ABSTRACT
Purpose of Study: Affective symptoms, such as depression, nervousness, anxiety, and irritability, are common yet complicating aspects for concussion patients, therefore addressing exasperations of these symptoms is essential for injury management. This is an especially important consideration for patient populations increasingly susceptible to affective disorders, such as those in rural regions and adolescents. Increases in adolescent mental health problems during the time of the COVID-19 pandemic pose an additional challenge for clinicians managing affective concussion symptoms in rural adolescents. The aim of this study is to quantify the mental health effects of the pandemic by comparing affective concussion symptoms in groups of adolescents with concussion and without concussion in the Central Oregon region. Methods Used: The study is a secondary data analysis of ImPACT Concussion Test symptom scores from a cohort of non-concussed (Baseline) and concussed (Post-Injury) adolescents between the ages of 12-18, pre-pandemic (January 1, 2015 - March 20, 2020) and pandemic (March 21, 2020 - April 1, 2022). Subjects were excluded from the study if they received special education, had a diagnosis of learning disabilities, ADD, dyslexia, autism, or received treatment for headaches, migraines, epilepsy, brain surgery, meningitis, substance use or psychiatric conditions. Prevalence of symptoms of 'headache', 'trouble falling asleep', 'irritability', 'nervousness', 'sadness', and 'feeling more emotional' were noted for each group during each time period. Summary of Results: A total of pre-pandemic non-concussed (n =2667), pre-pandemic concussed (n=643), pandemic non-concussed (n = 593) and pandemic concussed (n=87) were included in the final analysis. There was a statistically significant increase in the proportions of 'nervousness' (p=0.0209) and 'sadness' (p=0.0117) in pre-pandemic and pandemic non-concussed groups. Furthermore, there were statistically significant increases in the proportions of 'headache' (p=0.0331), 'irritability' (p=0.0006), 'nervousness' (p=0.0135), 'sadness' (p=0.0357) and 'feeling more emotional' (p=0.0039) between pre-pandemic and pandemic concussed adolescents. Conclusion(s): This study demonstrates a significant increase in affective symptoms in both concussed and non-concussed groups during the COVID-19 pandemic consistent with other studies. However, those with concussion during the COVID-19 pandemic showed greater number of affective symptoms as well as somatic symptoms (headache) compared to concussed pre-pandemic adolescents. The results of this study support the broader body of research examining the mental health burden of the COVID-19 pandemic on adolescents, and further encourages a biopsychosocial approach to injury management, in which social and emotional components of a patient's life are considered.
ABSTRACT
Background: A 54-year- old male presented to our centre with a chronic non-productive cough and breathlessness. Recent history of COVID treated and resolved few months back. He had a history of brain surgery performed five years back but details not known. Physical examination revealed no oedema and bilateral coarse creps with bronchiolar breathing. Laboratory findings indicated neutrophilic leucocytosis, elevated inflammatory markers, with elevated troponin I and D dimers. Urine analysis suggested microscopic haematuria with sediments. While 24 hour quantification revealed sub nephrotic proteinuria. As auto immune workup and vasculitis profile was negative and patient has not improved in spite of standard of therapy hence we went ahead with CT-Chest indicating ground-glass opacities in bilateral lung parenchyma and prominent interlobular/intralobular septal thickening. Then Bronchoscopy done which revealed the blood-stained secretions in the main stem bronchi and diffuse alveolar haemorrhage in bilateral bronchial segments indicating an inflammatory study, while tuberculosis diagnostic panel and infective bio fire panel in BAL was negative. Meanwhile, his repeat BAL culture suggested Carbapenem resistant Acinetobacter baumannii complex infection. As the patient did not respond to the standard of care for vasculitis. Probability considered was a small vessel vasculitis (namely Granulomatous polyangiitis) was considered due to lung manifestation involving upper respiratory tract with epistaxis, neutrophilic leucocytosis, elevated acute reactive protein, and renal manifestation including microscopic haematuria and proteinuria. However he responded poorly to conventional standard of treatment including pulse steroids and IVIG. Hence after MDT discussion we proceeded with lung biopsy which showed linear cores of lung tissue infiltrated by a malignant neoplasm and acinar pattern suggesting Invasive mucinous adenocarcinoma. Hence we went ahead with the biopsy diagnosis for the treatment plan. As he was to be started on chemotherapy, but he suddenly collapsed and went into hypotension, bradycardia, and cardiac arrest. In spite of high supports and post 4 cycles of CPR, was unable to revive and sadly succumbed to his illness. Discussion(s): In this rare case, the original diagnosis pointed to the pulmonary-renal syndrome, an autoimmune disease characterized by diffuse pulmonary haemorrhage and glomerulonephritis. However, negative autoimmune antibodies and vasculitis profile along with lung biopsy results indicated an unusual case of malignant lung adenocarcinoma presented with pulmonary renal syndrome. Conclusion(s): In cases suggesting pulmonary-renal syndromes, if autoimmune work up is negative and response is suboptimal relook the diagnosis.
ABSTRACT
Purpose Robotic systems are increasingly applied in healthcare (HC) but are confined to heavy load tasks (e.g. within a hybrid OR), are used for undemanding services (e.g. transport and supply) or as master-slave systems aim at increasing the precision of interventional procedures. Only minor they have become substitutes of medical personnel, only minor they have improved the quality of health care delivery and only minor they have truly been integrated in our clinics. The future health system is facing some critical problems, with the shortage of personnel and the maintenance of the quality of care being first in line. Robots offer quite attractive features to cover with these problems but need to be designed accordingly, have to provide autonomous tasks and have to become full team members. The article aims at the identification of weak points of the health care system and how robots can be used to shape its future. Methods The results and thoughts presented herein do originate from expert discussions and studies of the available literature, but do also originate from experiences made in course in daily practice. Also, aspects which were elaborated during the work on the patient hub concept [1] and have been debated in panel discussion on the OR of the future and on robots in healthcare are included. Still, the presented theses are speculative and visionary and thus cannot be based on a fully scientific background. Results Personnel shortage The most pressing challenge we are facing for the healthcare system is the shortage of personal, which became even more obvious during the COVID-19 pandemia. As it foreseeable, that we will not be able to replace missing workers by human personnel, care delivery must become les human depending and missing work craft has to be replaced by autonomous systems. Autonomous robotic systems represent a core technology in this respect and can help to take over simple and repetitive tasks, e.g. for the handling of medical goods, for bedding and mobilizing patients and rehabilitation. Climate change The HC system will also be affected by the warming of the atmosphere, as it is responsible for almost 5% of CO2 emissions. Transport and delivery of medical goods in this regard are the main contributors and could be optimized by reducing the rate of single-use devices and scaling down supply chains. Increasing the in-hospital sterilization capacities and implementing local fabrication facilities of medical devices might offer a solution here, however, would require human resources. Robots again can play a decisive role here and become an enabling technology, e.g. during the reprocessing of sterile goods and for 3D printing based manufacturing lines. Demographic change The aging of the population is becoming a relevant burden for society due to the increasing number of disabled people and people in need of care. Since families and the HC system cannot cope with this development, solutions must be found that support the independence and self-subsistence of the elderly. Care robots, mechatronic extraskeletons and smart assistive technologies for the home are key elements for caring for elderly people in a way that is gentle on staff and can also help to maintain their quality of life. Specialization and precision medicine The healthcare system is driven by striving for improved quality of service and precision medicine. Currently available systems, mainly master-slave devices have failed in contributing here as no superiority has been shown for robotic assisted surgeries so far. Nevertheless, robots are the most powerful solution for further reducing the access trauma, for miniaturizing devices and for the realization for autonomous capabilities by coupling with smart imaging solutions. As it was demonstrated with OCT-based microrobotic solutions for eye surgery, comparable solutions might be a driving technology for example for endovascular surgeries, brain surgery and endoscopic interventions. While surgeons become more and more specialized which maks their individual performance of high va ue assistive systems to take over less-demanding tasks (e.g. skin suturing, retraction, suction) could become a meaningful and resource-sparing aid and once again could be realized by robotic solutions. Multi-drug resistance and isolation As observed by patients suffering from multi-drug resistance even before the current pandemia an increasing number of patients are requiring isolated care. The isolated care is not only demanding in terms of personnel, but also produces enormous amounts of waste, which have a negative effect on CO2 emissions. Robots again offer here a valuable solution as they can remain in an isolated environment, as they can be disinfected which makes additional protective measures unnecessary and as they strictly follow to standard operative procedures thereby reducing the risk of unintended contamination. Conclusion Solutions to overcome the pending, or already present challenges in the HC system are urgently required and must provide autonomic functionalities to save personnel, have to reduce the amount of waste and HC related traffic to lower the Co2 emission and should enable us to develop smarter and less invasive approaches for the treatment of an increasing number of sick and care-depending patients. Numerous robotic solutions to cope with this problems have already been introduced [2], but need to be further adapted according to these requirements and fully integrated into a cooperative environment. The alignment between human and robotic tasks and the maintenance of ethical and legal aspects still have to be taken as unsolved problems for the further involvement of robots, however when solved could open up the basis for a highly efficient patient centred HC system.
ABSTRACT
AIMS: Primary central nervous system lymphoma (PCNSL) is a rare form of non-Hodgkin lymphoma with exclusive manifestations in the central nervous system, leptomeninges and eyes. It forms around 5% of all primary brain tumours. It is an aggressive tumour which has a poor prognosis if left untreated. It is imperative that diagnosis is made timely so treatment can be started promptly. Therefore, we performed an audit looking into the speed of diagnostic process of PCNSL in our tertiary Neuro-oncology Unit. METHOD: Single-centre retrospective review of PCNSL cases referred to a tertiary Neuro-Oncology Unit over a six month period from June to November 2020. RESULTS: A total of 1309 cases were discussed in the Neuro-oncology MDT meeting over the study period. Fourteen cases (6 male, 8 female;median age [range] 66 [59-83] years) were identified as highly likely PCNSL. Neuroimaging suggested PCNSL as the likely diagnosis in twelve patients. Twelve patients were started on steroids after CT or MRI brain scans. Nine patients had a surgical target and proceeded to have diagnostic brain biopsy. Two patients had different working diagnoses and three patients were deemed unsuitable for brain surgery. One patient required repeat brain biopsy. A tissue diagnosis was made in twelve patients. One patient deteriorated rapidly and one patient had a brain lesion that was deemed too high risk for surgery. The median time between neuroimaging and biopsy was 25 days. The median time taken from first investigation to the pathological confirmation of PCNSL was 36 days (range 6-86 days). CONCLUSION: The chief reason for delay in diagnosis of PCNSL was that patients were started on steroids before diagnostic investigations were completed. Steroids caused the brain lesions to become smaller or disappear. Accordingly, time was needed to allow withdrawal of steroids before diagnostic investigations could be repeated. Diagnostic delays may have been exacerbated by logistical issues associated with COVID-19. We propose that there needs to be greater awareness of how early introduction of steroids can markedly delay the diagnosis of PCNSL.