Frequency and predictors of complication clustering within 30 days of spinal fusion surgery: a study of children with neuromuscular scoliosis.

PURPOSE: There is limited information on the clustering or co-occurrence of complications after spinal fusion surgery for neuromuscular disease in children. We aimed to identify the frequency and predictive factors of co-occurring perioperative complications in these children. METHODS: In this retrospective database cohort study, we identified children (ages 10-18 years) with neuromuscular scoliosis who underwent elective spinal fusion in 2012-2020 from the National Surgical Quality Improvement Program-Pediatric database. The rates of co-occurring complications within 30 days were calculated, and associated factors were identified by logistic regression analysis. Correlation between a number of complications and outcomes was assessed. RESULTS: Approximately 11% (709/6677 children with neuromuscular scoliosis undergoing spinal fusion had co-occurring complications: 7% experienced two complications and 4% experienced ≥ 3. The most common complication was bleeding/transfusion (80%), which most frequently co-occurred with pneumonia (24%) and reintubation (18%). Surgical time ≥ 400 min (odds ratio (OR) 1.49 [95% confidence interval (CI) 1.25-1.75]), fusion ≥ 13 levels (1.42 [1.13-1.79]), and pelvic fixation (OR 1.21 [1.01, 1.44]) were identified as procedural factors that independently predicted concurrent complications. Clinical risk factors for co-occurring complications included an American Society of Anesthesiologist physical status classification ≥ 3 (1.73 [1.27-2.37]), structural pulmonary/airway abnormalities (1.24 [1.01-1.52]), impaired cognitive status (1.80 [1.41-2.30]), seizure disorder (1.36 [1.12-1.67]), hematologic disorder (1.40 [1.03-1.91], preoperative nutritional support (1.34 [1.08-1.72]), and congenital malformations (1.20 [1.01-1.44]). Preoperative tracheostomy was protective against concurrent complications (0.62 [0.43-0.89]). Significant correlations were found between number of complications and length of stay, non-home discharge, readmissions, and death. CONCLUSION: Longer surgical time (≥ 400 min), fusion ≥ 13 levels and pelvic fixation are surgical risk factors independently associated with co-occurring complications, which were associated with poorer patient outcomes. Recognizing identified nonmodifiable risk factors might also be important for preoperative planning and risk stratification of children with neuromuscular scoliosis requiring spinal fusion. LEVEL OF EVIDENCE: Level IV evidence.

Morphological and ultrastructural investigation of the posterior atlanto-occipital membrane: Comparing children with Chiari malformation type I and controls.

INTRODUCTION: The fibrous posterior atlanto-occipital membrane (PAOM) at the craniocervical junction is typically removed during decompression surgery for Chiari malformation type I (CM-I); however, its importance and ultrastructural architecture have not been investigated in children. We hypothesized that there are structural differences in the PAOM of patients with CM-I and those without. METHODS: In this prospective study, blinded pathological analysis was performed on PAOM specimens from children who had surgery for CM-I and children who had surgery for posterior fossa tumors (controls). Clinical and radiographic data were collected. Statistical analysis included comparisons between the CM-I and control cohorts and correlations with imaging measures. RESULTS: A total of 35 children (mean age at surgery 10.7 years; 94.3% white) with viable specimens for evaluation were enrolled: 24 with CM-I and 11 controls. There were no statistical demographic differences between the two cohorts. Four children had a family history of CM-I and five had a syndromic condition. The cohorts had similar measurements of tonsillar descent, syringomyelia, basion to C2, and condylar-to-C2 vertical axis (all p>0.05). The clival-axial angle was lower in patients with CM-I (138.1 vs. 149.3 degrees, p = 0.016). Morphologically, the PAOM demonstrated statistically higher proportions of disorganized architecture in patients with CM-I (75.0% vs. 36.4%, p = 0.012). There were no differences in PAOM fat, elastin, or collagen percentages overall and no differences in imaging or ultrastructural findings between male and female patients. Posterior fossa volume was lower in children with CM-I (163,234 mm3 vs. 218,305 mm3, p<0.001), a difference that persisted after normalizing for patient height (129.9 vs. 160.9, p = 0.028). CONCLUSIONS: In patients with CM-I, the PAOM demonstrates disorganized architecture compared with that of control patients. This likely represents an anatomic adaptation in the presence of CM-I rather than a pathologic contribution.

Frequency and predictors of concurrent complications in multi-suture release for syndromic craniosynostosis.

PURPOSE: Understanding the complication profile of craniosynostosis surgery is important, yet little is known about complication co-occurrence in syndromic children after multi-suture craniosynostosis surgery. We examined concurrent perioperative complications and predictive factors in this population. METHODS: In this retrospective cohort study, children with syndromic diagnoses and multi-suture involvement who underwent craniosynostosis surgery in 2012-2020 were identified from the National Surgical Quality Improvement Program-Pediatric database. The primary outcome was concurrent complications; factors associated with concurrent complications were identified. Correlations between complications and patient outcomes were assessed. RESULTS: Among 5,848 children identified, 161 children (2.75%) had concurrent complications: 129 (2.21%) experienced two complications and 32 (0.55%) experienced ≥ 3. The most frequent complication was bleeding/transfusion (69.53%). The most common concurrent complications were transfusion/superficial infection (27.95%) and transfusion/deep incisional infection (13.04%) or transfusion/sepsis (13.04%). Two cardiac factors (major cardiac risk factors (odds ratio (OR) 3.50 [1.92-6.38]) and previous cardiac surgery (OR 4.87 [2.36-10.04])), two pulmonary factors (preoperative ventilator dependence (OR 3.27 [1.16-9.21]) and structural pulmonary/airway abnormalities (OR 2.89 [2.05-4.08])), and preoperative nutritional support (OR 4.05 [2.34-7.01]) were independently associated with concurrent complications. Children who received blood transfusion had higher odds of deep surgical site infection (OR 4.62 [1.08-19.73]; p = 0.04). CONCLUSIONS: Our results indicate that several cardiac and pulmonary risk factors, along with preoperative nutritional support, were independently associated with concurrent complications but procedural factors were not. This information can help inform presurgical counseling and preoperative risk stratification in this population.

How do children fare compared with adults? Comparing relative outcomes after thrombectomy for acute ischemic stroke due to large-vessel occlusion.

OBJECTIVE: Safety and efficacy data for endovascular thrombectomy for acute ischemic stroke secondary to large-vessel occlusion in children are lacking compared with those for adults. We undertook an updated systematic review and meta-analysis of endovascular thrombectomy in children and compared their outcomes with adult data. METHODS: We searched PubMed, Medline, and EMBASE databases to identify prospective and retrospective studies describing patients <18 years treated with endovascular thrombectomy for acute ischemic stroke due to large-vessel occlusion. RESULTS: Eight pediatric studies were included (n = 192). Most patients were male (53.1 %), experienced anterior circulation large-vessel occlusion (81.8 %), and underwent endovascular thrombectomy by stent retreiver (70.7 %). The primary outcome was change in National Institutes of Health Stroke Scale score from presentation to 24 h after thrombectomy. Secondary outcomes included modified Rankin scale score improvement and 90-day score, recanalization rates, procedural complications, and mortality rates. After treatment, 88.5% of children had successful recanalization; the mean National Institutes of Health Stroke Scale score reduction was 7.37 (95 % CI 5.11-9.63, p < 0.01). The mean reduction of 6.87 (95 %CI 5.00-8.73, p < 0.01) for adults in 5 clinical trials (n = 634) was similar (Qb = 0.11; p = 0.74). Children experienced higher rates of good neurological outcome (76.1 % vs. 46.0 %, p < 0.01) and revascularization (88.5 % vs. 72.3 %, p < 0.01), fewer major periprocedural complications (3.6 % vs. 30.4 %, p < 0.01), and lower mortality (1.0 % vs. 12.9 %, p < 0.01). CONCLUSIONS: Endovascular thrombectomy may be safe and effective treatment for acute ischemic stroke due to large-vessel occlusion in children. The aggregated data demonstrated high rates of revascularization, favorable long-term neurological outcomes, and low complication rates.

Large saccular intracranial aneurysm in a child with RASA1-associated capillary malformation-arteriovenous malformation syndrome: illustrative case.

BACKGROUND: Large cerebral aneurysms are much less common in children than in adults. Thus, when present, these lesions require careful surgical evaluation and comprehensive genetic testing. RASA1-associated capillary malformation-arteriovenous malformation (RASA1-CM-AVM) syndrome is a rare disorder of angiogenic remodeling known to cause port-wine stains and arteriovenous fistulas but not previously associated with pediatric aneurysms. OBSERVATIONS: The authors report the case of a previously healthy 6-year-old boy who presented with seizure-like activity. Imaging demonstrated a lesion in the right ambient cistern with compression of the temporal lobe. Imaging characteristics were suggestive of a thrombosed aneurysm versus an epidermoid cyst. The patient underwent craniotomy, revealing a large saccular aneurysm, and clip ligation and excision were performed. Postoperative genetic analysis revealed a RASA1-CM-AVM syndrome. LESSONS: This is a rare case of a RASA1-associated pediatric cerebral aneurysm in the neurosurgical literature. This unique case highlights the need for maintaining a broad differential diagnosis as well as the utility of genetic testing for detecting underlying genetic syndromes in young children presenting with cerebral aneurysms.

Effect of Fusion and Arthroplasty for Cervical Degenerative Disc Disease in Active Duty Service Members Performed at an Overseas Military Treatment Facility: A 2-Year Retrospective Analysis.

INTRODUCTION: Among U.S. military active duty service members, cervicalgia, cervical radiculopathy, and myelopathy are common causes of disability, effecting job performance and readiness, often leading to medical separation from the military. Among surgical therapies, anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are options in select cases; however, elective surgeries performed while serving overseas (OCONUS) have not been studied. MATERIALS AND METHODS: A retrospective analysis of a prospectively collected surgical database from an OCONUS military treatment facility over a 2-year period (2019-2021) was queried. Patient and procedural data were collected to include ACDF or CDA surgery, military rank, age, tobacco use, pre- and post-operative visual analogue scales for pain, and presence of radiographic fusion after surgery for ACDF patients or heterotopic ossification for CDA patients. Chi-square and Student t-test analyses were performed to identify variables associated with return to full duty. RESULTS: A total of 47 patients (25 ACDF and 22 CDA) underwent surgery with an average follow-up of 192.1 days (range 7-819 days). Forty-one (87.2%) patients were able to return to duty without restrictions; 10.6% of patients remained on partial or limited duty at latest follow-up and one patient was medically separated from the surgical cohort. There was one complication and one patient required tour curtailment from overseas duty for ongoing symptoms. CONCLUSIONS: Both ACDF and CDA are effective and safe surgical procedures for active duty patients with cervicalgia, cervical radiculopathy, and cervical myelopathy. They can be performed OCONUS with minimal interruption to the patient, their family, and the military unit, while helping to maintain surgical readiness for the surgeon and the military treatment facility.

Craniotomies at an overseas military treatment facility: Maintaining readiness for the unit and the surgeon.

INTRODUCTION: Craniotomy and craniectomy are common neurosurgical procedures with wide applications in both civilian and military practice. Skill maintenance for these procedures is required for military providers in the event they are called to support forward deployed service members suffering from combat and non-combat injuries. The presents investigation details the performance of such procedures at a small, overseas military treatment facility (MTF). MATERIALS AND METHODS: A retrospective review of craniotomy procedures performed at an overseas military treatment facility (MTF) over a 2-year period (2019-2021) was performed. Patient and procedural data were collected for all elective and emergent craniotomies including surgical indications, outcomes, complications, military rank, and impact on duty status and tour curtailment. RESULTS: A total of 11 patients underwent a craniotomy or craniectomy procedure with an average follow-up of 496.8 days (range 103-797). Seven of the 11 patients were able to undergo surgery, recovery, and convalesce without transfer to a larger hospital network or MTF. Of the 6 patients that were active duty (AD), one returned to full duty while three separated and two remain in partial duty status at latest follow-up. There were four complications in four patients with one death. CONCLUSIONS: In this series, we demonstrate that cranial neurosurgical procedures can be performed safely and effectively while at an overseas MTF. There are potential benefits to the AD service members, their unit, and family as well as to the hospital treatment team and surgeon as this represents a clinical capability requisite to maintain trauma readiness for future conflicts.

An Initial Experience of Completion Hemispherotomy via Magnetic Resonance-Guided Laser Interstitial Therapy.

INTRODUCTION: In carefully selected patients with medically refractory epilepsy, disconnective hemispherotomy can result in significant seizure freedom; however, incomplete disconnection can result in ongoing seizures and poses a significant challenge. Completion hemispherotomy provides an opportunity to finish the disconnection. We describe the use of magnetic resonance-guided laser interstitial thermal ablation (MRgLITT) for completion hemispherotomy. METHODS: Patients treated with completion hemispherotomy using MRgLITT at our institution were identified. Procedural and seizure outcomes were evaluated retrospectively. RESULTS: Five patients (3 males) underwent six MRgLITT procedures (one child treated twice) for completion hemispherotomy at a median age of 6 years (range 1.8-12.9). Two children had hemimegalencephaly, two had Rasmussen encephalitis, and one had polymicrogyria. All five children had persistent seizures likely secondary to incomplete disconnection after their functional hemispherotomy. The mean time from open hemispherotomy to MRgLITT was 569.5 ± 272.4 days (median 424, range 342-1,095). One patient underwent stereoelectroencephalography before MRgLITT. The mean number of ablation targets was 2.3 ± 0.47 (median 2, range 2-3). The mean length of the procedure was 373 min ± 68.9 (median 374, range 246-475). Four of the five patients were afforded improvement in their neurocognitive functioning and speech performance after ablation, with mean daily seizure frequency at 1 year of 1.03 ± 1.98 (median 0, range 0-5). Two patients achieved Engel Class I outcomes at 1 year after ablation, one was Engel Class III, and two were Engel Class IV. The mean follow-up time was 646.8 ± 179.5 days (median 634, range 384-918). No MRgLITT-related complications occurred. Delayed retreatment (>1 year) occurred in three patients: one child underwent redo ablation and two underwent anatomic hemispherectomy. CONCLUSION: We have demonstrated the feasibility of a minimally invasive approach for completion hemispherotomy using MRgLITT. Delayed retreatment was needed in three patients; thus, further study of this technique with comparison to other surgical techniques is warranted.

Scaling up community-delivered mental health support and care: A landscape analysis.

Introduction: The mental health crisis has caused widespread suffering and has been further exacerbated by the COVID-19 pandemic. Marginalized groups are especially affected, with many concerns rooted in social determinants of mental health. To stem this tide of suffering, consideration of approaches outside the traditional biomedical model will be necessary. Drawing from task-sharing models of mental health care that have been pioneered in low-resource settings, community-initiated care (CIC) represents a potentially promising collection of approaches. This landscape analysis seeks to identify examples of CIC that have been implemented outside of the research context, with the aim of identifying barriers and facilitators of scale up. Methods: A narrative review approach was used for this landscape analysis in which the PubMed database was searched and further supplemented with Google Scholar. Promising programs were then discussed over multiple rounds of meetings with the research team, consisting of collaborators with varied experiences in mental health. Using the selection criteria and feedback derived from group meetings, a final list of programs was identified and summarized according to common characteristics and features. Results: The initial PubMed search yielded 16 results, supplemented by review of the first 100 entries in Google Scholar. Through 5 follow-up meetings among team members, consensus was reached on a final list of 9 programs, which were grouped into three categories based on similar themes and topics: (1) approaches for the delivery of psychosocial interventions; (2) public health and integrative approaches to mental health; and (3) approaches for addressing youth mental health. Key facilitators to scale up included the importance of sustainable financing and human resources, addressing social determinants and stigma, engaging diverse stakeholders, leveraging existing health infrastructure, using sustainable training models, ensuring cultural relevance and appropriateness, and leveraging digital technologies. Discussion: This landscape analysis, though not an exhaustive summary of the literature, describes promising examples of efforts to scale up CIC outside of the research context. Going forward, it will be necessary to mobilize stakeholders at the community, health system, and government levels to effectively promote CIC.

A history of neurosurgical capabilities in the United States Pacific Command: from World War II to present.

Neurosurgery has benefited from innovations as a result of military conflict. The volume and complexity of injuries sustained on the battlefield require medical teams to triage, innovate, and practice beyond their capabilities in order to treat wartime injuries. The neurosurgeons who practiced in the Pacific Command (PACOM) during World War II, the Korean War, and the War in Vietnam built upon field operating room knowledge and influenced the logistics of treating battle-injured patients in far-forward environments. Modern-day battles are held on new terrain, and the military neurosurgeon must adapt. War in the PACOM uniquely presented significant obstacles due to geographic isolation, ultimately accelerating the growth and adaptability of military neurosurgery and medical evacuation. The advancements in infrastructure and resource mobilization made during PACOM conflicts continue to inform modern-day practices and provide insight for future conflicts. In this historical article, the authors review the development and evolution of neurosurgical care, forward surgical teams, and mobile field hospitals with surgical capabilities through US conflicts in the PACOM.

Attitudes Toward Neurosurgery Education for the Nonneurosurgeon: A Survey Study and Critical Analysis of U.S. Military Training Techniques and Future Prospects.

BACKGROUND: The U.S. military requires medical readiness to support forward-deployed combat operations. Because time and distance to neurosurgical capabilities vary within the deployed trauma system, nonneurosurgeons are required to perform emergent cranial procedures in select cases. It is unclear whether these surgeons have sufficient training in these procedures. METHODS: This quality-improvement study involved a voluntary, anonymized specialty-specific survey of active-duty surgeons about their experience and attitudes toward U.S. military emergency neurosurgical training. RESULTS: Survey responses were received from 104 general surgeons and 26 neurosurgeons. Among general surgeons, 81% have deployed and 53% received training in emergency neurosurgical procedures before deployment. Only 16% of general surgeons reported participating in craniotomy/craniectomy procedures in the last year. Nine general surgeons reported performing an emergency neurosurgical procedure while on deployment/humanitarian mission, and 87% of respondents expressed interest in further predeployment emergency neurosurgery training. Among neurosurgeons, 81% had participated in training nonneurosurgeons and 73% believe that more comprehensive training for nonneurosurgeons before deployment is needed. General surgeons proposed lower procedure minimums for competency for external ventricular drain placement and craniotomy/craniectomy than did neurosurgeons. Only 37% of general surgeons had used mixed/augmented reality in any capacity previously; for combat procedures, most (90%) would prefer using synchronous supervision via high-fidelity video teleconferencing over mixed reality. CONCLUSIONS: These survey results show a gap in readiness for neurosurgical procedures for forward-deployed general surgeons. Capitalizing on capabilities such as mixed/augmented reality would be a force multiplier and a potential means of improving neurosurgical capabilities in the forward-deployed environments.

Integrating hypertension and HIV care in Namibia: A quality improvement collaborative approach.

BACKGROUND: Hypertension (HTN) is highly prevalent among people with HIV (PWH) in Namibia, but screening and treatment for HTN are not routinely offered as part of HIV care delivery. We report the implementation of a quality improvement collaborative (QIC) to accelerate integration of HTN and HIV care within public-sector health facilities in Namibia. METHODS: Twenty-four facilities participated in the QIC with the aim of increasing HTN screening and treatment among adult PWH (>15 years). HTN was defined according to national treatment guidelines (i.e., systolic blood pressure >140 and/or diastolic blood pressure >90 across three measurements and at least two occasions), and decisions regarding initiation of treatment were made by physicians only. Teams from participating hospitals used quality improvement methods, monthly measurement of performance indicators, and small-scale tests of change to implement contextually tailored interventions. Coaching of sites was performed on a monthly basis by clinical officers with expertise in QI and HIV, and sites were convened as part of learning sessions to facilitate diffusion of effective interventions. RESULTS: Between March 2017 and March 2018, hypertension screening occurred as part of 183,043 (86%) clinical encounters at participating facilities. Among 1,759 PWH newly diagnosed with HTN, 992 (56%) were initiated on first-line treatment. Rates of treatment initiation were higher in facilities with an on-site physician (61%) compared to those without one (51%). During the QIC, facility teams identified fourteen interventions to improve HTN screening and treatment. Among barriers to implementation, teams pointed to malfunctions of blood pressure machines and stock outs of antihypertensive medications as common challenges. CONCLUSIONS: Implementation of a QIC provided a structured approach for integrating HTN and HIV services across 24 high-volume facilities in Namibia. As rates of HTN treatment remained low despite ongoing facility-level changes, policy-level interventions-such as task sharing and supply chain strengthening-should be pursued to further improve delivery of HTN care among PWH beyond initial screening.

Lumbar Fusion for Active Duty Service Members Performed at an Overseas Military Treatment Facility: A 2-Year Retrospective Analysis.

INTRODUCTION: Among U.S. Military active duty service members, low back pain (LBP) and lumbar radiculopathy are common causes of disability and effect job performance and readiness and can lead to medical separation from the military. Among surgical therapies, lumbar fusion is an option in select cases; however, elective lumbar fusion performed while serving overseas has not been studied extensively. MATERIALS AND METHODS: A retrospective analysis of a prospectively collected surgical database from an overseas military treatment facility (MTF) over a 2-year period (2019-2021) was queried. Patient and procedural data were collected to include single and 2-level lumbar fusion, indications for surgery, military rank, age, tobacco use, pre- and postoperative Visual Analog Scale (VAS) scores for pain, and the presence of radiographic fusion after surgery. Chi-square and Student's t-test analyses were performed to identify variables associated with return to full duty. RESULTS: A total of 21 patients underwent lumbar fusion with an average follow-up of 303.2 days (110-832 days). Eleven (52.4%) were able to return to full duty without restriction. Four (19%) patients ultimately required medical separation from the military, and six (28.6%) remained in a partial or limited duty status. Three (14.3%) patients required tour curtailment and return from overseas duty prematurely. Older age (40.2 ± 5.9 years), rank of E7 or greater, and reduction in VAS of 50% postoperatively were all associated with return to full unrestricted active duty. Three surgical complications occurred; all patients were able to recover overseas within a 3-month postoperative period. CONCLUSIONS: Low back pain (LBP) and lumbar radiculopathy may ultimately require treatment with instrumented lumbar fusion and decompression. In this series, we demonstrate that overseas duty with treatment at a community-sized MTF does not preclude this therapy and should be considered among treatment options.

Carole A. Miller, MD: Matriarch of the Ohio State University's Department of Neurosurgery.

Carole A. Miller, M.D., was born (May 7, 1939) and raised in Kalamazoo, Michigan. She obtained her undergraduate and medical degrees at the Ohio State University. She went on to complete her neurosurgical training at the Ohio State University Medical Center. After her first faculty role at the University of Michigan (1971), she returned to the Ohio State University Medical Center (1975) where she spent nearly 4 decades. She thrived in the specialty, achieving in every facet of academic practice including scientific contributions, graduate medical education, clinical care, and leadership roles within her academic department, locally, and at the national level of organized neurosurgery. Dr. Miller passed away peacefully, on October 28, 2015, after a courageous battle with cancer. Based on her essential programmatic and specialty-related contributions, she is remembered as the 'founding mother' of neurosurgery at the Ohio State University.

Effective management of district-level malaria control and elimination: implementing quality and participative process improvements.

Although it is widely recognized that strong program management is essential to achieving better health outcomes, this priority is not recognized in malaria programmatic practices. Increased management precision offers the opportunity to improve the effectiveness of malaria interventions, overcoming operational barriers to intervention coverage and accelerating the path to elimination. Here we propose a combined approach involving quality improvement, quality management, and participative process improvement, which we refer to as Combined Quality and Process Improvement (CQPI), to improve upon malaria program management. We draw on evidence from other areas of public health, as well as pilot implementation studies in Eswatini, Namibia and Zimbabwe to support the proposal. Summaries of the methodological approaches employed in the pilot studies, overview of activities and an outline of lessons learned from the implementation of CQPI are provided. Our findings suggest that a malaria management strategy that prioritizes quality and participative process improvements at the district-level can strengthen teamwork and communication while enabling the empowerment of subnational staff to solve service delivery challenges. Despite the promise of CQPI, however, policy makers and donors are not aware of its potential. Investments are therefore needed to allow CQPI to come to fruition.

Civil commitment for opioid misuse: do short-term benefits outweigh long-term harms?

In response to a sharp rise in opioid-involved overdose deaths in the USA, states have deployed increasingly aggressive strategies to limit the loss of life, including civil commitment-the forcible detention of individuals whose opioid use presents a clear and convincing danger to themselves or others. While civil commitment often succeeds in providing short-term protection from overdose, emerging evidence suggests that it may be associated with long-term harms, including heightened risk of severe withdrawal, relapse and opioid-involved mortality. To better assess and mitigate these harms, states should collect more robust data on long-term health outcomes, decriminalise proceedings and stays, provide access to medications for opioid use disorder and strengthen post-release coordination of community-based treatment.

Roll-out of HIV pre-exposure prophylaxis: a gateway to mental health promotion.

HIV remains a pressing global health problem, with 1.5 million new infections reported globally in 2020. HIV pre-exposure prophylaxis (PrEP) can lower the likelihood of HIV acquisition among populations at elevated risk, yet its global roll-out has been discouragingly slow. Psychosocial factors, such as co-occurring mental illness and substance use, are highly prevalent among populations likely to benefit from PrEP, and have been shown to undermine persistence and adherence. In this analysis, we review the high burden of mental health problems among PrEP candidates and contend that inattention to mental health stands to undermine efforts to implement PrEP on a global scale. We conclude that integration of mental health screening and treatment within PrEP scale-up efforts represents an important strategy for maximising PrEP effectiveness while addressing the high burden of mental illness among at-risk populations. As implementers seek to integrate mental health services within PrEP services, efforts to keep access to PrEP as low-threshold as possible should be maintained. Moreover, programmes should seek to implement mental health interventions that are sensitive to local resource constraints and seek to reduce intersecting stigmas associated with HIV and mental illness.

Magnetic resonance-guided laser interstitial thermal therapy for pediatric periventricular nodular heterotopia-related epilepsy.

OBJECTIVE: Periventricular nodular heterotopia (PVNH) is a result of disrupted neuronal migration from the ventricular system and can be a rare cause of refractory focal epilepsy. The goal of this case series was to describe the treatment of pediatric PVNH-related epilepsy with MR-guided laser interstitial thermal ablation. METHODS: Patients treated at a single institution with MR-guided laser interstitial thermal therapy (MRgLITT) for PVNH-related epilepsy were identified. Preoperative and postoperative seizure outcomes and procedural information were evaluated. RESULTS: Five children with PVNH treated with MRgLITT were reviewed; 1 child was treated twice. Three patients were female; the median age was 10.9 years. Five of 6 treatments were preceded by stereoelectroencephalography phase II monitoring. Three children experienced unilateral PVNH, and 2 had bilateral seizures. The median number of seizures recorded during phase II monitoring was 2; the median number of ablation targets was 2 (range 1-4). All patients experienced a decrease in seizure frequency; 4 patients (80%) had an Engel class ≤ III at the last follow-up (range I-IV). One child experienced right hemianopia posttreatment. CONCLUSIONS: This case series investigation has illustrated a novel, minimally invasive approach for treating pediatric PVNH-related epilepsy. Further study of this technique with comparison with other surgical techniques is warranted.