Initial Score Research Articles

Abstract WP209: Functional Outcomes After Craniotomy or Endoscopic Procedure for Hematoma Evacuation in Patients of Intracerebral Hemorrhage Associated With Oral Anticoagulants

Background and Purpose: The role of surgical evacuation using craniotomy or endoscopic procedure in patients with intracerebral hemorrhage (ICH) associated with oral anticoagulants is not well described. We investigated the 6-month functional outcomes of patients with ICH associated with oral anticoagulants after hematoma evacuation using either craniotomy or endoscopic procedures. Methods: We analyzed data of consecutive ICH patients who underwent hematoma evacuation using either craniotomy or endoscopic procedures. We compared the outcomes between patients with ICH associated with oral anticoagulants to those with spontaneous ICH. We also compared the results between patients treated with craniotomy and those treated with endoscopic procedures. We performed multivariate analyses to assess the effect of ICH associated with oral anticoagulants on modified Rankin Scale (mRS) at 6 months, which was analyzed both as dichotomous and ordinal endpoints after adjusting for age, gender, initial GCS score, initial hematoma volume, and presence or absence of intraventricular hemorrhage. Results: Of the 148 ICH patients undergoing hematoma evacuation, 25 (17%) had ICH associated with oral anticoagulants. There were no statistically significant differences between the two groups in terms of age, gender, admission Glasgow Coma scale (GCS) score, admission National Institutes of Health Stroke Scale (NIHSS) score, peri and post-operative hematoma volume, presence of cardiovascular disease, hypertension, or dyslipidemia. There was no difference in the proportion of patients with mRS 0-2 at 6 months among patients with and without ICH related to oral anticoagulants (4/25 (16%) versus 27/123 (22%), p-value = 0.5). In the ordinal analysis, there was no significant association between ICH associated with oral anticoagulants and mRS grades (OR 1.62 (0.25, 9.65), p-value 0.598. Conclusion: Prior anticoagulation use is not associated with poor functional outcome (mRS 3-6) in patients with intracerebral hemorrhage, procedure use for hematoma evacuation (craniotomy or endoscopic) does not predict good functional outcome at 6 months.

Abstract WP38: Nurse-Driven Emergency Evaluation Improves Timely Acute Stroke Response

Background: Stroke is associated with high rates of death and disability; prompt and effective interventions are imperative. Depending on emergency department (ED) physicians to initiate stroke codes may delay critical time targets, especially for patients arriving by private vehicle (POV). This study examines existing stroke care protocols in the ED of a Comprehensive Stroke Center and evaluates a new nurse-driven acute stroke response protocol. Purpose: The primary goal of this initiative was to improve outcomes for patients arriving by POV, by reducing triage delays and accelerating time-sensitive acute stroke interventions. Methods: This retrospective study implemented a nurse-led stroke activation process, in lieu of the conventional physician-led method. Nurses received comprehensive training in intervention goals and identification of stroke symptoms and last known-well times. The nurse-led model targeted patients presenting to the ED with a minimum of 2 stroke symptoms within 6 hours of symptom onset—an assessment tool, incorporating the FAST algorithm (Face, Arm, Speech, Time) and key National Institutes of Health Stroke Scale (NIHSS) exam components, enhanced symptom specificity. Critical intervention times were evaluated for improvement. Results: ED POV arrival patients with acute stroke symptoms were studied from 11/7/21-7/31/23; the nurse-driven process was implemented on 11/7/22. Pre-intervention review included 247 patients with 216 patients in the post-intervention review. Median door-to-activation times fell from 17 to 10 minutes, door-to-CT from 24 to 19 minutes, and door-to-needle times from 49 to 43.5 minutes. Median NIHSS scores in tPA-treated patients were compared pre- and post-intervention. In the physician-led group, initial median NIHSS scores were 6, reducing to 1 at discharge. The nurse-led group showed an initial median NIHSS score of 5, also reducing to 1 at discharge. Conclusions: The nurse-driven method effectively shortened critical time metrics in the stroke code process, while maintaining optimal patient outcomes. A paradigm shift towards ED triage nurse-led stroke code activation for acute stroke may lead to higher quality acute stroke care.

Abstract 7: Scrambler Therapy for Treatment of Post Stroke Pain

Objective: Infarcts involving sensory pathways can result in a post-stroke pain syndrome that is often refractory to traditional medical therapy. Scrambler Therapy (ST) is a noninvasive electroanalgesia device effectively used to treat peripheral neuropathy; however, data is scarce regarding its use in the central nervous system. In this pilot, we evaluate the efficacy of ST to treat post-stroke pain syndromes. Methods: Twenty patients with a history of stroke resulting in contralateral pain were enrolled and randomized to receive ST or Sham as an adjunct to their current medication regimen. Participants underwent 5 consecutive sessions, each lasting 40 minutes. Pain scores were recorded at baseline, as well as before and after each session using a Numeric Rating Scale (0-10). The study was double-blinded to both the participant and operator. Following treatment, pain scores were collected weekly for 4 weeks. Student’s t tests were used to compare scores at: baseline, immediately post-treatment #5, and at 4 week follow-up, between groups as well as the change in pain score between individuals. Results: To date, 15 patients have been enrolled and completed the intervention; 10 have completed longer-term follow-up. The average age of the cohort was 57.8 years; 47% were male; 53% black; and the average time from stroke was 26 months. Participants randomized to ST (n=7) had a mean pain score of 6.52 at baseline; the Sham group (n=8) had a mean score of 5.83. The ST group had a mean change from initial score to score after 5 days of treatment of -4.17 (SD 2.64), while the Sham group had a mean change in score of -1.03 (SD 1.42). For patients completing follow-up, the ST group (n=5) saw a mean change pain score from baseline to follow-up of -3.37 (SD 1.71). The Sham group (n=5) a mean change of -0.37 (SD 0.34). Differences in change in score were significant between groups at both time points (p=0.01 and 0.005 respectively). Conclusion: There is a significant difference in both acute and longer-term pain reduction for patients with post-stroke pain who undergo treatment using ST compared to Sham that suggests it may be an effective treatment option. Larger studies are needed to evaluate confounders such as stroke location, time from stroke, and concomitant treatment with medications.

Implementasi Teori Belajar Humanistik dalam Pembelajaran Berdiferensiasi IPAS di Sekolah Dasar

This research aims to analyze the application of humanistic learning theory in differentiated science learning for grade 5 phase C in elementary schools. Humanistic learning theory and differentiated science learning have similarities in understanding the importance of respecting the human side in order to suit individual characteristics. The research was conducted using a qualitative descriptive method through case studies. Research involves observing the planning, implementation and evaluation of science differentiated learning. Data is collected through diagnostic tests, observation, performance and final tests. The research subjects were 25 grade 5 students at SD Negeri 33 Sawahan for the 2023/2024 academic year. The research results show that the application of humanistic learning theory in differentiated science learning has a positive impact on student creativity and learning achievement. This can be seen from the increase in the average student creativity score from 60.69 to 87.21. Apart from that, this learning also increases student learning outcomes from an initial score of 75.45 to 88.86. The results of the research show that the application of differentiated science and science learning with humanistic learning theory can increase student creativity and learning outcomes.

Implementation of robot-assisted lymphaticovenous anastomoses in a microsurgical unit

BackgroundNumerous papers have been published evaluating the clinical benefits of robot-assisted microsurgery. In this study, we describe the incorporation of the MUSA-2 robot (Microsure, Eindhoven, The Netherlands) into a plastic surgery unit outside of its development centre. We aimed to assess robot implementation timeframes, areas of future development, and key learning points for centres considering the establishment of a robot-assisted microsurgery service.MethodsWe identified 12 female patients with upper limb lymphoedema secondary to breast cancer treatment, who consented to have a robotic-assisted lymphaticovenous anastomosis (LVA) from September 2022 to March 2023. All patients had at least one robot-assisted LVA. Post operatively, a surgical evaluation of the robot’s performance and of the surgeon’s intraoperative workload was measured. Each patient completed a postoperative Likert scale, which measured their surgical experience.ResultsThe mean robot time per case was 60.25 min. The mean time taken for the first robot-assisted anastomosis was 32 min. The second robot anastomoses was 30% faster than the first, taking a mean of 22.5 min. The average anastomosis had 4.5 sutures placed robotically. Initial mean scores in the workload survey completed by the surgeon were highest for frustration and effort, both reduced with increasing volume of cases. In 91% of cases, physical intraoperative discomfort was reported by the surgeon but completely resolved following repositioning.ConclusionsThe current technology can be readily incorporated into a microsurgical unit. We developed four key learning points from the implementation of robot-assisted LVA in our microsurgical unit.Level of evidence: Level IV, risk/prognostic study

Aggregated demand-side response in residential distribution areas based on tiered incentive prices

The residential area refers to the power supply area from distribution transformers to the end users that contains multiple types of flexible resources, such as photovoltaics, energy storage, and power users. Focusing on the challenge of insufficient demand response incentives to multiple types of users in residential distribution areas, a tiered incentive price-based demand-side aggregated response method is proposed in this paper. Users in residential distribution areas are classified with an improved k-means clustering method for obtaining typical types of users. Thereafter, initial scores of users are calculated, and their grades are assigned based on their scores. Corresponding tiered incentive prices are designed for different grades. On this basis, a leader–follower game is proposed to obtain the demand response base price, and tiered incentives are provided to users of different grades to increase their enthusiasm for participating in demand response. In the case study, an actual urban residential distribution area is studied. The results show that the proposed user clustering method has an accuracy of 99.8% in classifying users in a residential distribution area. In addition, the proposed method has better performance in terms of improving the benefit of the load aggregator and users in the residential distribution area compared with methods such as potential game, hidden Markov, and Monte Carlo. Specifically, from the results, the benefit of load aggregators is increased by 101.96%, 76.07%, and 112.37%, and the income of the users is increased by 54.51%, 36.94%, and 64.91%.

Prognostic impact of KIHON checklist score in elderly patients with hemodialysis initiation

BackgroundFrailty pervades the demographic of individuals afflicted by chronic kidney disease (CKD) and exhibits a robust correlation with a less favorable prognosis. Nonetheless, the evaluation and prognostication of frailty within the incipient stages of dialysis initiation remain shrouded in ambiguity. The necessity arises for an uncomplicated metric that holistically assesses frailty among aged CKD patients, one which lends itself to pragmatic clinical application.MethodsIn our prospective endeavor, we conducted assessments using the “KIHON checklist (KCL),” a questionnaire comprising 25 points, thoughtfully crafted by the Japanese Ministry of Health, Labour and Welfare to provide a thorough evaluation of the elderly population. This assessment was administered at the commencement of hemodialysis in patients aged 65 years or older. Subsequently, we analyzed the prognostic ramifications of the initial KCL scores on the composite primary endpoint, which encompassed the undesirable outcomes of either being bedridden or succumbing to mortality.ResultsA total of 24 patients (median age 76 years, 20 men) were included. The median KCL score was 6 [4, 10] points, and it was significantly correlated with the number of components in the revised Japanese Cardiovascular Health Study, which is a diagnostic criterion for frailty (p < 0.05). The group with a KCL score ≥ 10 points had a significantly lower 1-year freedom from the primary endpoints than the other group (43% versus 87%, p < 0.05). Among the components of the KCL, physical strength was significantly associated with the prognosis (p < 0.05).ConclusionThe screening protocol employing the KCL during the commencement of hemodialysis among elderly individuals proved to be a valuable tool for the anticipation of both the state of being bedridden and mortality.

P1191 Genetic determinants for smoking behaviour improve our understanding of sporadic versus familial Inflammatory Bowel Disease

Abstract Background Inflammatory bowel disease (IBD) is influenced by genetic and environmental factors. The latter are often difficult to quantify and may vary over time, unlike genetics. Here, instead of looking at actual smoking behaviour, we explored the impact of genetic determinants of smoking behaviour on IBD risk in sporadic and familial IBD. Methods We calculated polygenic scores (PRS) for smoking initiation, smoking cessation, age of smoking initiation, and cigarettes per day in 2784 sporadic cases (1700 CD, 1084 UC), 682 non-IBD controls, and 60 multiplex IBD families with ≥3 affected first-degree relatives (FDR) (142 CD, 31 UC and 100 unaffected FDR). PRS were calculated for different p-value thresholds (5e-8, 1e-5, 0.01, 0.05, 0.1, 0.5 and 1), and based on effect estimates of Saunders et al (Nature 2022, table 1). Groups were compared using logistic regression. P&amp;lt;1.43e-3 was the significance threshold for Bonferroni correction. Results Sporadic IBD cases had a higher PRS for smoking initiation than controls (p=4.49e-3), which was driven by the CD cases (p=7.17e-4, fig 1A). CD cases also showed a trend for a higher PRS for cigarettes per day (p=0.026). In familial cases compared to unaffected FDR, we observed some differences in PRS for smoking, but none survived multiple testing (fig 1B). Comparing familial and sporadic cases, we found that the PRS for age at smoking initiation was higher in familial than in sporadic UC (p=9.09e-4, fig 1C). Familial CD showed a trend towards a lower PRS for age at smoking initiation (p=0.023) and smoking cessation (p=0.013) than sporadic CD. Familial CD cases are thus more at risk than sporadic CD cases as they genetically tend to start smoking younger, while the opposite is seen for UC. Also, unaffected FDR of UC families showed a lower PRS for age at smoking initiation (p=5.47e-5, fig 1D) than controls, giving them additional protection. The PRS for smoking cessation (p=3.88e-5) and cigarettes per day (p=4.47e-3) was greater in unaffected FDR of mixed families than in controls, while familial mixed cases had a lower cigarettes per day PRS than sporadic cases (p=1.59e-4). Conclusion We found that genetic determinants of smoking behaviour are associated with disease risk in familial and sporadic IBD. While CD risk overall is associated with a greater genetic propensity for smoking initiation, the higher risk in families is linked to genetic age at start of smoking. Meanwhile, unaffected FDR of these families are protected through a higher genetic propensity to stop smoking in mixed families, or to start smoking sooner in UC families, compared to population controls. This study improves our understanding of familial vs sporadic IBD, and could help stratify individuals at risk of IBD.

Moral Resilience Reduces Levels of Quiet Quitting, Job Burnout, and Turnover Intention among Nurses: Evidence in the Post COVID-19 Era.

The aim of the study was to examine the impact of moral resilience on quiet quitting, job burnout, and turnover intention among nurses. A cross-sectional study was implemented in Greece in November 2023. The revised Rushton Moral Resilience Scale was used to measure moral resilience among nurses, the Quiet Quitting Scale to measure levels of quiet quitting, and the single-item burnout measure to measure job burnout. Moreover, a valid six-point Likert scale was used to measure turnover intention. All multivariable models were adjusted for the following confounders: gender, age, understaffed department, shift work, and work experience. The multivariable analysis identified a negative relationship between moral resilience and quiet quitting, job burnout, and turnover intention. In particular, we found that increased response to moral adversity and increased moral efficacy were associated with decreased detachment score, lack of initiative score, and lack of motivation score. Additionally, personal integrity was associated with reduced detachment score, while relational integrity was associated with reduced detachment score, and lack of initiative score. Moreover, response to moral adversity was associated with reduced job burnout. Also, increased levels of response to moral adversity were associated with lower probability of turnover intention. Moral resilience can be an essential protective factor against high levels of quiet quitting, job burnout, and turnover intention among nurses. This study was not registered.

Initial stroke severity and discharge outcome in patients with muscle mass deficit.

This study aimed to investigate the association between muscle mass deficit and the initial severity of ischemic stroke. The impact of muscle mass deficit on the discharge outcome was also evaluated. This retrospective study included 660 patients with acute ischemic stroke who underwent bioelectrical impedance analyses. We compared the National Institute of Health Stroke Scale (NIHSS) score, occurrence of moderate stroke (NIHSSS ≥ 5) at admission, and unfavorable functional outcome (modified Rankin Scale score ≥ 2) at discharge between patients with and without muscle mass deficit using Poisson and logistic regression analyses. The mean age of the study patients was 65.6 ± 13.0, and 63.3% were males. Muscle mass deficit was present in 24.4% of patients. Muscle mass deficit was significantly and independently associated with NIHSS score or moderate stroke (all p < 0.05). This association was noted regardless of patient characteristics. Among the respective NIHSS items, muscle mass deficit was significantly associated with facial palsy, motor function of the arm or leg, limb ataxia, and dysarthria. Muscle mass deficit also led to unfavorable functional outcome, which was mediated by the initial NIHSS score. In conclusion, muscle mass deficit is associated with higher NIHSS score and unfavorable functional outcome in patients with acute ischemic stroke.

Penerapan Model Problem Based Learning untuk Meningkatkan Kemampuan Pemecahan Masalah Matematis Siswa di Kelas VIII – A SMP Negeri 1 Stabat

This study aims to determine whether applying the Problem Based Learning model can improve the mathematical problem solving ability of students of class VIII-A SMP Negeri 1 Stabat on SPLDV. This research is a class action research conducted in two cycles. Each cycle consists of 2 meetings. The subjects in this study were students of class VIII-A SMP Negeri 1 Stabat totalling 30 students. The object of this research is the improvement of students' mathematical problem solving ability through the application of the Problem Based Learning learning model on SPLDV material at SMP Negeri 1 Stabat in the 2023/2024 school year. Based on the results of data analysis, the average initial test score was 47.11 with the number of students who reached mastery as many as 4 students (13.33%) and students who had not reached mastery as many as 26 students (86.67%). Then learning was carried out with the Problem Based Learning learning model in cycle I and there was an increase in the problem solving ability test with an average value of 63.44 with 19 students or as many as (63.33%). Then students who have not reached completeness are 11 students or as many as (36.67%). Then in cycle II there was an increase with the average value of the student problem solving ability test being 84.11, with a total completeness of 26 students or as many as (86.67%) and the number of students who had not reached completeness was 4 students or as many as (13.33%). The level of student completeness of the problem solving ability test given in cycle II reached the good category, therefore it can be said that learning has been achieved. Thus it can be said that the class has reached more than 85% of students who have been completed to solve problems. So it can be concluded that using the Problem Based Learning model can improve students' mathematical problem solving skills.

MAGIC: Malware behaviour analysis and impact quantification through signature co-occurrence and regression

Malware poses risks by compromising both data integrity and system security. Proactive defense efforts have led to the adoption of malware scoring, allowing analysts to assess the severity and develop countermeasures. These scores indicate the degree of malware maliciousness based on triggered signatures. However, current scoring methods do not precisely depict the true extent of malware's maliciousness. This inaccuracy is attributed to an inadequate assessment of the impact of behaviour corresponding to signatures on both system and network resources. To address this limitation, the paper proposes a novel scoring approach that accurately quantifies the impact of signatures triggered by malware through co-occurrence analysis. The method assesses the ensemble behaviour of signatures across two phases. In the first phase of signature scoring, an impact score quantification algorithm initializes each signature to predefined severity score bands based on the studied severity and frequency. The second phase refines initial scores iteratively, considering mutual information among signatures co-occurring in the malware's execution. Experimental results validate the proposed method's ability to accurately reflect signature maliciousness. This novel scoring method enhances malware analysis platforms in generating more precise scores compared to traditional methods, thereby improving resilience against evolving malware threats in the dynamic cybersecurity landscape.

Moving towards a personalised understanding of the nutritional impact of self-expanding metallic stents (SEMS) in gastro-oesophageal cancer: A retrospective case note review of a tertiary referral oncology centre.

301 Background: Dysphagia is a common life-impacting complication for patients with gastro-oesophageal (O-G) cancer. Options to alleviate dysphagia include insertion of SEMS or percutaneous endoscopic gastrostomy (PEG). SEMS improve quality of life by enabling a person to eat a varied diet, but are associated with complications including pain and need for reintervention. Although studies have shown SEMS improve dysphagia, consequent longitudinal impact on nutritional status has not been evaluated. There is a need to better characterise risks and benefits of SEMS to allow a personalised approach to both insertion and follow-up. Methods: We identified patients with a confirmed diagnosis of O-G cancer, who underwent SEMS insertion at The Christie NHS Foundation Trust in 2021 and 2022. Data was retrospectively collected about patient and stent characteristics, and patient outcomes to quantify benefits and risks of SEMS. Results: 112 patients had 127 SEMS inserted at The Christie. Patients’ International Dysphagia Diet Standardisation Initiative (IDDSI) score significantly improved after SEMS insertion (N=120); prior to SEMS 62% were only managing liquids and purees (IDDSI 3 and 4) and 24% were not able to eat enterally. Post SEMS, 76% tolerated textured foods (IDDSI 5 and above) and only 21.5% were limited to liquids/purees. We observed a significant reduction in the rate of weight loss (% body weight/10 days) following SEMS insertion (-0.010 ± 0.009 vs. -0.001 ± 0.010, P &lt; 0.001). 12% of patients experienced grade 3 SEMS-related toxicity or stent failure within 30 days, and 20% developed significant pain within 24 hours of SEMS insertion. Conclusions: SEMS provide meaningful nutritional benefit in the majority of patients with O-G cancer, as weight loss is significantly slowed following insertion. However, we identified two groups of patients who did not benefit from SEMS; those who continued to lose weight and those who had stent failure. We did not find predictive factors for stent failure from multivariate analysis of baseline demographics or stent characteristics. Therefore, more detailed analysis of tumour factors, imaging findings and SEMS location from a larger cohort of patients may be required to identify patients who are unlikely to benefit from SEMS, and alternative interventions such as PEG feeding could be considered.

Seasonal Variations in Stroke and a Comparison of the Predictors of Unfavorable Outcomes among Patients with Acute Ischemic Stroke and Cardioembolic Stroke.

We investigated the seasonal variations in stroke in 4040 retrospectively enrolled patients with acute ischemic stroke (AIS) admitted between January 2011 and December 2022, particularly those with cardioembolic (CE) stroke, and compared predictors of unfavorable outcomes between AIS patients and CE stroke patients. The classification of stroke subtypes was based on the Trial of ORG 10172 in Acute Stroke Treatment. Stroke occurrence was stratified by seasons and weekdays or holidays. Of all AIS cases, 18% were of CE stroke. Of all five ischemic stroke subtypes, CE stroke patients were the oldest; received the most thrombolysis and thrombectomy; had the highest initial National Institutes of Stroke Scale (NIHSS) and discharge modified Rankin Scale (mRS) scores; and had the highest rate of in-hospital complications, unfavorable outcomes (mRS > 2), and mortality. The highest CE stroke prevalence was noted in patients aged ≥ 85 years (30.9%); moreover, CE stroke prevalence increased from 14.9% in summer to 23.0% in winter. The main predictors of death in patients with CE stroke were age > 86 years, heart rate > 79 beats/min, initial NIHSS score > 16, neutrophil-to-lymphocyte ratio (NLR) > 6.4, glucose > 159 mg/dL, cancer history, in-hospital complications, and neurological deterioration (ND). The three most dominant factors influencing death, noted in not only patients with AIS but also those with CE stroke, are high initial NIHSS score, ND, and high NLR. We selected the most significant factors to establish nomograms for predicting fatal outcomes. Effective heart rhythm monitoring, particularly in older patients and during winter, may help develop stroke prevention strategies and facilitate early AF detection.

Automated evaluation of collateral circulation for outcome prediction in acute ischemic stroke

IntroductionThe assessment of collateral circulation in acute ischemic stroke management is essential. Modern tools, such as Brainomix's e-CTA, powered by artificial intelligence, provide detailed insights into collateral assessment. This retrospective study aims to identify factors contributing to favorable collateral status and compare outcomes between patients with good collaterals (grade 3) and fair collaterals (grade 0–2). MethodThis retrospective study included 97 patients admitted to the Stroke Unit at the Hospital de Clínicas of the Federal University of Paraná, Brazil, from September 2021 to January 2023. Comparative analyses involved demographic factors, cardiovascular risk factors, and the combined outcome of mortality and moderate to severe disability at discharge, 30-day, and 90-day follow-ups. ResultsAmong the 97 cases, 58.8 % showed 'good collaterals' with a grade 3 status. Variables affecting collateral status included age (p = 0.042), neutrophil-lymphocyte ratio (p = 0.005), and initial NIHSS scores (p<0.001). The presence of good collaterals according to e-CTA reduced the odds of death and moderate-severe disability at discharge (p = 0.003; OR 0.27) and at 30 days (p = 0.015; OR 0.33), although this effect diminished at the 90-day mark after multivariate analysis. DiscussionAutomated collateral assessment through e-CTA is a valuable tool in acute ischemic stroke evaluation. Good e-CTA collateral score serve as a promising imaging biomarker, guiding informed clinical decisions during Stroke Unit hospitalizations. This study highlights the relationship between collaterals and stroke outcomes and underscores the potential for AI-driven tools to enhance stroke care management.

Ocular Surface Evaluation after Switch from Latanoprost 0.005% to Latanoprostene Bunod 0.024.

To evaluate the ocular surface of patients treated with latanoprost (LT) 0.005% who switched to latanoprostene bunod (LBN) 0.024%. A prospective and nonrandomized clinical study of a case series was performed, including patients with chronic open-angle glaucoma who were on previous LT-only treatment and, after a washout period, switched to LBN, with a 3-month follow-up. The main parameter to be evaluated was the ocular surface disease index (OSDI) test. In addition, best-corrected visual acuity (BCVA), intraocular pressure (IOP), biomicroscopic aspect of the ocular surface, measuring tear breakup time, fluorescein staining (grading performed on Oxford scale) and Schirmer I test were evaluated. A total of 36 patients (72 eyes) were included, 21 women (58.3%) and 15 men (41.7%, with a mean age of 65.6 ± 10.9 years (37-86). The initial OSDI score was 17.8 ± 12.1 and improved to 11.1 ± 10.5 (p < 0.01). From the data evaluated at biomicroscopy, an improvement was observed in the Oxford scale from 0.6 ± 0.7 to 0.2 ± 0.8 (p: 0.01), but no statistically significant changes were observed in the break-up time (BUT) and Schirmer. BCVA remained stable, as did IOP, which was initially 13.4 ± 2.1 mm Hg and, after performing the LBN treatment change, went to 13.1 ± 1.7 mm Hg. After the change of treatment from LT 0.005% to LBN 0.024%, the patients had an improvement in the ocular surface, maintaining control of their IOP. The need to investigate possible beneficial mechanisms on the ocular surface in glaucoma patients treated with LBN, potentially related to nitric oxide, is raised. Patients treated with LT 0.005% who switched to LBN 0.024% had an improvement in ocular surface symptoms and signs, keeping IOP under control.Latanoprostene bunod (LBN) 0.024% may have beneficial effects on the ocular surface, which should be further studied. Zanutigh V, Galetto L, Valvecchia F, et al. Ocular Surface Evaluation after Switch from Latanoprost 0.005% to Latanoprostene Bunod 0.024%. J Curr Glaucoma Pract 2023;17(4):205-209.

Diagnostic Efficacy of SOFA Score in Predicting Outcome and Mortality: An ICU Experience from Pakistan

Objective: To determine the cut-off value of Sequential Organ Failure Assessment score at the time of admission in Intensive Care Unit to predict mortality and outcome in critically ill patients.&#x0D; Materials and Methods: This cross-sectional, descriptive study was undertaken at Intensive Care Unit of Rawalpindi Teaching Hospital, Rawalpindi, Pakistan between April and August 2023. SOFA score of all critically ill patients at the time of admission in ICU and their outcome (expired or discharged) was recorded. Receiver Operator Characteristics Curve (ROC) was drawn for SOFA score and mortality. Cut off value for SOFA score was calculated. Outcome of patients above and below the cut off value for SOFA score was studied using Chi-square test.&#x0D; Results: A total of 100 patients (54% females and 46% males) were included in the study with mean patient age of 68.93±11.09 years. Out of 100 patients, 48 (48%) improved and 52 (52%) expired. The Mean initial SOFA score was 5.44±3.99 in patients who improved and 9.91±4.20 in patients who expired. Coordinates of the ROC curve showed that SOFA score cut off value 7.5 had best corresponding sensitivity (0.777) and specificity (0.740). The patients were categorized to Group I (SOFA score ≤7), and Group II (SOFA score ≥8). 34.04% of the Group I and 75.47% of the Group II patients expired (p-value 0.0000001)&#x0D; Conclusions: Mortality was higher in patients who had higher SOFA score at the time of admission in Intensive Care Unit. At admission SOFA scores (≤7 and &gt;8) are best predictor of outcome in critically ill patients.

Determinants of Accuracy of Freehand, EVD Placement by Neurosurgical Trainees.

Background: The insertion of an external ventricular drain (EVD) is a fundamental neurosurgical procedure predominantly performed by junior neurosurgical trainees. It is vital for managing conditions like hydrocephalus, intracranial hypertension, traumatic brain injury, and others. The procedure's success heavily relies on the precise identification of anatomical landmarks and the trainee's experience. Objective: This study aims to assess the precision and safety of EVD placement in patients treated by first-year (R1) and second-year (R2) neurosurgical residents, evaluating the impact of the residents' experience levels on the outcomes of the procedure. Methods: Conducted at the Neurosurgery Department of Jinnah Post Graduate Medical Center, Karachi, from February to July 2022, this prospective cohort study involved individuals aged 18 years or older undergoing EVD placement for hydrocephalus. Exclusion criteria included patients with more than 5mm midline shift on initial scans or those without a post-EVD placement scan. Procedures were performed under senior resident supervision, with postoperative CT scans assessing catheter tip placement and potential complications. Statistical analyses utilized IBM SPSS Statistics for Windows, Version 25.0, with Student’s t-test, Chi-square, and Fisher exact tests applied as appropriate. Results: The study comprised 152 patients (mean age: 39.4 ± 10.7 years; 52.6% male). The initial GCS scores varied, with 44.7% scoring above 8. Most EVD placements (60.5%) were by residents in their fourth or fifth year. The average procedure duration was 43 ± 8.7 minutes, with an average of 1.44 ± 0.12 passes. Optimal placement (Kakarla Grade 1) was achieved in 59.2% of cases, with significant differences in placement accuracy between R1 and R2 residents (p&lt;0.05). Conclusion: The study highlights the significant role of experience and training in the successful placement of EVDs. The higher accuracy rates in more experienced residents underscore the need for enhanced training programs for junior neurosurgical trainees, focusing on anatomical landmark identification and procedural practice.

Appropriate timing of veno-arterial extracorporeal membrane oxygenation initiation after cardiac surgery

BackgroundVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be initiated during cardiac surgery or later in ICU according to the hemodynamic profile and organ perfusion. Our aim was to study the appropriate timing of post-cardiotomy ECMO (PC-ECMO) initiation. We retrospectively analyzed 152 adult patients supported with PC-ECMO in our cardiac center between 2016 and 2022. The patients were divided into two groups: the intra-operative ECMO and the postoperative ECMO groups. The primary outcome was all-and-on-ECMO hospital mortality. The secondary outcomes included ECMO duration, new need for dialysis, cerebrovascular stroke, and length of ICU stay.ResultsOur cohort analysis revealed that 81(53.3%) patients were intra-operatively supported with VA-ECMO while 71(46.7%) patients were postoperatively supported in ICU. The postoperative ECMO group had significantly lesser SAVE score (p = 0.001), higher SAVE risk classes (p < 0.001), and higher SOFA score (p = 0.008) compared to the intra-operative ECMO group. The postoperative ECMO group had significantly more frequent hospital mortality (p = 0.003), on-ECMO mortality (p = 0.006), cerebrovascular stroke (p = 0.034), acute renal failure requiring dialysis (p < 0.001), and lesser lactate clearance at 12 h (p = 0.016) and at 24 h (p = 0.023) compared to the intra-operative group. There were statistically insignificant differences between the two groups regarding post-ECMO hospital mortality, cerebral bleeding, limb ischemia, ECMO, and ICU duration. Postponed postoperative ECMO insertion was associated with an increased risk of death (HR 1.628, 95%CI 1.102–2.403, p =0.014) with cox-proportional hazard regression. Logistic multivariable regression showed that atrial fibrillation (OR 6.2, 95% CI 2.71–61.84, p = 0.002), initial SOFA score (OR 1.46, 95% CI 1.041–3.83, p = 0.001), and postoperative ECMO insertion (OR 1.93, 95% CI 1.04–8.73, p = 0.031) were the predictors of hospital mortality.ConclusionsPostponed ECMO insertion in critically sick patients was associated with increased mortality after cardiac surgery. Early intra-operative initiation of PC-ECMO may have the potential to improve outcomes after cardiac surgeries.

Effectiveness of Medical Cannabis for the Treatment of Depression: A Naturalistic Outpatient Study.

There is a lack of studies on the course and effectiveness of medical cannabis in the treatment of major depressive disorder (MDD). Retrospective longitudinal (18 weeks) study of n=59 outpatients with MDD, treated with medical cannabis via a telemedical platform. Previous treatment with antidepressant medication was required for inclusion into the study. Standardized data collection was carried out at entry and during monthly consultations. Severity of depression was measured on a 0-10 point rating scale. Side-effects were assessed by a checklist. Patients were 20-54 years old; 72.9% were male; one third reported times of regular cannabis consumption within the previous five years. Drop-out rate was 22% after 18 weeks. Mean severity of depression decreased from 6.9 points (SD 1.5) at entry to 3.8 points (2.7) at week 18 (baseline observation carried forward; 95% CI for the mean difference: 2.4 to 3.8; p<0.001). A treatment response (>50% reduction of the initial score) was seen in 50.8% at week 18. One third of patients complained about side effects, none was considered as severe. Concomitant antidepressant medication (31% of patients) was not associated with outcome. Medical cannabis was well tolerated and dropout rate was comparable to those in clinical trials of antidepressant medication. Patients reported a clinically significant reduction of depression severity. Further research on the effectiveness of medical cannabis for MDD seems warranted. Risks of this medication, such as sustaining or inducing a cannabis use disorder, or side effects such as poor concentration, must be taken into consideration.