Abdulhakim B. Jamjoom

Safety and Efficacy of Early Pharmacological Thromboprophylaxis in Traumatic Brain Injury: Systematic Review and Meta-Analysis

Patients with traumatic brain injury (TBI) are at an increased risk of developing venous thromboembolic events (VTE). Pharmacological thromboprophylaxis (PTP) is routinely delayed because of concerns of exacerbating intracranial hemorrhage (ICH). The aim of this review is to examine the literature and assimilate suitable data to assess the safety and efficacy of PTP administered within 72u2009h in TBI patients. We systematically searched the literature for randomized controlled trials or cohort studies reporting on the timing of PTP in TBI. We dichotomized the timing of PTP to early and late at 72u2009h post-injury. The rates of VTE and ICH progression were our primary endpoints and were pooled using a fixed-effects model. A total of five retrospective cohort studies were included within the review including a total of 1624 patients, of which 713 received early PTP and 911 received late PTP. Within the early and late group there was a total of 43 and 106 VTE respectively, with a risk ratio of 0.52 (0.37, 0.73). Assessing safety, the relative risk of ICH progression in the early compared with the late PTP group was 0.64 (0.35, 1.14). Based on the available literature, we can tentatively conclude that early PTP (<72u2009h) reduces the risk of VTE without affecting progression of ICH. However, much work is yet to be done to better clarify ICH subtypes at risk of progression and the implementation of evidence-based guidelines backed up with randomized control trial level evidence.

Efficacy of intraoperative epidural steroids in lumbar discectomy: a systematic review

BackgroundThis study is a descriptive review of the literature aimed at examining the efficacy of the use of intraoperative epidural steroids in lumbar disc surgery, a matter that remains controversial.MethodsThe relevant clinical trials were selected from databases and reviewed. The methodological quality of each included study was assessed and graded for perceived risk of bias. All the documented significant and non-significant findings were collected. Our outcome targets were reduction in postoperative pain scores, consumption of analgesia, duration of hospital stay and no increase in complication rates. The variation in the timing of postoperative pain assessments necessitated grouping the outcome into three postoperative stages; early: 0 to 2xa0weeks, intermediate: more than 2xa0weeks to 2xa0months and late: more than 2xa0months to 1xa0year.ResultsSixteen trials that were published from1990 to 2012 were eligible. At least one significant reduction in pain score was reported in nine of the eleven trials that examined pain in the early stage, in four of the seven trials that examined pain in the intermediate stage and in two of the eight trials that examined pain in the late stage. Seven of the nine trials that looked at consumption of postoperative analgesia reported significant reduction while six of the ten trails that examined the duration of hospital stay reported significant reduction. None of the trials reported a significant increase of steroid-related complications.ConclusionsThere is relatively strong evidence that intraoperative epidural steroids are effective in reducing pain in the early stage and reducing consumption of analgesia. There is also relatively strong evidence that they are ineffective in reducing pain in the late stage and in reducing duration of hospital stay. The evidence for their effectiveness in reducing pain in the intermediate stage is considered relatively weak. The heterogeneity between the trials makes it difficult to make undisputed conclusions and it indicates the need for a large multicenter trial with validated outcome measures that are recorded at fixed time intervals.

Attitudes Towards Informed Consent: A Comparison between Surgeons Working in Saudi Arabia and the United Kingdom

OBJECTIVESnChanges in legal standing and new guidelines for consent have generated changes in medical culture that doctors must adhere to. This study aims to highlight the differences in the way the surgeons in the two cultures view the informed consent for surgery processes.nnnMETHODSnThe attitudes towards informed consent of a group of surgeons working in Saudi Arabia (KSA) were compared with those of a similar group working in the United Kingdom (UK), a country with a longer medical history and a more established medico-legal system.nnnRESULTSnThe study shows that KSA surgeons tend to view informed consent not only as an ethical and legal obligation but also as a benefit to patients. In addition, KSA surgeons are more likely to adopt a paternalistic attitude during informed consent. They believe that information about harmful risks may dissuade their patients from undergoing the operation and they admit that the amount of information they provide to their patients is significantly influenced by a number of patient and non-patient related factors.nnnCONCLUSIONnIt is concluded that surgeons in KSA should be more aware of the informed consent guidelines and they should adhere to them. In addition, there is room for the introduction of formal training on informed consent in both countries and for making written information more widely available particularly in KSA.

Impact of country-specific characteristics on scientific productivity in clinical neurology research

Objectives The objective of this study was to identify the top 50 countries in the world in clinical neurology research and to use their data to assess the impact of a number of country-specific characteristics on scientific productivity in clinical neurology. Methods The SCImago Journal & Country Rank (SCR) web site was used to identify the top 50 countries in the world based on their total documents in clinical neurology. Using their data 5 country-specific characteristics and 6 productivity indicators (total documents, total cites, h-index, citable documents, self-cites and citations per document) were correlated and examined statistically. Results The number of universities in the world top 500 and the number of clinical neurology journals enlisted in SCR correlated significantly with each of the 6 indicators. The gross domestic product (GDP) per capita and the percentage of GDP spent on research and development (R & D) correlated significantly with 3 and 4 out of the 6 indicators respectively. The population size did not correlate significantly with any of the 6 indicators. Conclusions The number of universities in the world top 500 and the number of clinical neurology journals enlisted in SCR appear to have a strong impact on scientific productivity. GDP per capita and spending on R & D appear to have a moderate impact on productivity that is influenced by the indicator used. Furthermore, population size appears to have no significant impact on productivity in clinical neurology research.

State of clinical neuroscience research in Saudi Arabia: where do we rank in the world?

Journal impact factor (IF) is a measure that reflects the average citation numbers of a recent publication in a journal. The h-index is a measure that indicates output and citation impact of articles published by a scientist. The wide acceptance of these 2 metrics signifies the importance of quantifying the scientific creditability of research and researchers. The IF and h-index can also be used to compare the scientific contribution of various countries to a particular specialty. The world ranking of universities had attracted substantial interest and it is also expected that the world ranking of medical specialty research will generate considerable appeal. Over the last 3 decades clinical neuroscience researchers from the Kingdom of Saudi Arabia (KSA) have contributed to the national and international literature. However, to date there has been no reports that compared the input of KSA researchers to the rest of the world. The objective of this study was to evaluate the state of clinical neuroscience research in KSA by determining its world ranking based on the quantity and citation impact of its research on the subject. In addition the study aimed to examine some of the features that may influence a country’s position among the top 50 in the world in clinical neuroscience research. SCImago Journal & Country Rank (SCR)1 is a portal that incorporates journal and country scientific indicators developed from Scopus database. The web site provides lists of country rankings based on 6 individual features: total documents, total citations, h-index, citable documents, citations per document, and self-citations. The findings vary according to the searched subject area, category, region and year. The SCR site was searched on twentieth August 2015 using the parameters “medicine” for subject area, “clinical neurology” for subject category, “1996-2014” for year and “all” for region. The site was also searched for “clinical neurology journals” and found to include 335 international journals that cover the range of clinical neuroscience specialties. The listed journals included Neuroscience (Riyadh) journal as well as 31 Neurosurgery journals including Pan Arab Journal of Neurosurgery. As a result it was considered appropriate to refer to “clinical neurology” in the SCR site as “clinical neuroscience” thereafter in this article. Using the site 3 separate top 50 world rankings based on total publications, total citations, and h-index in clinical neuroscience were obtained. These 3 parameters were chosen as they were considered appropriate indicators of the quantity and quality of research from any country. A correlation coefficient (R) was calculated between the 3 rankings. An adjusted top 50 ranking list was structured using mean values of the 3 rankings. When means were equal the country with higher total publications was ranked ahead. In addition to the 3 parameters the following country-related data were collected: population size from the worldometer web site,2 gross domestic2 product at purchasing power parity per capita (GDP/capita) from the International Monetary Fund database3 and the number of universities in the world top 500 from the Shanghai ranking web site.4 Furthermore, the number of clinical neuroscience journals listed in the SCR site for each country was determined. Using the median as a cut-off point, countries ranked 1-25 were compared to those ranked 26-50 utilizing the following parameters: population in million (≤23.5 versus >23.5), GDP/capita (≤ #31,500 versus >#31,500), number of universities in the world top 500 (≤ 3 versus >3) and the number of clinical neuroscience journals listed in the SCR site (1 versus >1). The findings were examined by a chi-squared test and significance was determined when p was less than 0.05. The Social Sciences Statistics site5 was used for the statistical analysis. Table 1 shows the adjusted ranking of the top 50 countries in the world in clinical neuroscience research during the period 1996-2014. The list integrates the 3 rankings: total publications, total citations, and h-index. The calculation of the mean was validated by the strongly positive correlation between the top 50 rankings based on total publications and total citations (R=0.9469), total publications and h-index (R=0.9215) and total citations and h-index (R=0.9908). According to the findings of this study, KSA is ranked fortieth in the world and fourth in the Middle East in clinical neuroscience research.

Fate of registered clinical trials performed in Saudi Arabia

[No abstract available] Saudi Med J 2015; Vol. 36 (10): 1245-1248 doi: 10.15537/smj.2015.10.12506

Survey of h-index for neurosurgeons in Saudi Arabia.

Objectives: To calculate the h-index for neurosurgeons in the Kingdom of Saudi Arabia (KSA), and to assess its association with a number of features relating to neurosurgical practice in KSA. Methods: The h-index for 84 neurosurgeons that worked in KSA during 1990-2013 was evaluated using Google Scholar during the period September to October 2014. The correlation between the h-index and a number of neurosurgeon and neurosurgical center characteristics was determined and examined statistically. Results: The median h-index was 2.5 (range 0-33) and the mean was 5.04. The h-index was significantly higher for neurosurgeons who obtained their certification before 2001 and those working at the King Faisal Specialist Hospital, Riyadh, KSA. The h-index was also higher, but without reaching significance, for non-Saudi neurosurgeons, those with international certification and those working at the university hospitals. Additionally, the h-index was significantly lower for neurosurgeons working in the Ministry of Health hospitals. Conclusion: Application of the h-index to KSA neurosurgeons revealed a significant correlation with the duration after certification and with certain centers. Evaluation of the h-index should be included in the consideration for academic positions in KSA. Saudi neurosurgeons should be encouraged to publish in journals with high impact factor.

The most cited neurosurgical publications in the literature.

Measuring the academic strength of a publication is a complicated matter that has become a topic of interest in recent years. The impact factor (IF) of a journal and the Hirsh-index (H-index) of a researcher rely on article citation numbers which in the absence of more reliable methods, may be taken as a reflection of the academic strength of the article. Neurosurgeons are aware of many of the famous articles in their field however to our knowledge there has been no attempt at identifying the most cited neurosurgical articles in the literature that can be considered as the elite neurosurgical publications. Using the article citation numbers provided by Google Scholar in January 2010, we identified and reviewed the top 100 and the top 15 most cited articles which were published in neurosurgical, neurosciences and other medical journals that were written primarily by or in collaboration with neurosurgeons. The citation numbers of the top 100 articles ranged from 5215 to 371 (median 466) and the top 15 ranged from 5215 to 908 (median 1265). The top 100 most cited articles were published in journals with IF ranging from 1.6 to 50 (median 2.1) while the top 15 articles were published in journals with IF of similar range but a median of 4.1. All the articles were published in journals that were launched before 1985 with 83% of the top 100 being in journals that are more than 60 years old. The characteristics of the two groups are summarized (Table I). Amongst the 100 most cited neurosurgical articles there was a predominance of publications in the Journal of Neurosurgery (58%), from the USA (67%), during the period 1981–2000 (74%) and on vascular and trauma-related work (70%). While amongst the 15 most cited neurosurgical articles there was good representation of articles from the USA (62.5%), the UK (25%), in the New England Journal of Medicine (IF1⁄4 50) and the Lancet (IF1⁄4 28.4) (37.5%), before 1991 (87.5%) and articles describing a new scale or technique (50%) or controlled trials (31%). It is of interest that the top 5 most cited neurosurgical articles in the literature were:

Rapid evolution of a choroid plexus papilloma in an infant

Choroid plexus papilloma (CPP) is primarily found in children less than 2 years of age but can also be diagnosed prenatally. The presentation of a large CPP during infancy is not uncommon and surgical excision is usually recommended without delays. As a result, information about the growth rate of CPP during infancy is lacking. We report a preterm infant who presented with a choroid plexus papilloma that grew from being undetected on MRI to reaching a large size in 5 months. The case is unique in that it provides documentation of the rapid growth potential of this benign tumour in infancy. A possible explanation for this occurrence is discussed.

The impact of British Neurosurgery on traumatic brain injury research

To the Editor , Traumatic brain injury (TBI) is a major health problem that has been studied extensively. There is a large literature base focusing on both laboratory and clinical research. Anecdotally, British neurosurgeons have had an important role in shaping our understanding of TBI and the way patients are cared for. We aimed to try and quantify this impact through the analysis of the most highly cited articles in the TBI literature. By using the search phrases ‘ Traumatic Brain Injury ’, ‘ Head Injury ’, ‘ Head Trauma ’ in Google Scholar in June 2014, we identified the citation numbers for the 50 most cited articles in the TBI literature. Articles were considered British when the first author was affiliated to a British neurosurgical centre. Each article was assessed by the two authors independently and disagreements were discussed. For each article, a range of parameters were identified including country of origin, primary research unit, level of evidence (LOE) and journal impact factor (IF). We found that the citation numbers of the 50 top cited TBI articles ranged from 8564 to 532 (median: 746). The articles were published during the period 1956 – 2004 (median: 1987). Twelve (24%) of the 50 top cited TBI articles were considered British (Table I). Ten of the British articles originated from Glasgow and two from Oxford. The research in six of these articles was carried out in a single centre while the remaining six articles were multicentre collaborations. The average number of citations for the British articles was 1739 (range: 8564 – 532). The publishing journals and number of articles were Lancet (6), Journal of Neurology Neurosurgery and Psychiatry (4), Acta Neurochirurgica (1) and Histopathology (1). The research topic was description of a new scale, classification or syndrome (4), prognosis (3), management (2), complications (1), diagnosis (1) and laboratory and experimental research (1). The levels of evidence of the 11 clinical studies and number of articles were Level I (1) and Level IV (10). The Glasgow Coma Scale, which recently celebrated its fortieth birthday, topped the list 1 followed by the description of the Glasgow Outcome Scale. 2 In fact, half the British articles focused on the description and validation of the Glasgow scales. Other major British contributions to TBI care based upon the most cited articles included the histological description of diffuse axonal injury, helping to identify the potential role of apolipoprotein E polymorphism on outcome after head injury and investigating the value of corticosteroids in TBI. The most cited articles had a number of recurring primary authors, who were topped by Brian Jennet and included Graham Teasdale and J. Douglas Miller in the top 10 authors. This review demonstrates the important role British Neurosurgery has had on shaping the assessment and care of patients with TBI. Due to the time it takes to accumulate citations, this list does not reflect more recent articles in the literature. It does however highlight that the core of earlier contributions emanated from a small cohort of highly proliferative authors in a handful of units. This model continues with a number of units and individuals who have a particular focus on neurotrauma research in the UK. Academic training and higher degree programmes are ensuring that current trainees are developing the interest and academic skills to continue strong translational research. However, another important contributor to the continued success of British Neurosurgery in TBI research is the expansion of collaborative multi-centred research. This is being achieved through the British Neurotrauma Group (BNTG) and, more recently, the British Neurosurgical Trainee Research Collaborative (BNTRC). Currently, LETTER TO THE EDITOR