71 research outputs found
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Use of the Neurological Pupil Index to Predict Postoperative Visual Function After Resection of a Tuberculum Sellae Meningioma: A Case Report.
The Neurological Pupil index (NPi) is a standardized method for evaluating pupil reactivity that removes inter-examiner variability. Changes in the NPi can predict clinical deterioration in patients with traumatic brain injury (TBI); however, its use to predict visual impairment after the resection of parasellar meningiomas has not been described. A 71-year-old female underwent a modified expanded bifrontal craniotomy for resection of a 3.1 cm tuberculum sella meningioma that caused compression of the optic chiasm and resulted in left temporal and right superior temporal visual field deficits. Postoperatively, she lost vision in the right eye. Pupillometer measurements demonstrated an asymmetrically low NPi at that time, which improved to normal prior to partial vision recovery. The average NPi in the right pupil was 1.67 during the time of vision loss compared to 3.47 in the left pupil (p=1.7x10-10). Statistical analysis was performed with the Student's t-test and the significance level was set at p-value < 0.01. Resection of parasellar meningiomas is challenging because of the proximity of the optic apparatus. We report a case of unilateral vision loss after resection of a tuberculum sella meningioma in which the impaired eye's NPi value correlated closely with visual function. NPi values that decrease below 3 predict spikes in intracranial pressure in TBI patients; similarly, increases in the NPi value above 2.5-3 predict improvement in vision in the case reported here. By monitoring the proximal portion of the oculomotor reflex, the NPi can be a marker of visual impairment after surgery
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Management of Noncatastrophic Internal Carotid Artery Injury in Endoscopic Skull Base Surgery.
Arterial injuries are the most feared complication of endoscopic skull base surgery. During resection of the middle fossa component of a large ventral skull base chondrosarcoma, arterial bleeding was encountered near the right internal carotid artery (ICA). Durable hemostasis could not be achieved with packing and the patient was taken for an emergent angiogram that revealed a pseudoaneurysm of the proximal intradural ICA. Given the presence of good collateral flow through the anterior and posterior communicating arteries, the right ICA was sacrificed by coil embolization. The patient was taken back to the operating room for closure then transferred to the intensive care unit and maintained on vasopressors for five days to ensure adequate perfusion. The right ICA was coil embolized and the patient was taken back to the operating room for closure. The patient recovered without complication. Arterial injuries, although serious, are not always catastrophic. Critical steps are immediate recognition of bleeding, vascular imaging, and vessel sacrifice if necessary
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Salmonella Infection After Craniotomy.
Salmonella is an uncommon cause of meningitis, especially after neurosurgery. Here, we present a case of Salmonella meningitis after craniotomy, likely due to physical contact with a snake after surgery, with contiguous spread from the patient's hand to her wound. The purpose of this report is to serve as a reminder that patients undergoing neurosurgery should avoid contact with pets, including snakes and other reptiles, in the postoperative period and practice good hand hygiene
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Patient-Specific Fetal Dose Determination for Multi-Target Gamma Knife Radiosurgery: Computational Model and Case Report.
A 42-year-old woman at 29 weeks gestation via in vitro fertilization who presented with eight metastatic brain lesions received Gamma Knife stereotactic radiosurgery (GKSRS) at our institution. In this study, we report our clinical experience and a general procedure of determining the fetal dose from patient-specific treatment plans and we describe quality assurance measurements to guide the safe practice of multi-target GKSRS of pregnant patients. To estimate fetal dose pre-treatment, peripheral dose-to-focal dose ratios (PFRs) were measured in a phantom at the distance approximating the fundus of uterus. Post-treatment, fetal dose was calculated from the actual patient treatment plan. Quality assurance measurements were carried out via the extrapolation dosimetry method in a head phantom at increasing distances along the longitudinal axis. The measurements were then empirically fitted and the fetal dose was extracted from the curve. The computed and measured fetal dose values were compared with each other and associated radiation risk was estimated. Based on low estimated fetal dose from preliminary phantom measurements, the patient was accepted for GKSRS. Eight brain metastases were treated with prescription doses of 15-19 Gy over 143 min involving all collimator sizes as well as composite sector mixed shots. Direct fetal dose computation based on the actual patient's treatment plan estimated a maximum fetal dose of 0.253 cGy, which was in agreement with surface dose measurements at the level of the patient's uterine fundus during the actual treatment. Later phantom measurements also estimated fetal dose to be in the range of 0.21-0.28 cGy (dose extrapolation curve R2 = 0.998). Using the National Council on Radiation Protection and Measurements (NCRP) population-based model, we estimate the fetal risk of secondary malignancy, which is the primary toxicity after 25 weeks gestation, to be less than 0.01%. Of note, the patient delivered the baby via scheduled cesarean section at 36 weeks without complications attributable to the GKSRS procedure. GKSRS of multiple brain metastases was demonstrated to be safe and feasible during pregnancy. The applicability of a general patient-specific fetal dose determination method was also demonstrated for the first time for such a treatment
Anatomy of the inferior orbital fissure: Implications for endoscopic cranial base surgery
Considering many approaches to the skull base confront the inferior orbital fissure (IOF) or sphenomaxillary fissure, the authors examine this anatomy as an important endoscopic surgical landmark. In morphometric analyses of 50 adult human dry skulls from both sexes, we divided the length of the IOF into three segments (anterolateral, middle, posteromedial). Hemotoxylin- and eosin-stained sections were analyzed. Dissections were performed using transnasal endoscopy in four formalin-fixed cadaveric cranial specimens (eight sides); three endoscopic approaches to the IOF were performed.IOF length ranged from 25 to 35 mm (mean 29 mm). Length/width of the individual anterolateral, middle, and posteromedial segments averaged 6.46/5, 4.95/3.2, and 17.6/ 2.4 mm, respectively. Smooth muscle within the IOF had a consistent elationship with several important anatomical landmarks. The maxillary introstomy,total ethmoidectomy approach allowed access to the posteromedial segment of the fissure. The endoscopic modified, medial maxillectomy approach allowed access to the middle and posterior-medial segment. The Caldwell-Luc approach allowed complete exposure of the IOF. The IOF serves as an important anatomic landmark during endonasal endoscopic approaches to the skull base and orbit. Each of the three segments provides a characteristic endoscopic corridor, unique to the orbit and different fossas surrounding the fissure.Fil: de Battista, Juan Carlos. University of Cincinnati; Estados Unidos. Universidad Nacional de CĂłrdoba. Facultad de Medicina. Instituto de Anatomia Normal; Argentina. Consejo Nacional de Investigaciones CientĂficas y TĂ©cnicas; ArgentinaFil: Zimmer, Lee A.. University of Cincinnati; Estados UnidosFil: Theodosopoulos, Philip V.. University of Cincinnati; Estados UnidosFil: Froelich, Sebastien C.. University of Cincinnati; Estados UnidosFil: Keller, Jeffrey T.. University of Cincinnati; Estados Unidos. Mayfield Clinic; Estados Unido
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Recurrent non-canonical histone H3 mutations in spinal cord diffuse gliomas.
Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis
BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London
The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study
AIM: The SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery. METHODS: This was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4âweeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin. RESULTS: Overall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4âweeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, PÂ =Â 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, Pâ<â0.001). After adjustment, delay was not associated with a lower rate of complete resection (OR 1.18, 95% CI 0.90-1.55, PÂ =Â 0.224), which was consistent in elective patients only (OR 0.94, 95% CI 0.69-1.27, PÂ =Â 0.672). Longer delays were not associated with poorer outcomes. CONCLUSION: One in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease
Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study
Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.
Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.
Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05â2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001).
Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication
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Small Vestibular Schwannomas: Does Surgery Remain a Viable Treatment Option?
BackgroundâSurgery for small vestibular schwannomas (Koos grade I and II) has been increasingly rejected as the optimal primary treatment, instead favoring radiosurgery and observation that offer lower morbidity and potentially equal efficacy. Our study assesses the outcomes of contemporary surgical strategies including tumor control, functional preservation, and implications of pathologic findings. DesignâRetrospective review. Setting/ParticipantsâEighty consecutive patients (45 women, 35 men; mean: 47 years of age). Main Outcomes MeasuresâApproaches included retrosigmoid approach (52%), translabyrinthine (40%), and middle fossa (8%). Operated on by the same surgical team, we analyzed presentation, radiographic imaging, surgical data, and outcomes. ResultsâAt last follow-up (mean: 34 months), 95% had good facial nerve function (House-Brackmann grade I or II); 36% who presented with serviceable hearing retained it; and 93% who presented with vestibular dysfunction reported resolution. Pathology identified two grade I meningiomas. ConclusionsâAs one of the largest contemporary surgical series of small vestibular schwannomas, we discuss some nuances to help refine treatment algorithms. Although observation and radiosurgery have established roles, our results reinforce microsurgery as a viable, safe option for a subgroup of patients
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