Paediatric epilepsy surgery: Techniques and outcomes.

Epilepsy is a neurological condition characterised by recurrent and persistent seizures. For paediatric patients, achieving early seizure freedom can have positive impacts on cognition, development, social integration and mental health, leading to improved quality of life. In general, one third of patients with epilepsy are refractory to medication; for these patients, epilepsy surgery may offer the only chance for improved seizure control. Epilepsy surgery as a therapeutic intervention has become increasingly accepted in the past few decades, with more diverse options available (including neuromodulatory and minimally invasive techniques). In this context, we discuss here the pre-operative workup for paediatric patients with medically refractory epilepsy and provide an updated review on current and emerging surgical therapies for this condition. We also discuss the clinical, neuropsychological, quality of life and economic impacts of epilepsy surgery.

The Association of Vitamin D Status with Acute Respiratory Morbidity in Preterm Infants.

OBJECTIVE: To assess the association between serum 25-hydroxyvitamin D (25OHD) levels and outcomes in preterm infants (<32 weeks gestation). STUDY DESIGN: Serum 25OHD was measured in mothers and their infants within 24 hours of birth, before the start of enteral vitamin D supplementation, and at discharge from the neonatal intensive care unit. We evaluated the associations between vitamin D status and various early preterm outcomes. RESULTS: Ninety-four preterm infants and their mothers were included; 92% of the infants had a 25OHD level≤50 nmol/L (20 ng/mL), and 64% had a 25OHD level<30 nmol/L (12 ng/mL). A low 25OHD level (<30 nmol/L) in preterm infants at birth was associated with increased oxygen requirement (P=.008), increased duration of intermittent positive-pressure ventilation during resuscitation at delivery (P=.032), and greater need for assisted ventilation (P=.013). CONCLUSION: We observed a high prevalence of low 25OHD (<30 nmol/L), and found an association between vitamin D status and acute respiratory morbidity in preterm infants after birth.

Inadequate vitamin D levels are associated with culture positive sepsis and poor outcomes in paediatric intensive care.

AIM: This study aimed to assess vitamin D status, and its determinants, in paediatric patients with suspected sepsis who were admitted to a paediatric intensive care unit (PICU). We also investigated the association between vitamin D status and clinical outcomes. METHODS: Serum 25-hydroxy vitamin D (25OHD) and clinical determinants were prospectively assessed in children with suspected sepsis (<12 years old) admitted to the PICU. The relationship between 25OHD and clinical outcomes was evaluated. Vitamin D status was also assessed in control children of a similar age. RESULTS: We enrolled 120 children with suspected sepsis admitted to the PICU and 30 paediatric controls. 25OHD was <50 nmol/L in 59% of the children admitted to the PICU and 25OHD was lower than in the controls (47 ± 29 vs 66 ± 26 nmol/L, p < 0.001). After adjusting for potential confounders, 25OHD was strongly associated with culture positive sepsis (p < 0.001), the paediatric index of mortality (p = 0.026) and the duration of mechanical ventilation (p = 0.008). There was a negative correlation between 25OHD and C-reactive protein (CRP): each 0.1% decrease in 25OHD increased CRP (p = 0.04). CONCLUSION: Children admitted to the PICU with suspected sepsis had lower 25OHD than controls and inadequate 25OHD status was associated with confirmed sepsis and poor outcomes.

Breakthrough spikes in rapid eye movement sleep from the epilepsy monitoring unit are associated with peak seizure frequency.

STUDY OBJECTIVES: Rapid eye movement sleep (REM) usually suppresses interictal epileptiform discharges (IED) and seizures. However, breakthrough IEDs in REM sometimes continue. We aimed to determine if the amount of IED and seizures in REM, or REM duration, is associated with clinical trajectories. METHODS: Continuous electroencephalogram (EEG) recordings from the epilepsy monitoring unit (EMU) were clipped to at least 3 h of concatenated salient findings per day including all identified REM. Concatenated EEG files were analyzed for nightly REM duration and the "REM spike burden" (RSB), defined as the proportion of REM occupied by IED or seizures. Patient charts were reviewed for clinical data, including patient-reported peak seizure frequency. Logistic and linear regressions were performed, as appropriate, to explore associations between two explanatory measures (duration of REM and RSB) and six indicators of seizure activity (clinical trajectory outcomes). RESULTS: The median duration of REM sleep was 43.3 (IQR 20.9-73.2) min per patient per night. 59/63 (93.7%) patients achieved REM during EMU admission. 39/59 (66.1%) patients had breakthrough IEDs or seizures in REM with the median RSB at 0.7% (IQR 0%-8.4%). Every 1% increase in RSB was associated with 1.69 (95% CI = 0.47-2.92) more seizures per month during the peak seizure period of one's epilepsy (p = 0.007). CONCLUSIONS: Increased epileptiform activity during REM is associated with increased peak seizure frequency, suggesting an overall poorer epilepsy trajectory. Our findings suggest that RSB in the EMU is a useful biomarker to help guide about what to expect over the course of one's epilepsy.

Potential drug interactions in cancer patients receiving supportive care exclusively.

Cancer patients at the end of life often take many medications and are at risk for drug interactions. The purpose of this study was to describe the epidemiology of potential drug interactions in cancer patients receiving supportive care exclusively. We retrospectively reviewed the charts of consecutive adult cancer outpatients attending palliative care clinics at the Princess Margaret Hospital, Toronto, Canada. Drugs were screened for interactions by the Drug Interaction Facts software, which classifies interactions by levels of severity (major, moderate, and minor) and scientific evidence (1-5, with 1=the strongest level of evidence). Among 372 eligible patients, 250 potential drug interactions were identified in 115 patients (31%, 95% confidence interval 26%-36%). The most common involved warfarin and phenytoin. Most interactions were classified as being of moderate severity (59%) and 42% of them were supported by Levels 1-3 of evidence. In multivariable analysis, increasing age (P<0.001), presence of comorbidity (P=0.001), cancer type (brain tumors, P<0.001), and increasing number of drugs (P<0.001) were associated with risk of drug interactions. Potential drug interactions are common in palliative care and mostly involve warfarin and anticonvulsants. Older patients, those with comorbid conditions, brain tumor patients, and those taking many medications are at greater risk of drug interactions.

Information-Seeking Behaviors of Medical Students: A Cross-Sectional Web-Based Survey.

BACKGROUND: Medical students face an information-rich environment in which retrieval and appraisal strategies are increasingly important. OBJECTIVE: To describe medical students' current pattern of health information resource use and characterize their experience of instruction on information search and appraisal. METHODS: We conducted a cross-sectional web-based survey of students registered in the four-year MD Program at Dalhousie University (Halifax, Nova Scotia, and Saint John, New Brunswick, sites), Canada. We collected self-reported data on information-seeking behavior, instruction, and evaluation of resources in the context of their medical education. Data were analyzed using descriptive statistics. RESULTS: Surveys were returned by 213 of 462 eligible students (46.1%). Most respondents (165/204, 80.9%) recalled receiving formal instruction regarding information searches, but this seldom included nontraditional tools such as Google (23/107, 11.1%), Wikipedia, or social media. In their daily practice, however, they reported heavy use of these tools, as well as EBM summaries. Accessibility, understandability, and overall usefulness were common features of highly used resources. Students identified challenges managing information and/or resource overload and source accessibility. CONCLUSIONS: Medical students receive instruction primarily on searching and assessing primary medical literature. In their daily practice, however, they rely heavily on nontraditional tools as well as EBM summaries. Attention to appropriate use and appraisal of nontraditional sources might enhance the current EBM curriculum.

Vitamin D status in Irish children and adolescents: value of fortification and supplementation.

BACKGROUND: Vitamin D has important skeletal and extraskeletal roles but those living at northerly latitudes are at risk of suboptimal levels because of reduced sunlight exposure. AIM: To describe the vitamin D status of Irish children and identify factors predictive of vitamin D status. METHODS: A prospective cross sectional study was undertaken over a 12 month period. Two hundred and fifty two healthy children attending for minor medical or surgical procedures were recruited. All had 25-hydroxyvitamin D (25OHD), parathyroid hormone and bone profiles measured. RESULTS: The mean (standard deviation) for 25OHD was 51(25) nmol/L (20.4 (10) ng/mL). Forty-five percent had levels >50 nmol/L (20 ng/mL). The following variables were significantly associated with 25OHD levels >50 nmol/L (20 ng/mL): sample drawn in April-September, use of vitamin D supplements, consumption of formula milk, and non-African ethnicity. CONCLUSION: More than half of the children in this study had 25OHD levels less than 50 nmol/L (20 ng/mL). Vitamin D status was significantly improved by augmented oral vitamin D intake.

Symptom and medication profiles among cancer patients attending a palliative care clinic.

BACKGROUND: Patients with advanced cancer frequently experience distressful symptoms and receive numerous medications. We describe the symptomatology and medication profile of ambulatory cancer patients receiving exclusively supportive care at the Princess Margaret Hospital. MATERIALS AND METHODS: This was a retrospective, cross-sectional study. We reviewed the charts of consecutive adult cancer patients attending palliative care clinics and who were no longer receiving cancer-directed therapy. From the medical records, we collected information about self-reported symptoms [screened for with the numerical Edmonton symptom assessment system (ESAS) scale; range, 0-10, with 10=worst symptom] and medication profiles. Summary statistics were used to describe the results. RESULTS: Two hundred fifty five patients met the inclusion criteria. The most frequent self-reported symptoms of any severity were fatigue (77%), pain (75%), and lack of appetite (66%). These were also the most severe symptoms: fatigue (median ESAS score=7), pain (median ESAS=5), and lack of appetite (median ESAS=5). The median number of medications per patient after consultation in the palliative care service was 6, and the most common classes of drugs prescribed were opioids (67%), laxatives/stool softeners (54%), corticosteroids (41%), and acetaminophen (41%). Palliative care physicians made at least one medication change in 75% of the patients, with the most frequent change being the addition of new medication(s); dexamethasone was the most commonly added individual drug (18% of the patients). CONCLUSION: Among patients with advanced cancer not receiving antineoplastic therapy, the most frequent and severe symptoms were fatigue, pain, and lack of appetite. The medication profile represented drugs that could both alleviate and contribute to these symptoms. Audit of patient symptoms and medication prescription in palliative care may inform clinical practice and help the development of research specific to patient symptoms.

Disclosure of conflicts of interest by authors of clinical trials and editorials in oncology.

PURPOSE: There is concern that financial relationships between sponsors and investigators may bias research results. Our objective was to evaluate the epidemiology of conflicts of interest (COIs) among authors of clinical trials and editorials in oncology and the relationship between COI disclosure and source of funding. METHODS: We did a cross-sectional survey of clinical trials and editorials of anticancer agents and supportive care medications published in the Journal of Clinical Oncology (JCO) during a 1-year period. RESULTS: Of 1,533 articles published in JCO between January 1, 2005, and January 31, 2006, 332 met our inclusion criteria; 289 (87%) were clinical trials, and 43 (13%) were editorials. The pharmaceutical industry entirely or partially funded 44% of the clinical trials. At least one COI was disclosed in 69% of clinical trials and 51% of editorials. The most common types of COI reported by authors were consultancy fees, honoraria, and research funds. The highest monetary levels of interest reported by authors were for research grants, but the majority of authors with COIs received less than US$10,000. In multivariable analysis, authors of clinical trials conducted in North America (North America v Europe: odds ratio [OR] = 2.9, P = .002) and authors of trials funded entirely (industry only v nonprofit: OR = 13.8, P < .001) or partially (both industry and nonprofit v nonprofit only: OR = 5.8, P < .001) by industry were more likely to report personal COIs. CONCLUSION: COIs are common in clinical cancer research and usually take the form of consultancy fees, honoraria, and research funds. Source of study funding was significantly associated with COI disclosure.

Independent factors associated with mortality, reintervention, and achievement of complete repair in children with pulmonary atresia with ventricular septal defect.

OBJECTIVES: We described morphologic characteristics, particularly pulmonary anatomy, and determined the prevalence of definitive end states and their determinants in children with pulmonary atresia associated with ventricular septal defect (PAVSD). BACKGROUND: Pulmonary atresia associated with ventricular septal defect represents a broad morphologic spectrum that greatly influences management and outcomes. METHODS: From 1975 to 2004, 220 children with PAVSD presented to our institution. Blinded angiographic review (n = 171) characterized bronchopulmonary segment arterial supply. RESULTS: A total of 185 patients underwent surgery, and repair was definitive in 75%. Initial operations included systemic-pulmonary artery shunt in 57%, complete primary repair in 31%, or right ventricular outflow tract reconstruction in 12%. Based on angiographic review, 118 patients had simple PAVSD and 53 patients had PAVSD with major aortopulmonary collateral arteries (MAPCAs). Overall survival from initial operation was 71% at 10 years. Risk factors for death after initial operation included younger age at repair, earlier birth cohort, fewer bronchopulmonary segments supplied by native pulmonary arteries, and initial placement of a systemic-pulmonary artery shunt. Competing-risks analysis for initially palliated patients predicted that after 10 years, 68% achieved complete repair (with associated factors including later birth cohort and more bronchopulmonary segments supplied by native pulmonary arteries), 22% died without repair, and 10% remained alive without repair. Reoperations after complete repair occurred in 38 children (27%), with risk factors including older age at palliation, MAPCAs, and more segments supplied by collaterals. CONCLUSIONS: Outcomes in children with PAVSD have improved over time, and are better in completely repaired cases. Bronchopulmonary arterial supply is an important determinant of mortality, achievement of definitive repair, and post-repair reoperation.