Background: and Purpose Tenecteplase is a thrombolytic agent with pharmacological advantages over alteplase and has been shown to be noninferior to alteplase for acute ischemic stroke in randomized trials. However, evidence pertaining to the safety and efficacy of tenecteplase in patients from different ethnic groups is lacking. The aim of this systematic review and metaanalysis was to investigate ethnicity-specific differences in the safety and efficacy of tenecteplase versus alteplase in patients with acute ischemic stroke. Methods: Following an International Prospective Register of Systematic Reviews (PROSPERO)- registered protocol (CRD42023475038), three authors conducted a systematic review of the PubMed/MEDLINE, Embase, Cochrane Library, and CINAHL databases for articles comparing the use of tenecteplase with any thrombolytic agent in patients with acute ischemic stroke up to November 20, 2023. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Two independent authors extracted data onto a standardized data collection sheet. A pairwise meta-analysis was conducted in risk ratios (RR). Results: From 34 studies (59,601 participants), the rate of complete recanalization was significantly higher (P<0.01) in Asian (RR: 1.91, 95% confidence interval [CI]: 1.30 to 2.80) versus Caucasian patients (RR: 0.99, 95% CI: 0.87 to 1.14). However, Asian patients (RR: 1.18, 95% CI: 0.87 to 1.62) had significantly higher (P=0.01) rates of mortality compared with Caucasian patients (RR: 1.10, 95% CI: 1.00 to 1.22). Caucasian patients were also more likely to attain a modified Rankin Scale (mRS) score of 0 to 2 at follow-up (RR: 1.14, 95% CI, 1.10 to 1.19) compared with Asian (RR: 1.00, 95% CI, 0.95 to 1.05) patients. There was no significant difference in the rate of symptomatic intracranial hemorrhage (P=0.20) and any intracranial hemorrhage (P=0.83) between Asian and Caucasian patients. Conclusion Tenecteplase was associated with significantly higher rates of complete recanalization in Asian patients compared with Caucasian patients. However, tenecteplase was associated with higher rates of mortality and lower rates of mRS 0 to 2 in Asian patients compared with Caucasian patients. It may be beneficial to study the variations in response to tenecteplase among patients of different ethnic groups in large prospective cohort studies.

A 19-year-old man had an accidental fall from the 2nd floor and sustained multiple injuries. On radiological evaluation, the patient had symmetrical quadruple limb involvement with bilateral humerus shaft, bilateral olecranon, bilateral femur shaft, and bilateral patella fractures. The patient was actively managed using damage control orthopaedics, and a sequence of skeletal fixation was planned based on the hemodynamic stability and periodical serum lactate assessment. Symmetrical quadruple limb fractures are very rare, which could be associated with higher mortality. A meticulous clinical evaluation, periodical blood parameter assessment and strict adherence to the principles of damage control orthopaedics can be conducive to prevent life-endangering complications.
Male ; Humans ; Young Adult ; Adult ; Femoral Fractures/complications* ; Femur ; Fracture Fixation ; Accidental Falls ; Radiography

PURPOSE: Hip fractures in elderly have a high mortality. However, there is limited literature on the excess mortality seen in hip fractures compared to the normal population. The purpose of this study was to compare the mortality of hip fractures with that of age and gender matched Indian population. METHODS: There are 283 patients with hip fractures aged above 50 years admitted at single centre prospectively enrolled in this study. Patients were followed up for 1 year and the follow-up record was available for 279 patients. Mortality was assessed during the follow-up from chart review and/or by telephonic interview. One-year mortality of Indian population was obtained from public databases. Standardized mortality ratio (SMR) (observed mortality divided by expected mortality) was calculated. Kaplan-Meir analysis was used. RESULTS: The overall 1-year mortality was 19.0% (53/279). Mortality increased with age (p < 0.001) and the highest mortality was seen in those above 80 years (aged 50 - 59 years: 5.0%, aged 60 - 69 years: 19.7%, aged 70 - 79 years: 15.8%, and aged over 80 years: 33.3%). Expected mortality of Indian population of similar age and gender profile was 3.7%, giving a SMR of 5.5. SMR for different age quintiles were: 3.9 (aged 50 - 59 years), 6.6 (aged 60 - 69 years), 2.2 (aged 70 - 79 years); and 2.0 (aged over 80 years). SMR in males and females were 5.7 and 5.3, respectively. CONCLUSIONS Indian patients sustaining hip fractures were about 5 times more likely to die than the general population. Although mortality rates increased with age, the highest excess mortality was seen in relatively younger patients. Hip fracture mortality was even higher than that of myocardial infarction, breast cancer, and cervical cancer.
Aged ; Aged, 80 and over ; Female ; Humans ; Male ; Asian People ; Databases, Factual ; Hip Fractures/mortality* ; Hospitalization ; Risk Factors ; India ; Middle Aged

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact in Asia and has placed significant burden on already stretched healthcare systems. We examined the impact of COVID-19 on the safety attitudes among healthcare workers (HCWs), as well as their associated demographic and occupational factors, and measures of burnout, depression and anxiety. METHODS: A cross-sectional survey study utilising snowball sampling was performed involving doctors, nurses and allied health professions from 23 hospitals in Singapore, Malaysia, India and Indonesia between 29 May 2020 and 13 July 2020. This survey collated demographic data and workplace conditions and included three validated questionnaires: the Safety Attitudes Questionnaire (SAQ), Oldenburg Burnout Inventory and Hospital Anxiety and Depression Scale. We performed multivariate mixed-model regression to assess independent associations with the SAQ total percentage agree rate (PAR). RESULTS: We obtained 3,163 responses. The SAQ total PARs were found to be 35.7%, 15.0%, 51.0% and 3.3% among the respondents from Singapore, Malaysia, India and Indonesia, respectively. Burnout scores were highest among respondents from Indonesia and lowest among respondents from India (70.9%-85.4% vs. 56.3%-63.6%, respectively). Multivariate analyses revealed that meeting burnout and depression thresholds and shifts lasting ≥12 h were significantly associated with lower SAQ total PAR. CONCLUSION Addressing the factors contributing to high burnout and depression and placing strict limits on work hours per shift may contribute significantly towards improving safety culture among HCWs and should remain priorities during the pandemic.
Humans ; Cross-Sectional Studies ; Pandemics ; COVID-19/epidemiology* ; Burnout, Psychological ; Health Personnel

Background/Aims: Non-alcoholic fatty liver disease (NAFLD) is associated with the development of cardiovascular disease. While existing studies have examined cardiac remodeling in NAFLD, there has been less emphasis on the development of carotid atherosclerosis and stroke. We sought to conduct a meta-analysis to quantify the prevalence, risk factors, and degree of risk increment of carotid atherosclerosis and stroke in NAFLD. Methods: Embase and Medline were searched for articles relating to NAFLD, carotid atherosclerosis, and stroke. Proportional data was analysed using a generalized linear mixed model. Pairwise meta-analysis was conducted to obtain odds ratio or weighted mean difference for comparison between patients with and without NAFLD. Results: From pooled analysis of 30 studies involving 7,951 patients with NAFLD, 35.02% (95% confidence interval [CI], 27.36–43.53%) had carotid atherosclerosis with an odds ratio of 3.20 (95% CI, 2.37–4.32; P<0.0001). Pooled analysis of 25,839 patients with NAFLD found the prevalence of stroke to be 5.04% (95% CI, 2.74–9.09%) with an odds ratio of 1.88 (95% CI, 1.23–2.88; P=0.02) compared to non-NAFLD. The degree of steatosis assessed by ultrasonography in NAFLD was closely associated with risk of carotid atherosclerosis and stroke. Older age significantly increased the risk of developing carotid atherosclerosis, but not stroke in NAFLD. Conclusions This meta-analysis shows that a stepwise increment of steatosis of NAFLD can significantly increase the risk of carotid atherosclerosis and stroke development in NAFLD. Patients more than a third sufferred from carotid atherosclerosis and routine assessment of carotid atherosclerosis is quintessential in NAFLD.

Methods: This study included 420 operated cases of degenerative lumbar pathology with a prospective follow-up of at least 6 months. Patients were divided into the open surgery and MIS groups, and the incidences of DT, early return to work, and various demographic and operative factors were compared. Results: A total of 156 and 264 patients underwent MIS and open surgery, respectively. Incidental durotomy was documented in 52 cases (12.4%); this was significantly less in the MIS group versus the open surgery group (6.4% vs. 15.9%, p <0.05). In the open surgery group, four patients underwent revision for persistent dural leak or pseudomeningocele, but none of the cases in the MIS group had revision surgery due to DT-related complications. The incidence of DT was higher among patients with high body mass index, patients with diabetes mellitus, and patients who underwent revision surgery (p <0.05) regardless of the approach. The MIS group returned to work significantly earlier. Conclusions MIS was associated with a significantly lower incidence of DT and earlier return to work compared with open surgery among patients with degenerative lumbar pathology.

Background: and Purpose Mechanical thrombectomy (MT) is an effective treatment for patients with basilar artery occlusion (BAO) acute ischemic stroke. It remains unclear whether bridging intravenous thrombolysis (IVT) prior to MT confers any benefit. This study compared the outcomes of acute BAO patients who were treated with direct MT versus combined IVT plus MT. Methods: This multicenter retrospective cohort study included patients who were treated for acute BAO from eight comprehensive stroke centers between January 2015 and December 2019. Patients received direct MT or combined bridging IVT plus MT. Primary outcome was favorable functional outcome defined as modified Rankin Scale 0–3 measured at 90 days. Secondary outcome measures included mortality and symptomatic intracranial hemorrhage (sICH). Results: Among 322 patients, 127 (39.4%) patients underwent bridging IVT followed by MT and 195 (60.6%) underwent direct MT. The mean±standard deviation age was 67.5±14.1 years, 64.0% were male and median National Institutes of Health Stroke Scale was 16 (interquartile range, 8 to 25). At 90-day, the rate of favorable functional outcome was similar between the bridging IVT and direct MT groups (39.4% vs. 34.4%, P=0.361). On multivariable analyses, bridging IVT was not asComorbidisociated with favorable functional outcome, mortality or sICH. In subgroup analyses, patients with underlying atherosclerosis treated with bridging IVT compared to direct MT had a higher rate of favorable functional outcome at 90 days (37.2% vs. 15.5%, P=0.013). Conclusions Functional outcomes were similar in BAO patients treated with bridging IVT versus direct MT. In the subgroup of patients with underlying large-artery atherosclerosis stroke mechanism, bridging IVT may potentially confer benefit and this warrants further investigation.

Conjoint nerve root (CNR) is an embryological nerve root anomaly that mainly involves the lumbosacral region. The presence of CNR during tubular discectomy raises the chances of failure in spinal surgery and the risk of neural injuries. Tubular discectomy can be challenging in the presence of CNR owing to limited visualization. Here, we present a technical note on two cases of L5–S1 disc prolapse in the presence of conjoint S1 nerve root that was operated via a minimally invasive tubular approach. Any intraoperative suspicion of CNR while using the tubular approach should prompt the surgeon to perform a thorough tubular decompression prior to nerve root retraction. In patients with a large disc, disc should be approached via the axilla because the axillary area between the dura and the medial boarder of the root is very easy to approach in the presence of CNR. Safe performance of tubular discectomy is possible even in the presence of CNR in the lumbar spine.

INTRODUCTION: Diabetes increases the risk of ischaemic stroke especially among Asians. This study aims to investigate contemporaneous long-term cardiovascular outcomes of ischaemic stroke patients with diabetes in a multi-ethnic Asian cohort. METHODS: Consecutive patients with ischaemic stroke were recruited from the National University Hospital, Singapore. Data on age, gender, ethnicity, risk factors (including diabetes status and body mass index [BMI]), stroke severity and mechanisms were collected. These patients were followed up until the day of the first cardiovascular event or July 2016, whichever was earlier. The primary endpoint was the time from enrolment to the first occurrence of a composite of cerebrovascular and coronary artery events. RESULTS: Between July 2011 and December 2013, 720 patients (mean age 60.6 years, 71% men, 43% with diabetes, median National Institute Health Stroke Severity scale 2) were enrolled and followed up. A total of 175 cardiovascular events occurred during a median follow-up of 3.25 years (6.90 events per 1,000 person-month), comprising 133 cerebrovascular and 42 coronary artery events. The adjusted hazard ratio of diabetes was 1.50 (95% CI 1.08-2.10). In a multivariable Cox proportional hazards model, Malay and Indian ethnicities, BMI <23kg/m2 and a prior diagnosis of diabetes were identified as independent predictors of recurrent cardiovascular events. CONCLUSION Our study provides quantitative data on the event rates of ischaemic stroke patients with diabetes. These findings provide insights on stroke predictors in a multi-ethnic Asian population, which may have implications in the design of future interventional studies.