Pediatric CSF diversion procedures for treatment of hydrocephalus during the COVID-19 pandemic.

OBJECTIVE: Because there is not a link between COVID-19 and pediatric hydrocephalus, the COVID-19 pandemic should not have altered the incidence of pediatric hydrocephalus or the rate of CSF diversion procedures or shunt failure. Therefore, hydrocephalus-related surgical volume should have remained constant. The goal of this study was to evaluate the rates of hydrocephalus surgeries in the COVID-19 era compared with the baseline pre-COVID-19 era. METHODS: Ten institutions collected information about all hydrocephalus-related surgeries performed between March 2018 and February 2022. The period after March 1, 2020, was considered the COVID-19 era; the period prior to this date was considered the baseline pre-COVID era. Four COVID surge periods were defined using the New York Times COVID-19 database. Total case volumes were compared between the COVID era and baseline, both overall and for each surge period. Sex, race, ethnicity, insurance status, Area Deprivation Index (ADI), and rural-urban commuter area were collected for each surgery. Proportions of patients were then compared overall and for each surge based on these variables. RESULTS: Of 8056 procedures, 54% were in male patients (n = 4375), 65% in White patients (n = 5247), 18% in Hispanic patients (n = 1423), and 54% in patients with public insurance (n = 4371). There was no change in the number of surgeries per site per month in the COVID era compared with baseline (16.7 vs 17.9, p = 0.113). However, there was a significant decrease in the first surge period (April 2020; 11.5 vs 17.7, p = 0.034). Male sex (p < 0.0039) and Black race (p < 0.001) were found to be associated with a significantly higher proportion of hydrocephalus procedures during the COVID-19 era. Some surge periods showed different proportions of privately insured patient and ADI levels. However, these relationships were inconsistent between surges. CONCLUSIONS: Overall average monthly case numbers were not significantly different between the pre-COVID and COVID eras. There was a significant decrease in hydrocephalus surgery during the first COVID surge. More hydrocephalus surgeries were performed in children of male sex and Black race proportionally during the COVID period overall, but not during individual surges.

Vasospasm and subsequent stroke from paraneoplastic syndrome in a pediatric patient with an intracranial mature teratoma: a case report.

Teratomas account for 18-20% of all intracranial germ cell tumors and mostly occur in the pineal region with only a few cases of pediatric sellar and suprasellar teratomas described in the literature. Here, we present a case of a child with an intracranial mature teratoma with pancreatic features causing vasospasm and subsequent stroke, found to be positive for CDKN2A-an independent variant associated with malignancy and small vessel disease leading to stroke.

Pro-inflammatory cerebrospinal fluid profile of neonates with intraventricular hemorrhage: clinical relevance and contrast with CNS infection.

BACKGROUND: Interpretation of cerebrospinal fluid (CSF) studies can be challenging in preterm infants. We hypothesized that intraventricular hemorrhage (IVH), post-hemorrhagic hydrocephalus (PHH), and infection (meningitis) promote pro-inflammatory CSF conditions reflected in CSF parameters. METHODS: Biochemical and cytological profiles of lumbar CSF and peripheral blood samples were analyzed for 81 control, 29 IVH grade 1/2 (IVH1/2), 13 IVH grade 3/4 (IVH3/4), 15 PHH, 20 culture-confirmed bacterial meningitis (BM), and 27 viral meningitis (VM) infants at 36.5 ± 4 weeks estimated gestational age. RESULTS: PHH infants had higher (p < 0.02) CSF total cell and red blood cell (RBC) counts compared to control, IVH1/2, BM, and VM infants. No differences in white blood cell (WBC) count were found between IVH3/4, PHH, BM, and VM infants. CSF neutrophil counts increased (p ≤ 0.03) for all groups compared to controls except IVH1/2. CSF protein levels were higher (p ≤ 0.02) and CSF glucose levels were lower (p ≤ 0.003) for PHH infants compared to all other groups. In peripheral blood, PHH infants had higher (p ≤ 0.001) WBC counts and lower (p ≤ 0.03) hemoglobin and hematocrit than all groups except for IVH3/4. CONCLUSIONS: Similarities in CSF parameters may reflect common pathological processes in the inflammatory response and show the complexity associated with interpreting CSF profiles, especially in PHH and meningitis/ventriculitis.

Racial differences in the care of pediatric sagittal craniosynostosis: a single-institution cohort study affecting state Medicaid policy.

OBJECTIVE: Although research has shown the cost-effectiveness of endoscopic versus open repair of sagittal synostosis, few studies have shown how race, insurance status, and area deprivation impact care for these patients. The authors analyzed data from children evaluated for sagittal synostosis at a single institution to assess how socioeconomic factors, race, and insurance status affect the surgical treatment of this population. They hypothesized that race and indicators of disadvantage negatively impact workup and surgical timing for craniosynostosis surgery. METHODS: Medical records of patients treated for sagittal synostosis between 2010 and 2019 were reviewed. Area deprivation index (ADI) and rural-urban commuting area codes, as well as median income by zip code, were used to measure neighborhood disadvantage. Black and White patients were compared as well as patients using Medicaid versus private insurance. RESULTS: Fifty patients were prospectively included in the study. Thirty-one underwent open repair; 19 had endoscopic repair. All 8 (100%) Black patients had open repair, compared to 54.8% of White patients (p = 0.018). Black patients were more likely to use Medicaid compared to White patients (75.0% vs 28.6%, p = 0.019). White patients were younger at surgery (5.5 vs 10.0 months, p = 0.001), and Black patients had longer surgeries (147.5 minutes vs 110.0 minutes, p = 0.021). The median household income by zip code was similar for the two groups. Black patients were generally from areas of greater disadvantage compared to White patients, based on both state and national ADI scores (state: 7.5 vs 4.0, p = 0.013; national: 83.5 vs 60.0, p = 0.013). All (94.7%) but 1 patient undergoing endoscopic repair used private insurance compared to 14 (45.2%) patients in the open repair group (p = 0.001). Patients using Medicaid were from areas of greater disadvantage compared to those using private insurance by both state and national ADI scores (state: 6.0 vs 3.0, p = 0.001; national: 75.0 vs 52.0, p = 0.001). CONCLUSIONS: Because Medicaid in the geographic region of this study did not cover helmeting after endoscopic repair of sagittal synostosis, these patients usually had open repair, resulting in significant racial and socioeconomic disparities in treatment of sagittal synostosis. This research has led to a change in Alabama Medicaid policy to now cover the cost of postoperative helmeting.

Endoscopic Placement of Intracystic Catheters: A Technical Note.

BACKGROUND: Intraventricular neuroendoscopic surgery for tumor resection, biopsy, or cyst fenestration frequently requires precise placement of an intraventricular or intracystic catheter. Placement under direct visualization is not feasible because of small bore of working channel of the standard small ventriculoscope. Various techniques have been reported using a separate transcortical trajectory, endoluminal endoscope, or endovascular guide wire. OBJECTIVE: To describe a technique allowing precise placement of intraventricular/intracystic catheter using a small bore working ventriculoscope, without need for additional equipment. METHODS: Description of the technique including intraoperative photographs, video, and illustrative cases are provided. RESULTS: The peel-away sheath is peeled off approximately 1 to 2 cm to allow for the shaft of the endoscope to pass past its tip. Ventricular access is gained using the peel-away sheath. After the stylet is removed, the peel-away sheath is not peeled further or stapled to the skin. The endoscope is introduced into the ventricle through the peel-away sheath. After the required intraventricular work is performed, the endoscope is maneuvered into the location of the desired catheter position. The peel-away sheath is slowly advanced over the stationary endoscope past its tip. While the peel-away sheath is being held in place, the endoscope is removed. After the catheter has been introduced into the peel-away sheath to a premeasured depth, the peel-away sheath is peeled and removed. The catheter is then connected to collection system, reservoir or shunt system. CONCLUSION: The current technique allows for the precise placement of intraventricular/intracystic catheters without the need for additional equipment or a separate transcortical trajectory.

Fast electro-plasmonic detection of heart signal in Balb/C cells onto one-dimensional plasmonic grating.

The heart is a vital and complex organ in the human body that forms with most organs between the second week of pregnancy, and fetal heart rate is an important indicator or biological index to know the condition of fetal well-being. In general, long-term measurement of fetal heart rate is the most widely used method of providing information about fetal health. In addition to fetal life, growth, and maturity, information such as congenital heart disease, often due to structural or functional defects in heart structure that often occur during the first trimester of pregnancy during fetal development, can be detected by continuous monitoring of fetal heart rate. The gold standard for monitoring the fetus's health is the use of non-invasive methods and portable devices so that while maintaining the health of the mother and fetus, it provides the possibility of continuous monitoring, especially for mothers who have a high-risk pregnancy. Therefore, the present study aimed to propose a low-cost, compact, and portable device for recording the heart rate of 18-day-old fetal mouse heart cells. Introduced device allows non-invasive heart rate monitoring instantly and without side effects for mouse fetal heart cells. One-dimensional gold-plated plasmonic specimens as a physiological signal recorder are mainly chips with nanoarray of resonant nanowire patterns perform in an integrated platform. Here the surface plasmon waves generated in a one-dimensional plasmonic sample are paired with an electrical wave from the heart pulse, and this two-wave pairing is used to record and detect the heart rate of fetal heart cells with high accuracy and good sensitivity. This measurement was performed in normal mode and two different stimulation modes. Stimulation of cells was performed once using adrenaline and again with electrical stimulation. Our results show that our sensor is sensitive enough to detect heart rate in both standard and excitatory states and is also well able to detect and distinguish between changes in heart rate caused by different excitatory conditions.

Mapping Local Failure Following Bladder Radiotherapy According to Dose.

AIMS: To determine the relationship between local relapse following radical radiotherapy for muscle-invasive bladder cancer (MIBC) and radiation dose. MATERIALS AND METHODS: Patients with T2-4N0-3M0 MIBC were recruited to a phase II study assessing the feasibility of intensity-modulated radiotherapy to the bladder and pelvic lymph nodes. Patients were planned to receive 64 Gy/32 fractions to the bladder tumour, 60 Gy/32 fractions to the involved pelvic nodes and 52 Gy/32 fractions to the uninvolved bladder and pelvic nodes. Pre-treatment set-up was informed by cone-beam CT. For patients who experienced local relapse, cystoscopy and imaging (CT/MRI) was used to reconstruct the relapse gross tumour volume (GTVrelapse) on the original planning CT . GTVrelapse D98% and D95% was determined by co-registering the relapse image to the planning CT utilising deformable image registration (DIR) and rigid image registration (RIR). Failure was classified into five types based on spatial and dosimetric criteria as follows: A (central high-dose failure), B (peripheral high-dose failure), C (central elective dose failure), D (peripheral elective dose failure) and E (extraneous dose failure). RESULTS: Between June 2009 and November 2012, 38 patients were recruited. Following treatment, 18/38 (47%) patients experienced local relapse within the bladder. The median time to local relapse was 9.0 months (95% confidence interval 6.3-11.7). Seventeen of 18 patients were evaluable based on the availability of cross-sectional relapse imaging. A significant difference between DIR and RIR methods was seen. With the DIR approach, the median GTVrelapse D98% and D95% was 97% and 98% of prescribed dose, respectively. Eleven of 17 (65%) patients experienced type A failure and 6/17 (35%) patients type B failure. No patients had type C, D or E failure. MIBC failure occurred in 10/17 (59%) relapsed patients; of those, 7/11 (64%) had type A failure and 3/6 (50%) had type B failure. Non-MIBC failure occurred in 7/17 (41%) patients; 4/11 (36%) with type A failure and 3/6 (50%) with type B failure. CONCLUSION: Relapse following radiotherapy occurred within close proximity to the original bladder tumour volume and within the planned high-dose region, suggesting possible biological causes for failure. We advise caution when considering margin reduction for future reduced high-dose radiation volume or partial bladder radiotherapy protocols.

Complications and outcomes of posterior fossa decompression with duraplasty versus without duraplasty for pediatric patients with Chiari malformation type I and syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium.

OBJECTIVE: The aim of this study was to determine differences in complications and outcomes between posterior fossa decompression with duraplasty (PFDD) and without duraplasty (PFD) for the treatment of pediatric Chiari malformation type I (CM1) and syringomyelia (SM). METHODS: The authors used retrospective and prospective components of the Park-Reeves Syringomyelia Research Consortium database to identify pediatric patients with CM1-SM who received PFD or PFDD and had at least 1 year of follow-up data. Preoperative, treatment, and postoperative characteristics were recorded and compared between groups. RESULTS: A total of 692 patients met the inclusion criteria for this database study. PFD was performed in 117 (16.9%) and PFDD in 575 (83.1%) patients. The mean age at surgery was 9.86 years, and the mean follow-up time was 2.73 years. There were no significant differences in presenting signs or symptoms between groups, although the preoperative syrinx size was smaller in the PFD group. The PFD group had a shorter mean operating room time (p < 0.0001), fewer patients with > 50 mL of blood loss (p = 0.04), and shorter hospital stays (p = 0.0001). There were 4 intraoperative complications, all within the PFDD group (0.7%, p > 0.99). Patients undergoing PFDD had a 6-month complication rate of 24.3%, compared with 13.7% in the PFD group (p = 0.01). There were no differences between groups for postoperative complications beyond 6 months (p = 0.33). PFD patients were more likely to require revision surgery (17.9% vs 8.3%, p = 0.002). PFDD was associated with greater improvements in headaches (89.6% vs 80.8%, p = 0.04) and back pain (86.5% vs 59.1%, p = 0.01). There were no differences between groups for improvement in neurological examination findings. PFDD was associated with greater reduction in anteroposterior syrinx size (43.7% vs 26.9%, p = 0.0001) and syrinx length (18.9% vs 5.6%, p = 0.04) compared with PFD. CONCLUSIONS: PFD was associated with reduced operative time and blood loss, shorter hospital stays, and fewer postoperative complications within 6 months. However, PFDD was associated with better symptom improvement and reduction in syrinx size and lower rates of revision decompression. The two surgeries have low intraoperative complication rates and comparable complication rates beyond 6 months.

Input-decoupled discrete-time sliding mode control algorithm for servo multi-field multi-armature DC machine.

The multivariable modeling of a servo actuating system consisting of multi-field multi-armature direct current (MFMADC) machine is extracted and a novel discrete time nonlinear algorithm is proposed for the corresponding system. The proposed control algorithm demonstrates robustness against modeling uncertainty and by utilizing its novel mathematical structure, decouples the dynamical interactions of the connected motors. The main contribution of this paper is the proposition of a new decoupling control algorithm that in which, the driving (commanding) voltages of the connected driving motors are extracted separately and independently using the Lyapunov principle in discrete time. In fact, the obtained coupled stabilizing convex inequalities of the controlling voltages, resulting from the evaluation of the Lyapunov functions, are analytically decoupled using elementary matrix operations. Consequently, each motor now has the capability to perform its controlling task (position control or torque control) with asymptotic stability and robustness against uncertainty. To assess the performance of the proposed controlling algorithm and its verification, a MFMADC machine is attached to a harmonic drive reducer (HDR) whose flex spline and circular spline are fabricated using viscoelastic polyesters PLA and thermoplastic PLA, respectively. A number of experiments are conducted where in the first test, the MFMADC is controlled in only-position mode while in the second test, the MFMADC is controlled in simultaneous position-torque control mode. Comparative assessments confirm that the MFMADC technology is needed when a high precision tracking of position, under high frequency disturbances, is desired.

Thermoplasmonic effect onto Toad physiology signals by plasmonic microchip structure.

Cardiovascular diseases are considered as the leading cause of death and almost 80% of deaths from this disease are developed in poor and less developed countries where early detection facilities are less available, along with overlooking the importance of screening. In other words, real-time monitoring of the physiological signals using flexible and wearable biosensors plays an important role in human life style. Thus, the present study aims to propose two dimensional flexible and wearable gold covered plasmonic samples as a physiological signal recorder, in which chips with nano array of resonant nanowire patterns performing in an integrated platform of plasmonic devices. The produced surface plasmon waves in our main chip were paired with an electric wave from the heart pulse and it use for recording and detecting the heartbeat of a toad with high accuracy. This measurement was performed in normal state and under external laser heating process to check the ability of signal recording and also thermoplasmonic effect onto the toad's heart signal. Our results show that our sensor was enough sensitive for detection while raising the body temperature of the toad and changing its heart rate as flatting T and P waves by thermoplasmonic effect.

Socioeconomic Implications of Professional Relationships within Modern Care Delivery Systems.

No physician can successfully deliver high-value patient care in the modern-day health care system in isolation. Delivery of effective patient care requires integrated and collaborative systems that depend on dynamic professional relationships among members of the health care team. An overview of the socioeconomic implications of professional relationships within modern care delivery systems and potential employment models is presented.

Comparison of aesthetic outcomes between open and endoscopically treated sagittal craniosynostosis.

OBJECTIVE: In the last several decades, there has been much debate regarding the ideal treatment for sagittal synostosis. The purpose of this study was to compare perioperative, anthropometric, and subjective assessments of cosmetic outcomes between open and endoscopic management of isolated sagittal synostosis. METHODS: At their routine postoperative follow-up, pediatric patients with sagittal craniosynostosis were recruited to undergo digital cranial measurement and standardized photography for objective and subjective assessments of perioperative outcomes. Age-normalized z-scores for cephalic index, head circumference, euryon-euryon diameter (Eu-Eu), and glabella-opisthocranion diameter (G-Op) were calculated for each patient. Faculty surgeons, surgical trainees, nurses, and laypersons were asked to rate the normalcy of craniofacial appearances using a 5-point Likert scale. Outcomes were compared between patients treated with endoscopic correction and those treated with open repair. RESULTS: A total of 50 patients were included in the study. Thirty-one had undergone open surgical correction, and 19 had undergone endoscopic treatment. Endoscopic repair involved significantly lower operative time, blood loss, transfusion rate, and hospital length of stay than those with open repair (p < 0.001). There was no significant difference between groups in terms of z-scores for head circumference (p = 0.22), cephalic index (p = 0.25), or Eu-Eu (p = 0.38). Endoscopic treatment was associated with a significantly lower G-Op (p = 0.009). Additionally, the average subjective rating of head shape was higher for endoscopic treatment when corrected for age, gender, and ethnicity (p = 0.02). CONCLUSIONS: The study findings suggest that patients who are treated endoscopically may have an overall more normal appearance in skull morphology and cosmesis, although these results are limited by poor reliability.

Dural augmentation approaches and complication rates after posterior fossa decompression for Chiari I malformation and syringomyelia: a Park-Reeves Syringomyelia Research Consortium study.

OBJECTIVE: Posterior fossa decompression with duraplasty (PFDD) is commonly performed for Chiari I malformation (CM-I) with syringomyelia (SM). However, complication rates associated with various dural graft types are not well established. The objective of this study was to elucidate complication rates within 6 months of surgery among autograft and commonly used nonautologous grafts for pediatric patients who underwent PFDD for CM-I/SM. METHODS: The Park-Reeves Syringomyelia Research Consortium database was queried for pediatric patients who had undergone PFDD for CM-I with SM. All patients had tonsillar ectopia ≥ 5 mm, syrinx diameter ≥ 3 mm, and ≥ 6 months of postoperative follow-up after PFDD. Complications (e.g., pseudomeningocele, CSF leak, meningitis, and hydrocephalus) and postoperative changes in syrinx size, headaches, and neck pain were compared for autograft versus nonautologous graft. RESULTS: A total of 781 PFDD cases were analyzed (359 autograft, 422 nonautologous graft). Nonautologous grafts included bovine pericardium (n = 63), bovine collagen (n = 225), synthetic (n = 99), and human cadaveric allograft (n = 35). Autograft (103/359, 28.7%) had a similar overall complication rate compared to nonautologous graft (143/422, 33.9%) (p = 0.12). However, nonautologous graft was associated with significantly higher rates of pseudomeningocele (p = 0.04) and meningitis (p < 0.001). The higher rate of meningitis was influenced particularly by the higher rate of chemical meningitis (p = 0.002) versus infectious meningitis (p = 0.132). Among 4 types of nonautologous grafts, there were differences in complication rates (p = 0.02), including chemical meningitis (p = 0.01) and postoperative nausea/vomiting (p = 0.03). Allograft demonstrated the lowest complication rates overall (14.3%) and yielded significantly fewer complications compared to bovine collagen (p = 0.02) and synthetic (p = 0.003) grafts. Synthetic graft yielded higher complication rates than autograft (p = 0.01). Autograft and nonautologous graft resulted in equal improvements in syrinx size (p < 0.0001). No differences were found for postoperative changes in headaches or neck pain. CONCLUSIONS: In the largest multicenter cohort to date, complication rates for dural autograft and nonautologous graft are similar after PFDD for CM-I/SM, although nonautologous graft results in higher rates of pseudomeningocele and meningitis. Rates of meningitis differ among nonautologous graft types. Autograft and nonautologous graft are equivalent for reducing syrinx size, headaches, and neck pain.

Objective Craniometric Versus Subjective Outcome Ratings in Endoscopic and Open Sagittal Synostosis Surgery.

BACKGROUND: Despite advances in surgical treatments and assessments of objective outcomes in surgery for sagittal synostosis, there is no agreement regarding the optimal assessment of postoperative outcomes. Additionally, few studies have evaluated subjective assessments of cranial morphology after surgical correction. This study sought to evaluate the utility of subjective aesthetic outcome assessment and compare these assessments to established craniometric outcomes in patients undergoing surgery for isolated sagittal synostosis. METHODS: Nineteen raters (5 parents, 4 surgeons, 5 trainees and 5 nurses) evaluated fifty patients who underwent surgical correction of isolated sagittal synostosis using standardized postoperative patient photos and a five-point Likert scale. Previously established anthropomorphic measurements were recorded postoperatively in these same patients and comparisons were made between the objective anthropomorphic and subjective outcome evaluations. RESULTS: There were no statistically significant correlations between age-controlled cephalic index, head circumference, or euryon-euryon diameter and subjective aesthetic scores. Lay persons assigned a significantly lower proportion of scores (37.9%) as middle values (2, 3, or 4) compared with faculty (64.8%). There was a statistically significant association between high scores given by surgical faculty and laypersons (P < 0.001). CONCLUSIONS: Subjective measurement of cosmetic outcome is a useful metric in surgical correction of craniosynostosis. Although no correlations were found between objective measurements and subjective aesthetic scores, cosmetic assessments by surgeons demonstrated strong correlation with lay perception, indicating that these ratings may be a good gauge of overall cosmetic outcome. When used in combination, objective and subjective measurements provide unique value to assess outcomes after surgery for craniosynostosis.

Novel adsorptive PVC nanofibrous/thiol-functionalized TNT composite UF membranes for effective dynamic removal of heavy metal ions.

The development of efficient strategies for the removal of heavy metal ions from aqueous solutions is rapidly demanded as these contaminants are very toxic and carcinogenic and show detrimental effects on the living creatures. The main focus of the current study is on the preparation and assessment of electrospun adsorptive nanofiber membranes for the removal of toxic Ni(II) and Cu(II) from wastewater in the ultrafiltration process. Hydrothermally synthesized titanate nanotubes (TNT) was modified with thiol functional groups and then directly incorporated to the polyvinyl chloride nanofiber matrices via electrospinning process to fabricate an adsorptive membrane. The as-prepared electrospun nanofiber membranes and the nanoadsorbents were characterized with respect to the physiochemical properties, surface structure and morphology, applying XPS, FTIR, FESEM, EDX and TEM analysis and then, the membranes were evaluated in terms of the removal of the heavy metal ions in a continuous ultrafiltration mode. In adsorptive filtration of the metal ions, the effective factors including nanoadsorbents loading (0.5-1.5 wt%), initial metal ion concentration (60-150 mg/L), feed temperature (~25 °C-45 °C), presence of competing ion and reusability were investigated in the UF system where the membranes containing 1.5 wt% thiol-modified TNT and virgin TNT adsorbents demonstrated excellent removal efficiency compared to the other membranes. The Cu(II) and Ni(II) removal efficiency of the membrane containing 1.5 wt% functionalized TNT was 90% and 86.7%, respectively which was the highest ones. As was expected and due to the uniform dispersion and less aggregation of the modified TNT adsorbents on the large surface area of the electrospun nanofibers, more adsorption capacity of the nanoparticles can be exploited. Moreover, the strong affinity of the thiol functional groups toward the metal cations, these membranes removed metal contaminants more efficiently. Besides, the Cu(II) removal efficiency of the fabricated membranes didn't show any drastic changes in the presence of the competing ions. Furthermore, acceptable performance was achieved for the prepared membranes even after four adsorption/regeneration cycles in the continuous UF experiments, demonstrating the feasibility and effectiveness of the prepared adsorptive nanofiber membranes for the removal of heavy metal ions.

Comparison of anticoagulation and antiplatelet therapy for treatment of blunt cerebrovascular injury in children <10 years of age: a multicenter retrospective cohort study.

PURPOSE: Blunt cerebrovascular injury (BCVI) is uncommon in the pediatric population. Among the management options is medical management consisting of antithrombotic therapy with either antiplatelets or anticoagulation. There is no consensus on whether administration of antiplatelets or anticoagulation is more appropriate for BCVI in children < 10 years of age. Our goal was to compare radiographic and clinical outcomes based on medical treatment modality for BCVI in children < 10 years. METHODS: Clinical and radiographic data were collected retrospectively for children screened for BCVI with computed tomography angiography at 5 academic pediatric trauma centers. RESULTS: Among 651 patients evaluated with computed tomography angiography to screen for BCVI, 17 patients aged less than 10 years were diagnosed with BCVI (7 grade I, 5 grade II, 1 grade III, 4 grade IV) and received anticoagulation or antiplatelet therapy for 18 total injuries: 11 intracranial carotid artery, 4 extracranial carotid artery, and 3 extracranial vertebral artery injuries. Eleven patients were treated with antiplatelets (10 aspirin, 1 clopidogrel) and 6 with anticoagulation (4 unfractionated heparin, 2 low-molecular-weight heparin, 1 transitioned from the former to the latter). There were no complications secondary to treatment. One patient who received anticoagulation died as a result of the traumatic injuries. In aggregate, children treated with antiplatelet therapy demonstrated healing on 52% of follow-up imaging studies versus 25% in the anticoagulation cohort. CONCLUSION: There were no observed differences in the rate of hemorrhagic complications between anticoagulation and antiplatelet therapy for BCVI in children < 10 years, with a nonsignificantly better rate of healing on follow-up imaging in children who underwent antiplatelet therapy; however, the study cohort was small despite including patients from 5 hospitals.

Effect of Amniotic Membrane Dressing on Pain and Healing of Palatal Donor Site: A Randomized Controlled Trial.

BACKGROUND: Free gingival graft is the most commonly practiced predictable technique for gingival augmentation. OBJECTIVE: To assess the effectiveness of human amniotic membrane, a biological dressing, on wound healing and post-operative pain after its application on the palatal donor site after free gingival graft surgery. METHODS: Of 27 eligible patients, 15 were randomized into a test group and received human amniotic membrane dressing sutured over their palatal donor site; 12 were randomized into a control group in whom the palatal donor site was only sutured. Standard clinical photographs were taken at 7, 14, and 21 days post-operatively and evaluated by 3 periodontists. The pain score at the donor site was assessed by a visual analog score; the number of analgesics taken was also recorded. RESULTS: The mean color match scores were higher in the test group than the control group at 14 (p<0.01) and 21 days after surgery (p=0.02). The difference in tissue texture (p=0.01) and inflammation (p=0.02) between the two groups was only significant on day 14 (p<0.05). The pattern of pain relief was better in the test group compared with the control group, especially in first days, although the differences were not significant in terms of the number of analgesics taken or the pain score. CONCLUSION: Application of human amniotic membrane can accelerate wound healing and may decrease post-operative pain and discomfort by a limited amount.

Styloidogenic jugular venous compression syndrome: a case report and review of the literature.

BACKGROUND: Styloidogenic jugular venous compression syndrome (SJVCS) has been shown to present with a similar symptomatology to idiopathic intracranial hypertension (IIH) and is caused by compression of the internal jugular vein (IJV) between the lateral tubercle of C1 and the styloid process. Treatments including venous stenting and styloidectomy have been reported with good outcomes; however, treatment of a pediatric patient with SJVCS with styloidectomy has not previously been reported in the literature. CASE REPORT: A 12-year-old male presented with refractory positional headaches, nausea, and vomiting, and after, workup including lumbar puncture (LP) and intracranial pressure (ICP) monitoring was found to have intracranial hypertension associated with contralateral neck turning. Computed tomography venogram (CTV) revealed severe bilateral compression of the IJV's between the styloid processes and C1 tubercle. The patient was successfully treated with unilateral right-sided styloidectomy with symptomatic relief. CONCLUSIONS: This is the first reported pediatric case of SJVCS treated successfully with styloidectomy to our knowledge and adds to the limited literature that styloidectomy is a durable treatment option for SJVCS.

The initial experience of InterSurgeon: an online platform to facilitate global neurosurgical partnerships.

OBJECTIVE: Despite general enthusiasm for international collaboration within the organized neurosurgical community, establishing international partnerships remains challenging. The current study analyzes the initial experience of the InterSurgeon website in partnering surgeons from across the world to increase surgical collaboration. METHODS: One year after the launch of the InterSurgeon website, data were collected to quantify the number of website visits, average session duration, total numbers of matches, and number of offers and requests added to the website each month. Additionally, a 15-question survey was designed and distributed to all registered members of the website. RESULTS: There are currently 321 surgeon and institutional members of InterSurgeon representing 69 different countries and all global regions. At the time of the survey there were 277 members, of whom 76 responded to the survey, yielding a response rate of 27.4% (76/277). Twenty-five participants (32.9%) confirmed having either received a match email (12/76, 15.8%) or initiated contact with another user via the website (13/76, 17.1%). As expected, the majority of the collaborations were either between a high-income country (HIC) and a low-income country (LIC) (5/18, 27.8%) or between an HIC and a middle-income country (MIC) (9/18, 50%). Interestingly, there were 2 MIC-to-MIC collaborations (2/18, 11.1%) as well as 1 MIC-to-LIC (1/18, 5.6%) and 1 LIC-to-LIC partnership. At the time of response, 6 (33.3%) of the matches had at least resulted in initial contact via email or telephone. One of the partnerships had involved face-to-face interaction via video conference. A total of 4 respondents had traveled internationally to visit their partner's institution. CONCLUSIONS: Within its first year of launch, the InterSurgeon membership has grown significantly. The partnerships that have already been formed involve not only international visits between HICs and low- to middle-income countries (LMICs), but also telecollaboration and inter-LMIC connections that allow for greater exchange of knowledge and expertise. As membership and site features grow to include other surgical and anesthesia specialties, membership growth and utilization is expected to increase rapidly over time according to social network dynamics.

Evaluation of pediatric glioma outcomes using intraoperative MRI: a multicenter cohort study.

BACKGROUND: The use of intraoperative MRI (iMRI) during treatment of gliomas may increase extent of resection (EOR), decrease need for early reoperation, and increase progression-free and overall survival, but has not been fully validated, particularly in the pediatric population. OBJECTIVE: To assess the accuracy of iMRI to identify residual tumor in pediatric patients with glioma and determine the effect of iMRI on decisions for resection, complication rates, and other outcomes. METHODS: We retrospectively analyzed a multicenter database of pediatric patients (age ≤ 18 years) who underwent resection of pathologically confirmed gliomas. RESULTS: We identified 314 patients (mean age 9.7 ± 4.6 years) with mean follow-up of 48.3 ± 33.6 months (range 0.03-182.07 months) who underwent surgery with iMRI. There were 201 (64.0%) WHO grade I tumors, 57 (18.2%) grade II, 24 (7.6%) grade III, 9 (2.9%) grade IV, and 23 (7.3%) not classified. Among 280 patients who underwent resection using iMRI, 131 (46.8%) had some residual tumor and underwent additional resection after the first iMRI. Of the 33 tissue specimens sent for pathological analysis after iMRI, 29 (87.9%) showed positive tumor pathology. Gross total resection was identified in 156 patients (55.7%), but this was limited by 69 (24.6%) patients with unknown EOR. CONCLUSIONS: Analysis of the largest multicenter database of pediatric gliomas resected using iMRI demonstrated additional tumor resection in a substantial portion of cases. However, determining the impact of iMRI on EOR and outcomes remains challenging because iMRI use varies among providers nationally. Continued refinement of iMRI techniques for use in pediatric patients with glioma may improve outcomes.