Evaluation of the effect of standard neuronavigation and augmented reality on the integrity of the perifocal structures during a neurosurgical approach

OBJECTIVE Intracranial minimally invasive procedures imply working in a restricted surgical corridor surrounded by critical structures, such as vessels and cranial nerves. Any damage to them may affect patient outcome. Neuronavigation systems may reduce the risk of such complications. In this study, the authors sought to compare standard neuronavigation (NV) and augmented reality (AR)–guided navigation with respect to the integrity of the perifocal structures during a neurosurgical approach using a novel model imitating intracranial vessels. METHODS A custom-made box, containing crisscrossing hard metal wires, a hidden nail at its bottom, and a wooden top, was scanned, fused, and referenced for the purpose of the study. The metal wires and an aneurysm clip applier were connected to a controller, which counted the number of contacts between them. Twenty-three naive participants were asked to 1) use NV to define an optimal entry point on the top, perform the smallest craniotomy possible on the wooden top, and to use a surgical microscope when placing a clip on the nail without touching the metal wires; and 2) use AR to preoperatively define an ideal trajectory, navigate the surgical microscope, and then perform the same task. The primary outcome was the number of contacts made between the metal wires and the clip applier. Secondary outcomes were craniotomy size, and trust in NV and AR to help avoid touching the metal wires, as assessed by a 9-level Likert scale. RESULTS The median number of contacts tended to be lower with the use of AR than with NV (AR, median 1 [Q1: 1, Q3: 2]; NV, median 3 [Q1: 1, Q3: 6]; p = 0.074). The size of the target-oriented craniotomy was significantly lower with the use of AR compared with NV (AR, median 4.91 cm2 [Q1: 4.71 cm2, Q3: 7.55 cm2]; and NV, median 9.62 cm2 [Q1: 7.07 cm2; Q3: 13.85 cm2]). Participants had more trust in AR than in NV (the differences posttest minus pretest were mean 0.9 [SD 1.2] and mean −0.3 [SD 0.2], respectively; p < 0.05). CONCLUSIONS The results of this study show a trend favoring the use of AR over NV with respect to reducing contact between a clip applier and the perifocal structures during a simulated clipping of an intracranial aneurysm. Target-guided craniotomies were smaller with the use of AR. AR may be used not only to localize surgical targets but also to prevent complications associated with damage to structures encountered during the surgical approach.

Use of lumen-apposing metal stents (LAMS) in the management of gastro jejunostomy stricture following Roux-en-Y Gastric Bypass for obesity: a prospective series

Background Chronic strictures following Roux-en-Y Gastric Bypass (RYGB) are a troublesome complication that can lead to significant morbidity. The use of stents has been described but the need for X-ray and risk of migration have meant limited use in the management of these strictures. Lumen apposing metal stents (LAMS) have traditionally been used for management of pancreatic pseudocysts. They don’t require X-ray and are easy to deploy with a short learning curve. This paper explores the use of LAMS to treat post RYGB strictures and explores their safety and efficacy. Methods A prospective study over a 4-year period looking at 14 patients with post RYGB strictures. These patients were privately insured patients operated within a tertiary Private facility. The patients were followed up for between 1 and 3 years. We have prospectively collected data on the efficacy and safety of LAMS in these patients. Patients were followed up until stent removal or definitive surgery to correct a stricture. Results 421 patients underwent RYGB in the study period. 14 (3.3%) of these patients developed a stricture that resulted in insertion of LAMS. There was no immediate complications and 12 patients had complete resolution of their stricture. There were no reoperations due to migration related issues although a migration rate of 19% was noted. 2 patients required surgery to correct refractory strictures not relieved by a LAMS stent, both of these were strictures associated with marginal ulceration of the gastro jejunostomy. Conclusion LAMS are a safe and effective method to manage post RYGB strictures. They have a high rate of resolution of strictures and can be safely deployed across strictures with no immediate complication. Migration does still appear to be a problem, however, does not appear to affect patient outcome or increase morbidity. Insertion is straightforward and doesn’t appear to be associated with a long learning curve.

A DESCRIPTIVE STUDY TO ASSESS THE LEVEL OF STRESS AMONG FAMILY MEMBERS OF ORTHOPEDIC PATIENTS ADMITTED IN PARKASH HOSPITAL, AMRITSAR, PUNJAB

Chronic stress causes biological disturbances. Admission in orthopaedic unit produces a crisis situation for both the patient and family members. If the event is not handled properly, the result may be prolonged physical and psychological instability of family member, a situation that may adversely affect patient outcome. The present researchstatementistoassessthelevelofstressamongfamilymemberpatient admitted in orthopedic ward Amritsar. Approach to research involves the description of plan to investigate phenomenon under study. In non – experimental approach, the research describes the phenomenon. A descriptive research approach will be used for present study. Non experimental research design is used assess the level of stress among family member patient admitted in orthopedic ward of Parkash hospital. In this study the sample size is 60 family member of patient admitted in orthopedic ward. It was concluded that almost any form of exercise or movement can increase your fitness level while decreasing your stress.

Co-deletion of ATAD1 with PTEN primes cells for BIM-mediated apoptosis

PTEN is a potent tumor suppressor gene that is frequently mutated or deleted in human cancers. Such deletions often include portions of the 10q23 locus beyond the bounds of PTEN itself, in many cases resulting in the disruption of additional genes. Coincidental loss of PTEN-adjacent genes might impose vulnerabilities that could either affect patient outcome basally or be exploited therapeutically. Here we describe how the loss of ATAD1, which is adjacent to and frequently co-deleted with PTEN, predisposes cancer cells to apoptosis and correlates with improved survival in cancer patients. ATAD1 directly and specifically extracts the pro-apoptotic BIM protein from mitochondria to inactivate it. Cells lacking ATAD1 are hypersensitive to clinically used proteasome inhibitors, which increase BIM and trigger apoptosis. Thus, we demonstrate that mitochondrial protein quality control interfaces with cell death in a clinically actionable manner.

Hypercapnia in the critically ill: insights from the bench to the bedside

Carbon dioxide (CO 2 ) has long been considered, at best, a waste by-product of metabolism, and at worst, a toxic molecule with serious health consequences if physiological concentration is dysregulated. However, clinical observations have revealed that ‘permissive’ hypercapnia, the deliberate allowance of respiratory produced CO 2 to remain in the patient, can have anti-inflammatory effects that may be beneficial in certain circumstances. In parallel, studies at the cell level have demonstrated the profound effect of CO 2 on multiple diverse signalling pathways, be it the effect from CO 2 itself specifically or from the associated acidosis it generates. At the whole organism level, it now appears likely that there are many biological sensing systems designed to respond to CO 2 concentration and tailor respiratory and other responses to atmospheric or local levels. Animal models have been widely employed to study the changes in CO 2 levels in various disease states and also to what extent permissive or even directly delivered CO 2 can affect patient outcome. These findings have been advanced to the bedside at the same time that further clinical observations have been elucidated at the cell and animal level. Here we present a synopsis of the current understanding of how CO 2 affects mammalian biological systems, with a particular emphasis on inflammatory pathways and diseases such as lung specific or systemic sepsis. We also explore some future directions and possibilities, such as direct control of blood CO 2 levels, that could lead to improved clinical care in the future.

Association Between Polymorphonuclear Leukocyte Cell Percentage in Cerebrospinal Fluid and Outcome of Tuberculous Meningitis Patients in a Tertiary Hospital in Indonesia

Tuberculous (TB) meningitis is the most severe type of extrapulmonary TB with high morbidity and mortality rates. Many factors affect patient outcome, including the intracranial inflammation process. In acute inflammation, recruitment of a high number of polymorphonuclear (PMN) cells can cause edema which may eventually increase the intracranial pressure. This increase in intracranial pressure may lead to functional decline, disability, and even death. This study aimed to explore the association between the PMN percentage in cerebrospinal fluid (CSF) and TB meningitis patient outcome as measured by the Glasgow Outcome Scale at Dr. Hasan Sadikin General Hospital Bandung, which is a tertiary hospital in Indonesia. This was a retrospective cohort study using patient medical record data from 2017. All TB meningitis patients over 18 years old were included. Patients with missing PMN results in medical record were excluded, which led to a total 88 subjects participating in this study. Variables analyzed were PMN percentage in CSF and patient outcome that were categorized as poor, moderate, and good. Analysis were performed using theKruskal-wallis test. An increase in PMN median as the patient outcome declined were observed, but the association between the PMN percentage in CSF and patient outcome was insignificant (p=0.186). Hence, no association between PMN percentage in CSF and TB meningitis patient outcome was identified in this study.

Post-surgical physiotherapy in frozen shoulder: A review

Despite its prevalence, the optimal management of frozen shoulder is unclear. A range of conservative measures are often undertaken with varying degrees of success. In cases of severe and persistent symptoms, release procedures which could include any combination of manipulation under anaesthetic, arthroscopic capsular release or hydrodilatation are frequently offered, none of which has been shown to offer superior outcome over the others. When surgical release is performed a period of rehabilitation is normally recommended but no best practice guidelines exist resulting in considerable variations in practice which may or may not directly affect patient outcome. During this narrative review, we hypothesise that these differing responses to treatment (both conservative and surgical options) are potentially the result of different causal mechanisms for frozen shoulder and may also suggest that post-release rehabilitation may need to take this into account.