bluuebunny/crossref_metadata_2025 huggingface dataset:
Human Milk Expression Practices, Experiences and Perceptions among Mothers: A Systematic Literature Review
Authors: Mohamad Alwi Nor Kamariah , Sulaiman Zaharah , Tengku Ismail Tengku Alina
Published: October 2023

Human milk expression is commonly practiced among breastfeeding mothers. Their practices, experiences, and perceptions varies due to many underlying environments and issues. This review describes practices, experiences, and perceptions of mothers in expressing milk. Literature search was conducted for peer-reviewed articles on milk expression using Scopus, Krisalis Discovery, CINAHL, and PubMed from 2010 to 2020 for qualitative and mixed studies. This review and reporting was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Screening and selection of articles were conducted using Distiller Systematic Review (DSR). Twenty-two qualitative studies were identified focusing on the milk expression practices, experiences, and perceptions of mothers. Their practices indicated time, duration and method of milk expression. The experiences found were on the reasons, challenges, coping strategies and motivations. The perceptions on milk expression were found to influence the experience and practices of milk expression. Human milk expression practices, experiences and perceptions have been highlighted in many studies; however, there is no clear association between practices, experiences and perception.
Anticoagulant Activity in Medicinal Plants: A Systematic and Bibliometric Review Over 10 Years (2011-2021)
Authors: Kamaru Azman Auni Nur Sabrina , Amal A.M. Elgharbawy
Published: October 2023

Anticoagulants are helpful as treatment for coagulation disorders. Medicinal plants have been demonstrated to be part of history as a traditional treatment for this disorder, and these plants have anticoagulant properties. Hence, the goal of this study is to review the available publications on anticoagulant activity in medicinal plants from the year 2011 until 2021 using Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines and bibliometric analysis. This review was performed based on the PRISMA guidelines and VOSviewer as a bibliometric analysis tool, using three search databases which were PubMed, MyMedR, and ScienceDirect. The findings of this study revealed that 27 articles met the inclusion criteria and focused on anticoagulant activity in medicinal plants. In each study, anticoagulant properties in medicinal plants were addressed. Meanwhile, the results of the bibliometric analysis demonstrated that China has the most publication for anticoagulant activity in medicinal plants and had the mostcollaboration among institutes in their country. For the most used keywords used by the author, the word "anticoagulant activity" came on top of the results. To conclude, this study can contribute to the field of study as it helps combine the data related to anticoagulant activities in medicinal plants.
Carbapenem-Resistant Enterobacteriaceae Bacteraemia in Intensive Care Unit: A Descriptive Study on Risk Factors and Clinical Outcome
Authors: Nachamuthu Sivasangari , Ibrahim Noor Airini , Su Min Hu Felicia , Ganesh Shahmini
Published: October 2023

INTRODUCTION: Over the past 10 years, the prevalence of carbapenem-resistant Enterobacteriaceae (CRE) has been increasing dramatically with numerous hospital outbreaks reported. Bacteraemia caused by CRE have limited treatment options and have been associated with high mortality rates. As a result, preventing both CRE transmission and CRE bloodstream infections have become important objectives in managing intensive care unit (ICU) patients. The study aims to determine the incidence and risk factors of CRE bacteraemia in intensive care settings, and its’ clinical outcome. MATERIALS AND METHODS: A retrospective, descriptive study was conducted, where data of the patients admitted to general ICU of Hospital Pulau Pinang from January 2017 till December 2018 were collected and assessed for incidence, presence of predisposing factors and clinical outcome for CRE bloodstream infection. RESULTS: Out of 2,585 total ICU admissions, there were 37 cases of CRE bacteraemia with an incidence rate of 1.43%. An analysis of risk factors revealed that the use of indwelling catheter has the highest association with CRE bacteraemia in which 95% of the patients were exposed. The commonest organisms of CRE bacteraemia were Klebsiella pneumoniae (97.3%) and Escherichia coli (2.7%). The 30-day mortality rate after CRE bacteraemia was 78.4%. CONCLUSION: CRE bacteraemia among ICU patients showed a high mortality rate. Most of the patients were exposed to multiple risk factors. A high index of suspicion and rapid identification of patients at risk for CRE infection are important for effective therapy and initiation of infection control measures to prevent further spread.
Sources of Perceived Social Support and Associated Factors for Depression amongst Malay Primary School Adolescents in Kelantan, Malaysia
Authors: Rahman Azriani , Rani Nor Azila , Wan Mohammad Wan Mohd Zahiruddin , Zakaria Norzila
Published: October 2023

INTRODUCTION: Adolescent depression is a substantial health concern nowadays, and perceived social support determines the outcome. Lack of research on depression amongst Malaysian younger group of adolescents, puts them at risk of being under diagnosed and under treated. Furthermore, the function of various social supports for depression in early adolescents is less explored. The primary objective of this study was to determine the level of support for adolescent depression from five different sources: i) parents, ii) teachers, iii) close friends, iv) classmates, and v) others in school. The secondary objective is to study the prevalence of depression amongst primary school adolescents and establish their association and the other factors that influence depression. MATERIALS AND METHODS: A cross-sectional study involving 576 adolescents between the ages of 10-11 year olds were conducted from August 2020 till September 2020 using the Malay Children Depression Inventory (M-CDI) and Malay Child and Adolescent Social Support Scale (M-CASSS). RESULTS: The respondents reported that teachers were the most supportive. Approximately 131 (22.7%) of them had depressive symptoms. Only parental support significantly reduced their risk of developing depression. Having a single parent household, being bullied, emotional abuse, and performing poorly in school increased the likelihood of developing depression. CONCLUSION: Findings from this study, demonstrated the necessity for early depression screening amongst primary school adolescents and the need for stakeholders to continue supporting parents in their efforts to deal with adolescent concerns.
Clinical Characteristics and Outcomes of Klebsiella Pneumonia Bacteraemia in Adult
Authors: Lee Tiong Chan , Md Arif Asma’ , Razali Nurul Huda , Kulaisingham Vicknesan , Sukesh Hashvina , Tay Voon Yaa , Ghazali Mohd Ashraf , Ewe Jin Koh , Omar Sitinah , Othman Hamizan , Teck Toh Phang
Published: October 2023

INTRODUCTION: Klebsiella pneumonia (K. pneumonia) bacteremia is one of the leading causes of hospital morbidity and mortality. Our study aimed to evaluate the clinical characteristics, risk factors and outcomes of K. pneumonia bacteremia in a Malaysian public hospital. MATERIALS AND METHODS: A retrospective cross-sectional study of adults with K. pneumonia bacteremia was conducted in a hospital in Johor, Malaysia. Demographics, medical comorbidities, source of infections and the mortality rate was reviewed and analyzed. RESULTS: A total of 185 cases of K. pneumonia bacteremia were included for analysis. The mean age for this study was 54.9 (SD 15.4), with 56.8% males and 46.5% in-hospital mortality. Extended-spectrum Beta Lactamase (ESBL) producing and Carbapenem-resistant K. pneumonia contributed to 37.3% and 1.1 % of K. pneumonia bacteremia, respectively. Among those who contracted K. pneumonia bacteremia, two most frequent sources were primary bloodstream infections (n=75, 40.5%), pneumonia (n=44, 23.8%) and urinary tract infections (n=28, 15.1%). There was statistically significant associations found between diabetes mellitus (AOR 1.46, 95% CI 1.02-2.08), cancer (AOR 2.02, 95% CI 1.33-3.05) and alcohol use disorder (AOR 7.73,95% CI 1.38-43.21 ) with K. pneumonia bacteremia. In-hospital mortality was higher in older patients by 1.03 odds (p=0.003). CONCLUSION: Diabetes mellitus, cancer, and alcohol use disorder were independent risk factors associated with K. pneumonia bacteremia. Patients with advanced age had a higher mortality rate.
Factors Associated with Risk Exposure to Human Rabies among Mammal Bite Cases in Mukah Division, Sarawak, East Malaysia
Authors: Abdullah Nik Nairan , Hassan Mohammad Syafiq , Ibrahim Khalid
Published: October 2023

INTRODUCTION: Rabies is a neglected disease. Before the epidemic of rabies in Sarawak in July 2017, surveillance of mammal bites was not well implemented throughout the state. Our objective was to determine the prevalence of mammal bites in the Mukah Division and the factors that are associated with the risk of exposure to human rabies. MATERIALS AND METHODS: This is a cross-sectional study that used data from reported cases of mammal bites in Mukah Division, Sarawak, from 2018–2019. A universal sampling method was used, and 457 cases of mammal bites were included in the analysis. Data was analysed using single logistic regression and multiple logistic regression. RESULTS: The prevalence of mammal bites in Mukah Division was 0.35% with a cumulative incidence of 354 per 100 000 population. Age group 0-14 years old (AOR 6.49, 95%CI 1.26-33.53), free-roaming pet (AOR 2.93, 95% 1.36-6.28) and stray mammals (AOR 10.88, 95% CI 5.05-23.48) were found to be significantly associated with risk exposure to human rabies in Mukah Division in the final model. CONCLUSION: Health awareness and education should be emphasized to the community and medical personnel on the identified risk factors so that rabies infection can be prevented.
Nowoczesne metody neuroobrazowania we współczesnej neuroekonomii i neurozarządzaniu
Authors: Rutkowska Anna
Published: October 2023

Współczesne realia społeczno-gospodarcze implikują interdyscyplinarne podejście badawcze do psychologiczno-ekonomicznych uwarunkowań zjawisk i zachowań podmiotów rynkowych. Coraz większą rolę w identyfikacji mózgowych korelatów procesów decyzyjnych na gruncie naukowym i biznesowym odgrywa neuronauka. Celem artykułu jest przedstawienie nowoczesnych metod neuroobrazowania stosowanych najczęściej na gruncie ekonomii i zarządzania, a także określenie ich użyteczności w aspekcie poznawczym i aplikacyjnym. Artykuł ma charakter teoretycznych rozważań i stanowi tło teoretyczne do przeprowadzenia własnych badań empirycznych. Mając na uwadze konieczność interdyscyplinarnego podejścia do badania zachowań konsumenckich, dokonano przeglądu wybranej literatury przedmiotu z zakresu neuroekonomii i neurozarządzania. Syntetycznie scharakteryzowano istotę neuroobrazowania, przedstawiono wybrane wyniki badań, a także możliwość wykorzystania metody funkcjonalnego rezonansu magnetycznego (fMRI) i elektroencefalografii (EEG) w obszarze neurofinansów, neuromarketingu i neurozarządzania.
Badania literaturowe służyły podkreśleniu rosnącej roli holistycznego podejścia badawczego do analizy konsumenta oraz ukazaniu przydatności metody fMRI i EEG na gruncie badań ekonomicznych. Praktycznym aspektem wykorzystania metody fMRI i EEG w sferze biznesowej jest możliwość optymalnego dostosowania oferty produktowo-usługowej do potrzeb i preferencji konsumentów. Pomimo wielu zalet neuroobrazowania, należałoby jednak zwrócić większą uwagę na kwestie etyczne prowadzonych badań i komercyjnego wykorzystania wyników badań.
Professional Activation and Social Integration from the Perspective of the Social Economy Sector in Poland: the Example of Social Integration Centres
Authors: Łojko Majka
Published: October 2023

This paper examines the role and responsibilities of the social economy (SE) in Poland in promoting social and professional integration for individuals at risk of exclusion. It specifically focuses on Social Integration Centres as an example. The central argument is that these centres play a crucial role in providing multi-level support to at-risk individuals, enabling them to achieve social and professional integration.
The paper provides an overview of the topic, drawing conclusions from relevant literature, data from Statistics Poland, reports from the Ministry of Family, Labour and Social Policy, and scientific studies related to the social economy. The analysis shows that Social Integration Centres in Poland assist in the restoration and enhancement of the abilities of those who are socially excluded to enable them to perform social and professional roles independently. They implement multifaceted reintegration efforts, helping individuals to acquire the necessary skills to reengage in professional and social activities.
Role of Academia in the Life of an Academic City: a Case Study of Poznań, Poland
Authors: Stanowicka Agnieszka
Published: October 2023

The aim of this study has been to evaluate how a city-academia cooperation model functions, using the city of Poznań as a case for this study. Several benefits were identified from having a college or university seated in a city, for instance: stimulation of the city’s economic growth and development and of its cultural life, positive influence on the labour market, shaping a positive image of the city. For these reasons, the city authorities have been making efforts to attract students to Poznań, to sustain their interest in the city while in academia, and to retain the graduates in the city. It is highly probable that the cooperation model identified in Poznań will work in other academic centres, generating a number of development benefits.
Perspectives for energy development in Poland and in the European Union in the context of the European Green Deal: renewable energy and energy efficiency
Authors: Szczubełek Grzegorz
Published: October 2023

The European Green Deal is a development strategy which aims to transform the European Union into a climate-neutral area by 2050. Due to the scale of reforms it envisages, it is considered the largest legislative initiative in the history of the European Union. The research aims to analyse the prospects for energy development in Poland and in the European Union in the context of the European Green Deal, with a particular focus on potential ways to increase the share of renewable energy sources and improve energy efficiency.
Given the highly disparate environmental and socio-economic conditions, a number of EU countries will find it challenging to meet the ambitious requirements of the European Green Deal. Additionally, considering the huge impact of the Coronavirus pandemic and the war between Russia and Ukraine, the use of a sustainable energy security concept seems justified, as it takes into account the socio technical specificities of individual states. A predictable energy and climate policy consistent with the EU’s objectives may facilitate Poland’s fair transition towards sustainable development.
Structure of Assets and Liabilities of Non-financial Corporations by Selected NACE Sections
Authors: Zawadzka Agnieszka , Szmit Kornelia
Published: October 2023

Experience from nations with established market economies demonstrates that small and medium-sized businesses are more inventive and able to respond to client demands and needs more quickly than giant businesses. Many publications produced by the EU institutions emphasize their crucial function. Small- and medium-sized enterprises (SMEs) reflect a society's entrepreneurial spirit and a sign of healthy competition in every economy. However, these businesses have numerous growth constraints in a setting that is changing quickly. At first, it is not simple. Due to the higher risk that start-ups face compared to larger corporations, they have difficulty obtaining funding from traditional sources and SME enterprises experience an equity gap. As a result, having access to finance has become crucial to expanding and competing in a particular market. In accordance with the accepted legal norms, the receiver is required to comply with the conditions set forth by the capital donor-recipient to be able to access external sources.

One of the most significant influences on a company's ability to fulfil current obligations in full and generate adequate financial results is adherence to the fundamentals of asset financing, which highlight, among other things, the structural relationships in a company's balance sheet. The purpose of the analysis presented in this text is to identify differences in the structure of assets and liabilities between selected NACE sections of non-financial corporations in 2021 year. All analysed assets and liabilities are characterized by very strong asymmetry. Therefore, the outlier effect has been standardized using Weber median. Further statistical analyses used Kruskal-Wallis non-parametric ANOVA test to determine the similarity between assets and liabilities of selected NACE sections. The analysis showed that there are no significant differences in the assets and liabilities of the different NACE sections.

The PROFIT analysis allowed for a graphical representation of the structure of the similarities between the NACE sections analysed and their arrangement due to the intensity of the assets and liabilities. As regards the NACE sections analysed, three homogeneous groups can be distinguished, of which industry and trade constitute two of them and the others - the third. It has been shown that the industry section is characterized by the highest intensity in both assets and liabilities.
Anterolateral upper cervical approach for ventral C1–C2 meningioma
Authors: Rahmanov Serdar , Doğruel Yücel , Güngör Abuzer , Türe Uğur
Published: October 2023

The surgical management of ventral upper cervical meningiomas poses significant challenges due to their deep location and limited accessibility. These tumors have the potential to compress or involve nearby neurovascular structures, leading to various neurological complications including inferior cranial nerve palsy, motor deficits, and sensory disturbances such as hypoesthesia, paresthesia, and impaired coordination. To address this issue, surgical intervention through an anterolateral or far lateral approach has been recognized as the optimal treatment strategy. In this video, the authors present a detailed demonstration of the operative technique using an anterolateral upper cervical approach to safely resect a ventrally located C1–2 meningioma.
Resection of intradural intramedullary subependymoma of the cervicothoracic spine: 2-dimensional operative video
Authors: Vignolles-Jeong Joshua , Gruber Maxwell D. , Munjal Vikas , Cua Santino , Baum Justin , Chakravarthy Vikram B.
Published: October 2023

This video presents the case of a 44-year-old male with a 2-year history of pain in the left upper extremity that had worsened over the course of the last 6 months with associated weakened grip strength and had extended into his right arm. T2-weighted sagittal and axial MRI demonstrated an expansive nonenhancing solid intramedullary lesion extending from C5 to T1. The patient underwent a C5–T1 laminectomy and laminoplasty with near-complete resection of the intradural intramedullary subependymoma. At 3 months’ follow-up, he reported doing well and had experienced significant improvement in motor strength with ongoing therapies.
Thoracic laminectomy and midline myelotomy for resection of a spinal ependymoma
Authors: Scherschinski Lea , Winkler Ethan A. , Furey Charuta G. , Gooldy Timothy C. , Catapano Joshua S. , Lawton Michael T.
Published: October 2023

Spinal cord ependymomas comprise 25% of all intramedullary tumors and are typically treated with resection. A man in his mid-60s presented with imbalance and sensory deficits in both lower extremities, and a spinal thoracic intramedullary ependymoma spanning the levels T2 and T3 was diagnosed. After a laminectomy was performed, the tumor was microsurgically resected, and the patient demonstrated no neurological deficits on postoperative examination. Subsequent MRI showed complete resection of the tumor. This video showcases a thoracic intramedullary ependymoma resected using careful microdissection into the median raphe as a safe entry zone to preserve neurological function.
Dorsal cervical approach for recurrent intradural anaplastic ependymoma
Authors: Laws Maxwell T. , Arhin Martin , Ampie Leonel , Chittiboina Prashant
Published: October 2023

The video demonstrates an operative approach to a recurrent cervical anaplastic ependymoma. MYCN-amplified anaplastic ependymomas are locally aggressive, recurrent, and have a high risk of iatrogenic injury. In this case, the patient presented with local, aggressive tumor expansion, arachnoid adhesions, and pial invasion ventral to the spinal cord. Subcapsular decompression minimized cord retraction from a dorsal approach. Removal of the tumor capsule was guided by bipolar stimulation paired with neuromonitoring. Local gross-total resection was achieved, and the patient had a postoperative improvement in his neurological deficits and myelopathy.
To use or not to use antithrombotics in unruptured cerebrovascular malformations? A systematic review focusing on this clinical and surgical dilemma
Authors: Bianconi Andrea , Ceraudo Marco , Nico Elsa , Minardi Massimiliano , Allevi Mario , Prior Alessandro , Garbossa Diego , Zona Gianluigi , Fiaschi Pietro
Published: October 2023

OBJECTIVE

Antithrombotic medications (ATMs), including antiplatelet therapy (APT) and oral anticoagulants (OACs), are widely used in current clinical practice for the prevention and treatment of a variety of cardiovascular diseases, deep vein thrombosis, and pulmonary thromboembolisms. The long-term usage of these drugs, associated with an inherent risk of bleeding, raises concerns for unruptured cerebrovascular malformations (UCVMs), such as arteriovenous malformations (AVMs), cerebral cavernous malformations (CCMs), and intracranial aneurysms (IAs), in which the bleeding risk also poses a major threat. The aim of this study was to assess the safety and risk-benefit ratio of ATMs in these various neurosurgical diseases and to give neurosurgeons a safe and reasonable choice regarding whether to administer ATMs to these patients during the course of the disease.

METHODS

The authors conducted a systematic review of the literature (PubMed/MEDLINE and Embase) according to Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines, which yielded 4 papers about CCMs, 2 about AVMs, and 9 about IAs. The risk of bias was assessed using the Cochrane Collaboration’s tool.

RESULTS

For AVMs, only 2 studies with a total of only 14 patients were included. Data on AVMs and ATMs are limited and weak, relying on small case series. Nevertheless, there is no evidence for either an increased risk of intracranial hemorrhage in patients with AVMs who are receiving ATMS or the need to interrupt ATMs in those patients who have been diagnosed with sporadic, unruptured brain AVMs. With respect to CCMs, the literature search resulted in 4 cohort studies and 1 meta-analysis. These studies affirmed the absence of a correlation between ATMs and an increased risk of CCM bleeding while simultaneously suggesting a protective role of ATMs against bleeding. Concerning IAs, the topic is more complex and debated, despite larger case series on IAs than on AVMs or CCMs. The benefits of ATMs for IAs may vary according to the type of intervention and specific drug administered. Evidence supports the continuation of long-term APT for all patients newly diagnosed with an IA, whereas starting APT in patients with incidentally discovered IA as a means of prophylaxis against rupture is unclear.

CONCLUSIONS

The findings of this review should be taken as a wide overview of UCVM and ATM. Future research should consider the relationship of AVM, CCM, and IA with APT and OAC independently.
Association of tirofiban with improvement of functional outcomes of direct thrombectomy for acute anterior circulation occlusion: a retrospective, nonrandomized, multicenter, real-world study
Authors: Guan *Qiaochu , Yun Wenwei , Li Xiaobo , Ni Huanyu , Lv Weiping , Xie Ziyi , Zhang Lu , Zhou Junshan , Xu Yun , Li Jingwei , Zhang Qingxiu
Published: October 2023

OBJECTIVE

Although tirofiban and endovascular thrombectomy have been widely used in the treatment of acute ischemic stroke (AIS) patients, the effectiveness of their combined application remains a subject of debate. This study aimed to assess the efficacy and safety of tirofiban in direct thrombectomy for AIS with anterior circulation vessel occlusion.

METHODS

A total of 204 patients undergoing direct thrombectomy between January 2020 and December 2021 for AIS with anterior circulation vessel occlusion from four hospitals were included in this study. Patients at high risk of reocclusion with severe atherosclerosis, those who achieved successful recanalization for ≥ 3 stent retriever passes, or those who underwent emergency stenting or balloon angioplasty for severe residual stenosis were treated with tirofiban. Following a low-dose intra-arterial bolus (0.25–1 mg) immediately after endovascular treatment, tirofiban was administered continuously through intravenous infusion (0.1 μg/kg/min) for 12–24 hours. The primary efficacy outcome was evaluated using the 90-day modified Rankin Scale score. The safety outcome was assessed using symptomatic intracerebral hemorrhage (sICH) and mortality rates.

RESULTS

The tirofiban group and nontirofiban group each included 102 patients. The favorable outcome rate in the tirofiban group was significantly higher than that in the nontirofiban group (53.9% vs 35.3%, p = 0.007). However, the sICH and 90-day mortality rates were lower in the tirofiban group, despite a lack of statistical significance (sICH: 15.7% vs 16.7%, p = 0.849; 90-day mortality: 16.67% vs 24.51%, p = 0.166). Finally, it was found that older patients (> 72 years), male patients, patients with admission National Institutes of Health Stroke Scale scores > 14, patients with a time from onset to reperfusion > 327 minutes, and patients with a medical history of diabetes tend to benefit from tirofiban treatment.

CONCLUSIONS

This study suggests that tirofiban combined with direct thrombectomy improves functional outcomes of AIS and reduces the 90-day mortality rate. Therefore, it could be considered as a suitable treatment option for AIS patients with anterior circulation vessel occlusion.
Cilostazol for the management of moyamoya disease: a systematic review of the early evidence, efficacy, safety, and future directions
Authors: Abedi Aidin , Sizdahkhani Saman , Choi Wooseong , Nguyen Vincent N. , Rennert Robert C. , Russin Jonathan J.
Published: October 2023

Surgical revascularization remains the standard treatment for symptomatic moyamoya disease (MMD). As with any major surgical treatment, revascularization is associated with risks and limitations, denoting the need for noninvasive treatments to improve ischemic symptoms and prevent strokes. Cilostazol is a selective phosphodiesterase III inhibitor with antiplatelet, antithrombotic, and vasodilatory effects commonly used in peripheral vascular disease. Clinical studies assessing the efficacy of cilostazol in the management of stroke and MMD were recently reported, although a comprehensive assessment of the overall evidence is lacking. A systematic scoping review was conducted to assess the early evidence on cilostazol administration in patients with MMD. The inclusion criteria encompassed original human studies primarily focused on cilostazol’s safety, efficacy, or utilization in managing MMD patients. A search of the PubMed database was conducted in June 2023, yielding 5 peer-reviewed publications that satisfied the inclusion criteria and were subjected to narrative synthesis. Risk of bias assessment was not applicable due to the scoping nature of this review. East Asian studies demonstrate increasing rates of cilostazol prescriptions for patients with MMD. In a large population-based study, cilostazol was compared to other antiplatelet medications and yielded the largest decrease in mortality among patients with newly diagnosed MMD. Other studies reported significant improvements in cerebral blood flow and cognitive function, which were deemed to be independent of one another. There are limited data on the safety profile of cilostazol in the MMD population, although the evidence derived from various studies performed in the general stroke population can likely provide insights into its potential utility in MMD patients. Cilostazol targets several critical pathways involved in the pathophysiology of MMD. The evidence corroborates the potential benefits of cilostazol for the management of MMD, although these findings should be interpreted with caution due to the small number of studies and lack of randomized trials. Subgroups of patients need to be identified who can safely undergo medical management in lieu of revascularization surgery or to improve surgical outcomes. Additional studies are needed to assess the efficacy and safety of cilostazol therapy, especially in Western populations.
Effect of perioperative anticoagulant prophylaxis in patients with traumatic subdural hematoma and a history of anticoagulant use: a propensity-matched National Trauma Data Bank analysis
Authors: Jiang Sam H. , Hukamdad Mishaal , Gould Andrew , Bhaskara Mounika , Chiu Ryan G. , Sadeh Morteza , Mehta Ankit I.
Published: October 2023

OBJECTIVE

The use of anticoagulation to prevent venous thromboembolism (VTE) is controversial in the setting of neurosurgical decompression for traumatic subdural hematoma (SDH). In these patients, there is concern that anticoagulation may cause secondary hemorrhage, increasing the risk of death and other complications. Patients with a history of anticoagulant use are at further risk of VTE, but the effect of VTE prophylaxis (VTEP) following neurosurgery for SDH has not been thoroughly investigated in this population. This study aims to investigate the differences in in-hospital outcomes in patients with SDH and preexisting anticoagulant use who received VTEP following neurosurgical intervention compared with those who did not.

METHODS

The National Trauma Data Bank was queried from 2017 to 2019 for all patients with preexisting anticoagulant use presenting with an SDH who subsequently underwent neurosurgical intervention. Patients who received VTEP were propensity score matched with patients who did not based on demographics, insurance type, injury severity, and comorbidities. Paired Student t-tests, Pearson’s chi-square tests, and Benjamini-Hochberg multiple comparisons correction were used to compare differences in in-hospital complications, length of stay (LOS), and mortality rate between the two groups. A logistic regression model was developed to identify risk factors for in-hospital mortality.

RESULTS

Two thousand seven hundred ninety-four patients matching the inclusion criteria were identified, of whom 950 received VTEP. Following one-to-one matching and multiple comparisons correction, the VTEP group had a lower mortality rate (18.53% vs 34.53%, p < 0.001) but longer LOS (14.09 vs 8.57 days, p < 0.001) and higher rates of pressure ulcers (2.11% vs 0.53%, p = 0.01), unplanned intensive care unit admission (9.05% vs 3.47%, p < 0.001), and unplanned intubation (9.47% vs 6.11%, p = 0.021). The multivariable logistic regression showed that use of unfractionated heparin (UH; OR 0.36, p < 0.001) and low-molecular-weight heparin (LMWH; OR 0.3, p < 0.001) were associated with lower odds of in-hospital mortality.

CONCLUSIONS

In patients with traumatic SDH and a history of anticoagulant use, perioperative VTEP was associated with increased LOS but provided a mortality benefit. LMWH and UH use were the strongest predictors of survival.
Perioperative continuation or ultra-early resumption of antithrombotics in elective neurosurgical cranial procedures
Authors: Rychen Jonathan , Weiger Valentin F. , Halbeisen Florian S. , Ebel Florian , Ullmann Muriel , Mariani Luigi , Guzman Raphael , Soleman Jehuda
Published: October 2023

OBJECTIVE

Discontinuation of antithrombotics (AT) prior to elective cranial procedures is common practice, despite the higher risk of thromboembolic complications in these patients. The aim of this study was to investigate the risks and benefits of a new perioperative management protocol of continuation or ultra-early AT resumption in elective cranial procedures.

METHODS

This study was an analysis of a prospectively collected cohort of patients undergoing elective cranial surgery with (AT group) and without (control group) AT. For extraaxial or shunt surgeries, acetylsalicylic acid (ASA) was continued perioperatively. For intraaxial pathologies, ASA was discontinued 2 days before surgery and resumed on postoperative day 3. All other AT were discontinued according to their pharmacokinetics, and resumed on postoperative day 3 after unremarkable postoperative imaging. Additionally, the authors performed a retrospective analysis of patients with AT who underwent surgery before implementation of this new AT management protocol (historical AT group). Primary and secondary outcomes were the incidence of hemorrhagic and thromboembolic complications within 3 months after surgery.

RESULTS

Outcomes of 312 patients were analyzed (83 [27%] in the AT group, 106 [34%] in the control group, and 123 [39%] in the historical AT group). For all 3 patient groups, the most common type of surgery was craniotomy for intraaxial tumors (14 [17%] in the AT group, 28 [26%] in the control group, and 60 [49%] in the historical AT group). The most commonly used AT were ASA (38 [46%] in the AT group and 78 [63%] in the historical AT group), followed by non–vitamin K oral anticoagulants (32 [39%] in the AT group and 18 [15%] in the historical AT group). The total perioperative discontinuation time in the AT group was significantly shorter than in the historical AT group (median of 4 vs 16 days; p < 0.001). The rate of hemorrhagic complications was 4% (95% CI 1–10) (n = 3/83) in the AT group, 6% (95% CI 2–12) (n = 6/106) in the control group, and 7% (95% CI 3–13) (n = 9/123) in the historical AT group (p = 0.5). The rate of thromboembolic complications was 5% (95% CI 1–12) (n = 4/82) in the AT group, 8% (95% CI 3–15) (n = 8/104) in the control group, and 7% (95% CI 3–13) (n = 8/120) in the historical AT group (p = 0.7).

CONCLUSIONS

The presented perioperative management protocol of continuation or ultra-early resumption of AT in elective cranial procedures does not seem to increase the hemorrhagic risk. Moreover, it appears to potentially protect patients from thromboembolic complications.
Systematic review and meta-analysis of topical tranexamic acid in spine surgery
Authors: Izima Chiemela , Sampath Shailen G. , Tang Anthony J. , Ambati Vardhaan S. , Chou Dean , Chan Andrew K.
Published: October 2023

OBJECTIVE

Tranexamic acid (TXA) is an antifibrinolytic drug associated with reduced blood loss in a range of surgical specialties, including neurosurgery, orthopedic surgery, and cardiac surgery. Concerns about venous thromboembolism and seizures from intravenous (IV) TXA have led to increased use of topical TXA. Given the relative scarcity of the literature on topical TXA compared with that on IV TXA within neurosurgery, the authors aimed to conduct a systematic review and meta-analysis on the safety, efficacy, and optimal administration of topical TXA in a wide range of spinal procedures and pathologies.

METHODS

The PRISMA guidelines, Cochrane risk of bias tool, and Newcastle-Ottawa Scale were used to extract randomized controlled trials and high-quality case-control and cross-sectional/cohort studies (adult studies only) from PubMed, Web of Science, Cochrane Library, and Embase published between 2016 and 2023. Studies were analyzed by two independent reviewers for variables including dosage, TXA administration route, type of spine procedure, blood loss, adverse events including thromboembolism and infection, postoperative hemoglobin level, and hospitalization length. Pooled analysis comparing intraoperative and postoperative blood loss, postoperative hemoglobin levels, and hospitalization length of stay on the basis of route of TXA administration was conducted.

RESULTS

Four cohort studies, 1 cross-sectional study, 1 case-control study, and 12 randomized controlled trials, together involving 2045 patients, were included. The most common route of topical TXA administration was via TXA in saline solution. Other routes of topical TXA included retrograde injection and TXA-soaked Gelfoam. In pooled analysis, topical TXA significantly reduced visible blood loss (standardized mean difference [SMD] −0.22, 95% CI −0.45 to −0.00001), postoperative blood loss (SMD −1.63, 95% CI −2.03 to −1.22), and length of hospital stay (SMD −1.02, 95% CI −1.42 to −0.61), as well as higher postoperative hemoglobin (SMD 0.59, 95% CI 0.34–0.83), compared with non-TXA controls. No significant differences in outcomes were found between topical and IV TXA or between combined (topical and IV) and IV TXA. Thromboembolism and infection rates did not significantly differ between any TXA administration group and non-TXA controls.

CONCLUSIONS

In pooled analyses, topical TXA was associated with decreased perioperative blood loss in a wide range of scenarios, including cervical spine surgery and thoracolumbar trauma, as well as in patients with a thromboembolic history.
Effect of chronic antiplatelet therapy on clinical outcomes of endovascular thrombectomy for treatment of acute ischemic stroke
Authors: Dicpinigaitis Alis J. , Chowdhury Adeeb , Gagliardi Thomas A. , Soliman Zeina , Mahmoud Noor A. , Nolan Bridget , Clare Kevin , Willey Joshua Z. , Rostanski Sara K. , Medicherla Chaitanya , Patel Neisha , Kaur Gurmeen , Chong Ji Y. , Bowers Christian A. , Gandhi Chirag D. , Al-Mufti Fawaz
Published: October 2023

OBJECTIVE

The objective of this study was to investigate the prognostic significance of chronic antiplatelet therapy (APT) usage in acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT). Long-term APT may enhance recanalization but may also predispose patients to an increased risk of hemorrhagic transformation.

METHODS

Weighted hospitalizations for anterior-circulation AIS treated with EVT were identified in a large United States claims-based registry. Baseline clinical characteristics and outcomes were compared between patients with and without chronic APT usage prior to admission. Multivariable logistic regression analysis was performed to assess adjusted associations between APT and study endpoints.

RESULTS

This analysis identified 36,560 patients, of whom 8170 (22.3%) were on a chronic APT regimen prior to admission. These patients were older and demonstrated a higher burden of comorbid disease, but had similar stroke severity on presentation in comparison with those not on APT. On unadjusted analysis, patients with prior APT demonstrated higher rates of favorable outcomes (24.3% vs 21.5%, p < 0.001), lower rates of mortality (7.0% vs 10.1%, p < 0.001), and lower rates of any intracranial hemorrhage (ICH; 20.3% vs 24.2%, p < 0.001), but no difference in rates of symptomatic ICH (sICH). Following multivariable adjustment for baseline clinical characteristics including age, acute stroke severity, and comorbidity burden, prior APT was associated with favorable outcome (adjusted odds ratio [aOR] 1.21, 95% CI 1.17–1.24, p < 0.001) and a lower likelihood of mortality (aOR 0.73, 95% CI 0.70–0.77, p < 0.001), without an increased likelihood of ICH (any ICH aOR 0.84, 95% CI 0.81–0.87, p < 0.001; sICH aOR 0.92, 95% CI 0.82–1.03, p = 0.131).

CONCLUSIONS

Retrospective evaluation of patients with AIS treated with EVT using registry-based data demonstrated an association of prior APT usage with favorable outcomes, without an increased risk of hemorrhagic transformation.
Impact of premorbid oral anticoagulant use on survival in patients with traumatic intracranial hemorrhage
Authors: Botros David , Gautam Diwas , Hamrick Forrest A. , Nguyen Sarah , Cortez Janet , Young Jason B. , Lombardo Sarah , McCrum Marta L. , Menacho Sarah T. , Grandhi Ramesh
Published: October 2023

OBJECTIVE

Although oral anticoagulant use has been implicated in worse outcomes for patients with a traumatic brain injury (TBI), prior studies have mostly examined the use of vitamin K antagonists (VKAs). In an era of increasing use of direct oral anticoagulants (DOACs) in lieu of VKAs, the authors compared the survival outcomes of TBI patients on different types of premorbid anticoagulation medications with those of patients not on anticoagulation.

METHODS

The authors retrospectively reviewed the records of 1186 adult patients who presented at a level I trauma center with an intracranial hemorrhage after blunt trauma between 2016 and 2022. Patient demographics; comorbidities; and pre-, peri-, and postinjury characteristics were compared based on premorbid anticoagulation use. Multivariable Cox proportional hazards regression modeling of mortality was performed to adjust for risk factors that met a significance threshold of p < 0.1 on bivariate analysis.

RESULTS

Of 1186 patients with a traumatic intracranial hemorrhage, 49 (4.1%) were taking DOACs and 53 (4.5%) used VKAs at the time of injury. Patients using oral anticoagulants were more likely to be older (p < 0.001), to have a higher Charlson Comorbidity Index (p < 0.001), and to present with a higher Glasgow Coma Scale (GCS) score (p < 0.001) and lower Injury Severity Score (ISS; p < 0.001) than those on no anticoagulation. Patients using VKAs were more likely to undergo reversal than patients using DOACs (53% vs 31%, p < 0.001). Cox proportional hazards regression demonstrated significantly increased hazard ratios (HRs) for VKA use (HR 2.204, p = 0.003) and DOAC use (HR 1.973, p = 0.007). Increasing age (HR 1.040, p < 0.001), ISS (HR 1.017, p = 0.01), and Marshall score (HR 1.186, p < 0.001) were associated with an increased risk of death. A higher GCS score on admission was associated with a decreased risk of death (HR 0.912, p < 0.001).

CONCLUSIONS

Patients with a traumatic intracranial injury who were on oral anticoagulant therapy before injury demonstrated higher mortality rates than patients who were not on oral anticoagulation after adjusting for age, comorbid conditions, and injury presentation.
Examining the safety profile of a standard dose tranexamic acid regimen in spine surgery
Authors: Setliff Joshua , Dalton Jonathan , Sadhwani Shaan , Tang Melissa Yunting , Mirvish Asher , Adida Samuel , Wawrose Richard , Lee Joon Y. , Fourman Mitchell S. , Shaw Jeremy D.
Published: October 2023

OBJECTIVE

Perioperative blood loss during spinal surgery is associated with complications and in-hospital mortality. Weight-based administration of tranexamic acid (TXA) has the potential to reduce blood loss and related complications in spinal surgery; however, evidence for standardized dosing is lacking. The purpose of this study was to evaluate the impact of a standardized preoperative 2 g bolus TXA dosing regimen on perioperative transfusion, blood loss, thromboembolic events, and postoperative outcomes in spine surgery patients.

METHODS

An institutional review board approved this retrospective review of prospectively enrolled adult spine patients (> 18 years of age). Patients were included who underwent elective and emergency spine surgery between September 2018 and July 2021. Patients who received a standardized 2 g dose of TXA were compared to patients who did not receive TXA. The primary outcome measure was perioperative transfusion. Secondary outcomes included estimated blood loss and thromboembolic or other perioperative complications. Descriptive statistics were calculated, and continuous variables were analyzed with the two-tailed independent t-test, while categorical variables were analyzed with the Fisher’s exact test or chi-square test. Stepwise multivariate regression analysis was performed to examine independent risk factors for perioperative outcomes.

RESULTS

TXA was administered to 353 of 453 (78%) patients, and there were no demographic differences between groups. Although the TXA group had more operative levels and a longer operative time, the transfusion rate was not different between the TXA and no-TXA groups (7.4% vs 8%, p = 0.83). Stepwise multivariate regression found that the number of operative levels was an independent predictor of perioperative transfusion and that both operative levels and operative time were correlated with estimated blood loss. TXA was not identified as an independent predictor of any postoperative complication.

CONCLUSIONS

A standardized preoperative 2 g bolus TXA dosing regimen was associated with an excellent safety profile, and despite increased case complexity in terms of number of operative levels and operative time, patients treated with TXA did not require more blood transfusions than patients not treated with TXA.
The precise midline myelotomy through anatomical posterior median septum by dissecting dorsal column in microsurgical resection of ependymoma (2-dimensional operative video)
Authors: Kim Jun-Hoe , Chung Chun Kee
Published: October 2023

Although resection is the gold standard treatment for spinal ependymoma, permanent neurological deterioration has been reported postoperatively in 20%–27% of patients. Despite thorough dissection of the tumor from its surroundings, conventional longitudinally directed midline myelotomy can lead to injury to the dorsal column, possibly due to deformation of the posterior median septum as the tumor grows. To address this issue, the authors have been performing precise midline myelotomy through the anatomical posterior median septum by directly dissecting the dorsal column. This video presents the principles and application of this technique.
Location-specific technical nuances of spinal meningioma resection: an operative video case series
Authors: Fisher Wilson A. M. , Upadhyaya Cheerag , Galgano Michael
Published: October 2023

The objective of this video was to demonstrate technical nuances of intradural spinal meningioma (ISM) resection through a high-quality surgical video. The authors describe 3 patients with ISM in the cervicomedullary, cervical, and thoracic regions. Patients underwent surgery in the prone position with laminectomy, dorsal durotomy, and then resection of the mass. Case 1 required a suboccipital craniectomy and dissection of the tumor away from the vertebral artery. In case 2, special emphasis is placed on sectioning the dentate ligament with cord rotation. Case 3 highlights meticulous circumferential arachnoid release and the use of ultrasound. Patients saw significant neurological improvement postoperatively. This video provides clear instruction on location-specific technical nuances of ISM removal.
A rapid clinical deterioration of a cervical exophytic intradural intramedullary sporadic hemangioblastoma diagnosed during pregnancy
Authors: Erginoglu Ufuk , Keles Abdullah , Ataoglu Cagdas , Başarslan Seyit Kağan , Baskaya Mustafa K.
Published: October 2023

Hemangioblastomas are benign CNS tumors that can occur sporadically or in conjunction with von Hippel–Lindau disease. While 2% of spinal cord tumors are hemangioblastomas, combined cervical hemangioblastomas and pregnancy is rare. Some reports suggest that hemodynamic and hormonal changes in pregnancy might increase hemangioblastoma growth and aggravate symptoms. Urgent tumor removal is required when neurological problems deteriorate after failed symptomatic treatment. Neurosurgeons should collaborate with anesthesiologists and obstetricians in such cases. Herein, the authors present the first known video case of a sporadic cervical hemangioblastoma diagnosed during pregnancy that required urgent surgery due to failed symptomatic treatment and progressive clinical deterioration.