Bilateral and Optimistic Warning Paradigms Improve the Predictive Power of Intraoperative Facial Motor Evoked Potentials during Vestibular Schwannoma Surgery

Facial muscle corticobulbar motor evoked potentials (FMcoMEPs) are used to monitor facial nerve integrity during vestibular schwannoma resections to increase maximal safe tumor resection. Established warning criteria, based on ipsilateral amplitude reduction, have the limitation that the rate of false positive alarms is high, in part because FMcoMEP changes occur on both sides, e.g., due to brain shift or pneumocephalus. We retrospectively compared the predictive value of ipsilateral-only warning criteria and actual intraoperative warnings with a novel candidate warning criterion, based on “ipsilateral versus contralateral difference in relative stimulation threshold increase, from baseline to end of resection” (BilatMT ≥ 20%), combined with an optimistic approach in which a warning would be triggered only if all facial muscles on the affected side deteriorated. We included 60 patients who underwent resection of vestibular schwannoma. The outcome variable was postoperative facial muscle function. Retrospectively applying BilatMT, with the optimistic approach, was found to have a significantly better false positive rate, which was much lower (9% at day 90) than the traditionally used ipsilateral warning criteria (>20%) and was also lower than actual intraoperative warnings. This is the first report combining the threshold method with an optimistic approach in a bilateral multi-facial muscle setup. This method could substantially reduce the rate of false positive alarms in FMcoMEP monitoring.

Analysis of Spatio-Temporal Spread of Mega-Drought: Setting Forecast and Warning Criteria

In South Korea, drought disasters frequently occur due to the narrow area of the river basin and the concentration of rainfall in summer. In addition, climate change caused extreme droughts in 2015, levels that had never been experienced before. Thus, more severe droughts are expected in the future. To date, however, no countermeasures, such as preliminary warning standards for severe drought, have been prepared. In this study, we analyzed the degree of spatio-temporal spread of mega-drought entry situations and prepared the criteria for warnings based on the results. The results of the study can be used as basic data to prepare standards for responding to possible extreme droughts in the future.

Motor Evoked Potential Warning Criteria in Supratentorial Surgery: A Scoping Review

During intraoperative monitoring of motor evoked potentials (MEP), heterogeneity across studies in terms of study populations, intraoperative settings, applied warning criteria, and outcome reporting exists. A scoping review of MEP warning criteria in supratentorial surgery was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Sixty-eight studies fulfilled the eligibility criteria. The most commonly used alarm criteria were MEP signal loss, which was always a major warning sign, followed by amplitude reduction and threshold elevation. Irreversible MEP alterations were associated with a higher number of transient and persisting motor deficits compared with the reversible changes. In almost all studies, specificity and Negative Predictive Value (NPV) were high, while in most of them, sensitivity and Positive Predictive Value (PPV) were rather low or modest. Thus, the absence of an irreversible alteration may reassure the neurosurgeon that the patient will not suffer a motor deficit in the short-term and long-term follow-up. Further, MEPs perform well as surrogate markers, and reversible MEP deteriorations after successful intervention indicate motor function preservation postoperatively. However, in future studies, a consensus regarding the definitions of MEP alteration, critical duration of alterations, and outcome reporting should be determined.

Deteksi Pasien Obstetrik Kritis dengan Maternal Early Warning System

Adaptasi fisiologis yang terjadi pada ibu hamil dapat menyamarkan tanda-tanda penyakit maternal berat. Ini mempersulit identifikasi kolaps maternal yang akan terjadi. Penggunaan early warning system (EWS) yang dimodifikasi untuk penggunaan pada pasien ibu hamil dan postpartum akan membantu dalam identifikasi, treatment dini, dan penanganan pasien yang memiliki, atau akan mengalami, penyakit kritis. Maternal Early Warning System (MEWS) seharusnya mengidentifikasi pasien yang berisiko untuk mengalami perburukan pada saat intervensi dini dapat mencegah perburukan ke morbiditas berat MEWS telah digunakan secara ekstensif dalam praktek obstetrik, tetapi sistem yang digunakan sangat bervariasi. Parameter-parameter yang sering dimasukkan dalam MEWS antara lain denyut jantung, tingkat pernapasan, tekanan darah, dan tingkat kesadaran. Dari berbagai MEWS yang telah dikembangkan, ada tiga MEWS utama, yaitu (1) modified early obstetric warning system (MEOWS), (2) Maternal Early Warning Criteria (MEWC), dan (3) Maternal Early Warning Trigger (MEWT) tool. Hingga kini masih belum diketahui sistem MEWS apa yang terbaik, dan setiap rumah sakit mungkin memerlukan penyesuaian dalam parameter MEWS. Literatur yang ada menunjukkan kemungkinan manfaat dan mendukung penggunaan MEWS. Implementasi dan penggunaan MEWT telah dikaitkan dengan penurunan morbiditas maternal komposit dan morbiditas maternal berat. Akan tetapi, respon apa yang optimal untuk setting tertentu agar memperbaiki pelayanan maternal setelah tanda peringatan muncul hingga kini masih belum jelas. Detection of Critically Ill Obstetric Patients with Maternal Early Warning System Abstract Physiological adaptations that develop in pregnant women may obscure signs of severe maternal diseases. These causes difficulties in identifying the impending maternal collapse. An early warning system (EWS) modified for pregnant and postpartum women may assist in identification, early treatment, and management of patients who already or will develop critical illness. Maternal Early Warning System MEWS has been extensively used in obstetric practices; however, the systems used in preactice are varied. The most considered parameters for MEWS are heart rate, respiratory rate, blood pressure, and level of consciousness. From many MEWS developed, three primary MEWS existed, (1) modified early obstetric warning system (MEOWS), (2) Maternal Early Warning Criteria (MEWC), dan (3) Maternal Early Warning Trigger (MEWT) tool. There is still no consensus regarding which MEWS is superior, and different hospitals may require adjustments in MEWS parameters. The existing literatures suggested the potential benefit of MEWS and supported MEWS in clinical practice. Implementation and adoption of MEWS had been associated with reduced composite maternal morbidities and severe maternal morbidities. However, the optimal response for certain settings to improve maternal services after warning system has been activated is still lacking.