Outcomes after deep brain stimulation for elderly versus non-elderly patients with Parkinson's disease.

INTRODUCTION: The decision to offer deep brain stimulation (DBS) to elderly patients with Parkinson's disease (PD) presents challenges due to higher perceived risks and uncertain long-term benefits. Here, we aimed to compare the outcomes after DBS for elderly versus non-elderly patients with PD. METHODS: We analyzed data from our institutional cohort and retrieved publicly available data through a systematic review. The exposure was age at DBS electrode insertion, which was defined as elderly (≥70 years old) and non-elderly (<70 years old). The outcomes examined were changes in the Movement Disorders Society-Parkinson's Disease Rating Scale (MDS-UPDRS) or UPDRS part III total score, levodopa-equivalent daily dose (LEDD), and adverse events. RESULTS: The included studies and our cohort comprised a total of 527 patients, with 111 (21.1 %) classified as elderly. There was no statistically significant difference in the change in MDS-UPDRS or UPDRS part III total score and generally no statistically significant difference in the change in LEDD between the elderly and non-elderly patients. Elderly patients had a higher incidence of wound infection (elderly 5.4 % vs non-elderly 1.9 %; p = 0.087) and inadequate wound healing (elderly 3.6 % vs non-elderly 1.4 %; p = 0.230), but this difference was not statistically significant. There was no significant difference in the incidence of mortality (elderly 0 % vs non-elderly 0 %; p = 1.000), stroke (elderly 0 % vs non-elderly 0.2 %; p = 1.000), and cognitive decline between the age groups. CONCLUSIONS: Notwithstanding the trend towards a higher risk of wound infection and inadequate wound healing, elderly patients have similar motor outcomes and levels of PD medication reduction as non-elderly patients after DBS for PD. Hence, age should not be used as the sole criterion for determining eligibility for DBS, and the decision to offer DBS to elderly patients should be personalized and made in a multidisciplinary setting, taking into consideration patient- and disease-related factors.

Lobectomy versus gross total resection for glioblastoma multiforme: A systematic review and individual-participant data meta-analysis.

Overall survival (OS)for glioblastoma multiforme (GBM) has a known association with the extent of tumor resection with gross total resection (GTR) typically considered as the upper limit. In certain regions such as the anterior temporal lobe, more extensive resection by means of a lobectomy may be feasible. In our systematic review and meta-analysis, we aimed to compare the outcomes of lobectomy and GTR for GBM. PubMed and Embase were queriedfor studies that compared the outcomes after lobectomy or GTR for GBM. The primary outcomes were OS, progression-free survival (PFS), and Karnofksy Performance Status (KPS) score at the latest follow-up. The secondary outcomes were seizure control at the latest follow-up and complication rates. Meta-analysis for OS and PFS was performed using individual-participant data reconstructed from published Kaplan-Meier curves. Random-effect meta-analysis was performed for KPS. The secondary outcomes were pooled using descriptive statistics. Of the 795 records screened, 6 were included in our study. Meta-analysis revealed that anterior temporal, frontal, or occipital lobectomy was associated with significantly better OS (p < 0.001) and PFS (p < 0.001) than GTR, but not KPS (MD = 6.37; 95% CI=(-13.80, 26.54); p = 0.536). Anterior temporal lobectomy was associated with significantly better seizure control rates than GTR for temporal GBM (OR = 27; 95% CI=(1.4, 515.9); p = 0.002). There was no statistically significant difference in complication rates between anterior temporal, frontal, or occipital lobectomy and GTR. In conclusion, lobectomy was associated with significantly better OS, PFS, and seizure control than GTR for GBM.

An antibiotic envelope to reduce infections in deep brain stimulation surgery.

The therapeutic benefits of Deep Brain Stimulation (DBS) surgery in patients with movement disorderssuch as Parkinson's Diseaseare life-altering. Surgical site infections (SSI), however, can result in increasedhospitalisations, prolonged antibiotics and neurological sequelae. We performed aretrospective review to evaluate the effectiveness of an antibiotic envelope to reduce SSI in DBS surgeries.This study includedall DBS surgeries performed between August 2020 to May 2022 using a single-use, multifilament, antibiotic-coated mesh envelope wrapped around the DBS implantable pulse generator (IPG)(TYRX™ Absorbable Antibacterial Envelope,Medtronic Fridley, MN, USA). Standardised infection-prevention measures were applied and various patient-specific and surgery-specific factors were analysed.44 patients were analysed with 26 (59.1 %) primary implantations and 18 (40.9 %) revision surgeries.The median age was 65 years old with an average follow-up of 13.5 months (range 3-24 months). The mean Body Mass Indexwas 24.0 (range 16.7-35.6). 8 (18.2 %) patients had underlying diabetes mellitus. There were only 2 (4.5 %) SSIs reported with neither involvingthe subcutaneous IPG and antibiotic envelope. 1 superficial-incisional SSI (2.3 %) was from a prior retro-auricular abscess around a lead-wirerequiring antibiotics and subcutaneous implanttransposition. The other was a deep-incisional SSI (2.3 %) from repetitive trauma causingdelayed scalp wound dehiscence and lead-wire extrusion, requiring antibiotics and wound revision. Both subjects were discharged well with no implants removed. Theantibioticenvelope therefore appears to be a safe and well-tolerated adjunct that may reduce SSIs in DBS surgery. Further prospective work withlarger sample sizes in a multi-institution setting is required.

Low uptake of isoniazid window prophylaxis in patients exposed to a health-care worker with pulmonary tuberculosis in a paediatric ward.

AIM: A nurse on a paediatric multidisciplinary ward was diagnosed with smear-positive pulmonary tuberculosis. Children <2 years old, immunocompromised, or >40 h of contact (n = 173) were contact-traced. METHODS: Children received clinical review, chest X-ray, tuberculin skin test (TST; <5 years old) and/or an interferon-gamma release assay (Quantiferon TB-Gold, ≥5 years old). Infants <6 months old or children <5 years old screened <2 months from exposure were recommended isoniazid window prophylaxis (WP) until a repeat TST at 6 months old or 8-10 weeks after the last exposure to the index case, respectively. Empiric treatment for latent tuberculosis infection (LTBI) was individually considered for immunocompromised patients. RESULTS: Of 173 children (135 immunocompetent, 38 immunocompromised), two were uncontactable, seven refused screening and two immunocompromised children excluded. Eight of 126 immunocompetent children were diagnosed with LTBI (initial TST positive n = 7, TST conversion n = 1); seven started isoniazid. Thirty-two of 36 immunocompetent children were recommended WP; 15 accepted (one non-compliant after 1 month). Six of seven immunocompromised children accepted empiric LTBI treatment due to severe immunosuppression/initial indeterminate Quantiferon TB-Gold result. Of 15 immunocompromised children offered WP, only five accepted. CONCLUSIONS: There was high acceptance of screening but low uptake of isoniazid WP in high-risk children exposed to pulmonary tuberculosis. Perception of exposure risk and chemoprophylaxis should be explored further.

Incidence of biomarkers in high-grade gliomas and their impact on survival in a diverse SouthEast Asian cohort - a population-based study.

BACKGROUND: Gliomas consist of a heterogeneous group of tumors. This study aimed to report the incidences of O6-methylguanine-DNA-methyltransferase (MGMT) promoter methylation, 1p19q co-deletion, isocitrate dehydrogenase (IDH) gene mutations, and inactivating mutations of alpha-thalassemia/mental retardation syndrome X-linked (ATRX) in high-grade gliomas in an ethnically diverse population. METHODS: Records of patients who underwent surgery for high-grade gliomas from January 2013 to March 2017 at our institution were obtained. The patients' age, gender, ethnicity, Karnofsky Performance Scale (KPS) score, ability to perform activities of daily living (ADLs), tumor location and biomarkers status were recorded. Data were analyzed using chi-square and Mann-Whitney U tests, Kaplan-Meier estimates and log-rank test. RESULTS: 181 patients were selected (56 with grade III gliomas, 125 with grade IV gliomas). In the grade III group, 55% had MGMT promoter methylation, 41% had 1p19q co-deletion, 35% had IDH1 mutation and none had ATRX loss. In the grade IV group, 30% had MGMT promoter methylation, 2% had 1p19q co-deletion, 15% had IDH1 mutation and 8% had ATRX loss. After adjusting for effects of age, surgery and pre-operative ADL statuses, only MGMT promoter methylation was found to be significantly associated with longer overall survival time in grade III (p = 0.024) and IV patients (p = 0.006). CONCLUSIONS: The incidences of MGMT promoter methylation and IDH1 mutation were found to be comparable to globally reported rates, but those of 1p19q co-deletion and ATRX loss seemed to be lower in our cohort. MGMT promoter methylation was associated with increased overall survival in our cohort and might serve as favorable prognostic factor.

Prevalence of Asymptomatic Unruptured Intracranial Aneurysms in a Southeast Asian Population.

BACKGROUND: The prevalence of asymptomatic unruptured intracranial aneurysms (AUIA) in a Southeast Asian population has not been previously studied. Knowing the disease burden and population at risk can assist us in making informed decisions when managing AUIAs. We aimed to determine if the local prevalence of AUIAs differed from other populations in the published literature. METHODS: Magnetic resonance angiography radiology reports and images for 4572 patients between January 2013 and January 2014 were reviewed for AUIAs. RESULTS: The overall prevalence of AUIAs was 3.5% (160/4572). It was significantly higher in women (4.5%) compared with men (2.6%) (P < 0.001). The mean aneurysm size was 3.2 ± 1.7 mm. Of the aneurysms, 88.5% (146/165) measured less than 5 mm, 9.7% (16/165) measured 5-9 mm, and 1.8% (3/165) measured more than 9 mm. Most of the aneurysms were located in the cavernous segment (72/165, 43.6%) and ophthalmic segment (34/165, 20.6%) of the internal carotid artery, followed by the middle cerebral artery (16/165, 9.7%). The posterior circulation contributed 9.1% (15/165) of the AUIAs. During the study period, 1 aneurysm ruptured and the rest of the aneurysms did not show any growth. CONCLUSIONS: In this large cohort of a Southeast Asian population, the prevalence of AUIA was 3.5%. Most of the AUIAs were less than 5 mm and did not require intervention at time of discovery and did not progress within the year of follow-up.

Cryptococcosis mimicking lung carcinoma with brain metastases in an immunocompetent patient.

Cryptococcosis is a fungal infection caused by Cryptococcus spp. that enters the body via inhalation. This ubiquitous yeast has gained notoriety as an opportunistic pathogen in the immunosuppressed population. The authors report a case of a previously-well adult male presented with left-sided weakness. Imaging demonstrated a pulmonary mass and 2 contrast-enhancing intracranial lesions-all features suggestive of a primary lung carcinoma with brain metastases. However, further investigations confirmed disseminated cryptococcosis, without evidence of malignancy. The patient was successfully treated with a course of antifungals. To the authors' knowledge, this is the first reported case of dissemintated cryptococcosis in an immunocompetent adult male, simulating as primary lung carcinoma with brain metastases.