Outcomes of laparoscopic and open ventriculoperitoneal shunt placement.

OBJECTIVE: Ventriculoperitoneal (VP) shunt placement requires a concurrent abdominal procedure. For peritoneal access laparoscopic or open approach may be utilized. Our aim was to compare patient/procedure characteristics and outcomes by peritoneal approach for VP shunts in children. METHODS: NSQIP-Pediatric procedure targeted cerebral spinal fluid shunt Participant Use Data Files from 2016 to 2020 were queried. Patients were grouped into laparoscopic vs open abdominal approach. Patient demographics, procedure characteristics and 30-day outcomes were compared. RESULTS: 7742 NSQIP-Pediatric patients underwent VP shunt placement. Patients undergoing laparoscopic approach were older and required less preoperative support. Mean operative time was longer with laparoscopy (mean(SD): 74.2(48.1) vs. 64.6(39) minutes, p â€‹< â€‹0.0001) but had shorter hospital LOS. There was no difference in SSI, readmissions, or reoperation rates. CONCLUSION: Patients undergoing laparoscopy for distal VP shunts are older with less support needs preoperatively. While laparoscopic approach had a shorter hospital LOS, there was no demonstratable difference in SSI, readmissions or reoperations between approaches. Further studies are needed to assess long-term outcomes.

Endoscopic Third Ventriculostomy and Endoscopic Intracranial Cyst Fenestration in an Outpatient Ambulatory Surgery Center Yields Reduced Cost But Equal Efficacy and Safety Compared with Surgery in the Hospital.

BACKGROUND: A transition is underway in neurosurgery to perform relatively safe surgeries outpatient, often at ambulatory surgery centers (ASC). We sought to evaluate whether simple intracranial endoscopic procedures such as third ventriculostomy and cyst fenestration can be safely and effectively performed at an ASC, while comparing costs with the hospital. METHODS: A retrospective chart review was performed for patients who underwent elective intracranial neuroendoscopic (NE) intervention at either a quaternary hospital or an affiliated ASC between August 2014 and September 2017. Groups were compared on length of stay, perioperative and 30-day morbidity, as well as clinical outcome at last follow-up. The total cost for these procedures were compared in relative units between all ASC cases and a small subset of hospital cases. RESULTS: In total, 16 NE operations performed at the ASC (mean patient age 29.8 years) and 37 at the hospital (mean age 15.4 years) with average length of stay of 3.5 hours and 23.1 hours respectively (P < 0.05). There were no acute complications in either cohort or morbid events requiring hospitalization within 30 days. Surgical success was noted for 75% of the ASC patients and 73% of the hospital cohort. The mean cost of 5 randomly selected hospital operations with same-day discharge and 5 with overnight stay was 3.4 and 4.1 times that of the ASC cohort, respectively (P < 0.05). CONCLUSIONS: Elective endoscopic third ventriculostomy and other simple NE procedures can be safely and effectively performed at an ASC for appropriate patients with significantly reduced cost compared with the hospital.

A pediatric carotid body tumor.

Carotid body tumors are rare childhood extra-adrenal paragangliomas. We present an 8-year old female with a neck mass mistaken as reactive lymphadenopathy. Computed tomography and magnetic resonance angiography, as well as preoperative embolization and balloon test occlusion, were utilized for planning and management. Surgical excision of the tumor was successful and pathological examination revealed a benign paraganglioma. Surgical treatment is curative for these benign lesions, however rare cases have presented years later with metastatic disease. Therefore, a child, like our patient, will require lifelong surveillance for the development of potential metastasis.

Economic benefit of carpal tunnel release in the Medicare patient population.

OBJECTIVE The epidemiology of carpal tunnel syndrome (CTS) has been extensively researched. However, data describing the economic burden of CTS is limited. The purpose of this study was to quantify the disease burden of CTS and determine the economic benefit of its surgical management. METHODS The authors utilized the PearlDiver database to identify the number of individuals with CTS in the Medicare patient population, and then utilized CPT codes to identify which individuals underwent surgical management. These data were used to calculate the total number of disability-adjusted life years (DALYs) associated with CTS. A human capital approach was employed and gross national income per capita was used to calculate the economic burden. RESULTS From 2005 to 2012 there were 1,500,603 individuals identified in the Medicare patient population with the diagnosis of CTS. Without conservative or surgical management, this results in 804,113 DALYs without age weighting and discounting, and 450,235 DALYs with age weighting and a discount rate of 3%. This amounts to between $21.8 and $39 billion in total economic burden, or $2.7-$4.8 billion per year. Surgical management of CTS has resulted in the aversion of 173,000-309,000 DALYs. This has yielded between $780 million and $1.6 billion in economic benefit per year. Endoscopic carpal tunnel release provided between $11,683 and $23,186 per patient at 100% success while open carpal tunnel release provided between $10,711 and $22,132 per patient at 100% success. The benefit-cost ratio at its most conservative is 2.7:1, yet could be as high as 6.9:1. CONCLUSIONS CTS is prevalent in the Medicare patient population, and is associated with a large amount of economic burden. The surgical management of CTS leads to a large reduction in this burden, yielding extraordinary economic benefit.

Vertebral Artery Dissection in a Bouncy Castle Injury: Case Report and Literature Review.

There is an increased rate of injuries associated with activities on bouncy castles. The purpose of this article was to describe the case of a 6-year-old boy who sustained a brain infarct as a consequence of a left posterior inferior cerebellar artery dissection due to improper landing in a bouncy castle and who required a suboccipital craniotomy. The second goal was to outline the literature review regarding cervical trauma related to trampoline or bouncy castle accidents in pediatric populations. Based on the described case and reviewed studies, bouncy castle or any other activity resulting in hyperflexion or hyperextension of the neck should be carefully evaluated for cervical spine fractures and vascular injuries.

Episodic ventriculomegaly due to hypernatremia mimicking shunt malfunction: case report.

Patients with shunted hydrocephalus presenting with altered mental status and ventriculomegaly are generally considered to be in shunt failure requiring surgical treatment. The authors describe a case of shunted hydrocephalus secondary to a disseminated neuroectodermal tumor in a pediatric patient in whom rapid fluctuations in sodium levels due to diabetes insipidus repeatedly led to significant changes in ventricle size, with invasively confirmed normal shunt function and low intracranial pressure. This clinical picture exactly mimics shunt malfunction, requires urgent nonsurgical therapy, and underscores the importance of considering serum osmolar abnormalities in the differential diagnosis for ventriculomegaly.

The comparative effectiveness of ventricular shunt placement versus endoscopic third ventriculostomy for initial treatment of hydrocephalus in infants.

OBJECT: The purpose of this study was to compare the effectiveness of CSF diversion with endoscopic third ventriculostomy (ETV) versus shunt therapy in infants with hydrocephalus. METHODS: The authors conducted a retrospective analysis of 5416 infants 1 year of age or younger with hydrocephalus (congenital or acquired) in whom CSF diversion was performed using either ETV or shunt placement at 41 children's hospitals between 2004 and 2009. Data were obtained from the Pediatric Health Information Systems database. Surgical failure was defined as the need for a repeat diversion operation within 1 year of initial surgery. The authors compared failure rates of ETV and shunt, as well as patient demographics and clinical characteristics, using hierarchical regression according to treatment group. RESULTS: During the period examined, 872 infants (16.1%) initially underwent ETV and 4544 (83.9%) underwent ventricular shunt placement. The median infant age was 37 days (IQR 11-122 days) for both ETV and shunt placement. More infants who underwent ETV rather than shunt placement were born prematurely (41.6% vs 23.9%, respectively; p < 0.01) and had intraventricular hemorrhage (45.4% vs 17.5%, respectively; p < 0.01). Higher operative failure rates at 1 year were observed in infants who underwent ETV as opposed to shunt surgery (64.5% vs 39.6%, respectively; OR 2.9 [95% CI 2.3-3.5], p < 0.01). After controlling for prematurity, intraventricular hemorrhage, and spina bifida, ETV remained associated with a higher risk of failure (OR 2.6 [95% CI 2.1-3.2]). CONCLUSIONS: In infants with hydrocephalus, a greater 1-year CSF diversion failure rate may occur after ETV compared with shunt placement. This risk is most significant for procedures performed within the first 90 days of life. Further investigation of the need for multiple reoperations, cost, and impact of surgeon and hospital experience is necessary to distinguish which treatment is more effective in the long term.

Risk factors of sudden death in young adult patients with myelomeningocele.

OBJECT: Although survival for patients with myelomeningocele has dramatically improved in recent decades, the occasional occurrence of sudden, unexplained death in young adult patients with myelomeningocele has been noted by the authors. This study was undertaken to determine risk factors for sudden death in this population. METHODS: The authors performed a retrospective chart review of patients born between 1978 and 1990 who received care at Children's Hospital Boston. The relationship between sudden death and patient demographics, presence of CSF shunt and history of shunt revisions, midbrain length as a marker for severity of hindbrain malformation, seizures, pulmonary and ventilatory dysfunction, body mass index, scoliosis, renal dysfunction, and cardiac disease was evaluated using the t-test, Fisher exact test, and logistic regression analysis. RESULTS: The age range for 106 patients in the study cohort was 19-30 years, with 58 (54.7%) women and 48 (45.3%) men. Six patients, all of whom were young women, experienced sudden death. In multivariate analysis, female sex, sleep apnea, and midbrain elongation ≥ 15 mm on MR imaging remained significantly associated with a higher risk of sudden death. These risk factors were cumulative, and female patients with sleep apnea and midbrain length ≥ 15 mm had the greatest risk (adjusted risk ratio 24.0, 95% CI 7.3-79.0; p < 0.05). No other comorbidities were found to significantly increase the risk of sudden death. CONCLUSIONS: Young adult women with myelomeningocele are at significantly increased risk of sudden death in the setting of midbrain elongation and sleep apnea. Further investigation is needed to determine the benefit of routine screening to identify at-risk patients for closer cardiopulmonary monitoring and treatment.

Estrogen receptor beta isoforms exhibit differences in ligand-activated transcriptional activity in an estrogen response element sequence-dependent manner.

Estrogen receptor beta (ERbeta) has been reported to have lower estradiol (E2)-induced transcriptional activity than human (h)ERalpha from estrogen response element (ERE)-driven reporters in transiently transfected cells. Conflicting data for activities of full-length and short hERbeta [hERbeta1, 530 amino acids (aa); and hERbeta1s, 477aa] have been reported. To test the hypothesis that hERbeta1 has higher transcriptional activity than hERbeta1s, we compared E2, 2,3-bis(4-hydroxyphenyl)propionitrile (a selective ERbeta agonist), and resveratrol-induced transcription by hERbeta1, hERbeta1s, and rat (r) ERbeta with hERalpha on different EREs in transiently transfected CHO-K1 and HEC-1A cells. Our results demonstrate for the first time that hERbeta1 has similar E2-induced activity to hERalpha and greater activity than rERbeta or hERbeta1s on a consensus palindromic ERE, either as a single or double copy; a minimal ERE; and the nonpalindromic pS2 ERE. 2,3-Bis(4-hydroxyphenyl)propionitrile showed greater efficacy with hERbeta1 and hERbeta1s than for rERbeta or hERalpha. We found that transcriptional differences between the ERbeta isoforms and ERalpha depend on the ERE sequence, confirming that the DNA sequence bound by ER is an allosteric effector of ER action. For the minimal 13-bp ERE and the pS2 ERE, the increase in transcriptional activity with hERbeta1 correlated with increased binding affinity. Coactivators steroid receptor coactivator-1 and cAMP response element binding protein-binding protein synergistically activated hERalpha and ERbeta transcription and showed reduced efficacy with rERbeta and hERbeta1s, suggesting a role for the N terminus of ERbeta1 in coactivator interaction. Collectively, these data indicate that the cellular expression of ERbeta isoforms may differentially impact ERE-regulated target gene expression in a ligand-dependent manner.

The agonist activity of tamoxifen is inhibited by the short heterodimer partner orphan nuclear receptor in human endometrial cancer cells.

Short heterodimer partner (SHP) is an orphan nuclear receptor that interacts with ER(alpha) and ERbeta and inhibits E2-induced transcription. We examined how SHP affects tamoxifen's estrogen agonist activity in endometrial cells. We report that SHP interacts with 4-hydroxytamoxifen (4-OHT) or E2-occupied ER(alpha) in a temperature-dependent manner in vitro. In transient transfection assays, SHP inhibited 4-OHT-stimulated reporter gene activity from an estrogen response element (ERE) in ER-positive RL95-2 but not in HEC-1A human endometrial carcinoma cells transfected with ER(alpha) or ERbeta. SHP inhibited E2-induced transcriptional activity in ER(alpha)- or ERbeta-transfected HEC-1A or Chinese hamster ovary-K1 cells. SHP inhibition of E2 activity was greater for ER(alpha) than ERbeta from the nonpalindromic ERE in the pS2 gene promoter in Chinese hamster ovary-K1 but not HEC-1A cells. Thus, ER subtype, cell type, and ERE sequence influence SHP repressor activity. An ER(alpha) mutant lacking activator function-1 showed reduced inhibition by SHP. In glutathione S-transferase pull-down experiments, SHP inhibited ER(alpha) dimerization, providing a possible mechanism to account for the inhibitory effect of SHP on ER activity. These results identify SHP as novel target for blocking 4-OHT agonist activity in endometrial cells.