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BACKGROUND: Surgical revascularization decreases the long-term risk of stroke in children with moyamoya arteriopathy but can be associated with an increased risk of stroke during the perioperative period. Evidence-based approaches to optimize perioperative management are limited and practice varies widely. Using a modified Delphi process, we sought to establish expert consensus on key components of the perioperative care of children with moyamoya undergoing indirect revascularization surgery and identify areas of equipoise to define future research priorities. METHODS: Thirty neurologists, neurosurgeons, and intensivists practicing in North America with expertise in the management of pediatric moyamoya were invited to participate in a three-round, modified Delphi process consisting of a 138-item practice patterns survey, anonymous electronic evaluation of 88 consensus statements on a 5-point Likert scale, and a virtual group meeting during which statements were discussed, revised, and reassessed. Consensus was defined as ≥ 80% agreement or disagreement. RESULTS: Thirty-nine statements regarding perioperative pediatric moyamoya care for indirect revascularization surgery reached consensus. Salient areas of consensus included the following: (1) children at a high risk for stroke and those with sickle cell disease should be preadmitted prior to indirect revascularization; (2) intravenous isotonic fluids should be administered in all patients for at least 4 h before and 24 h after surgery; (3) aspirin should not be discontinued in the immediate preoperative and postoperative periods; (4) arterial lines for blood pressure monitoring should be continued for at least 24 h after surgery and until active interventions to achieve blood pressure goals are not needed; (5) postoperative care should include hourly vital signs for at least 24 h, hourly neurologic assessments for at least 12 h, adequate pain control, maintaining normoxia and normothermia, and avoiding hypotension; and (6) intravenous fluid bolus administration should be considered the first-line intervention for new focal neurologic deficits following indirect revascularization surgery. CONCLUSIONS: In the absence of data supporting specific care practices before and after indirect revascularization surgery in children with moyamoya, this Delphi process defined areas of consensus among neurosurgeons, neurologists, and intensivists with moyamoya expertise. Research priorities identified include determining the role of continuous electroencephalography in postoperative moyamoya care, optimal perioperative blood pressure and hemoglobin targets, and the role of supplemental oxygen for treatment of suspected postoperative ischemia.
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Revascularización Cerebral , Enfermedad de Moyamoya , Accidente Cerebrovascular , Niño , Humanos , Técnica Delphi , Enfermedad de Moyamoya/cirugía , Accidente Cerebrovascular/etiología , Atención Perioperativa , Cuidados Posoperatorios , Revascularización Cerebral/efectos adversos , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
BACKGROUND: Recent studies suggest that cerebral revascularization surgery may be a safe and effective therapy to reduce stroke risk in patients with sickle cell disease and moyamoya syndrome (SCD-MMS). METHODS: We performed a multicenter, retrospective study of children with SCD-MMS treated with conservative management alone (conservative group)-chronic blood transfusion and/or hydroxyurea-versus conservative management plus surgical revascularization (surgery group). We monitored cerebrovascular event (CVE) rates-a composite of strokes and transient ischemic attacks. Multivariable logistic regression was used to compare CVE occurrence and multivariable Poisson regression was used to compare incidence rates between groups. Covariates in multivariable models included age at treatment start, age at moyamoya diagnosis, antiplatelet use, CVE history, and the risk period length. RESULTS: We identified 141 patients with SCD-MMS, 78 (55.3%) in the surgery group and 63 (44.7%) in the conservative group. Compared with the conservative group, preoperatively the surgery group had a younger age at moyamoya diagnosis, worse baseline modified Rankin scale scores, and increased prevalence of CVEs. Despite more severe pretreatment disease, the surgery group had reduced odds of new CVEs after surgery (odds ratio = 0.27, 95% confidence interval [CI] = 0.08-0.94, p = .040). Furthermore, comparing surgery group patients during presurgical versus postsurgical periods, CVEs odds were significantly reduced after surgery (odds ratio = 0.22, 95% CI = 0.08-0.58, p = .002). CONCLUSIONS: When added to conservative management, cerebral revascularization surgery appears to reduce the risk of CVEs in patients with SCD-MMS. A prospective study will be needed to validate these findings.
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Anemia de Células Falciformes , Revascularización Cerebral , Enfermedad de Moyamoya , Accidente Cerebrovascular , Humanos , Niño , Estudios Retrospectivos , Enfermedad de Moyamoya/etiología , Revascularización Cerebral/efectos adversos , Revascularización Cerebral/métodos , Estudios Prospectivos , Accidente Cerebrovascular/etiología , Anemia de Células Falciformes/complicaciones , Resultado del TratamientoRESUMEN
BACKGROUND: Macrocephaly is present in 2.3% of children with important neurosurgical conditions in the differential diagnosis. The objective of this study was to identify clinical associations with actionable imaging findings among children with head imaging for macrocephaly. METHODS: We conducted a case-control study of head imaging studies ordered for macrocephaly among children 24 months and younger in a multistate children's health system. Four neurosurgeons reviewed the images, determining cases to be a 'concern' if neurosurgical follow-up or intervention was indicated. Electronic health records were reviewed to collect patient-level data and to determine if surgery was performed. Controls were matched 3:1 to cases of 'concern' in a multivariate model using conditional logistic regression. RESULTS: In the study sample (n = 1293), 46 (4%) were concern cases, with 15 (1%) requiring surgery. Significant clinical factors associated with neurosurgical concern were bulging fontanel [aOR 7.47, (95% CI: 2.28-24.44), P < 0.001], prematurity [aOR 21.26, (95% CI: 3.76-120.21), P < 0.001], any delay [aOR 2.67, (95% CI: 1.13-6.27), P = 0.03], and head-weight Z-score difference (W_diff, defined as the difference between the Z-scores of head circumference and weight) [aOR 1.70, (95% CI: 1.22-2.37), P = 0.002]. CONCLUSIONS: Head imaging for macrocephaly identified few patients with findings of concern and fewer requiring surgery. A greater head-weight Z-score difference appears to represent a novel risk factor for neurosurgical follow-up or intervention.
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Megalencefalia , Humanos , Niño , Preescolar , Estudios de Casos y Controles , Megalencefalia/diagnóstico por imagen , Megalencefalia/cirugía , Tomografía Computarizada por Rayos X , Factores de Riesgo , CefalometríaRESUMEN
ABSTRACT: Late presentation sagittal craniosynostosis presents a unique challenge due to the decreased ability of the skull to repair the bony defects created by standard of care techniques. Distraction osteogenesis is a viable strategy to correct this defect in late presenting cases. The authors describe a variation in technique in which the temporalis muscle origin is retained, creating an osteoplastic bone flap with retained vascularity through the tem-poralis muscle. This may improve postoperative bony healing of bony defects in this compromised population. The authors present two patients who presented to them late with sagittal synostosis who were treated with distraction osteogenesis in which vascular continuity to the parietal bones is preserved through the temporalis muscle.
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Craneosinostosis , Anomalías Maxilomandibulares , Osteogénesis por Distracción , Craneosinostosis/diagnóstico por imagen , Craneosinostosis/cirugía , Craneotomía/métodos , Humanos , Anomalías Maxilomandibulares/cirugía , Osteogénesis por Distracción/métodos , Cráneo/cirugía , Colgajos Quirúrgicos/cirugíaRESUMEN
Low-pressure CSF shunt malfunction is a poorly understood complication of hydrocephalus affecting patients of all ages. Treatment commonly requires external drainage of CSF to subatmospheric pressures for days to weeks in an intensive care setting. The current communication describes the repurposing of an established therapeutic technique, epidural blood patch, for successful initial management in 2 cases of low-pressure shunt malfunction in the absence of a recognized spinal CSF fistula. This technique may shorten length of stay and obviate potential morbidity in the management of what is otherwise a vexatious clinical problem.
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Parche de Sangre Epidural , Hidrocefalia , Presión del Líquido Cefalorraquídeo , Derivaciones del Líquido Cefalorraquídeo/efectos adversos , Drenaje , Humanos , Hidrocefalia/cirugía , Punción Espinal/efectos adversosRESUMEN
BACKGROUND: How the existence of trauma systems affects the care of less severely injured patients has received little attention. OBJECTIVE: The current study examines the longitudinal effect on the care of children with traumatic brain injuries (TBIs) of the incorporation of a pediatric trauma center into a regional trauma system. METHODS: The Delaware Trauma System provided registry data from 2000 to 2014. Inclusion criteria were age less than 18 years and ICD9 diagnostic coding for any head injury. Admissions were assessed as "substantial" or "non-substantial" based on study criteria. We hypothesized a step-wise increase in registrations of mild TBI and non-substantial admissions coinciding with the opening of Delaware's pediatric trauma center in late 2006. RESULTS: There were 5,272 registrations. Before the opening of the pediatric trauma center, 1,737 of 2,038 (85.2 percent) head injuries were mild; afterwards mild TBI accounted for 2,894 of 3,230 registrations (89.6 percent; odds ratio 1.49, 95 percent Cl 1.26 - 1.76; p < 0.0001). Before the opening, 850 of 2,038 (41.7 percent) encounters were categorized as non-substantial; afterwards 1,528 of 3,230 admissions (47.3 percent) were non-substantial (odds ratio 1.25; 95 percent C 1.12 - 1.40; p < 0.0001). Inter-hospital transports within the system exhibited similar trends. CONCLUSIONS: Registrations of mild TBI and non-substantial admissions trended upward steadily during the years of this study with a suggestive step-wise increase correlating with the opening of a pediatric trauma center. Guidelines are needed to facilitate management of patients with minor injuries at the lowest appropriate level of care.
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Traumatismos Craneocerebrales , Asignación de Recursos para la Atención de Salud , Aceptación de la Atención de Salud/estadística & datos numéricos , Centros Traumatológicos , Adolescente , Niño , Preescolar , Traumatismos Craneocerebrales/diagnóstico , Traumatismos Craneocerebrales/epidemiología , Delaware/epidemiología , Femenino , Asignación de Recursos para la Atención de Salud/métodos , Asignación de Recursos para la Atención de Salud/estadística & datos numéricos , Humanos , Lactante , Estudios Longitudinales , Masculino , Evaluación de Necesidades , Transferencia de Pacientes/estadística & datos numéricos , Mejoramiento de la Calidad , Sistema de Registros/estadística & datos numéricos , Reproducibilidad de los Resultados , Centros Traumatológicos/estadística & datos numéricos , Índices de Gravedad del TraumaRESUMEN
There is intense interest in developing novel methods for the sustained delivery of low levels of clinical therapeutics. MAX8 is a peptide-based beta-hairpin hydrogel that has unique shear thinning properties that allow for immediate rehealing after the removal of shear forces, making MAX8 an excellent candidate for injectable drug delivery at a localized injury site. The current studies examined the feasibility of using MAX8 as a delivery system for nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF), two neurotrophic growth factors currently used in experimental treatments of spinal cord injuries. Experiments determined that encapsulation of NGF and BDNF within MAX8 did not negatively impact gel formation or rehealing and that shear thinning did not result in immediate growth factor release. ELISA, microscopy, rheology, and Western blotting experiments collectively demonstrate the functional capabilities of the therapeutic-loaded hydrogels to (i) maintain a protective environment against in vitro degradation of encapsulated therapeutics for at least 28 days; and (ii) allow for sustained release of NGF and BDGF capable of initiating neurite-like extensions of PC12 cells, most likely due to NGF/BDGF signaling pathways. Importantly, while the 21 day release profiles could be tuned by adjusting the MAX8 hydrogel concentration, the initial shear thinning of the hydrogel (e.g., during injection) does not induce significant premature loss of the encapsulated therapeutic, most likely due to effective trapping of growth factors within structurally robust domains that are maintained during the application of shear forces. Together, our data suggests that MAX8 allows for greater dosage control and sustained therapeutic growth factor delivery, potentially alleviating side effects and improving the efficacy of current therapies.
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Portadores de Fármacos , Hidrogeles , Factor de Crecimiento Nervioso , Péptidos , Animales , Portadores de Fármacos/química , Portadores de Fármacos/farmacología , Humanos , Hidrogeles/química , Hidrogeles/farmacología , Factor de Crecimiento Nervioso/química , Factor de Crecimiento Nervioso/farmacología , Células PC12 , Péptidos/química , Péptidos/farmacología , RatasRESUMEN
Torticollis is a common complaint in the pediatric emergency department. Here, we report what we believe to be the first example in a young child of a fracture of the anterior arch of the atlas associated with an acquired, postsurgical defect of the posterior arch. A brief review of pediatric cervical spine injuries and fractures is presented. Atlas laminectomy may predispose patients to isolated atlas fractures even with minor trauma. Those fractures, however, are stable and treated by hard cervical orthosis.
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Atlas Cervical/lesiones , Fracturas de la Columna Vertebral/etiología , Accidentes por Caídas , Preescolar , Femenino , Humanos , Laminectomía , Fracturas de la Columna Vertebral/diagnóstico , Fracturas de la Columna Vertebral/terapia , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: Hydrocephalus is a chronic, treatable, but in most cases incurable condition characterized by long periods of stability punctuated by crises. Patients in crisis usually seek care in an emergency department (ED). How patients with hydrocephalus use EDs has received almost no epidemiological study. METHODS: Data were taken from the National Emergency Department Survey for 2018. Visits by patients with hydrocephalus were identified by diagnostic codes. Neurosurgical visits were identified by codes for imaging of the brain or skull or by neurosurgical procedure codes. Visits and dispositions were characterized by demographic factors for neurosurgical and unspecified visits by using methods for analysis of complex survey designs. Associations among demographic factors were assessed using latent class analysis. RESULTS: There were an estimated 204,785 ED visits by patients with hydrocephalus in the United States in 2018. Roughly 80% of patients with hydrocephalus who visited EDs were adults or elders. By a ratio of 2:1, patients with hydrocephalus visited EDs much more often for unspecified reasons than for neurosurgical reasons. Patients with neurosurgical complaints had more costly ED visits, and if they were admitted they had longer and more costly hospitalizations than did patients with unspecified complaints. Only 1 in 3 patients with hydrocephalus who visited an ED was sent home regardless of whether the complaint was neurosurgical. Neurosurgical visits ended in transfer to another acute care facility more than 3 times as often as unspecified visits. Odds of transfer were more strongly associated with geography and, specifically, with proximity to a teaching hospital than with personal or community wealth. CONCLUSIONS: Patients with hydrocephalus make heavy use of EDs, and they make more visits for reasons unrelated to their hydrocephalus than for neurosurgical reasons. Transfer to another acute care facility is an adverse clinical outcome that is much more common after neurosurgical visits. It is a system inefficiency that might be minimized by proactive case management and coordination of care.
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Hospitalización , Hidrocefalia , Adulto , Humanos , Estados Unidos/epidemiología , Anciano , Servicio de Urgencia en Hospital , Hidrocefalia/epidemiología , Hidrocefalia/cirugía , Cabeza , EncéfaloRESUMEN
OBJECTIVE: Hydrocephalus is a lifelong condition punctuated in most cases by unpredictable hospital admissions for surgical maintenance. It occupies more of the attention of the pediatric neurosurgeon than any other condition. Benchmarks for the measurement of outcomes are of interest to patients, their families, and the healthcare system. Compared to other metrics, 30-day outcomes require modest resources to collect, are conceptually transparent, and are responsive to process improvement. METHODS: The National Surgical Quality Improvement Program-Pediatric of the American College of Surgeons was queried for operations for hydrocephalus in the years 2013 through 2020. Demographic data and data regarding comorbidities were collected. Thirty-day rates of return to the operating room, of shunt infection, and of readmission to hospital were analyzed on a univariate basis and in multivariate models. RESULTS: There were 29,098 surgical procedures in the sample, including 10,135 shunt insertions, 16,420 shunt revisions, and 2543 endoscopic third ventriculostomies. The overall 30-day reoperation rate was 10.3%. The most powerful associations were with the nature of the index procedure and with a history of extreme prematurity. The 30-day shunt infection rate was 1.80%. The major associations were with young age, major cardiac risk factors, nutritional support, and ventilator dependence. The 30-day readmission rate was 17.2%. The nature of the index procedure, current malignancy, nutritional support, and recent steroid administration were major associations. Comorbidities negatively associated with these outcomes were highly prevalent. CONCLUSIONS: Precise benchmarks for important 30-day outcomes have been calculated from a very large sample of operations for hydrocephalus in childhood.
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OBJECTIVE: Accurate triage of minor head injuries remains a challenge for mature trauma systems. More than one-third of trauma transfers are overtriaged, and minor head injuries predominate. Overtriage is inefficient, wasteful of resources, and burdensome for families. The authors studied overtriage at the sole level I pediatric trauma center (PTC) in a small state with a view toward improvement of processes. METHODS: Data on transfer patients were extracted from an institutional trauma registry over an 8-year period. Three definitions of overtriage were examined: one based on transfer criteria from the American College of Surgeons Committee on Trauma, one based on resource utilization, and one adapted to the regional environment of the PTC. Associations of demographic, geographic, clinical, and social factors with overtriage were examined. RESULTS: There were 1754 unique patients transferred from the emergency departments (EDs) of other institutions to the PTC. Thirty-six percent of transfers were overtriaged by all 3 criteria, and 23% of all transfers were minor head injuries overtriaged by all criteria. Infants were more likely to be overtriaged than other age groups. Among racial categories, Black patients were least likely to be overtriaged. Patients with commercial insurance were more likely to be overtriaged. Overtriaged patients averaged shorter trips from the referring ED to the PTC, even though the PTC was farther from their homes. These observations suggest a sensitivity to social expectations in the exercise of ED physician judgments about transfer. CONCLUSIONS: More than one-third of all transfers to the study PTC were overtriaged, and almost one-quarter of all transfers were overtriaged minor head injuries. Minor head injuries are a potentially rewarding focus for system-wide quality improvement, but the interplay of social factors with ED physician judgments must be recognized.
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Traumatismos Craneocerebrales , Transferencia de Pacientes , Centros Traumatológicos , Triaje , Humanos , Transferencia de Pacientes/estadística & datos numéricos , Niño , Preescolar , Masculino , Traumatismos Craneocerebrales/terapia , Lactante , Femenino , Adolescente , Sistema de Registros , Recién Nacido , Servicio de Urgencia en Hospital/estadística & datos numéricosRESUMEN
OBJECTIVE: Cerebral revascularization surgery (CRS) has been used to prevent stroke in children with sickle cell disease (SCD) and cerebral vasculopathy (e.g., moyamoya syndrome). While results suggest that it may be an effective treatment, surgical indications have not been well defined. This study sought to determine indications for offering revascularization surgery in centers with established sickle cell programs in the US. METHODS: Three sequential surveys utilizing the Delphi methodology were administered to neurosurgeons participating in the Stroke in Sickle Cell Revascularization Surgery study. Respondents were presented with clinical scenarios of patients with SCD and varying degrees of ischemic presentation and vasculopathy, and the group's agreement to offer surgical revascularization was measured. Consensus was defined as ≥ 75% similar responses. RESULTS: The response rate to all 3 surveys was 100%. Seventeen neurosurgeons from 16 different centers participated. The presence of moyamoya collaterals (MMCs) and arterial stenosis matching an ischemic distribution yielded the strongest recommendations to offer surgery. There was consensus to offer revascularization in the presence of MMCs and at least 50% arterial stenosis matching an ischemic distribution. In contrast, there was no consensus to offer revascularization with 50%-70% stenosis not matching an ischemic presentation in the absence of MMCs. The presence of the ivy sign in the distribution of the stenotic artery also contributed to the consensus to offer surgery in certain scenarios. CONCLUSIONS: There were several clinical scenarios that attained consensus to offer surgery; the strongest was moderate to severe arterial stenosis that matched the distribution of ischemic presentation in the presence of MMCs. Radiological findings of decreased cerebral flow or perfusion also facilitated attaining consensus to offer surgery. The findings of this study reflect expert opinion about questions that deserve prospective clinical research. Determination of indications for CRS can guide clinical practice and aid the design of prospective studies.
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OBJECTIVE: Quality improvement (QI) is a methodology used to implement sustainable, meaningful change to improve patient outcomes. Given the complex pathologies observed in pediatric neurosurgery, QI projects could potentially improve patient care. Overall, there is a need to characterize the degree of QI opportunities, training, and initiatives within the field of pediatric neurosurgery. Herein the authors aimed to define the current QI landscape in pediatric neurosurgery. METHODS: A cross-sectional survey was sent to all members of the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Section on Pediatric Neurological Surgery via email. The responses were anonymized. Questions addressed several relatable QI topics including 1) training and participation in QI; 2) QI infrastructure; 3) QI program incentives; and 4) general opinions on the National Surgical Quality Improvement Program (NSQIP) database, various QI topics, and QI productivity. RESULTS: Responses were received from 129 participants (20% response rate). Most respondents practiced in an academic setting (59.8%) and at a free-standing pediatric hospital (65.4%). Participation in QI projects was high (81.7%), but only 23.8% of respondents had formal QI training. Only 36.5% of respondents had institutional requirements for QI work; the majority of those were only required to participate as a project team member. Nearly half of the respondents did not receive incentives or institutional support for QI. The majority agreed ("strongly" and "somewhat") that a QI course would be beneficial (75.5%), that QI projects should be considered for publication in neurosurgery journals (88.1%), and that there is a need for national quality metrics (81.4%). Over 88% have an interest in seeing QI project presentations at the annual Pediatric Joint Section meeting. Only 26.3% believed that the NSQIP was a useful QI guide. Respondents suggested further study of the following QI topics: overall rates of infection and their prevention, hydrocephalus, standardized treatment algorithms for common disorders, team communication, pediatric neurosurgery-specific database, access to care, and interprofessional education. CONCLUSIONS: Areas of opportunity include specialty-specific QI education, tactics for obtaining support to build the QI infrastructure, increased visibility of QI work within pediatric neurosurgery, and a review of available registries to provide readily available data relevant to this specialty.
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Neurocirugia , Niño , Humanos , Estudios Transversales , Neurocirujanos , Neurocirugia/educación , Complicaciones Posoperatorias , Mejoramiento de la Calidad , Encuestas y Cuestionarios , Estados UnidosRESUMEN
OBJECTIVE: The objective of this study was to describe the incidence and management of hydrocephalus in patients with achondroplasia over a 60-year period at four skeletal dysplasia centers. METHODS: The Achondroplasia Natural History Study (CLARITY) is a registry for clinical data from achondroplasia patients receiving treatment at four skeletal dysplasia centers in the US from 1957 to 2017. Data were entered and stored in a REDCap database and included surgeries with indications and complications, medical diagnoses, and radiographic information. RESULTS: A total of 1374 patients with achondroplasia were included in this study. Of these, 123 (9%) patients underwent treatment of hydrocephalus at a median age of 14.4 months. There was considerable variation in the percentage of patients treated for hydrocephalus by center and decade of birth, ranging from 0% to 28%, although in the most recent decade, all centers treated less than 6% of their patients, with an average of 2.9% across all centers. Undergoing a cervicomedullary decompression (CMD) was a strong predictor for treatment of hydrocephalus (OR 5.8, 95% CI 3.9-8.4), although that association has disappeared in those born since 2010 (OR 1.1, 95% CI 0.2-5.7). In patients born since 1990, treatment of hydrocephalus with endoscopic third ventriculostomy (ETV) has become more common; it was used as the first line of treatment in 38% of patients in the most recent decade. Kaplan-Meier analysis suggests that a single ETV will treat hydrocephalus in roughly half of these patients. CONCLUSIONS: While many children with achondroplasia have features of hydrocephalus with enlarged intracranial CSF spaces and relative macrocephaly, treatment of hydrocephalus in achondroplasia patients has become relatively uncommon in the last 20 years. Historically, there was a significant association between symptomatic foramen magnum stenosis and treatment of hydrocephalus, although concurrent treatment of both has fallen out of favor with the recognition that CMD alone will treat hydrocephalus in some patients. Despite good experimental data demonstrating that hydrocephalus in achondroplasia is best understood as communicating in nature, ETV appears to be reasonably successful in certain patients and should be considered an option in selected patients.
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Acondroplasia , Hidrocefalia , Neuroendoscopía , Tercer Ventrículo , Niño , Humanos , Lactante , Resultado del Tratamiento , Hidrocefalia/diagnóstico por imagen , Hidrocefalia/epidemiología , Hidrocefalia/etiología , Acondroplasia/complicaciones , Acondroplasia/epidemiología , Ventriculostomía/efectos adversos , Tercer Ventrículo/diagnóstico por imagen , Tercer Ventrículo/cirugía , Neuroendoscopía/efectos adversos , Estudios RetrospectivosRESUMEN
BACKGROUND: Case reports have suggested an association between the Chiari malformation type 1 (CM1) and spinal cord injury without radiographic abnormality (SCIWORA). No controlled observations have appeared. We report a case-control study. METHODS: The Kids' Inpatient Database (KID) is a product of the Healthcare Utilization Project of the Agency for Healthcare Research and Quality. For the years 1997, 2000, 2003, 2006, and 2009, the KID includes discharge data abstracted from almost 14 million pediatric admissions. We hypothesized that CM1 predisposes children to SCIWORA in the cervicomedullary region, and we reasoned that, if this hypothesis were true, then KID admissions coded for upper cervical SCIWORA would be associated with CM1 more frequently than admissions coded for lower cervical SCIWORA. RESULTS: After exclusion of admissions with a variety of confounding diagnostic codes, we identified 754 admissions coded for upper cervical SCIWORA and 424 coded for lower cervical SCIWORA. Concurrent coding for CM1 was more prevalent among admissions coded for upper cervical SCIWORA than for lower cervical SCIWORA, but the difference did not attain statistical significance (p = 0.093; Fisher's exact test). CONCLUSIONS: These controlled observations fail to support the hypothesis that CM1 is associated with SCIWORA in childhood. If there is a real association, in the context of recent estimates of the prevalence of CM1 in the pediatric population, the magnitude of the incremental risk must be very small.
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Malformación de Arnold-Chiari/diagnóstico por imagen , Malformación de Arnold-Chiari/epidemiología , Traumatismos de la Médula Espinal/diagnóstico por imagen , Traumatismos de la Médula Espinal/epidemiología , Adolescente , Malformación de Arnold-Chiari/complicaciones , Estudios de Casos y Controles , Vértebras Cervicales/diagnóstico por imagen , Niño , Bases de Datos Factuales/estadística & datos numéricos , Femenino , Humanos , Masculino , Prevalencia , Radiografía , Factores de Riesgo , Médula Espinal/diagnóstico por imagen , Traumatismos de la Médula Espinal/etiologíaRESUMEN
BACKGROUND: Studies of pedal cyclist injuries have largely focused on individual injury categories, but every region of the cyclist's body is exposed to potential trauma. Real-world injury patterns can be complex, and isolated injuries to one body part are uncommon among casualties requiring hospitalization. Latent class analysis (LCA) may identify important patterns in heterogeneous samples of qualitative data. METHODS: Data were taken from the Trauma Quality Improvement Program of the American College of Surgeons for 2017. Inclusion criteria were age 18 years or less and an external cause of injury code for pedal cyclist. Injuries were characterized by Abbreviated Injury Scale codes. Injury categories and the total number of injuries served as covariates for LCA. A model was selected on the basis of the Akaike and Bayesian information criteria and the interpretability of the classes. Associations were analyzed between class membership and demographic factors, circumstantial factors, metrics of injury severity, and helmet wear. Within-class associations of helmet wear with injury severity were analyzed as well. RESULTS: There were 6151 injured pediatric pedal cyclists in the study sample. The mortality rate was 0.5%. The rate of helmet wear was 18%. LCA yielded a model with 6 classes: 'polytrauma' (5.5%), 'brain' (9.0%), 'abdomen' (11.0%), 'upper limb' (20.9%), 'lower limb' (12.4%), and 'head' (41.2%). Class membership had highly significant univariate associations with all covariates except insurance payer. Helmet wear was most common in the 'abdomen' class and least common in the 'polytrauma' and 'brain' classes. Within classes, there was no association of helmet wear with severity of injury. CONCLUSIONS: LCA identified 6 clear and distinct patterns of injury with varying demographic and circumstantial associations that may be relevant for prevention. The rate of helmet wear was low, but it varied among classes in accordance with mechanistic expectations. LCA may be an underutilized tool in trauma epidemiology.
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BACKGROUND: Military neurosurgeons have long known that tangential cranial gunshot wounds can be associated with intracranial complications out of proportion to the external appearance of the injury. This phenomenon seems not to have been described in infancy. OBSERVATIONS: An infant suffered a massive, acute subdural hemorrhage from a contralateral tangential gunshot wound that did not facture the skull. LESSONS: Similar to adults, infants are subject to catastrophic intracranial injury from gunshots that do not penetrate the skull. The nature of the injury in this case reflected distinctive aspects of the tissue characteristics and proportions of the infant head.
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INTRODUCTION: The use of the emergency department (ED) has been increasing, and many visits occur for non-urgent conditions. A similar trend was found among adult visits to the ED for ocular conditions. In this study we analyzed the impact of sociodemographic factors, presentation timing, and the COVID-19 pandemic on pediatric ED (PED) encounters for ophthalmologic conditions. It is important to identify the multifold factors associated with overutilization of the ED for non-urgent conditions. Caring for these patients in an outpatient clinical setting is safe and effective and could decrease ED crowding; it would also prevent delays in the care of other patients with more urgent medical problems and lower healthcare costs. METHODS: We retrospectively reviewed electronic health records of PED ocular-related encounters at two children's hospitals before (January 2014-May 2018) and during the COVID-19 pandemic (March 2020-February 2021). Encounters were categorized based on the International Classification of Diseases codes into "emergent," "urgent," and non-urgent" groups. We analyzed associations between sociodemographic factors and degrees of visit urgency. We also compared visit frequencies, degrees of urgency, and diagnoses between pre-pandemic and pandemic data. RESULTS: Pre-pandemic ocular-related PED encounters averaged 1,738 per year. There were highly significant sociodemographic associations with degrees of urgency in PED utilization. During the 12-month pandemic timeframe, encounter frequency contracted to 183. Emergent visits decreased from 21% to 11%, while the proportions of urgent and non-urgent encounters were mostly unchanged. The most common pre-pandemic urgent diagnosis was corneal abrasion (50%), while visual disturbance was most common during the pandemic (92%). During both time periods, eye trauma was the most frequent emergent encounter and conjunctivitis was the most common non-urgent encounter. CONCLUSION: Sociodemographic factors may be associated with different types of PED utilization for ocular conditions. Unnecessary visits constitute major inefficiency from a healthcare-systems standpoint. The marked decrease in PED utilization and differing proportions of ocular conditions encountered during the pandemic may reflect a decrease in incidence of many of those conditions by social distancing; these changes may also reflect altered parental decisions about seeking care.
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COVID-19 , Adulto , COVID-19/epidemiología , Niño , Servicio de Urgencia en Hospital , Hospitales Pediátricos , Humanos , Pandemias , Estudios RetrospectivosRESUMEN
Ictal urinary urge is a rare symptom of focal epilepsy usually localising to the non-dominant hemisphere, specifically, the temporal lobe. Lateralisation in previously described cases has been established using scalp video-EEG monitoring or functional imaging. We report the case of a 19-year-old girl with refractory epilepsy and ictal urinary urge arising from the non-dominant temporal lobe, confirmed by invasive, subdural EEG monitoring. Since undergoing a temporal lobectomy two and a half years ago, the patient has not experienced ictal urinary urge. To our knowledge, this is the first report demonstrating localisation of ictal urinary urge epileptogenic zone to the non-dominant temporal lobe by invasive intracranial monitoring.
Asunto(s)
Electroencefalografía , Convulsiones/complicaciones , Convulsiones/fisiopatología , Lóbulo Temporal/fisiopatología , Incontinencia Urinaria de Urgencia/etiología , Incontinencia Urinaria de Urgencia/fisiopatología , Dominancia Cerebral , Epilepsias Parciales/complicaciones , Epilepsias Parciales/cirugía , Femenino , Lateralidad Funcional/fisiología , Humanos , Imagen por Resonancia Magnética , Magnetoencefalografía , Procedimientos Neuroquirúrgicos , Convulsiones/cirugía , Cirugía Asistida por Computador , Lóbulo Temporal/cirugía , Adulto JovenRESUMEN
BACKGROUND: In the United States social disparities in health outcomes are found wherever they are sought, and they have been documented extensively in trauma care. Because social factors cannot cause a trauma outcome directly, there must exist mediating causal factors related to the nature and severity of the injury, the robustness of the victim, access to care, or processes of care. An understanding these mediators is the point of departure for addressing inequities in outcomes. FINDINGS: Data were extracted from the registry of the Trauma Quality Improvement Program of the American College of Surgeons for 2007 through 2010. Inclusion criteria were age less than 19 years and head Abbreviated Injury Scale score of 4, 5, or 6. An Oaxaca-Blinder decomposition was undertaken to analyze the relative contributions of a large set of covariates to the difference in mortality rates between Black and White children. Covariates were aggregated into the following categories: "Severity," "Structure and Process," "Mechanism," "Demographics," and "Insurance." Eligible for analysis were 7273 White children and 2320 Black children. There were 1661 deaths (17.3%) The raw mortality rates were 15.6 and 22.8% for White and Black children, respectively. Factors categorized as "Severity" accounted for 95% of the mortality difference, "Mechanism" accounted for 13%, "Insurance" accounted for 5%, and "Demographics" accounted for 2%. The contribution of "Structure and Process" did not attain statistical significance. CONCLUSIONS: Severity of injury accounts for most of the disparity between Black and White children in traumatic brain injury mortality rates. Mechanism, insurance status, and gender make a small contributions. Because insurance status like other social factors cannot directly affect trauma survival, what mediates its contribution requires further study.