A Pilot Randomized Controlled Trial of Augmented Reality Just-in-Time Guidance for the Performance of Rugged Field Procedures.

INTRODUCTION: Medical resuscitations in rugged prehospital settings require emergency personnel to perform high-risk procedures in low-resource conditions. Just-in-Time Guidance (JITG) utilizing augmented reality (AR) guidance may be a solution. There is little literature on the utility of AR-mediated JITG tools for facilitating the performance of emergent field care. STUDY OBJECTIVE: The objective of this study was to investigate the feasibility and efficacy of a novel AR-mediated JITG tool for emergency field procedures. METHODS: Emergency medical technician-basic (EMT-B) and paramedic cohorts were randomized to either video training (control) or JITG-AR guidance (intervention) groups for performing bag-valve-mask (BVM) ventilation, intraosseous (IO) line placement, and needle-decompression (Needle-d) in a medium-fidelity simulation environment. For the interventional condition, subjects used an AR technology platform to perform the tasks. The primary outcome was participant task performance; the secondary outcomes were participant-reported acceptability. Participant task score, task time, and acceptability ratings were reported descriptively and compared between the control and intervention groups using chi-square analysis for binary variables and unpaired t-testing for continuous variables. RESULTS: Sixty participants were enrolled (mean age 34.8 years; 72% male). In the EMT-B cohort, there was no difference in average task performance score between the control and JITG groups for the BVM and IO tasks; however, the control group had higher performance scores for the Needle-d task (mean score difference 22%; P = .01). In the paramedic cohort, there was no difference in performance scores between the control and JITG group for the BVM and Needle-d tasks, but the control group had higher task scores for the IO task (mean score difference 23%; P = .01). For all task and participant types, the control group performed tasks more quickly than in the JITG group. There was no difference in participant usability or usefulness ratings between the JITG or control conditions for any of the tasks, although paramedics reported they were less likely to use the JITG equipment again (mean difference 1.96 rating points; P = .02). CONCLUSIONS: This study demonstrated preliminary evidence that AR-mediated guidance for emergency medical procedures is feasible and acceptable. These observations, coupled with AR's promise for real-time interaction and on-going technological advancements, suggest the potential for this modality in training and practice that justifies future investigation.

Ventriculosubgaleal shunts in the management of neonatal post-haemorrhagic hydrocephalus: technical note.

INTRODUCTION: Germinal matrix / intraventricular haemorrhage (GMIVH) remains a significant complication of prematurity. The more severe grades are associated with parenchymal haemorrhagic infarction (PHI) and hydrocephalus. A temporising procedure is usually the first line in management of neonatal post-haemorrhagic hydrocephalus (nPHH) as the risk of failure of a permanent cerebrospinal fluid (CSF) diversion is higher in the early stage. Our choice of temporising procedure is a ventriculosubgaleal shunt (VSGS). In this technical note, we describe a modification in technique whereby the pocket of the VSGS is fashioned away from the surgical wound. This resulted in lower CSF leak and subsequent infection rates in our centre. METHODS: We conducted a retrospective analysis of all patients who underwent insertion of a VSGS between September 2014 and February 2023. RESULTS: Twenty children were included in our study with a mean gestational age of 31 weeks + 4 days. Post-operatively, 10% of patients did not need a tap, and 10%, 20%, 15%, 25% and 20% respectively had 1, 2, 3, 4 and 5 taps. Two patients experienced CSF leak from their wounds. In both these patients, the pocket was deemed too close to the wound. None of the patients without suspected pre-existing CNS infection at the time of insertion of VSGS had a subsequent VSGS-related infection. VSGS conversion to permanent ventriculoperitoneal shunts (VPS) was required in 15 (75%) of the patients with an average interval duration of 72 days. On reviewing the literature, the infection rate following VSGS is quoted up to 13.5%. In our own centre, 13 patients had undergone VSGS insertion between 2005 and 2013 with a 30.8% infection rate which seemed related to increased leak rates. CONCLUSION: Our modified surgical approach seems to be effective in reducing the risk of infection, which we postulate is a direct result of reduction in the risk of leak from the surgical wound.

Fat in the Fossa and the Sphenoid Sinus: A Simple and Effective Solution to CSF Leaks in Transsphenoidal Surgery. Cohort Study and Systematic Review.

Objectives Cerebrospinal fluid (CSF) leak following endoscopic transsphenoidal surgery (TSS) remains a challenge and is associated with high morbidity. We perform a primary repair with f at in the pituitary f ossa and further fat in the s phenoid sinus (FFS). We compare the efficacy of this FFS technique with other repair methods and perform a systematic review. Design, Patients, and Methods This is a retrospective analysis of patients undergoing standard TSS from 2009 to 2020, comparing the incidence of significant postoperative CSF rhinorrhea (requiring intervention) using the FFS technique compared with other intraoperative repair strategies. Systematic review of current repair methods described in the literature was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Results In all, there were 439 patients, with 276 patients undergoing multilayer repair, 68 patients FFS repair, and 95 patients no repair. No significant differences were observed in baseline demographics between the groups. Postoperative CSF leak requiring intervention was significantly lower in the FFS repair group (4.4%) compared with the multilayer (20.3%) and no repair groups (12.6%, p < 0.01). This translated to fewer reoperations (2.9% FFS vs. 13.4% multilayer vs. 8.4% no repair, p < 0.05), fewer lumbar drains (2.9% FFS vs. 15.6% multilayer vs. 5.3% no repair, p < 0.01), and shorter hospital stay (median days: 4 [3-7] FFS vs. 6 (5-10) multilayer vs. 5 (3-7) no repair, p < 0.01). Risk factors for postoperative leak included female gender, perioperative lumbar drain, and intraoperative leak. Conclusion Autologous fat on fat graft for standard endoscopic transsphenoidal approach effectively reduces the risk of significant postoperative CSF leak with reduced reoperation and shorter hospital stay.

A Novel Point-of-care Ultrasound Curriculum for Air Critical Care Personnel.

INTRODUCTION: Point-of care-ultrasound (POCUS) has become ubiquitous in emergency medicine practice for the management of emergent pathophysiology. There is growing interest in its potential as a diagnostic tool in the prehospital setting. Few studies have examined the feasibility or efficacy of curricula targeted at teaching POCUS to prehospital personnel. Our objective in this study was to investigate a curriculum for the extended focused assessment with sonography in trauma (eFAST) exam in helicopter emergency medical services (HEMS) crews. METHODS: This was a pre/post intervention study of HEMS personnel at a tertiary care center. Subjects were administered a pre-intervention written test and an observed structured clinical evaluation (OSCE). Subsequently, they participated in an educational intervention intended to impart proficiency in performing the eFAST. Subjects underwent post-intervention written exams and OSCEs. We analyzed pre- and post-intervention test performance along with the number and quality of practice ultrasound examinations achieved. RESULTS: Sixteen subjects were enrolled (62.5% male, mean age 44.1). After undergoing the intervention, the mean written test score increased 22.1% (t=3.41; P <0.001) and the mean OSCE score increased by 64.5% (t=6.87, P <0.001). All subjects met "passing" criteria for the written test and OSCE on their post-intervention attempt. Subjects accomplished a mean of 21.1 clinically interpretable eFAST sonographs. Most subjects reported the curriculum was useful (90.1%) and that they would incorporate this skill into clinical practice (90.1%). CONCLUSION: A targeted POCUS curriculum was feasible and effective in establishing clinical proficiency in HEMS crews for performing and interpreting the eFAST exam.

Pericardiocentesis by an Air Medical Service for Cardiac Tamponade Caused by Purulent Pericarditis.

This case presentation describes the clinical management and course of an adult patient found to be in cardiac tamponade secondary to purulent pericarditis. This etiology represents an uncommon cause of pericardial tamponade and highlights the importance of recognizing clinical signs of this physiological state despite the uncommon presentation. This also reinforces that critical care transport teams must be trained and facile with high acuity-low occurrence skills such as pericardiocentesis as such time-sensitive measures may be necessary to stabilize patients for transport. The patient in this case had clinical improvement after pericardiocentesis was performed and this allowed for the safe transport of the patient to a tertiary care center.

Intraoperative Neurophysiological Monitoring for Intradural Extramedullary Spinal Tumours.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Intraoperative neurophysiological monitoring (IONM) is widely used in spinal neurosurgery, particularly for intramedullary tumours. However, its validity in intradural extramedullary (IDEM) spinal tumours is less clearly defined, this being the focus of this study. METHODS: We compared outcomes for patients that underwent resection of IDEM tumours with and without IONM between 2010 and 2020. Primary outcomes were postoperative American Spinal Injury Association (ASIA) scores. Other factors assessed were use of intraoperative ultrasound, drain placement, postoperative complications, postoperative Eastern Cooperative Oncology Group (ECOG) score, extent of resection, length of hospital stay, discharge location and recurrence. RESULTS: 163 patients were included, 71 patients in the IONM group and 92 in the non-IONM group. No significant differences were noted in baseline demographics. For preoperative ASIA D patients, 44.0% remained ASIA D and 49.9% improved to ASIA E in the IONM group, compared to 39.7% and 30.2% respectively in the non-IONM group. For preoperative ASIA E patients, 50.3% remained ASIA E and 44.0% deteriorated to ASIA D in the IONM group, compared to 30.2% and 39.7% respectively in the non-IONM group (all other patients deteriorated further). Length of inpatient stay was significantly shorter in the IONM group (P = .043). There were no significant differences in extent of resection, postoperative complications, discharge location or tumour recurrence. CONCLUSIONS: Research focusing on the use of IONM in IDEM tumour surgery remains scarce. Our study supports the use of IONM during surgical excision of IDEM tumours.

Systematic Review Comparing Open versus Endoscopic Surgery in Clival Chordomas and a 10-Year Single-Center Experience.

Objectives Chordomas are rare, slow-growing, and osteo-destructive tumors of the primitive notochord. There is still contention in the literature as to the optimal management of chordoma. We conducted a systematic review of the surgical management of chordoma along with our 10-year institutional experience. Design A systematic search of the literature was performed in October 2020 by using MEDLINE and EMBASE for articles relating to the surgical management of clival chordomas. We also searched for all adult patients surgically treated for primary clival chordomas at our institute between 2009 and 2019. Participants Only articles describing chordomas arising from the clivus were included in the analysis. For our institution experience, only adult primary clival chordoma cases were included. Main Outcome Measures Patients were divided into endoscopic or open surgery. Rate of gross total resection (GTR), recurrence, and complications were measured. Results Our literature search yielded 24 articles to include in the study. Mean GTR rate among endoscopic cases was 51.9% versus 41.7% for open surgery. Among the eight cases in our institutional experience, we found similar GTR rates between endoscopic and open surgery. Conclusion Although there is clear evidence in the literature that endoscopic approaches provide better rates of GTR with fewer overall complications compared to open surgery. However, there are still situations where endoscopy is not viable, and thus, open surgery should still be considered if required.

Infected cephalhaematoma causing osteomyelitis: case report and literature review.

Infected cephalhaematomas are rare and can lead to complications such as sepsis, meningitis and osteomyelitis. We present an infected cephalhaematoma in a neonate with resultant underlying osteomyelitis and a review of the literature. Our patient presented 6 days following birth with a fever and a swelling consistent with cephalhaematoma. He was managed with intravenous antibiotics and early surgical intervention. Imaging demonstrated underlying osteomyelitis. The patient made a full recovery and was discharged home on completing his antibiotic course. On reviewing the literature, it is clear that early diagnosis and treatment with surgical intervention and antibiotic therapy are associated with improved outcome and can reduce the possibility of osteomyelitis developing.

5-Aminolevulinic Acid-Guided Resection in Grade III Tumors-A Comparative Cohort Study.

BACKGROUND: The benefits of using 5-aminolevulinic acid (5-ALA) in resection of grade IV tumors have been extensively researched. However, few studies have investigated the use of 5-ALA in grade III gliomas. OBJECTIVE: To discover whether 5-ALA provides significant benefit in assisting resection of grade III gliomas. METHODS: A single-center, retrospective cohort study between January 2013 and January 2019 of adult patients with grade III gliomas. Patients were separated into a 5-ALA-guided surgery group (5-ALA-GS) and non-5-ALA-guided surgery group (non-5-ALA-GS). Primary outcome was overall survival (OS); secondary outcomes were both postoperative and 6-month performance status (PS6m), and extent of resection (EoR). RESULTS: Sixty-nine patients with grade III gliomas were included (39 and 30 patients in the 5-ALA-GS group and non-5-ALA-GS group, respectively). There was no significant difference in tumor characteristics between the groups. No significant difference was observed in OS (P = .072) and EoR (P = .609) between both the groups. In a subgroup of the 5-ALA-GS where gross total resection (GTR) was achieved, there was a better OS (P = .043). Significantly worse outcomes were seen postoperatively (P = .044) and at PS6m (P = .041) in the 5-ALA-GS group, mainly because of the poorer outcome in the subtotal resection subgroup. CONCLUSION: Despite the benefits of 5-ALA in grade IV glioma surgery, these benefits are limited to a smaller group of patients with grade III tumors where there is sufficient fluorescence to allow GTR. In this cohort of patients, 5-ALA use may result in worse neurological outcomes particularly when GTR is not feasible and therefore caution is warranted.

Surgical management and outcomes in spinal intradural arachnoid cysts: the experience from two tertiary neurosurgical centres.

PURPOSE: Evaluation of the presentation and outcomes of different surgical treatment approaches for spinal intradural arachnoid cysts (SIAC). METHODS: Cases were identified from electronic records of two major neurosurgical centres in London over the last 10 years (October 2009-October 2019) that have been surgically treated in both institutions. Clinical findings, surgical technique, and recurrence by procedure were statistically analysed. Statistical analysis was performed with STATA 13.1 Software. RESULTS: A total of 42 patients with SIAC were identified for this study with a mean age at the time of surgery of 53.6 years and a male:female ratio of 8:13. There were 31 patients with primary SIACs and 11 with secondary SIACs. The most common presenting symptom was paraesthesia (n = 27). The most common location of the cyst was in the thoracic region (n = 33). Syrinx was present in 26.2% of SIACs (n = 11). Resection was associated with significantly better postoperative pain compared to other surgical techniques (p = 0.01), significantly poorer postoperative urinary function (p = 0.029), and lower rates of sensory recovery in patients who presented preoperatively with sensory deficit (p = 0.041). No significant difference was seen in symptomatic outcomes between patients with primary and secondary SIACs. CONCLUSION: Resection and drainage are both effective methods of managing SIACs. In this observational study, resection was associated with significantly reduced pain postoperatively when compared with drainage, however also with significantly less improvement in postoperative urinary function. Therefore, resection should be the gold standard management option for SIACs, with drainage as an option where resection is unsafe, and drainage should also be considered in patients presenting with urinary dysfunction.

Is Cauda Equina Surgery Safe Out-of-Hours? A Single United Kingdom Institute Experience.

BACKGROUND: Cauda equina syndrome (CES) can have devastating neurological sequelae if surgical treatment is delayed. However, out-of-hours surgery (weekdays from 6:00 pm to 8:00 am and all weekend operations) can potentially result in higher rates of intraoperative complications, resulting in worse outcomes. In the present study, we have described our outcomes for patients with CES during an 8-year period (December 2011 to October 2019) with the aim of assessing the risk of out-of-hours surgery. METHODS: We performed a retrospective analysis of inpatient events and outcomes at 6 months of follow-up. Patient demographics, symptoms, and management data were extracted, and a risk factor analysis was performed using logistic regression. The outcome measures were the incidence of complications and symptom changes at follow-up. Symptom outcome changes between 2 time points were analyzed using repeated measures. RESULTS: A total of 278 patients were included in the present study. Surgery out-of-hours (P = 0.018) and prolonged operations (P = 0.018) were significant risk factors for intraoperative complications. Improved outcomes at 6 months of follow-up were found for lower back pain, sciatica, altered saddle sensation, and urinary sphincter disturbance, with no significant changes for the remaining symptoms. Out-of-hours surgeries did not significantly affect individual symptom outcomes. CONCLUSIONS: Our analysis has suggested that emergency decompressive surgery for patients with CES does not result in worsening of outcomes with out-of-hours surgery compared with in-hours. However, our findings also showed that no clear benefit exists to expediting surgery for those with severe presentations. Thus, decompressive surgery should be undertaken at the earliest possible time to safely do so.

Recurrent terminal ventricle cyst: a case report.

The terminal ventricle (TV) of Krause is a rare cystic dilation of the conus' central canal. Due to limited understanding surrounding its pathophysiology, optimal management remains controversial. We report a 25-year-old female presenting with acute paraparesis. Magnetic resonance imaging spine revealed a cystic conus medullaris lesion in keeping with an incidental TV cyst. However, the patient experienced a rapid resolution of symptoms. We hypothesize that the TV cyst spontaneously ruptured and auto-decompressed. To our knowledge, this is the first reported case of an enlarging symptomatic TV cyst with spontaneous rupture and resolution of symptoms, highlighting the variable natural history of this condition.

Adult WHO grade II ependymomas: is Ki67 a sex-specific proliferation marker?

Ki67 is a marker for proliferation of a given cell population. Low expression of Ki67 may be associated with a favourable outcome. We investigate how the proliferation index correlates with the location, morphology and behaviour of WHO grade II ependymomas with a single-centre cohort study of adult patients admitted for surgery of WHO grade II ependymomas between 2008 and 2018. Seventeen patients were included, seven had supratentorial and 10 had infratentorial tumours. Three patients died and eight had recurrent disease. Age, gender, location, extent of resection, chemotherapy, radiotherapy and histological markers were not associated with tumour progression. Both unadjusted and adjusted analysis confirmed a higher Ki67 index in male patients. Sensitivity analysis further supported the correlation between Ki67 and male gender. Ki67 may be sex specific but does not seem to correlate with survival and time to recurrence in this series.

5-Aminolevulinic acid-guided resection improves the overall survival of patients with glioblastoma-a comparative cohort study of 343 patients.

BACKGROUND: 5-Aminolevulic acid-guided surgery (5-ALA-GS) improves the extent of resection (EoR) and progression-free survival in patients with glioblastoma multiforme (GBM). METHODS: A single-center retrospective cohort study of adult patients with GBM who had surgical resection between 2013 and 2019, 5-ALA guided versus a non-5-ALA cohort. The primary outcome was the overall survival (OS). Secondary outcomes were EoR, performance status (PS), and new focal neurological deficit. RESULTS: Three hundred and forty-three patients were included: 253 patients in 5-ALA-GS group and 90 patients in the non-5-ALA-GS group. The OS (17.47 vs 10.63 months, P < .0001), postoperative PS (P < .0001), PS at 6 months (P = .002), new focal neurological deficit (23.3% vs 44.9%, P < .0001), and radiological EoR (gross total resection [GTR]-47.4% vs 22.9%, P < .0001) were significantly better in the 5-ALA-GS group compared to non-5-ALA-GS group. In multivariate analysis, use of 5-ALA (P = .003) and MGMT promoter methylation (P = .001) were significantly related with a better OS. In patients with radiological GTR, OS was also significantly better (P < .0001) in the 5-ALA-GS group compared to the non-5-ALA-GS group. CONCLUSIONS: 5-ALA-GS is associated with a significant improvement in the OS, PS after surgery and at 6 months, larger EoR, and fewer new motor deficits in patients with GBM.

Risk Factor Analysis and Surgical Outcomes of Acute Spontaneous Spinal Subdural Hematoma. An Institutional Experience of Four Cases and Literature Review.

OBJECTIVE: Spontaneous spinal subdural hematoma (SSSDH) is exceedingly rare, with significant morbidity in most patients. Acute neurologic deficit in the context of a SSSDH is considered a neurosurgical emergency. We performed a literature review and compared the results with our institutional experience to evaluate the risk factors and neurologic outcomes of SSSDH. METHODS: We retrospectively collected the medical, radiologic, and surgical information of 4 patients with SSSDH who were operated on in our neurosurgical unit. A literature review of surgically managed patients with SSSDH and their neurologic outcomes was performed. Ordered logistic regression statistics were used to study the risk factors influencing the postoperative Domenicucci grade. RESULTS: A total of 112 patients were evaluated, with a female/male ratio of 1.3:1. Mean patient age was 60.25 years. Our analysis of the data showed that the cohort of patients presenting with bladder dysfunction in addition to paraparesis were found to have worse neurologic outcomes postoperatively. Adjusted analysis identified 3 clinical characteristics that influenced surgical outcome: cervical SSSDH (P = 0.029), neurologic deficit (P < 0.001), and anticoagulation medication (P < 0.001). CONCLUSIONS: This review shows that patients aged ≥60 years and on anticoagulation are at an increased risk of sustaining a spontaneous subdural spinal hematoma without history of trauma. To our knowledge, this is also the first study to show a presenting symptom of bladder dysfunction as a significant risk factor for poor surgical outcome in SSSDH. Our study supports surgical evacuation of acute SSSDH in the presence of these risk factors.

Recurrent Appendicitis Caused by a Retained Appendiceal Tip: A Case Report.

BACKGROUND: Acute appendicitis is one of the most common surgical emergencies, and it is treated definitively with appendectomy. Recurrent appendicitis is a rare entity, being reported after approximately 1 in 50,000 appendectomies. It is typically caused by inflammation of the appendiceal stump. Inflammation of a retained appendiceal tip is a unique entity that can also cause recurrent appendicitis and presents similarly to primary appendicitis. CASE REPORT: We present a case of a 50-year-old man who had undergone laparoscopic appendectomy 1 year earlier and who subsequently presented with a chief complaint of right lower quadrant abdominal pain. The diagnosis of recurrent appendicitis caused by a retained appendiceal tip was made after a computed tomography scan. The patient underwent successful laparoscopic removal of the retained appendiceal fragment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The etiology of recurrent appendicitis is separate from the stump appendicitis that has been well described in the literature. Retained tip appendicitis poses a diagnostic dilemma because it is uncommon and, if missed, can lead to complications, such as perforation and severe sepsis. Recurrent appendicitis must be in the differential diagnosis for patients who are post-appendectomy and who present with right lower quadrant abdominal pain.