Enhanced recovery and same-day discharge after brain tumor surgery under general anesthesia: initial experience with Hospital-at-Home-based postoperative follow-up.

OBJECTIVE: The objective of this study was to describe the outcomes of outpatient oncological neurosurgery (OON) in a European clinical setting and to compare them with the conventional inpatient protocol. METHODS: Patients who had undergone OON (either tumor removal or biopsy) at the authors' center since 2019 were analyzed. A matched cohort of patients was selected from patients undergoing tumor surgery in the same period. Collected data included patient demographics, postoperative progress, specific location of the target lesion, and the procedure performed. RESULTS: There were 18 patients in the case group and 59 patients in the control group. The outpatient surgeries had a same-day discharge rate of 89%, and all ambulatory patients successfully completed the Enhanced Recovery After Surgery program within 6.24 hours of the procedure. All ambulatory patients underwent Hospital-at-Home postoperative follow-up for an average of 4.12 days. Radiological complications were present in 11% of the case group and 8% of the control group. Postoperative neurological deficit occurred in 6% of the same-day discharge group and 3% of the control group. Among the patients in the control group, 3% suffered from postoperative seizures, whereas no seizures were observed in the case group. These differences were not statistically significant. General anesthesia-related complications were not observed in any of the patients. CONCLUSIONS: The authors' findings demonstrate that Enhanced Recovery After Surgery protocols and same-day discharge craniotomy for tumor resection and image-guided biopsy under general anesthesia, when patients are carefully selected, can be safely performed with excellent outcomes in a European clinical setting. The OON program proved to be a viable alternative to conventional hospitalization, showing comparable safety records and offering advantages in terms of patient recovery.

Poor regulation, desperation, and misinformation, a countrywide analysis of self-medication and prescription patterns in Ecuador during the COVID-19 pandemic.

BACKGROUND: The rapid spread of the SARS-CoV-2 virus during the early phase of the pandemic led to an unprecedented global health crisis. Various factors have influenced self-medication practices among the general population and unsubstantiated prescribing practices among healthcare professionals. OBJECTIVE: This study aimed to describe trends in the purchase and sale of medicines during the COVID-19 pandemic period (2020-2022) in Ecuador, by comparing them with pre-pandemic periods. METHODS: In this study, a cross-sectional design was employed to conduct a comprehensive analysis of 28 pharmacological groups, categorized according to the Anatomical Therapeutic Chemical Classification (ATC). Utilizing an integrated drug consumption database, the study examined physician prescribing data, medicine usage, and spending levels in Ecuador during the COVID-19 pandemic. The analysis involved computing absolute differences in monthly resolution, calculating excessive expenditure in comparison to previous yearly averages, and using Defined Daily Dose (DDD) methodology for internationally comparable results. Furthermore, a correlation analysis was performed to investigate potential associations between prescribed and consumed medicines and the number of new cases and deaths. RESULTS: In Ecuador, the average yearly expenditure among these groups prior to the pandemic (2017-2019) amounted to $150,646,206 USD, whereas during 2020 and 2021, the same groups represented a total expenditure of $228,327,210, reflecting a significant increase. The excess expenditure during this period reached 51.4%, equivalent to $77,681,004 USD. Notably, 13% of this expenditure consisted of Over the Counter (OTC) Medicines. The study also identified a remarkable surge in sales of ivermectin, which increased by 2,057%, and hydroxychloroquine, which increased by 171%, as measured by DDD. CONCLUSIONS: This study highlights the substantial consumption of medicines by the population in Ecuador during the pandemic. It is concerning that many medications were sold without proven therapeutic indications, indicating that misinformation and desperation may have led to improper prescribing by physicians and patients resorting to ineffective drugs. Moreover, since the sale of these therapeutic drugs requires a prescription, poor regulation, and a lack of control within pharmacies likely contributed to such practices.

Barriers and facilitators in the implementation of a telemedicine-based outpatient brain tumor surgery program.

OBJECTIVE: Despite growing evidence on the benefits of outpatient oncological neurosurgery (OON), it is only performed in a few specialized centers and there are no previous descriptions of established OON programs in Europe. Moreover, increasing application of telemedicine strategies, especially after the start of the coronavirus disease 2019 (COVID-19) pandemic, is drastically changing neurosurgical management, particularly in the case of vulnerable populations such as neuro-oncological patients. In this context, the authors implemented an OON program in their hospital with telematic follow-up. Herein, they describe the protocol and qualitatively analyze the barriers and facilitators of the development process. METHODS: An OON program was developed through the following steps: assessment of hospital needs, specific OON training, multidisciplinary team organization, and OON protocol design. In addition, the implementation phase included training sessions, a pilot study, and continuous improvement sessions. Finally, barriers and facilitators of the protocol's implementation were identified from the feedback of all participants. RESULTS: An OON protocol was successfully designed and implemented for resection or biopsy of supratentorial lesions up to 3 cm in diameter. The protocol included the patient's admission to the day surgery unit, noninvasive anesthetic monitoring, same-day discharge, and admission to the hospital-at-home (HaH) unit for telematic and on-site postoperative care. After a pilot study including 10 procedures in 9 patients, the main barriers identified were healthcare provider resistance to change, lack of experience in outpatient neurosurgery, patient reluctance, and limitations in the recruitment of patients. Key facilitators of the process were the patient education program, the multidisciplinary team approach, and the HaH-based telematic postoperative care. CONCLUSIONS: Initiating an OON program with telematic follow-up in a European clinical setting is feasible. Nevertheless, it poses several barriers that can be overcome by identifying and maximizing key facilitators of the process. Among them, patient education, a multidisciplinary team approach, and HaH-based postoperative care were crucial to the success of the program. Future studies should investigate the cost-effectiveness of telemedicine to assess potential cost savings, from reduced travel and wait times, and the impact on patient satisfaction.

Monitoring recent changes of vegetation in Fildes Peninsula (King George Island, Antarctica) through satellite imagery guided by UAV surveys.

Mapping accurately vegetation surfaces in space and time in the ice-free areas of Antarctica can provide important information to quantitatively describe the evolution of their ecosystems. Spaceborne remote sensing is the adequate way to map and evaluate multitemporal changes on the Antarctic vegetation at large but its nature of occurrence, in relatively small and sparse patches, makes the identification very challenging. The inclusion of an intermediate scale of observation between ground and satellite scales, provided by Unmanned Aerial Vehicles (UAV) imagery, is of great help not only for their effective classification, but also for discriminating their main communities (lichens and mosses). Thus, this paper quantifies accurately recent changes of the vegetated areas in Fildes Peninsula (King George Island, Antarctica) through a novel methodology based on the integration of multiplatform data (satellite and UAV). It consists of multiscale imagery (spatial resolution of 2 m and 2 cm) from the same period to create a robust classifier that, after intensive calibration, is adequately used in other dates, where field reference data is scarce or not available at all. The methodology is developed and tested with UAV and satellite data from 2017 showing overall accuracies of 96% and kappa equal to 0.94 with a SVM classifier. These high performances allow the extrapolation to a pair of previous dates, 2006 and 2013, when atmospherically clear very high-resolution satellite imagery are available. The classification allows verifying a loss of the total area of vegetation of 4.5% during the 11-year time period under analysis, which corresponds to a 10.3% reduction for Usnea sp. and 9.8% for moss formations. Nevertheless, the breakdown analysis by time period shows a distinct behaviour for each vegetation type which are evaluated and discussed, namely for Usnea sp. whose decline is likely to be related to changing snow conditions.

The neural pathway midline crossing theory: a historical analysis of Santiago Rámon y Cajal's contribution on cerebral localization and on contralateral forebrain organization.

Throughout history, many scientists have wondered about the reason for neural pathway decussation in the CNS resulting in contralateral forebrain organization. Hitherto, one of the most accepted theories is the one described by the renowned Spanish physician, Santiago Rámon y Cajal at the end of the 19th century. This Nobel Prize winner, among his many contributions to science, gave us the answer to this question: the key lies in the optic chiasm. Based on the fact that the ocular lenses invert the image formed in the retina, Cajal explained how the decussation of the fibers in the optic chiasm is necessary to obtain a continuous image of the outside in the brain. The crossing of the tactile and motor pathways occurred posteriorly as a compensatory mechanism to allow the cortical integration of the sensory, motor, and visual functions. This theory had a great influence on the scientific community of his time, and maintains its importance today, in which none of the theories formulated to date has managed to entirely refute Cajal's. In addition, the decussation of neural pathways plays a significant role in different diseases, especially in the recovery process after a hemispheric lesion and in several congenital pathologies. The advantages of cerebral lateralization have also recently been published, although the evolutionary connection between fiber decussation and cortical function lateralization remains a mystery to be solved. A better understanding of the molecular and genetic substrates of the midline crossing processes might result in significant clinical advances in brain plasticity and repair.

Molecular and Clinical Insights into the Invasive Capacity of Glioblastoma Cells.

The invasive capacity of GBM is one of the key tumoral features associated with treatment resistance, recurrence, and poor overall survival. The molecular machinery underlying GBM invasiveness comprises an intricate network of signaling pathways and interactions with the extracellular matrix and host cells. Among them, PI3k/Akt, Wnt, Hedgehog, and NFkB play a crucial role in the cellular processes related to invasion. A better understanding of these pathways could potentially help in developing new therapeutic approaches with better outcomes. Nevertheless, despite significant advances made over the last decade on these molecular and cellular mechanisms, they have not been translated into the clinical practice. Moreover, targeting the infiltrative tumor and its significance regarding outcome is still a major clinical challenge. For instance, the pre- and intraoperative methods used to identify the infiltrative tumor are limited when trying to accurately define the tumor boundaries and the burden of tumor cells in the infiltrated parenchyma. Besides, the impact of treating the infiltrative tumor remains unclear. Here we aim to highlight the molecular and clinical hallmarks of invasion in GBM.

Evaluation of the use of very high resolution aerial imagery for accurate ice-wedge polygon mapping (Adventdalen, Svalbard).

The main objective of this paper is to verify the accuracy of delineating and characterizing ice-wedge polygonal networks with features exclusively extracted from remotely sensed images of very high resolution. This kind of mapping plays a key role for quantifying ice-wedge degradation in warming permafrost. The evaluation of mapping a network is performed in this study with two sets of aerial images that are compared to ground reference data determined by fieldwork on the same network, located in Adventdalen, Svalbard (78°N). One aerial dataset is obtained from a photogrammetric survey with RGB+NIR imagery of 20cm/pixel, the other from an UAV (Unmanned Aerial Vehicle) survey that acquired RGB images of 6cm/pixel of spatial resolution. Besides evaluating the degree of matching between the delineations, the morphometric and topological features computed for the differently mapped versions of the network are also confronted, to have a more solid basis of comparison. The results obtained are similar enough to admit that remotely sensed images of very high resolution are an adequate support to provide extensive characterizations and classifications of this kind of patterned ground.

Accurate determination of surface reference data in digital photographs in ice-free surfaces of Maritime Antarctica.

The ice-free areas of Maritime Antarctica show complex mosaics of surface covers, with wide patches of diverse bare soils and rock, together with various vegetation communities dominated by lichens and mosses. The microscale variability is difficult to characterize and quantify, but is essential for ground-truthing and for defining classifiers for large areas using, for example high resolution satellite imagery, or even ultra-high resolution unmanned aerial vehicle (UAV) imagery. The main objective of this paper is to verify the ability and robustness of an automated approach to discriminate the variety of surface types in digital photographs acquired at ground level in ice-free regions of Maritime Antarctica. The proposed method is based on an object-based classification procedure built in two main steps: first, on the automated delineation of homogeneous regions (the objects) of the images through the watershed transform with adequate filtering to avoid an over-segmentation, and second, on labelling each identified object with a supervised decision classifier trained with samples of representative objects of ice-free surface types (bare rock, bare soil, moss and lichen formations). The method is evaluated with images acquired in summer campaigns in Fildes and Barton peninsulas (King George Island, South Shetlands). The best performances for the datasets of the two peninsulas are achieved with a SVM classifier with overall accuracies of about 92% and kappa values around 0.89. The excellent performances allow validating the adequacy of the approach for obtaining accurate surface reference data at the complete pixel scale (sub-metric) of current very high resolution (VHR) satellite images, instead of a common single point sampling.