The impact of telephone consultations due to COVID-19 on paediatric neurosurgical health services.

PURPOSE: The aim of the study was to evaluate the role of telephone consultations due to the pandemic in the management of paediatric neurosurgical patients and, furthermore, to examine the proportion of patients who eventually needed a face-to-face appointment and assess the underline reasons for that. METHODS: This retrospective study included all the paediatric neurosurgical patients who had a telephone appointment during a 3-month lockdown period. Overall, 319 patients (186 males and 133 females) aged 8.36 ± 4.88 (mean ± SD) had a consultation via telephone. Two hundred fifty-one (78.7%) patients had a follow-up assessment and 68 (21.3%) were new appointments. RESULTS: Patients were divided between two main groups. Group A included 263 patients (82.4%) whose consultation was adequate via telephone, and Group B included 56 patients (17.6%) who required a complementary face-to-face appointment. Patients who were more likely to require a supplementary appointment were patients with either dysraphism or ventriculomegaly and benign enlarged subarachnoid spaces (BESS) (43.3% and 36.4%, respectively). Interestingly, most children with hydrocephalus who underwent a cerebrospinal fluid (CSF) diversion procedure and children with Chiari I malformation were appropriately assessed via telephone (85.1% and 83.3%, respectively). Finally, children aged < 2 years (55.2%) were better managed with face-to-face appointments. No difference was noticed regarding follow-up and new appointments. CONCLUSION: Although telemedicine was not unknown to neurosurgical services, the actual application of telephone or video consultations remained quite limited. It was COVID-19 pandemic who reinforced the use of telemedicine, and taking into consideration its promising results, we can safely assume that it can be incorporated into neurosurgical health care even once the pandemic crisis has resolved.

The Sensor Reservoir-does it change management?

BACKGROUND: The Miethke Sensor Reservoir sits within a ventriculoperitoneal shunt system to give a reading of the pressure within the shunt. This information can guide the management of hydrocephalus patients who present frequently with headaches. METHODS: We reviewed a cohort of 12 patients who underwent implantation of a Sensor Reservoir to assess how the management of their symptoms changed over a 4-year period. RESULTS: When comparing the group before the Sensor Reservoir and after the Sensor Reservoir insertion, there was a 75% reduction in number of CT head scans (P<0.05), 100% reduction in episodes of ICP monitoring (P<0.05), 55% reduction in number of X-ray shunt series, and a 50% reduction in acute presentation to hospital with shunt-related symptoms. The number of clinic attendances increased by 44%. In addition, cost analysis showed a saving of £6952 per patients over the 2-year period following Sensor Reservoir insertion as a result of reduced admissions and investigations. Complications were seen in 3 patients-two patients developed shunt-related infections, and 1 patient underwent shunt revision due to a proximal shunt obstruction. Seventy-five percent of patients showed an improvement in their symptoms at the end of the 4-year period. CONCLUSION: Implantation of a Sensor Reservoir in shunt patients with chronic headaches can reduce the number of investigations and hospital admissions and guide management resulting in a clinical improvement.

Extended endoscopic supracerebellar infratentorial (EESI) approach for a complex pineal region tumour-a technical note.

Endoscopic-assisted approaches have been shown to be a suitable alternative to the standard microscopic approach to pineal region tumours. With extension laterally into the ventricles, the 0° endoscope and microscope have significant limitations. We describe the extended endoscopic supracerebellar infratentorial (EESI) approach using angled endoscopes for a complex pineal region tumour that extended into the lateral ventricle. A 15-year-old boy presented with headaches and ataxia. MRI revealed a pineal region tumour extending into the lateral ventricle. The patient was positioned in the sitting position. The supracerebellar infratentorial corridor was accessed through a small craniotomy. The tumour was resected completely via the endoscope. Postoperatively, the patient's symptoms resolved completely. We believe that this case highlights the benefit of using the endoscopic extended supracerebellar infratentorial (EESI) approach to resect pineal region lesions that extend beyond the midline.

Percutaneous ultrasound-guided insertion of ventriculo-atrial shunts.

Ventriculo-atrial (VA) shunts have been in use for >60 years but less frequently so of late. This is due to a combination of the risk of cardiac complications, lack of expertise and a lengthy operation. We present our consecutive prospective series of 10 VA shunts inserted using a percutaneous method employing the Sonowand Invite™ neuronavigation system for both the distal and proximal catheters, over a 13-month period. We had two complications of cases needing revision, but our series highlights a safe and reproducible method of inserting a VA shunt. About 30% of the procedures were carried out by a trainee as the primary surgeon. This technique does not necessarily require the expertise of a complex hydrocephalus surgeon and is thus able to be in the armoury of any neurosurgeon needing to do a VA shunt procedure. The indications, operative data and outcomes of our patients are discussed.

Diffuse intrinsic pontine glioma: is MRI surveillance improved by region of interest volumetry?

BACKGROUND: Paediatric diffuse intrinsic pontine glioma (DIPG) is noteworthy for its fibrillary infiltration through neuroparenchyma and its resultant irregular shape. Conventional volumetry methods aim to approximate such irregular tumours to a regular ellipse, which could be less accurate when assessing treatment response on surveillance MRI. Region-of-interest (ROI) volumetry methods, using manually traced tumour profiles on contiguous imaging slices and subsequent computer-aided calculations, may prove more reliable. OBJECTIVE: To evaluate whether the reliability of MRI surveillance of DIPGs can be improved by the use of ROI-based volumetry. MATERIALS AND METHODS: We investigated the use of ROI- and ellipsoid-based methods of volumetry for paediatric DIPGs in a retrospective review of 22 MRI examinations. We assessed the inter- and intraobserver variability of the two methods when performed by four observers. RESULTS: ROI- and ellipsoid-based methods strongly correlated for all four observers. The ROI-based volumes showed slightly better agreement both between and within observers than the ellipsoid-based volumes (inter-[intra-]observer agreement 89.8% [92.3%] and 83.1% [88.2%], respectively). Bland-Altman plots show tighter limits of agreement for the ROI-based method. CONCLUSION: Both methods are reproducible and transferrable among observers. ROI-based volumetry appears to perform better with greater intra- and interobserver agreement for complex-shaped DIPG.

Screening for spinal stenosis in achondroplastic patients undergoing limb lengthening.

The need for a screening programme for spinal stenosis in children with achondroplasia undergoing limb lengthening was identified in a tertiary limb reconstruction service. The aim of this study was to evaluate whether screening would identify the 'at risk' group. A total of 26 achondroplastic patients underwent our screening programme. Canal diameters were measured by MRI. Neurosurgical interventions were recorded. Of the patients, 13 had severe foramen magnum narrowing. Six patients required single or multiple surgical decompressions. We identified female sex, delayed milestones and a tight cervicomedullary junction as high risks. We stress upon the importance of developing a nationalized screening programme with guidelines to identify a high-risk group.

Novel use of intrathecal baclofen drug delivery system for periodic focal dystonia in a teenager.

INTRODUCTION: Focal dystonia, often affecting part of a limb, is a manifestation of complex regional pain syndrome (CRPS). This can be difficult to diagnose and treat. Furthermore, there may be significant latency between the onset of dystonia after the diagnosis of CRPS. We present the case of a 15-year-old girl with periodic focal dystonia who has been successfully treated with an intrathecal baclofen pump. MATERIALS AND METHODS: The patient had sustained a minor ankle fracture four years prior to presentation. Despite radiologic evidence of adequate bony union, the patient continued to complain of spasms and pain in her left foot leading to dystonic posturing of the foot. Multiple therapies including subcutaneous morphine infusion, ankle splinting, physiotherapy, and local botulinum injections had not provided adequate relief. Intrathecal baclofen on three separate occasions resulted in successful temporary resolution of the dystonia. A placebo double-blinded injection of intrathecal saline at a separate setting however did not resolve the dystonia. RESULTS: We then proceeded with permanent delivery of baclofen by implantation of an intrathecal drug delivery pump, which resulted in resolution of the dystonia. The patient also was able to receive bolus doses of intrathecal baclofen. The patient is now able to partake in sporting and dancing activities. A detailed history of the patient, along with the difficulties in diagnosis and management, is presented. CONCLUSION: Intrathecal baclofen therapy can be effective in the management of focal dystonia after rigorous preoperative testing and counseling of adolescents with CRPS.

Rapid brain shift, remote site hemorrhage, and a spinal hematoma after craniotomy for a large arachnoid cyst.

Arachnoid cysts are prevalent among the general population. The management options of symptomatic arachnoid cysts each have their own merits and disadvantages. We report a case where a large arachnoid cyst was treated by open fenestration and marsupialization that was complicated by remote intraparenchymal and spinal subdural hemorrhage. The potential physiological changes underlying these complications as well as the related literature are reviewed.

Endoscopic endonasal resection of the odontoid peg for paediatric basilar invagination.

Osteogenesis imperfecta (OI) is a genetic disorder whose primary manifestations are fractures, bone deformity and bone pain. Brainstem compression due to basilar invagination is a rare and potentially life-threatening complication of OI. Children with this condition often require significant medical input and multiple admissions to hospital. Traditionally, anterior decompression is carried out through an open trans-oral route. We describe an endoscopic endonasal approach for resection of the peg in a child with OI and basilar invagination. We believe this approach provides an excellent alternative with minimal morbidity and decreased length of stay especially in the paediatric population.

Wins, winning and winners: the commercial advertising of lottery gambling.

This study analyzed a sample of 920 lottery ads that were placed or played in Atlantic Canada from January 2005 to December 2006. A content analysis, involving quantitative and qualitative techniques, was conducted to examine the design features, exposure profiles and focal messages of these ads and to explore the connections between lottery advertising and consumer culture. We found that there was an "ethos of winning" in these commercials that provided the embedded words, signs, myths, and symbols surrounding lottery gambling and conveyed a powerful imagery of plentitude and certitude in a world of potential loss where there was little reference to the actual odds of winning. The tangible and emotional qualities in the ads were especially inviting to young people creating a positive orientation to wins, winning and winners, and lottery products that, in turn, reinforced this form of gambling as part of youthful consumption practices. We concluded that enticing people with the prospects of huge jackpots, attractive consumer goods and easy wins, showcasing top prize winners, and providing dubious depictions that winning is life-changing was narrow and misleading and exploited some of the factors associated with at-risk gambling.

A qualitative model of mortality in honey bee (Apis mellifera) colonies infested with tracheal mites (Acarapis woodi).

The tracheal mite has been associated with colony deaths worldwide since the mite was first discovered in 1919. Yet controversy about its role in honey bee colony mortality has existed since that time. Other pathogens such as bacteria and viruses have been suggested as the cause of colony deaths as well as degenerative changes in individual honey bees. Using data from published work we developed a qualitative mortality model to explain colony mortality due to tracheal mite infestation in the field. Our model suggests that colonies of tracheal-mite infested honey bees, with no other pathogens present, can die out in the late winter/early spring period due to their inability to thermoregulate. An accumulation of factors conspire to cause colony death including reduced brood/bee population, loose winter clusters, reduced flight muscle function and increasing mite infestation. In essence a cascade effect results in the colony losing its cohesion and leading to its ultimate collapse.

Brood-cell size does not influence the susceptibility of honey bees (Apis mellifera) to infestation by tracheal mites (Acarapis woodi).

Tracheal mites have been associated with the condition in honey bees that devastated colonies in Britain and Ireland in the early 1900s. The first outbreak of this condition, that became known as the 'Isle of Wight' disease, coincided with the period when brood-cell size was increased from about 5.0 mm to about 5.5 mm in width. We undertook an inoculation experiment over a 7-day period to establish if the act of increasing the brood-cell size could have triggered the onset of tracheal mites in honey bees. The standard-sized cells used had a cell width of 5.44 mm and the small-sized cells a width of 5.07 mm. Using callow (newly emerged) bees, from three colonies that had mixed cell sizes, we compared the susceptibility of bees reared in standard-sized cells with that of those raised in small-sized cells. The results indicated similar levels of female mite abundance (0.49 vs. 0.52 mites per bee) and mean fecundity (4.33 vs. 4.22 offspring per female mite), and produced no evidence of any difference in the overall susceptibility between the bees raised in the standard-sized cells versus small-sized brood cells.

Gambling households in Canada.

This paper examines the distribution of gambling dollars in Nova Scotia, Saskatchewan and Canada and studies the impact of this spending on households. We focus first on how gambling expenditures are related to the level and source of household income as well as to other demographic characteristics such as age, education, household composition, geographical area, and sources of income. Next we analyze how gambling expenditures are distributed among those households that gamble. We show how expenditure patterns differ in the intensity of gambling as measured by the proportion of household income or total amount of dollars spent on gambling. Then we study the affects that gambling has on spending on household necessities, changes in net worth, retirement savings and household debt. Finally we determine whether gambling expenditures act as a substitute or a complement to other recreational spending on entertainment products and services. Throughout the paper we offer a comparative analysis of provincial and national data.