immunohistochemical testing. Availability and efficiency of this testing is currently suboptimal

ANTI-NMDA ENCEPHALITIS IN THE ACUTE SETTING

Background: Encephalitis associated with antibodies targeted against the N-methyl-D-aspartate (NMDA) receptor is increasingly recognised as a major cause of an acute presentation of organic psychosis. Misdiagnosis and subsequent inappropriate referral to psychiatric services is common and avoidable. This review focuses on addressing this issue in the acute setting. Methods: The authors present a review of existing literature relating to the pathophysiology and presentation of anti-NMDA receptor encephalitis, prior to proposing a management pathway avoiding delays to treatment incurred through misdiagnosis or inappropriate referral. Conclusions: Acute care physicians should have a low threshold for suspecting anti-NMDA receptor encephalitis in any patient presenting with acute psychosis in the context of non-specific coryzal and constitutional symptoms in whom infective causes have been excluded. The presence of pleocytosis and reduced protein in routine CSF analysis should further raise suspicion, and samples should be sent for immunohistochemical testing. Availability and efficiency of this testing is currently suboptimal

Do Patients Taking Warfarin Experience Delays to Theatre, Longer Hospital Stay, and Poorer Survival After Hip Fracture?

BACKGROUND: Patients sustaining a fractured neck of the femur are typically of advanced age with multiple comorbidities. As a consequence, the proportion of these patients receiving warfarin therapy is approximately 10%. There are currently few studies investigating outcomes in this subset of patients. QUESTIONS/PURPOSES: The purpose of this study was to assess the association between warfarin therapy and time to surgery, length of hospital stay, and survival in patients sustaining a fractured neck of the femur. METHODS: Data for 2036 patients admitted to our center between July 2009 and July 2014 with a fractured neck of the femur were extracted from the National Hip Fracture Database. Fifty-seven patients received no surgical treatment and were excluded from analysis. Multivariable ordinary least squares regression was performed to test the association between warfarin treatment on time to surgery and length of stay, and Cox proportional hazards to test followup survival. Variables included in the regression model were age, sex, American Society of Anesthesiologists (ASA) score, admission Abbreviated Mental Test Score (AMTS), fracture type, operation type, and premorbid Work Ability Index (WAI). One hundred fifty-two of 1979 surgically treated patients (8%) were receiving warfarin therapy at the time of admission. RESULTS: After controlling for age, sex, ASA score, AMTS, fracture type, operation type, and WAI, we found that patients taking warfarin were less likely to go to surgery by 36 hours (odds ratio [OR], 0.20; 95% CI, 0.14-0.30), and less likely to go to surgery by 48 hours (OR, 0.17; 95% CI, 0.11-0.24). Patients taking warfarin had a longer length of stay (median, 15 days; interquartile range [IQR], 12-22 days) compared with patients not taking warfarin (median, 13 days; IQR, 9-20 days; p < 0.001). Survival analysis to June 2015 showed a higher mortality for patients taking warfarin (12-month survival, 66% vs 76%; hazard ratio, 1.57; 95% CI, 1.21-2.04; p < 0.001). CONCLUSIONS: After controlling for multiple prognostic factors such as age, ASA score, AMTS, and WAI, warfarin therapy at the time of injury is associated with increased time to surgery, length of stay, and decreased survival. This study highlights the need to view warfarin therapy as a 'red flag' in patients presenting with a fractured neck of the femur. Preoperatively, prompt warfarin reversal together with adequate investigation and optimization of the patient should ensure timely, safe surgery. Early involvement of the anesthesia team should ensure an appropriate level of postoperative care for these patients. LEVEL OF EVIDENCE: Level III, therapeutic study.This is the final version of the article. It first appeared from Springer via http://dx.doi.org/10.1007/s11999-016-5056-

Volumetric growth rates of meningioma and its correlation with histological diagnosis and clinical outcome: a systematic review.

INTRODUCTION: Tumour growth has been used to successfully predict progression-free survival in low-grade glioma. This systematic review sought to establish the evidence base regarding the correlation of volumetric growth rates with histological diagnosis and potential to predict clinical outcome in patients with meningioma. METHODS: This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Databases were searched for full text English articles analysing volumetric growth rates in patients with a meningioma. RESULTS: Four retrospective cohort studies were accepted, demonstrating limited evidence of significantly different tumour doubling rates and shapes of growth curves between benign and atypical meningiomas. Heterogeneity of patient characteristics and timing of volumetric assessment, both pre- and post-operatively, limited pooled analysis of the data. No studies performed statistical analysis to demonstrate the clinical utility of growth rates in predicting clinical outcome. CONCLUSION: This systematic review provides limited evidence in support of the use of volumetric growth rates in meningioma to predict histological diagnosis and clinical outcome to guide future monitoring and treatment

The financial outcome of traumatic brain injury: a single centre study.

OBJECTIVES: Severe traumatic brain injury (TBI) is a potentially devastating insult to the brain with high rates of fatality and neurological deficits. TBI can result in substantial costs to the centre providing care. We sought to present the experience of a Major Trauma Centre (MTC) and ascertain the financial implications of this healthcare provision, in particular detailed costs, reimbursement and the surplus or deficit accrued by the centre. DESIGN: All cranial non-elective neurosurgical admissions with a TBI over 4.5 months (26 October 2014 to 15 March 2015) were analysed retrospectively, excluding cases of chronic subdural haematoma, at an MTC in England. Demographic data were collected alongside detailed cost and income data. RESULTS: Ninety four patients were identified. The majority of patients presented with more than one diagnosis of cranial trauma. Average length of stay was 18.8 ± 21.6 days. Total deficits as a result of treating this cohort amounted to £558,034. There was a significant association between (i) more complex presentations and (ii) a longer length of stay and the deficit accrued by the centre. The major drivers of the financial outcome were costs associated with wards, medical staffing and overheads. CONCLUSION: There was a substantial deficit accrued as a result of the management of patients with TBI at an MTC. The more complex the presentation, extensive the intervention, and lengthy the stay, the greater the deficit accrued by the centre. The current tariff payment system is not effectively reflecting the severity of injury or intensity of management of patients with TBI.PJH is supported by a NIHR Research Professorship and the NIHR Cambridge Biomedical Research Centre.This is the author accepted manuscript. The final version is available from Taylor & Francis via https://doi.org/10.1080/02688697.2016.124425

The Established Status Epilepticus Trial 2013

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/99653/1/epi12288.pd

Methyl N,N‐dimethylanthranilate and ethyl propionate: repellents effective against spotted wing drosophila, Drosophila suzukii

BACKGROUND Spotted wing drosophila, Drosophila suzukii (Matsumura) (Diptera: Drosophilidae), is an economically important pest of soft and stone fruit crops. The aim of this study was to identify repellents, formulated in dispensers, which could protect crops from D. suzukii. Fourteen potential repellents were screened against summer- and winter-morph D. suzukii through electroantennography and behavioural bioassays. Repellents effective in the laboratory were tested in polytunnels to determine their efficacy in reducing catches in fruit-baited traps. Further trials of three potential repellents were conducted to determine the distances over which repellent dispensers could reduce D. suzukii emergence in a strawberry crop. RESULTS All 14 chemicals screened were detected by the antennae of both D. suzukii morphs. Hexyl acetate and geosmin both elicited a significantly greater corrected EAG response in summer morphs than winter morphs. Summer-morph D. suzukii were repelled by butyl acetate, ethyl propionate, methyl N,N-dimethyl anthranilate, geosmin, methyl salicylate, DEET and benzaldehyde at one or more doses test in laboratory bioassays. Winter morphs were repelled by ethyl propionate, methyl anthranilate, methyl N,N-dimethyl anthranilate, DEET, benzaldehyde and butyl anthranilate at one or more of the doses tested in the laboratory. Ethyl propionate, methyl N,N-dimethylanthranilate and benzaldehyde repelled both morphs from fruit-baited traps in polytunnel trapping trials. Ethyl propionate and methyl N,N-dimethylanthranilate reduced emergence of D. suzukii in a strawberry crop over 3–5 m. CONCLUSIONS Ethyl propionate and methyl N,N-dimethylanthranilate may protect strawberry crops against D. suzukii. Future work should test these repellents in combination with attractants in a ‘push-pull’ strategy

Large-Scale Spray Releases: Additional Aerosol Test Results

One of the events postulated in the hazard analysis for the Waste Treatment and Immobilization Plant (WTP) and other U.S. Department of Energy (DOE) nuclear facilities is a breach in process piping that produces aerosols with droplet sizes in the respirable range. The current approach for predicting the size and concentration of aerosols produced in a spray leak event involves extrapolating from correlations reported in the literature. These correlations are based on results obtained from small engineered spray nozzles using pure liquids that behave as a Newtonian fluid. The narrow ranges of physical properties on which the correlations are based do not cover the wide range of slurries and viscous materials that will be processed in the WTP and in processing facilities across the DOE complex. To expand the data set upon which the WTP accident and safety analyses were based, an aerosol spray leak testing program was conducted by Pacific Northwest National Laboratory (PNNL). PNNL’s test program addressed two key technical areas to improve the WTP methodology (Larson and Allen 2010). The first technical area was to quantify the role of slurry particles in small breaches where slurry particles may plug the hole and prevent high-pressure sprays. The results from an effort to address this first technical area can be found in Mahoney et al. (2012a). The second technical area was to determine aerosol droplet size distribution and total droplet volume from prototypic breaches and fluids, including sprays from larger breaches and sprays of slurries for which literature data are mostly absent. To address the second technical area, the testing program collected aerosol generation data at two scales, commonly referred to as small-scale and large-scale testing. The small-scale testing and resultant data are described in Mahoney et al. (2012b), and the large-scale testing and resultant data are presented in Schonewill et al. (2012). In tests at both scales, simulants were used to mimic the relevant physical properties projected for actual WTP process streams

The evolution of an SBNS-accredited NANSIG simulated skills workshop for aspiring neurosurgical trainees: an analysis of qualitative and quantitative data.

Funder: Newcastle UniversityBACKGROUND: The Neurology and Neurosurgery Interest Group (NANSIG) neurosurgical skills workshop is novel in teaching neurosurgical skills solely to medical students and foundation trainees in the UK. The aim is to offer an affordable option for a high-fidelity simulation course enabling students to learn and practise specific neurosurgical skills in a safe, supervised environment. METHODS: A 10-delegate cohort was quantitatively assessed at the NANSIG neurosurgical skills workshop. Two assessors used a novel modified Objective Structured Assessment of Technical Skills (mOSATS) assessment tool, comprising 5 domains ranked according to a 5-point scale to rate delegates' ability to create a burr hole. Qualitative data from previous workshops were collected, consisting of open-ended, closed-ended and 5-point Likert scale responses to pre- and post-workshop questionnaires. Data were analysed using SPSS® software. RESULTS: Delegates scored a mean total of 62.1% (21.75/35) and 85.1% (29.8/35) in pre- and post-workshop assessments respectively revealing a statistically significant improvement. Regarding percentage of improvement, no significant difference was shown amongst candidates when comparing the number of neurosurgical cases observed and/or assisted in the past. There was no significant difference in the overall rating between the last two workshops (4.89 and 4.8 out of 5, respectively). One hundred percent of the attendees reported feeling more confident in assisting in theatre after the last two workshops. CONCLUSION: We show that a simulation workshop cannot only objectively quantify the improvement of surgical skill acquisition but can also be beneficial regardless of the extent of prior experience

Hero turned villain: Identification of components of the sex pheromone of the tomato bug, Nesidiocoris tenuis

Nesidiocoris tenuis (Reuter) (Heteroptera: Miridae) is a tropical mirid bug used as a biocontrol agent in protected crops, including tomatoes. Although N. tenuis predates important insect pests, especially whitefly, it also causes damage by feeding on tomato plants when prey populations decline, resulting in significant economic losses for growers. The pest is now established in some all-year-round tomato crops in Europe and control measures involve the application of pesticides which are incompatible with current IPM programs. As part of future IPM strategies, the pheromone of N. tenuis was investigated. Volatile collections were made from groups and individuals of mated and unmated, females and males. In analyses of these collections by gas chromatography coupled with electroantennographic (EAG) recording from antennae of male bugs, two EAG-active components were detected and identified as 1-octanol and octyl hexanoate. Unlike other mirids, both male and female N. tenuis produced the two compounds, before and after mating, and both sexes gave EAG responses to both compounds. Furthermore, only octyl hexanoate was detected in whole body solvent washes from both sexes. These compounds are not related to the derivatives of 3-hydroxybutyrate esters found as pheromone components in other members of the Bryocrinae sub-family, and the latter could not be detected in volatiles from N. tenuis and did not elicit EAG responses. Nevertheless, experiments carried out in commercial glasshouses showed that traps baited with a blend of the synthetic pheromone components caught essentially only male N. tenuis, and significantly more than traps baited with octyl hexanoate alone. The latter caught significantly more N. tenuis than unbaited traps which generally caught very few bugs. Traps at plant height caught more N. tenuis males than traps 1 m above or at the base of the plants. The trap catches provided an indication of population levels of N. tenuis and were greatly reduced following an application of insecticide