End of life care at home: The role of critical care transfer services.

Background: Most people would rather die at home than in hospital but only 18% of patients do so. Palliative care focuses on the physical, spiritual and psychosocial wellbeing of patients and their families, which should include facilitating transfers home when possible. Patients can have more autonomy over their care and be surrounded by loved ones which can have a significant impact on their quality of life. In this article we describe two cases of home repatriation for palliation. Case 1 describes the transfer of a patient with difficulties and gaps in planning, but with a safe transfer ultimately. Case 2 recounts a more comprehensive planning process emphasising collaboration between teams. Benefits and difficulties of palliative critical care transfers: Facilitating home-based care aligns with patients' desires for familiar surroundings and emotional support. A secondary benefit is that releasing a bed space allows another patient to receive critical care treatment. Challenges of palliative critical care transfers include needing a highly trained team and thorough planning. Early discussion with the family and community palliative care teams makes this a more feasible option for patients. Conclusion: A multidisciplinary team of hospital and community healthcare professionals working with the patient and their family can facilitate the transfer from intensive care to allow them to die at a place of their choosing. We should aim to fulfil these wishes at the end of life as it can greatly improve the patient's and their family's physical and emotional wellbeing during this difficult time.

Minimally Invasive Hematoma Evacuation Using the MindsEye Expandable Tubular Retractor: A Technical Note.

BACKGROUND: Recent advances in intraoperative neuronavigation and cranial access devices have facilitated an increasing interest in the use of minimally invasive techniques (minimally invasive surgery) to safely treat subcortical lesions via a parafascicular approach. Newly developed expandable retractors, such as the MindsEye system further optimize such approaches. In this technical report, we describe the nuances in minimally invasive surgery parenchymal hematoma evacuation using the MindsEye device. METHODS: After placement of the device, the inner stylet and inner obturator are removed, and the expandable sheath is left in place and secured into place with a Greenberg refractor. The sheath easily dilates to the surgeonss preference with a dial, and the walls of the sheath are composed of a thin, clear, membrane to allow easy visualization of the lesion. We additionally retrospectively reviewed clinical characteristics and outcomes across three patients treated at our facility with spontaneous multicompartment intracranial hematoma using the MindsEye system. RESULTS: We provide a video case demonstrating the use of the MindsEye retractor in a transfrontal parenchymal hematoma evacuation. Successful evacuation with achieved in less than 90 minutes with near total clot removal and resolution of mass effect for all reviewed cases with no patients experiencing procedure-related postoperative decline. CONCLUSIONS: Minimally invasive catheter-based and parafascicular approaches using tubular retractors are increasingly recognized as a viable option in the treatment of subcortical lesions. The MindsEye is the first expandable brain access port designed for removal of deep intracranial lesions. We believe it represents a recent addition in the armament of cranial surgeons.

Asymmetry of the C2 pars interarticularis: a clinical anatomical study with relevance to screw placement.

PURPOSE: Potential asymmetries of the C2 posterior elements pose a problem for the spine surgeon seeking to make the best choice for spinal stabilization while reducing morbidity. METHODS: A digital caliper was used to measure the pars interarticularis height and length on left and right sides of 25 adult C2 vertebrae. The pars interarticularis was defined as the bone between the posterior most aspect of the superior articular process and the anterior most aspect of the inferior articular process of C2. Also, the C2 vertebrae from 49 patients were scanned by CT. Parasagittal images were reviewed and using the same definitions as were used for the skeletal specimens, the length and the height of the C2 pars interarticularis from both the left and right sides were measured using CT. The image slices were acquired at 3 mm intervals. The pars interarticularis height was determined on sagittal CT reconstruction, while the pars interarticularis length was calculated on the basis of the axial images. RESULTS: The lengths and the heights of the left and right pars interarticularis were compared using CTs of patients and skeletal specimens. No significant differences were found in the length and height measurements of the CT images on both sides. However, in the skeletal specimens, the left and right pars interarticularis did not differ significantly in length but differed significantly in height (p = 0.003). The mean height of the left pars interarticularis was approximately two times larger than the right in the skeletal specimens. Absolute differences were calculated between the side with the greater length and height and the side with the lesser length and height irrespective of their left-right orientations. For CT measurements, most differences in length and height between the greater pars interarticularis and lesser pars interarticularis occurred between 0 and 1 mm with each successive disparity interval yielding lower numbers. Skeletal measurements revealed a similar length disparity distribution to the CT measurements. However, height measurements in the skeletal specimens varied widely. Eight pars interarticularis specimens demonstrated a height difference between 0 and 1 mm. No dry bone pars interarticularis specimens demonstrated a height difference between 1 and 2 mm. The pars interarticularis of nine specimens demonstrated a height difference between 2 and 3 mm. Two demonstrated a height difference between 3 and 4 mm. Four demonstrated a height difference between 4 and 5 mm and two demonstrated a height difference greater than 5 mm. The greater pars interarticularis lengths and heights were combined and compared to their lesser counterparts on CT and skeletal measurements. In all measurements of this type, significant differences were found in the pars interarticularis length and height, whether measured through CT or via digital calipers. CONCLUSION: Asymmetry between the left and right C2 pars interarticularis as shown in the present study can alter surgical planning. Therefore, knowledge of this anatomical finding might be useful to spine surgeons.

A Fairness of Data Combination in Wireless Packet Scheduling.

With the proliferation of artificial intelligence (AI) technology, the function of AI in a sixth generation (6G) environment is likely to come into play on a large scale. Moreover, in recent years, with the rapid advancement in AI technology, the ethical issues of AI have become a hot topic. In this paper, the ethical concern of AI in wireless networks is studied from the perspective of fairness in data. To make the dataset fairer, novel dataset categorization and dataset combination schemes are proposed. For the dataset categorization scheme, a deep-learning-based dataset categorization (DLDC) model is proposed. Based on the results of the DLDC model, the input dataset is categorized based on the group index. The datasets based on the group index are combined using various combination schemes. Through simulations, the results of each dataset combination method and their performance are compared, and the advantages and disadvantages of fairness and performance according to the dataset configuration are analyzed.

The Longissimus Capitis Insertion as a Superficial Landmark for the Sigmoid Sinus: An Anatomical Study.

Objective Many external anatomical landmarks have been used for approximating deeper, intracranial structures. Herein, we evaluate the attachment of the longissimus capitis (LC) on the mastoid process as a landmark for the underlying sigmoid sinus. Methods Adult cadavers underwent dissection of the posterior occiput with special attention to the attachment of the LC muscle. Once the periphery of the muscle's tendon of attachment was determined, a burr hole was made in this area and evaluated internally for its relationship to the sigmoid sinus. Results From an intracranial view, burr holes on all sides were over the sigmoid sinus and just slightly lateral to the center of the sinus. The distance from the midline to the medial border of the insertion of the LC had a mean of 63.0 ± 7.2 mm. The width of the tendon of insertion of the LC on the mastoid process had a mean of 17.6 ± 5.7 mm. The length of the tendon insertion of the LC had a mean of 14.7 ± 4.7 mm. The distance from the inferior border of the insertion of the LC to the tip of the mastoid process had a mean of 6.2 ± 4.5 mm. Conclusion To our knowledge, use of the attachment site of the LC on the mastoid process as an external landmark for the underlying sigmoid sinus has not previously been reported. Based on our cadaveric findings, the sigmoid sinus is centered under the attachment of the LC regardless of the width of its tendon.

Review of the Petroclinoid Ligament.

An ossified left petroclinoid ligament was found during routine dissection of the skull base in an adult male cadaver. The petroclinoid ligament is clinically and surgically important given its anatomical relationships to cranial nerves III, V, and VI, so its ossification is a risk factor for injuries due to trauma, increased intracranial pressure, and vascular and tumor compression resulting in abducens and oculomotor palsies. The causes of petroclinoid ligament ossification are yet to be completely elucidated although several reports have associated them with age-related and physiological processes. Assessing the integrity of the petroclinoid ligament is important during skull base surgical interventions to avoid postoperative complications. Therefore, this paper reviews the petroclinoid ligament and its variation, the ossified petroclinoid ligament.

Chordae Willisii Within the Transverse Sinus: Morphologic Study.

OBJECTIVE: Some have suggested that trabeculae within the transverse sinuses (chordae Willisii) might restrict flow and potentially contribute to thrombus organization. In addition, these structures might be encountered with endovascular procedures within the transverse sinus and are now readily seen on imaging. Therefore as anatomic studies of these structures are scant, the current study aimed to better elucidate these structures within the transverse sinus via a morphologic study in cadavers. METHODS: Thirty fresh-frozen, cadaveric transverse sinuses were dissected, and their detailed morphology was recorded. Classification schemes were applied based on the anatomy and orientation of each chordae. RESULTS: Chordae were found on 70% of sides and were statistically more likely to be found on right sides (86.6%) (P < 0.01). Three types and 3 classes of chordae were identified. There was a statistically significant difference between sides regarding type of chordae (P = 0.02). CONCLUSIONS: To date, a comprehensive anatomic evaluation of the intraluminal chordae of the transverse sinuses has been lacking. Knowledge of these bands is also essential to those performing endovascular procedures of the dural venous sinuses and for those interpreting imaging of these structures.

Performance Analysis of Different Backoff Algorithms for WBAN-Based Emerging Sensor Networks.

The Carrier Sense Multiple Access with Collision Avoidance (CSMA/CA) procedure of IEEE 802.15.6 Medium Access Control (MAC) protocols for the Wireless Body Area Network (WBAN) use an Alternative Binary Exponential Backoff (ABEB) procedure. The backoff algorithm plays an important role to avoid collision in wireless networks. The Binary Exponential Backoff (BEB) algorithm used in different standards does not obtain the optimum performance due to enormous Contention Window (CW) gaps induced from packet collisions. Therefore, The IEEE 802.15.6 CSMA/CA has developed the ABEB procedure to avoid the large CW gaps upon each collision. However, the ABEB algorithm may lead to a high collision rate (as the CW size is incremented on every alternative collision) and poor utilization of the channel due to the gap between the subsequent CW. To minimize the gap between subsequent CW sizes, we adopted the Prioritized Fibonacci Backoff (PFB) procedure. This procedure leads to a smooth and gradual increase in the CW size, after each collision, which eventually decreases the waiting time, and the contending node can access the channel promptly with little delay; while ABEB leads to irregular and fluctuated CW values, which eventually increase collision and waiting time before a re-transmission attempt. We analytically approach this problem by employing a Markov chain to design the PFB scheme for the CSMA/CA procedure of the IEEE 80.15.6 standard. The performance of the PFB algorithm is compared against the ABEB function of WBAN CSMA/CA. The results show that the PFB procedure adopted for IEEE 802.15.6 CSMA/CA outperforms the ABEB procedure.

Tilt-table test: its role in modern practice.

Syncope is a major healthcare problem with significant morbidity, mortality and healthcare cost. It is a common symptom with a complex pathophysiology and, therefore, several aetiologies. Tilt-table testing (TTT) is an important, yet perhaps not widely-used, test that forms part of the management of syncope. We sought to assess the utilisation of this test in our institution for the investigation of patients with syncope, to study the referral patterns and the outcomes and usefulness of the TTT in a real-life setting. We undertook a retrospective study of all the TTT that were performed in our institution between January 2009 and October 2009. Of the 69 patients in which TTT was performed, 14 (20%) presented with presyncope, 24 (35%) with a single episode of syncope and 24 (44%) with multiple episodes. The average age was 57.2 years and 64% were female. Of the total patients, 35 (51%) had an abnormal TTT. Of the patients with normal TTT, four had internal loop recorders and six were referred to other medical specialities. The remaining patients (49%) had no formal diagnosis and were referred back to their general practitioner. TTT remains a common test modality and has great value when undertaken in the correct clinical context. This underlines the importance of a detailed clinical history. The European Society of Cardiology guidelines ensure a methodical and rational approach to syncopal patients and aide in choosing the right patient for the right test.

A very low power MAC (VLPM) protocol for Wireless Body Area Networks.

Wireless Body Area Networks (WBANs) consist of a limited number of battery operated nodes that are used to monitor the vital signs of a patient over long periods of time without restricting the patient's movements. They are an easy and fast way to diagnose the patient's status and to consult the doctor. Device as well as network lifetime are among the most important factors in a WBAN. Prolonging the lifetime of the WBAN strongly depends on controlling the energy consumption of sensor nodes. To achieve energy efficiency, low duty cycle MAC protocols are used, but for medical applications, especially in the case of pacemakers where data have time-limited relevance, these protocols increase latency which is highly undesirable and leads to system instability. In this paper, we propose a low power MAC protocol (VLPM) based on existing wakeup radio approaches which reduce energy consumption as well as improving the response time of a node. We categorize the traffic into uplink and downlink traffic. The nodes are equipped with both a low power wake-up transmitter and receiver. The low power wake-up receiver monitors the activity on channel all the time with a very low power and keeps the MCU (Micro Controller Unit) along with main radio in sleep mode. When a node [BN or BNC (BAN Coordinator)] wants to communicate with another node, it uses the low-power radio to send a wakeup packet, which will prompt the receiver to power up its primary radio to listen for the message that follows shortly. The wake-up packet contains the desired node's ID along with some other information to let the targeted node to wake-up and take part in communication and let all other nodes to go to sleep mode quickly. The VLPM protocol is proposed for applications having low traffic conditions. For high traffic rates, optimization is needed. Analytical results show that the proposed protocol outperforms both synchronized and unsynchronized MAC protocols like T-MAC, SCP-MAC, B-MAC and X-MAC in terms of energy consumption and response time.

Seamless interworking architecture for WBAN in heterogeneous wireless networks with QoS guarantees.

The IEEE 802.15.6 standard is a communication standard optimized for low-power and short-range in-body/on-body nodes to serve a variety of medical, consumer electronics and entertainment applications. Providing high mobility with guaranteed Quality of Service (QoS) to a WBAN user in heterogeneous wireless networks is a challenging task. A WBAN uses a Personal Digital Assistant (PDA) to gather data from body sensors and forwards it to a remote server through wide range wireless networks. In this paper, we present a coexistence study of WBAN with Wireless Local Area Networks (WLAN) and Wireless Wide Area Networks (WWANs). The main issue is interworking of WBAN in heterogenous wireless networks including seamless handover, QoS, emergency services, cooperation and security. We propose a Seamless Interworking Architecture (SIA) for WBAN in heterogenous wireless networks based on a cost function. The cost function is based on power consumption and data throughput costs. Our simulation results show that the proposed scheme outperforms typical approaches in terms of throughput, delay and packet loss rate.

A study of MAC protocols for WBANs.

The seamless integration of low-power, miniaturised, invasive/non-invasive lightweight sensor nodes have contributed to the development of a proactive and unobtrusive Wireless Body Area Network (WBAN). A WBAN provides long-term health monitoring of a patient without any constraint on his/her normal dailylife activities. This monitoring requires the low-power operation of invasive/non-invasive sensor nodes. In other words, a power-efficient Medium Access Control (MAC) protocol is required to satisfy the stringent WBAN requirements, including low-power consumption. In this paper, we first outline the WBAN requirements that are important for the design of a low-power MAC protocol. Then we study low-power MAC protocols proposed/investigated for a WBAN with emphasis on their strengths and weaknesses. We also review different power-efficient mechanisms for a WBAN. In addition, useful suggestions are given to help the MAC designers to develop a low-power MAC protocol that will satisfy the stringent requirements.

MAC-bridging for multi-PHYs communication in BAN.

Body Area Network (BAN) is a collection of low-power, miniaturised, and intelligent sensor nodes that are used for unobtrusive and ambulatory health monitoring of a patient without any additional constraints. These nodes operate on different frequency bands or Multiple Physical Layers (Multi-PHYs). Additionally, some BAN applications demand a logical connection between different nodes working on different Multi-PHYs. In this paper, the idea of controlling Multi-PHYs using one MAC protocol is introduced. Unlike existing procedures where different nodes working on different channels are connected at the link layer bridging/switching, the proposed procedure called bridging logically connects them at the MAC layer. In other words, the bridge is used to relay or filter packets between different PHYs in the same BAN. Numerical approximations are presented to analyze the stochastic behaviour of the bridges, all of them having Multi-PHYs interfaces. The MICS and the ISM bands are regarded as PHY1 and PHY2, respectively. The performance results are presented for PHY2 (given that data is already received from PHY1) in terms of probability of successful transmission, number of failed requests, power consumption, and delay. Simulations are conducted to validate the analytical results. It can be seen that the deployment of multiple bridges along with the corresponding nodes allows Multi-PHYs communication with high transmission probability, low power consumption, and tolerable delay.

Hydatid cysts of the brain.

BACKGROUND: Brain involvement with hydatid disease occurs in 1-2% of all Echinococcus granulosus infections. Cerebral hydatid cysts are usually supratentorial, whereas infratentorial lesions are quite rare. Objective of the study was to determine the clinical presentation and surgical outcome of cranial hydatidosis. METHODS: This retrospective study was performed in the department of neurosurgery LRH Peshawar from December 2000 to Oct 2007. Twenty one cases with intracranial hydatidosis were operated. The patients were either admitted through OPD or referred from other units. CT and/or MRI were the imaging modalities to reach the diagnosis in addition to serological and haematological tests. Surgery was the only treatment option used. Pericystic hydraulic method was the technique used for the excision of the hydatid cyst of brain. RESULTS: There were 9 males and 12 females with male to female ratio of 1:1.3. All patients belonged to paediatric age group with age range of 3-14 years and mean age of 7.42 +/- 3.2 years. Headache, vomiting, papilloedema were present in all the patients while seizures were the present in 16 patients. The lesion was removed surgically by adopting pericystic hydraulic method during craniotomy in all cases. There was no intra-operative morbidity except that the cyst ruptured in one case. No postoperative complications were noted and there was no mortality. CONCLUSION: Hydatid cyst of the brain presents clinically as intracranial space occupying lesion and is more common in children. Surgery is the treatment option with affordable morbidity and low mortality.

Nocturnal asthma in school children of south Punjab, Pakistan.

BACKGROUND: At the present time, the epidemiology of the childhood asthma is of considerable interest. There is an understandable concern that changes in the geographical area, lifestyle, and environment. This study was conducted to find the prevalence of nocturnal asthma, in school children of south Punjab, Pakistan. METHODS: It was a cross sectional, questionnaire based, descriptive survey of the children aged 3-18 years, in randomly selected primary and secondary schools, from October 2002 to March 2003. The data was analysed with Statistical Analysis System (SAS). RESULTS: Of 6120 questionnaire sent to the parents/guardians, we received 3180 back (52%). Of the 3180 respondents, 1767 (56%) were for boys and 1413 (44%) were for girls. The median age was 8.25 years. Around 71% of children were between 4 to 11 years of age. The parents reported nocturnal asthma in 177 (6%) of their children with an equal prevalence in boys and girls, i.e., (3% each, rounded off to nearest whole number). Of these 177 children with nocturnal asthma, 99 (56%) were boys and 78 (44%) were girls. Of the 1767 boys, and 1413 girls, the nocturnal asthma reported by parents was 6% each (99 and 78 respectively). The nocturnal asthma was not reported in 14-18 years age group of females. CONCLUSION: The asthma is taken as a stigma in our society and as such is not reported or disclosed rather denied. An extensive educational media campaign is required for awareness of the masses.

Simplified quantification of urinary protein excretion in children with nephrotic syndrome.

OBJECTIVE: To assess the value of single voided random (spot) urinary protein to creatinine ratio in accurately predicting the 24-hour urinary protein excretion in Pakistani pediatric population with nephrotic syndrome. DESIGN: Cross-sectional, analytical study. PLACE AND DURATION OF STUDY: The Pediatric Department, Nishtar Hospital/ Children Complex, Multan, from January 2003 to November, 2005. PATIENTS AND METHODS: Fifty seven children between 1-18 years with nephrotic syndrome were included. Seventy pairs of spot urine (5 milliliter) and 24-hour urine were collected in different phases of their disease e.g. initial, induction and remission. The protein to creatinine ratio was determined in spot urine samples and total protein content in 24-hour urine samples. The correlation between the ratio and 24-hour urinary protein excreted was determined using Pearson's coefficient (r) linear regression analysis. RESULTS: The protein to creatinine ratio in a spot urine sample was significantly correlated with the 24-hour urinary protein. The correlation coefficient (least square method) was found to be significant (r=0.9444). A random (spot) urinary protein to creatinine ratio of greater than 2 correlated well with the massive proteinuria (i.e. nephrotic syndrome), between 2 to 0.2 indicated glomerulopathy while a ratio of less than 0.2 was suggestive of physiological values. CONCLUSION: The random spot urinary protein to creatinine ratio can reliably be used to assess the degree of proteinuria in children with nephrotic syndrome and can replace the 24-hour urinary protein excretion/collection.

HydroCoil embolization of a ruptured infectious aneurysm in a pediatric patient: case report and review of the literature.

INTRODUCTION: Intracranial infectious aneurysms in the pediatric population are rare. Although surgery has been the traditional treatment of ruptured pediatric infectious aneurysms, endovascular coil embolization has become an attractive alternative due to its low rate of morbidity and mortality. CASE REPORT: A 9-year-old boy with a significant medical history of aortic valve replacement, antibiotic-treated infective endocarditis, and multiple embolic cerebral infarcts presented with a high-grade intraventricular hemorrhage due to the rupture of a large infectious proximal posterior circulation aneurysm. Computed tomography and cerebral angiogram demonstrated a right crural/ambient cistern hematoma and an associated infectious aneurysm of the right proximal posterior cerebral artery. The ruptured infectious aneurysm was coil-embolized with hydrogel-coated platinum coils without sacrifice of the distal parent artery. The aneurysm was completely occluded, and the patient regained all neurological function. CONCLUSION: Ruptured infectious aneurysms in the pediatric population occur despite aggressive medical therapy. Patients with infective endocarditis and embolic infarcts should be followed closely due to the risk of major hemorrhagic events, including aneurysm rupture. Hybrid coil embolization of ruptured infectious aneurysms with preservation of the distal parent artery is exceedingly rare and effective in the management of ruptured infectious aneurysms in the pediatric population.

Hypertriglyceridemia in pediatrics.

Primary hypertriglyceridemias are very rare in pediatric age group. A case of 12 years old boy with hypertriglyceridemia is presented. He was being treated as a case of thalassemia major since 2 years of age and was picked up incidentally when his serum turned milky on standing. Since hypertriglyceridemia is a known risk factor for the acute pancreatitis so an early detection is helpful in adoption of a healthy life style.