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Mispositioning of microelectrodes during deep brain stimulation surgery can incur serious complications for patients. Current practice of creating a burr hole for introduction of the microelectrode is done freehand and can cause trajectory misalignment. We aimed to create a sterilizable surgical adjunct to minimize error from burr hole placement.We designed and demonstrated clinical use of a 3D-printed surgical jig that can be mounted to the current Cosman-Roberts-Wells stereotactic frame. The jig allowed accurate placement of the perforating burr for creation of the burr hole.Intraoperative usage of the jig in 11 patients who underwent bilateral deep brain stimulation microelectrode placement for Parkinson disease demonstrated high accuracy of microelectrode placement, with an average 1.18 mm deviation (range, 0-2.7 mm) from intended trajectories. No intraoperative complications were encountered.This proof-of-concept study highlights the utility of 3D-printed surgical adjuncts that are fully customizable and rapidly produced to improve current surgical practice. The jig reduced surgery duration, need for multiple trajectories, and risk of potentially devastating neurological complications. As demonstrated, 3D-printed devices are useful as surgical adjuncts to optimize safety and efficacy in deep brain stimulation surgeries.

Background The decision to resume antithrombotic therapy after surgical evacuation of chronic subdural hematoma (CSDH) requires judicious weighing of the risk of bleeding against that of thromboembolism. This study aimed to investigate the impact of time to resumption of antithrombotic therapy on outcomes of patients after CSDH drainage. Methods Data were obtained retrospectively from three tertiary hospitals in Singapore from 2010 to 2017. Outcome measures analyzed were CSDH recurrence and any thromboembolic events. Logistic and Cox regression tests were used to identify associations between time to resumption and outcomes. Results A total of 621 patients underwent 761 CSDH surgeries. Preoperative antithrombotic therapy was used in 139 patients. 110 (79.1%) were on antiplatelets and 35 (25.2%) were on anticoagulants, with six patients (4.3%) being on both antiplatelet and anticoagulant therapy. Antithrombotic therapy was resumed in 84 patients (60.4%) after the surgery. Median time to resumption was 71 days (IQR 29 – 201). Recurrence requiring reoperation occurred in 15 patients (10.8%), of which 12 had recurrence before and three after resumption. Median time to recurrence was 35 days (IQR 27 – 47, range 4 – 82 days). Recurrence rates were similar between patients that were restarted on antithrombotic therapy before and after 14, 21, 28, 42, 56, 70 and 84 days, respectively. Thromboembolic events occurred in 12 patients (8.6%), of which five had the event prior to restarting antithrombosis. Conclusions Time to antithrombotic resumption did not significantly affect CSDH recurrence. Early resumption of antithrombotic therapy can be safe for patients with a high thromboembolic risk.

Little evidence exists to guide the preoperative selection of elderly brain tumor patients who are fit for surgery. We aimed to evaluate the safety of brain tumor resection in geriatric patients and identify predictors of postoperative 30-day systemic complications. We conducted a retrospective cohort study of 212 consecutive patients at or above the age of 60 years who underwent elective brain tumor resection between 2007 and 2017. The primary outcome measures analyzed were perioperative systemic complications within 30 days after the operation. A total of 212 geriatric brain tumor patients were included. Fifty-two (24.5%) had a 30-day systemic complication. Among them, 29 (13.7%) had systemic infections, 13 (6.1%) had perioperative seizures, 10 (4.7%) had syndrome of inappropriate antidiuretic hormone secretion (SIADH), five (2.4%) had deep venous thrombosis (DVT), four (1.9%) had perioperative stroke, three (1.4%) had acute myocardial infarction (AMI) and three (1.4%) had central nervous system (CNS) infections. One patient (0.5%) died. Perioperative stroke was predicted by previous stroke (p = 0.040), chronic liver disease (p 0.001) and vestibular schwannoma (p = 0.002 with reference to meningiomas). Perioperative AMI was predicted by co-existing ischemic heart disease (p = 0.031). Systemic infection was predicted by female gender (p = 0.007) and preoperative Karnofsky Performance Scale (KPS) score 70 (p = 0.019). DVT was predicted by GBM (p = 0.014). In conclusion, brain tumor surgery can be safe in carefully-selected geriatric patients. The risk factors identified in this study would be helpful to select suitable candidates for surgery.

Background: Although extracorporeal membrane oxygenation (ECMO) is frequently utilized as a salvage therapy for patients with cardiopulmonary failure, outcomes of its use in peripartum patients have not been clearly established. We aimed to review peer-reviewed publications on the use of ECMO in pregnant and postpartum patients, with analyses of maternal and fetal outcomes. Methods: Data were retrieved from MEDLINE, EMBASE, and Scopus databases from 1972 up to November 2017 for publications on ECMO in peripartum patients. Search terms included “ECMO,” “ECLS,”, “pregnancy,” “postpartum,” and “peripartum.” Publications with 3 or more patients were reviewed for quality using the Joanna Briggs Institute checklist for prevalence studies and case series. Results: After reviewing 143 publications, 9 observational studies met our inclusion criteria. Pooled prevalence of maternal survival was 77.2% (95% confidence interval [CI]: 64.1%-88.4%). Pooled prevalence of fetal survival was 69.1% (95% CI: 44.7%-89.8%). The level of heterogeneity across studies was low for both outcomes. Meta-regression did not reveal any correlation between pregnant women with pulmonary or cardiac indications and maternal survival. Individual patient data meta-regression demonstrated higher odds of survival for patients on venovenous ECMO compared to those on venoarterial ECMO that was close to statistical significance (odds ratio = 3.016, 95% CI: 0.901-11.144; P = .081) after adjusting for pregnancy status. Conclusions: Extracorporeal membrane oxygenation can be considered as an acceptable salvage therapy for pregnant and postpartum patients with critical cardiac or pulmonary illness.

Objective Despite a high burden of neurosurgical disease that is often assessed, investigated, and managed by generalists, to our knowledge, there is no specific medical school curriculum in neurosurgery. This scoping review was carried out to map available evidence pertaining to the provision of neurosurgery education in the medical school curriculum across the world. Methods This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews. Inclusion criteria were full-text articles reported from 1999 onward, which reported on neurosurgery education in the medical curriculum. Results Ten studies were included. Six were from the United Kingdom, 2 from the United States, and 1 each from Canada and Ireland. Seven studies reported perceptions of medical students and 5 reported perceptions of clinicians. Three main themes were identified. Neurosurgery was perceived as an important part of the general medical student curriculum by students and neurosurgeons but less so by medical school deans. Exposure to neurosurgery teaching was varied but, when received, deemed useful and students were keen to receive more. Interest in a neurosurgical career among surveyed medical students was high. Conclusions The limited evidence has shown variability of perceptions about the importance of neurosurgery among stakeholders and medical students' exposure to neurosurgery teaching. Our findings highlight the need to systematically assess specialty-specific teaching and determine adequacy. Stakeholders should include neurosurgeons, medical educators, general practitioners, and the variety of specialists who play a crucial role in the management of patients with neurosurgical conditions.

With the widespread use of imaging techniques, the possibility that an asymptomatic unruptured intracranial aneurysm (UIA) is detected has increased significantly. There is no established consensus regarding follow-up, duration, and frequency of such imaging surveillance. The objectives of this study include assessing the growth rate and rupture risk of small (less than 7mm) UIAs, identifying associated risk factors and providing an aneurysm surveillance protocol in appropriately selected patients. Systematic searches of Medline, Embase, and Cochrane Central were undertaken from database inception to March 2020 for published studies reporting the growth and rupture risks of small UIAs. Twenty-one studies reporting 8428 small UIAs were included in our meta-analysis. The pooled mean age was 61 years (95% CI: 55–67). The mean follow-up period for growth and rupture ranged from 11 to 108 months, with the pooled mean follow-up period across 14 studies being 42 months (95% CI: 33–51). Pooled overall growth rate was 6.0% (95% CI: 3.8–8.7). Pooled growth rates for aneurysms < 5mm and < 3 mm were 5.2% (95% CI: 3.0–7.9) and 0.8% (95% CI: 0.0–6.1), respectively. Pooled overall rupture rate was 0.4% (95% CI: 0.2–0.7). From the meta-regression analysis, having multiple aneurysms, smoking, hypertension, and personal history of SAH did not significantly predict growth, and a personal history of SAH, smoking, hypertension, and multiple aneurysms were not statistically significant predictors of rupture. Our findings suggest that small UIAs have low growth and rupture rates and very small UIAs have little or no risk for rupture. In the setting of incidental small UIAs, patients with multiple and/or posterior circulation aneurysms require more regular radiological monitoring.

Background It has been well-established that primary bariatric surgery is effective in inducing improvement of diabetes and other associated co-morbidities in patients with obesity. Evidence demonstrating the influence of revisional bariatric surgery on this trajectory, however, is lacking. Objectives We performed a systematic review and meta-analysis to examine the impact of revisional bariatric surgery on obesity-related metabolic outcomes. Setting University Hospital, Singapore Methods We examined outcomes of remission and improvement of diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea. Revisional surgeries included sleeve gastrectomy, Roux-en-Y gastric bypass, pouch revision, duodenal switch, and minigastric bypass. Results Our search identified 33 relevant studies including a total of 1593 patients. Meta-analysis of proportions demonstrated a 92% improvement in diabetes with 50% achieving remission after revisional bariatric surgery. Of patients, 81% achieved improvement of hypertension with 33% achieving complete remission. In both groups, the highest proportion of improvement was observed after revisional duodenal switch. Although reported by fewer studies, a remission of hyperlipidemia was reported in 37% of patients and improvement of obstructive sleep apnea was seen in 86% of patients. Conclusions Revisional bariatric surgery improves the outcomes of obesity-related co-morbidities and should be considered in patients with persistent metabolic disease after primary bariatric surgery.

Objectives:We examined data from the International Registry of the Extracorporeal Life Support Organization to identify risk factors for mortality in pregnant and peripartum patients receiving extracorporeal membrane oxygenation.Design:Retrospective analysis.Setting:International Registry of Extracorporeal Life Support Organization.Patients:We collected de-identified data on all peripartum patients who needed extracorporeal membrane oxygenation between 1997 and 2017 using International Classification of Diseases, 9th and 10th Edition criteria.Interventions:Our primary outcome measure was in-hospital mortality. We also collected data on demographics, preextracorporeal membrane oxygenation ventilator, hemodynamic and biochemical parameters, extracorporeal membrane oxygenation mode, duration, and complications. Initial bivariate analysis assessed potential associations between survival and various preextracorporeal membrane oxygenation as well as extracorporeal membrane oxygenation-related factors. Variables with p values of less than 0.1 were considered for logistic regression analysis which identified predictors of mortality.Measurements and Main Results:There were 280 peripartum patients who received extracorporeal membrane oxygenation. Overall maternal survival was 70%, with observed mortality for these patients decreasing over the 21-year time period. Multivariate regression identified extracorporeal cardiopulmonary resuscitation (odds ratio, 3.674; 95% CI, 1.425-9.473; overall p = 0.025), duration of extracorporeal membrane oxygenation ( 232 hr: odds ratio, 1.084; 95% CI, 0.429-2.737; p = 0.864; overall p = 0.017), and renal complications on extracorporeal membrane oxygenation (odds ratio, 2.346; 95% CI, 1.203-4.572; p = 0.012) as significant risk factors for mortality. There was no statistically significant difference in mortality between venovenous versus venoarterial versus mixed group extracorporeal membrane oxygenation (23.9 vs 34.4 vs 29.4%; p = 0.2) or between pulmonary versus cardiac indications (1.634; 95% CI, 0.797-3.352; p = 0.18) for extracorporeal membrane oxygenation.Conclusions:On analysis of this multicenter database, pregnant and peripartum patients with refractory cardiac or respiratory failure supported on extracorporeal membrane oxygenation had survival rates of 70%. We identified preextracorporeal membrane oxygenation as well as extracorporeal membrane oxygenation-related factors that are associated with mortality.

Introduction: External ventricular drain (EVD) placement is the gold standard for managing acute hydrocephalus. Freehand EVD, using surface anatomical landmarks, is performed for ventricular cannulation due to its simplicity and efficiency. This study evaluates accuracy and reason(s) for misplacements as few studies have analyzed the accuracy of freehand EVD insertion. Patients and Methods: Preoperative and postoperative computed tomography scans of patients who underwent EVD insertion in 2014 were retrospectively reviewed. Diagnosis, Evans ratio, midline shift, position of burr hole, length of the catheter, and procedural complications were tabulated. The procedures were classified as satisfactory (catheter tip in the frontal horn ipsilateral lateral ventricle) and unsatisfactory. Unsatisfactory cases were further analyzed in relation to position of burr hole from midline and length of the catheter. Results: Seventy-seven EVD placements in seventy patients were evaluated. The mean age of the patients was 57.5 years. About 83.1% were satisfactory placements and 11.7% were unsatisfactory in the contralateral ventricle, corpus callosum, and interhemispheric fissure. Nearly 5.2% were in extraventricular locations. Almost 2.6% EVD placements were complicated by hemorrhage and 1 catheter was reinserted. Suboptimal placements were significantly associated with longer intracranial catheter length. The mean length was 66.54 ± 10.1 mm in unsatisfactory placements compared to 58.32 ± 4.85 mm in satisfactory placements. Between the two groups, no significant difference was observed in Evans ratio, midline shift, surgeon's experience, distance of burr hole from midline, and coronal suture. Conclusion: Freehand EVD insertion is safe and accurate. In small number of cases, unsatisfactory placement is related to longer catheter length.

Aim To assess outcomes after clipping or coiling of distal anterior cerebral artery (DACA) aneurysms via a meta-analysis. Method Systematic searches of Medline, Embase and Cochrane Central were undertaken from 1st January 1973 until 1st May 2020 for published studies reporting microsurgical clipping and endovascular coiling of DACA aneurysms. Primary outcome measure was independent functional outcome (modified Rankin scale (mRS) 0–2, or Glasgow Outcome Scale (GOS) 4–5). Secondary outcomes were poor clinical outcome and mortality, perioperative complications, aneurysm occlusion rates, rebleeding and recurrence. Results 938 and 223 patients with ruptured and unruptured DACA aneurysms, respectively, were reported across 28 studies. Pooled rate of procedure-related morbidity was 6.8% (95%CI: 3.2 – 11.2) and 1.3% (95%CI: 0.0 – 9.1) for clipped and coiling ruptured DACA aneurysms respectively. Pooled rate of intraoperative rupture for clipped and coiled ruptured DACA aneurysms was 10.0% (95%CI: 2.5 – 20.6) and 5.7% (95%CI: 1.1 – 12.5) respectively. Pooled rate of acute hydrocephalus for clipped and coiled ruptured DACA aneurysms was 7.8% (95%CI: 0.5 – 19.7) and 1.4% (95% CI: 0.0 – 11.3) respectively. Pooled rate of perioperative mortality was 0.002% (95% CI: 0.0 – 0.7) ruptured DACA aneurysms treated by clipping. For clipped unruptured DACA aneurysms, pooled rates of procedure-related morbidity, intraoperative rupture, acute hydrocephalus were 2.5% (95%CI: 0.0 – 7.5), 0.002% (95%CI: 0.0 – 3.1) and 0.5% (95%CI: 0.0 – 5.1) respectively. Conclusions Clipping results in poorer short-term outcomes when compared to coiling. However, the final decision-making should be shared with the patient and be performed on a selective, case-by-case basis in order to maximize patient benefits.

Intraoperative magnetic resonance imaging (iMRI) allows for greater tumor visualization and extent of resection. It is increasingly used in transsphenoidal surgeries but its role is not yet established.We aimed to clarify the usefulness of iMRI in transsphenoidal surgery using direct statistical comparisons, with additional subgroup and regression analyses to investigate which patients benefit the most from iMRI use.Systematic searches of PubMed, Embase, and Cochrane Central were undertaken from database inception to May 2020 for published studies reporting the outcomes of iMRI use in transsphenoidal resection of pituitary adenoma.Thirty-three studies reporting 2106 transsphenoidal surgeries in 2099 patients were included. Of these surgeries, 1487 (70.6%) were for nonfunctioning pituitary adenomas, whereas 619 (29.4%) were for functioning adenomas. Pooled gross total resection (GTR) was 47.6% without iMRI and 66.8% with iMRI (risk ratio [RR], 1.32; P0.001). Subgroup and meta-regression analyses demonstrated comparable increases in GTR between microscopic (RR, 1.35; P0.001) and endoscopic (RR, 1.31; P0.001) approaches as well as functioning and nonfunctioning adenomas (P = 0.584). The pooled rate of hypersecretion normalization was 73.0% within 3 months and 51.7% beyond 3 months postoperatively. The pooled rate of short-term and long-term improvement in visual symptoms was 96.5% and 84.9%, respectively. The incidence of postoperative surgical complications was low. The pooled reoperation rate was 3.8% across 1106 patients.The use of iMRI as an adjunct significantly increases GTR for both microscopic and endoscopic resection of pituitary adenomas, with comparable benefits for both functioning and nonfunctioning adenomas. Satisfactory endocrinologic and visual outcomes were achieved.

Background Although the use of a postoperative drain after burr-hole evacuation of chronic subdural hematoma (CSDH) is known to improve surgical outcomes, the superiority of subdural over subperiosteal drains has not been firmly established. Evidence comparing these 2 drain types is largely restricted to single-center series with limited numbers. Using a multicenter cohort study, we aimed to show noninferiority of subperiosteal drains vis-a-vis subdural drains after burr-hole evacuation of CSDH. Methods We performed a retrospective analysis of all consecutive patients with CSDH aged 21 years and older who had undergone burr-hole craniostomy across 3 tertiary hospitals from 2010 to 2017. Primary outcome measures included CSDH recurrence and modified Rankin Scale (mRS) score at 6 months. Outcomes of patients in the subdural and subperiosteal drain groups were analyzed and confounders were adjusted for using multivariate logistic regression. Results Of the 570 cases analyzed, 329 (57.7%) received a subdural drain and 241 (42.3%) received a subperiosteal drain. There was no significant difference between the 2 drain groups in CSDH recurrence (13.1% in the subdural group vs. 11.2% in the subperiosteal group; P = 0.502) or 6-month mRS score (27.2% with mRS 4–6 in the subdural group vs. 20.4% in the subperiosteal group; P = 0.188). Independent predictors of CSDH recurrence identified on multivariate analysis included premorbid mRS score 0–3 (P = 0.021), separated CSDH type on preoperative computed tomography scan (P = 0.002), and postoperative pneumocephalus of ≥15 mm (P = 0.005). Conclusions Outcomes of subdural and subperiosteal drains after burr-hole craniostomy for CSDH are largely equivalent based on our findings.

Background and purpose Although COVID‐19 predominantly affects the respiratory system, recent studies have reported the occurrence of neurological disorders such as stroke in relation to COVID‐19 infection. Encephalitis is an inflammatory condition of the brain that has been described as a severe neurological complication of COVID‐19. Despite a growing number of reported cases, encephalitis related to COVID‐19 infection has not been adequately characterised. To address this gap, this systematic review and meta‐analysis aims to describe the incidence, clinical course, and outcomes of patients who suffer from encephalitis as a complication of COVID‐19. Methods All studies published between 1 November 2019 and 24 October 2020 that reported on patients who developed encephalitis as a complication of COVID‐19 were included. Only cases with radiological and/or biochemical evidence of encephalitis were included. Results In this study, 610 studies were screened and 23 studies reporting findings from 129,008 patients, including 138 with encephalitis, were included. The average time from diagnosis of COVID‐19 to onset of encephalitis was 14.5 days (range = 10.8–18.2 days). The average incidence of encephalitis as a complication of COVID‐19 was 0.215% (95% confidence interval [CI] = 0.056%–0.441%). The average mortality rate of encephalitis in COVID‐19 patients was 13.4% (95% CI = 3.8%–25.9%). These patients also had deranged clinical parameters, including raised serum inflammatory markers and cerebrospinal fluid pleocytosis. Conclusions Although encephalitis is an uncommon complication of COVID‐19, when present, it results in significant morbidity and mortality. Severely ill COVID‐19 patients are at higher risk of suffering from encephalitis as a complication of the infection.

Treatment techniques and management guidelines for intracranial aneurysms (IAs) have been continually developing and this rapid development has altered treatment decision-making for clinicians. IAs are treated in one of two ways: surgical treatments such as microsurgical clipping with or without bypass techniques, and endovascular methods such as coiling, balloon- or stent-assisted coiling, or intravascular flow diversion and intrasaccular flow disruption. In certain cases, a single approach may be inadequate in completely resolving the IA and successful treatment requires a combination of microsurgical and endovascular techniques, such as in complex aneurysms. The treatment option should be considered based on factors such as age; past medical history; comorbidities; patient preference; aneurysm characteristics such as location, morphology, and size; and finally the operator’s experience. The purpose of this review is to provide practicing neurosurgeons with a summary of the techniques available, and to aid decision-making by highlighting ideal or less ideal cases for a given technique. Next, we illustrate the evolution of techniques to overcome the shortfalls of preceding techniques. At the outset, we emphasize that this decision-making process is dynamic and will be directed by current best scientific evidence, and future technological advances.

Neurosurgeons today are inundated with rapidly amassing neurosurgical research publications. Systematic reviews and meta-analyses have consequently surged in popularity because, when executed properly, they constitute a high level of evidence and may save busy neurosurgeons many hours of combing and reviewing the literature for relevant articles. Meta-analysis refers to the quantitative (and discretionary) component of systematic reviews. It involves applying statistical techniques to combine effect sizes from multiple studies, which might offer more actionable insights than a systematic review without meta-analysis. Well-executed meta-analyses may prove instructive for clinical practice, but poorly conducted ones sow confusion and have the potential to cause harm. Unfortunately, recent audits have found the conduct and reporting of meta-analyses in neurosurgery (but also other surgical disciplines) to be relatively lackluster in methodologic rigor and compliance to established guidelines. Some of these deficiencies can be easily remedied through better awareness and adherence to prescribed standards-which will be reviewed in this article-but others stem from inherent problems with the source data (e.g., poor reporting of original research) as well as unique constraints faced by surgery as a field (e.g., lack of equipoise for randomized trials, or existence of learning curves for novel surgical procedures, which can lead to temporal heterogeneity), which may require unconventional tools (e.g., cumulative meta-analysis) to address. Therefore, it is also our goal to take stock of the unique issues encountered by surgeons who do meta-analysis and to highlight various techniques-some of which less well-known-to address such challenges.

Introduction COVID-19 is a multi-system infection which predominantly affects the respiratory system, but also causes systemic inflammation, endothelialitis and thrombosis. The consequences of this include renal dysfunction, hepatitis and stroke. In this systematic review, we aimed to evaluate the epidemiology, clinical course, and outcomes of patients who suffer from stroke as a complication of COVID-19. Methods We conducted a systematic review of all studies published between November 1, 2019 and July 8, 2020 which reported on patients who suffered from stroke as a complication of COVID-19. Results 326 studies were screened, and 30 studies reporting findings from 55,176 patients including 899 with stroke were included. The average age of patients who suffered from stroke as a complication of COVID-19 was 65.5 (Range: 40.4–76.4 years). The average incidence of stroke as a complication of COVID-19 was 1.74% (95% CI: 1.09% to 2.51%). The average mortality of stroke in COVID-19 patients was 31.76% (95% CI: 17.77% to 47.31%). These patients also had deranged clinical parameters including deranged coagulation profiles, liver function tests, and full blood counts. Conclusion Although stroke is an uncommon complication of COVID-19, when present, it often results in significant morbidity and mortality. In COVID-19 patients, stroke was associated with older age, comorbidities, and severe illness.

Objective: As COVID-19 has been spreading rapidly both globally and throughout the US, public fear of contracting and spreading the virus has greatly hindered access to medical care including fertility clinics Given the time-sensitive nature of fertility treatment, especially in older women, the American Society of Reproductive Medicine published updated guidelines for clinics to safely resume fertility services on April 24, 2020 The purpose of this study was to assess whether contacting established patients who missed or cancelled follow-up appointments via phone calls improved patient retention in the midst of the COVID-19 global pandemic Design: Practice management analysis Materials and Methods: Patients undergoing fertility treatment during the COVID-19 pandemic and who missed scheduled follow-up appointments were contacted by designated clinical staff members Patients who desired to continue their treatment were offered either physical appointments or telehealth consultations The contacting staff member documented patient responses and demographics in a master spreadsheet Approximately 1-4 weeks after the patients were initially contacted, their charts were revisited to determine if the follow-up prompted patients to pursue future treatment A Chi-square test was used to compare outcomes between Assisted Reproductive Technology (ART) cycles and Intrauterine Insemination (IUI) cycles Results: There were 700 patients identified who underwent 215 IUI cycles and 709 ART cycles in the form of Egg Retrieval (ER) or Embryo Transfer (ET) between January 2020 - April 2020 The average age of all patients undergoing IUI and ART was 37 9 and 39 6, respectively (p=0 001) The clinical team contacted 88 IUI and 213 ART patients who missed a follow-up appointment scheduled 2 weeks after undergoing their procedure Of those contacted, 13 (15%) IUI patients and 72 (34%) ART patients scheduled appointments with their physicians (p=0 001) Fear about COVID-19 was cited as the most common reason for missing their follow-up appointment (p=0 001) Conclusions: These data support contacting patients lost to follow-up in order to improve patient retention rates Patients who had undergone ART treatment were more likely to resume care compared to those who had IUI treatment One explanation is that IUI patients may be more comfortable delaying active treated while attempting unmonitored timed intercourse cycles at home There also may be differences in the population of patients undergoing ART vs IUI cycles, such as fertility prognosis or financial implications Tracking patients during the pandemic also identified those who became pregnant post-procedure and helped ensure early monitoring when appropriate, but this data is not presented here Lastly, the follow-up initiative provided clinical teams with a unique opportunity to assess patient satisfaction, as well as employee productivity during these difficult times References: None

The coronavirus disease 2019 (COVID-19) pandemic spread globally in the beginning of 2020. At present, predictors of severe disease and the efficacy of different treatments are not well understood. We conducted a systematic review and meta-analysis of all published studies up to 15 March 2020, which reported COVID-19 clinical features and/or treatment outcomes. Forty-five studies reporting 4203 patients were included. Pooled rates of intensive care unit (ICU) admission, mortality, and acute respiratory distress syndrome (ARDS) were 10.9%, 4.3%, and 18.4%, respectively. On meta-regression, ICU admission was predicted by increased leukocyte count (P

Bilateral chronic subdural hematoma (bCSDH) is frequently drained unilaterally when the contralateral CSDH is small and asymptomatic. However, reoperation rates for contralateral CSDH growth can be high. We aimed to develop a prognostic scoring system to guide the selection of suitable patients for unilateral drainage of bCSDH. Data were collected retrospectively across three tertiary hospitals from 2010 to 2017 on all consecutive bCSDH patients aged 21 or above. Predictors of reoperation were identified using multivariable logistic regression. A prognostic score was developed and internally validated. 240 bCSDH patients were analyzed. 98 (40.8%) underwent unilateral and 142 (59.2%) underwent bilateral evacuation. Clinical outcomes were comparable between the unilateral and bilateral evacuation groups. Within the unilateral evacuation group, 4 (4.1%) had a reoperation for contralateral CSDH growth. Reoperation for contralateral CSDH was predicted by preoperative use of anticoagulants (OR = 15.0, 95% CI: 1.49–169.15, p = 0.017). Complete resolution of contralateral CSDH was predicted by its preoperative maximum width, with a cut-off of 9 mm producing the highest sensitivity and specificity (OR = 4.17 for ≤9 mm, 95% CI: 1.54–11.11, p = 0.004). Using our prognostic score, reoperation rate for contralateral CSDH was 1.6%, 3.6%, 16.7%, and 50.0% in low-risk, moderate-risk, high-risk and very high-risk patients, respectively. With each increase of 1 in the prognostic score, patients were 4 times as likely to undergo reoperation for contralateral CSDH (OR = 3.98, 95% CI: 1.36–13.53, p = 0.013). Our proposed risk score may be used as an adjunct in clinical decision making for bCSDH patients undergoing unilateral evacuation.

Introduction Risk-prediction models for breakthrough pain facilitate interventions to forestall inadequate labour analgesia, but limited work has used machine learning to identify predictive factors. We compared the performance of machine learning and regression techniques in identifying parturients at increased risk of breakthrough pain during labour epidural analgesia. Methods A single-centre retrospective study involved parturients receiving patient-controlled epidural analgesia. The primary outcome was breakthrough pain. We randomly selected 80% of the cohort (training cohort) to develop three prediction models using random forest, XGBoost, and logistic regression, followed by validation against the remaining 20% of the cohort (validation cohort). Area-under-the-receiver operating characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were used to assess model performance. Results Data from 20 716 parturients were analysed. The incidence of breakthrough pain was 14.2%. Of 31 candidate variables, random forest, XGBoost and logistic regression models included 30, 23, and 15 variables, respectively. Unintended venous puncture, post-neuraxial analgesia highest pain score, number of dinoprostone suppositories, neuraxial technique, number of neuraxial attempts, depth to epidural space, body mass index, pre-neuraxial analgesia oxytocin infusion rate, maternal age, pre-neuraxial analgesia cervical dilation, anaesthesiologist rank, and multiparity, were identified in all three models. All three models performed similarly, with AUC 0.763–0.772, sensitivity 67.0–69.4%, specificity 70.9–76.2%, PPV 28.3–31.8%, and NPV 93.3–93.5%. Conclusions Machine learning did not improve the prediction of breakthrough pain compared with multivariable regression. Larger population-wide studies are needed to improve predictive ability.

Background The goal of glioblastoma (GBM) surgery is to maximize the extent of resection (EOR) while minimizing postoperative neurological complications. Awake craniotomy (AC) has been demonstrated to achieve this goal for low-grade gliomas in or near eloquent areas. However, the efficacy of AC for GBM resection has not been established. Therefore, we aimed to investigate the outcomes of AC for surgical resection of GBM using a systematic review and meta-analysis of published studies. Methods Systematic searches of Ovid MEDLINE, Embase, Cochrane Controlled Register of Controlled Trials, and PubMed were performed from database inception to September 14, 2019 for published studies reporting outcomes of AC for GBM resection. Outcome measures analyzed included EOR and the event rate of postoperative neurological deficits. Results A total of 1928 unique studies were identified. Fourteen studies reporting 278 patients were included in our meta-analysis. Mean age of patients was 46.9 years (95% confidence interval [CI]: 43.9–49.9). Early and late postoperative neurological deficits occurred in 34.5% (95% CI: 21.9–48.2) and 1.9% (95% CI: 0.0–9.2) of patients, respectively. Pooled percentage of gross total resection (GTR) was 74.7% (95% CI: 66.7–82.1), while the pooled percentage reduction in tumor volume was 95.3% (95% CI: 92.2–98.4). Conclusions Limited current evidence suggests that the use of AC for resection of supratentorial GBM is associated with a low rate of persistent neurological deficits while achieving an acceptable rate of GTR. Our findings demonstrate the potential viability of AC in GBM resection and highlight the need for further research on this topic.

Introduction Gamma Knife Surgery (GKS) is widely used for treatment of brainstem metastases (BSMs) with or without whole bran radiation therapy (WBRT). We hypothesized that BSMs treated with GKS using lower doses and omitting WBRT result in acceptable tumor control rates and low complication rates. Methods A retrospective single center study was performed to investigate the outcome following GKS of BSMs. All 33 patients with follow-up information treated with GKS for 39 metastases located in the cerebral peduncle, midbrain, pons or medulla oblongata were included in the study. The median treatment dose, defined as the lowest dose to 95% of the tumor volume, was 18 Gy. The tumor control rate as well as the survival time were related to a number of patients, tumor and treatment parameters. Results The local tumor control rate was 100% at one year and 89% at five years, and the overall median survival was 17 months. A good performance status and a treatable extracranial disease were favorably related to survival time. Two complications were observed, one lethal hemorrhage at the day of the treatment and one transient complication three months following GKS, resulting in a 6% complication rate at five years. Four of the 10 patient with symptomatic BSM improved clinically after GKS, while six remained unchanged. Conclusions High local control and a low complication rates can be achieved using GKS for BSMs using lower doses as compared to brain metastases in other locations.

The use of extracorporeal membrane oxygenation (ECMO) as salvage therapy for patients with severe cardiopulmonary failure has increased significantly in the past decade. However, the use of ECMO in pregnant and peripartum patients has received scant attention. We performed a systematic review of case reports in the literature, documenting indications and outcomes of ECMO in pregnancy and postpartum patients. Case reports on ECMO use in pregnant and postpartum patients were retrieved from MEDLINE, EMBASE and SCOPUS databases up to December 2018. Ninety publications reporting on 97 patients met our inclusion criteria. The majority of publications reported peripartum or postpartum ECMO use for cardiovascular failure (60.8%), while the remainder had respiratory failure. Adult Respiratory Distress Syndrome (91.9%) was the most common respiratory indication while pulmonary embolism (23.7%) and peripartum cardiomyopathy (16.9%) accounted for the two most common cardiovascular indications. Hemorrhage was the most common complication of ECMO reported (31.9%). Of 96 documented neonatal outcomes, 80 neonates (83.3%) survived while 88 of 97 (90.7%) mothers survived. Extracorporeal membrane oxygenation appears to be a viable life support modality in pregnant and postpartum women with severe cardiopulmonary failure, but publication bias in our study cohort should be considered. (C) 2020 Elsevier Ltd. All rights reserved.

To compare cumulative live birth rate according to the rate of use of metaphase II (MII) oocytes in conventional ovarian stimulation protocols for in vitro fertilization (IVF) or intracytoplasmic sperm injection.In a cohort study, patients aged 18-38 years undergoing their first IVF treatment at one US center were enrolled between February 1, 2009, and August 31, 2013. Ovarian response was categorized by the yield of MII oocytes (low: 1-2; intermediate: 3-6; high: ≥7). The main outcome measure was cumulative live birth rate over a 6-month period.Among 250 participants, 3240 oocytes (mean±SEM 12.96±0.50) were retrieved and there were 152 (60.8%) live births. Overall, 172 (68.8%) participants had a high oocyte yield, 61 (24.4%) an intermediate yield, and 17 (6.8%) a low yield. The cumulative live birth rate was 58.8% (10/17) in the low-yield group, 55.7% (34/61) in the intermediate-yield group, and 62.8% (108/172) in the high-yield group (P=0.35).In conventional ovarian stimulation, live birth rate is not affected by the ovarian response. Whether oocytes produced from a low ovarian response are biologically more effective than oocytes obtained from a high ovarian response remains to be determined.

Background An inverse relationship between oocyte efficiency and ovarian response was reported in conventional IVF. The purpose of this study was to report metaphase II (MII) oocyte efficiency according to oocyte yield in minimal/mild stimulation IVF (mIVF) and to assess whether oocyte yield affects live birth rate (LBR). Methods Infertile women (n = 264) aged 0.05). The number of MII oocytes had poor sensitivity and specificity for predicting a live birth. Conclusion These data extend the hypothesis of oocyte efficiency reported in conventional IVF protocols to mIVF protocols. Trial registration Registration clinicaltrials.gov: NCT00799929.