Evaluation of synbiotic combinations of commercial probiotic strains with different prebiotics in in vitro and ex vivo human gut microcosm model.

Exploring probiotics for their crosstalk with the host microbiome through the fermentation of non-digestible dietary fibers (prebiotics) for their potential metabolic end-products, particularly short-chain fatty acids (SCFAs), is important for understanding the endogenous host-gut microbe interaction. This study was aimed at a systematic comparison of commercially available probiotics to understand their synergistic role with specific prebiotics in SCFAs production both in vitro and in the ex vivo gut microcosm model. Probiotic strains isolated from pharmacy products including Lactobacillus sporogenes (strain not labeled), Lactobacillus rhamnosus GG (ATCC53103), Streptococcus faecalis (T-110 JPC), Bacillus mesentericus (TO-AJPC), Bacillus clausii (SIN) and Saccharomyces boulardii (CNCM I-745) were assessed for their probiotic traits including survival, antibiotic susceptibility, and antibacterial activity against pathogenic strains. Our results showed that the microorganisms under study had strain-specific abilities to persist in human gastrointestinal conditions and varied anti-infective efficacy and antibiotic susceptibility. The probiotic strains displayed variation in the utilization of six different prebiotic substrates for their growth under aerobic and anaerobic conditions. Their prebiotic scores (PS) revealed which were the most suitable prebiotic carbohydrates for the growth of each strain and suggested xylooligosaccharide (XOS) was the poorest utilized among all. HPLC analysis revealed a versatile pattern of SCFAs produced as end-products of prebiotic fermentation by the strains which was influenced by growth conditions. Selected synbiotic (prebiotic and probiotic) combinations showing high PS and high total SCFAs production were tested in an ex vivo human gut microcosm model. Interestingly, significantly higher butyrate and propionate production was found only when synbiotics were applied as against when individual probiotic or prebiotics were applied alone. qRT-PCR analysis with specific primers showed that there was a significant increase in the abundance of lactobacilli and bifidobacteria with synbiotic blends compared to pre-, or probiotics alone. In conclusion, this work presents findings to suggest prebiotic combinations with different well-established probiotic strains that may be useful for developing effective synbiotic blends.

Optic Nerve Edema in Pediatric Middle Cranial Fossa Arachnoid Cysts: Report of 51 Patients From a Single Institution.

BACKGROUND: Middle fossa arachnoid cysts (MFACs) are rare, congenital lesions that may rupture and cause symptoms of elevated intracranial pressure. We sought to describe the presence of and factors associated with optic nerve edema in MFACs, focusing on the utility of ophthalmologic evaluations for guiding cyst management. METHODS: We reviewed clinical and radiographic information for all patients with MFACs with ophthalmologic evaluations at our institution. Headache, cranial nerve palsy, emesis, altered mental status, fatigue, and seizures were considered MFAC-related symptoms. Univariate and multivariable analyses evaluated factors associated with optic edema. RESULTS: Fifty-one patients between 2003 and 2022 were included. Cysts were a median volume of 169.9 cm3 (interquartile range: 70.5, 647.7). Evidence of rupture with subdural hematoma/hygroma occurred in 19 (37.3%) patients. Eighteen (35.3%) patients underwent surgery for their cyst and/or rupture-associated intracranial bleed. Eleven (21.6%) patients had optic edema; all were symptomatic and experienced cyst rupture. Ten of these patients received surgery. Postoperatively, optic edema resolved in 80% of cases. Cyst volume and symptoms were not associated with optic edema; however, patients with ruptured cysts, particularly those with traumatic rupture, were more likely to have optic edema and receive surgery (P < 0.001). CONCLUSIONS: We found optic edema in 21.6% of evaluated MFACs, and this comprised of 57.9% of ruptured cases. Optic edema was not found in unruptured cysts. Cyst fenestration improved optic edema and patient symptoms. In conjunction with clinical history and neuroimaging, optic edema may help guide MFAC management, particularly in patients with cyst rupture.

Shedding Light on Acne Scars: A Comprehensive Review of CO2 vs. Erbium-Doped Yttrium Aluminium Garnet (Er:YAG) Laser Therapy.

Acne scars pose a significant cosmetic concern and can have a profound impact on individuals' self-esteem and quality of life. Laser therapy has emerged as a promising treatment modality for improving the appearance of acne scars by promoting collagen remodeling and tissue regeneration. This comprehensive review compares two commonly used laser modalities, CO2 and erbium-doped yttrium aluminum garnet (Er:YAG), focusing on their mechanisms of action, efficacy, safety profiles, and patient outcomes. While CO2 lasers offer deeper tissue penetration and the potential for more significant improvement in severe acne scars, Er:YAG lasers provide a gentler approach with a lower risk of post-inflammatory hyperpigmentation. Recommendations for clinical practice include tailoring treatment approaches to individual patient characteristics, educating patients about treatment expectations and post-treatment care, considering combination therapies for enhanced outcomes, and implementing regular follow-up care. Areas for further research include long-term outcome studies, investigation of laser therapy in ethnically diverse populations, exploration of combination therapies, and evaluation of emerging laser technologies. This review aims to provide clinicians and patients with valuable insights to inform treatment decisions and optimize outcomes in managing acne scars.

Drug-Induced Pseudoporphyria: A Case Report.

Pseudoporphyria is an uncommon dermatosis resembling porphyria cutanea tarda (PCT). The exclusion of true porphyria, especially PCT, is critically essential for diagnosing pseudoporphyria. It has an unknown underlying pathophysiology with a normal or near-normal porphyrin profile. Pseudoporphyria has been associated with chronic renal failure and hemodialysis, medications, and tanning beds. In drug-induced pseudoporphyria cases, eliminating the suspected photosensitizing drug improves the disease typically within weeks to months (on average eight weeks). In genetically predisposed individuals, phototoxic metabolites may trigger the development of skin fragility, bullae, milia, and scarring on the dorsum of the hands and other sun-exposed areas. Wearing a broad-spectrum sunscreen and maintaining strict ultraviolet protection is essential in cases of pseudoporphyria. We report the case of a 20-year-old male who presented to us with complaints of photosensitivity and multiple erosions with irregular scars over photo-exposed areas involving the dorsum of the hands and face predominantly. The patient was evaluated further to determine the underlying cause. A wood's lamp examination of the urine was done, which did not show fluorescence. Based on clinical and laboratory findings, the diagnosis of pseudoporphyria was made, and the patient was started on the oral antimalarial agent hydroxychloroquine sulfate with strict sun protection.

A Comprehensive Review on the Efficacy of Anti-CD20 Therapies in Pemphigus Treatment.

Pemphigus, an autoimmune blistering disorder, poses significant therapeutic challenges due to dysregulated B cells and the involvement of CD20. This review assesses the efficacy of anti-CD20 therapies, including rituximab, ofatumumab, ocrelizumab, and obinutuzumab, in pemphigus treatment. Mechanisms of action, clinical studies, and safety profiles were analyzed, revealing diverse impacts on disease severity. B cell depletion emerged as a pivotal factor, disrupting the autoimmune process and reducing pathogenic antibodies. Varied efficacy and safety profiles among agents underscore the need for personalized treatment strategies guided by biomarkers. Challenges such as resistance and long-term safety concerns necessitate continued research and vigilance. In clinical practice, insights from this review inform nuanced, tailored approaches for improved pemphigus management. The dynamic landscape of emerging therapies and personalized medicine emphasizes the need for ongoing research and strategic clinical decision-making. This review is a foundation for future investigations, providing insights for clinicians and researchers in optimizing pemphigus treatment.

Comparing vascular morphology and hemodynamics in patients with vein of Galen malformations using intracranial 4D flow MRI.

BACKGROUND AND PURPOSE: Vein of Galen malformation (VOGM) is the most common congenital cerebrovascular malformation, and many patients suffer high mortality rates and poor cognitive outcomes. Quantitative diagnostic tools are needed to improve clinical outcomes. MATERIALS AND METHODS: A prospective study of children with VOGM was conducted by acquiring 4D flow MRI to quantify total blood inflow to the brain, flow in the pathologic falcine sinus, and flow in the superior sagittal sinus. Linear regression was used to test the relationships between these flows and age, clinical status, and the mediolateral diameter of the lesion's outflow tract through the falcine or straight sinus (MD), which is a known morphological prognostic metric. RESULTS: In all 11 subjects (mean age 22±17 weeks [SD]), total blood flow to the brain always exceeded normal levels (1063±403 ml/min [mean±SD]). Significant correlations were observed between falcine sinus flow and MD, the posterior/middle cerebral artery flow ratio and age at scan, and between superior sagittal sinus flow proximal to malformation inflow and age at scan. CONCLUSIONS: Using 4D flow MRI we established the hemodynamic underpinnings of MD, and investigated metrics representing parenchymal venous drainage that could be used to monitor the normalization of hemodynamics during embolization therapy. ABBREVIATIONS: ACA = anterior cerebral artery; BA = basilar artery; MD = falcine or straight sinus mediolateral diameter; NAR = neonatal at risk; PCA = posterior cerebral artery; PCom = posterior communicating artery; SSS = superior sagittal sinus; VOGM = vein of Galen malformation.

Elephantiasis Nostras Verrucosa in a Patient With Lymphedema Tarda.

This case report presents a rare and complex clinical scenario of a 42-year-old male diagnosed with elephantiasis nostras verrucosa in the context of lymphedema tarda. The patient's seven-year history of insidious and progressively worsening swelling over the left lower limb, inguino-scrotal region, and left upper limb posed diagnostic challenges, leading to a multidisciplinary evaluation. Clinical examination, imaging studies, and laboratory investigations were integral in confirming the diagnosis. The manifestation of elephantiasis nostras verrucosa, characterized by extensive hyperkeratosis, added a unique dimension to the clinical presentation. A comprehensive treatment approach involving nutritional supplementation and pharmacological interventions was initiated to address the multifaceted aspects of lymphatic dysfunction. This case underscores the importance of a collaborative and holistic approach to managing complex lymphatic disorders, contributing valuable insights to the medical literature.

Painful Limb Ulcers: A Case Report on Ulcerative Discoid Lupus Erythematosus.

Lupus erythematosus is an autoimmune disorder with varied clinical features. Discoid Lupus Erythematosus (DLE) presents as erythematous, raised plaques. The patients might present with photosensitivity, arthralgia, and nail changes. However, dermoscopy, clinical features, and laboratory markers like high titers of Antinuclear antibodies (ANA) help in clenching the diagnosis. We report a patient in her mid-60s presented with non-healing ulcers oozing pus discharge associated with pain and joint stiffness. Thus, a series of investigations, treatment modifications, and the healing progression of the lesions highlight the importance of retrospective diagnosis.

Frailty is a Predictor of Increased Readmissions and Increased Postoperative Complications After Elective Treatment of Unruptured Aneurysms.

INTRODUCTION: Frailty is a state of decreased physiologic reserve associated with adverse treatment outcomes across surgical specialties. We sought to determine whether frailty affected patient outcomes after elective treatment (open microsurgical clipping or endovascular therapy [EVT]) of unruptured cerebral aneurysms (UCAs). METHODS: The National Readmissions Database was queried from 2010 to 2014 to identify patients who had a known UCA and underwent elective clipping or EVT. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty indicator tool. Multivariable exact logistic regression analyses were conducted to assess the associations between frailty and the primary outcome variables of 30- and 90-day readmissions, complications, length of stay (LOS), and patient disposition. RESULTS: Of 18,483 patients who underwent elective treatment for UCAs, 358 (1.9%) met the criteria for frailty. After adjusting for patient- and hospital-based factors, frailty (30-day: odds ratio [OR], 1.55; 95% confidence interval [CI], 1.11-2.17; P = 0.01; 90-day: OR, 1.47; 95% CI, 1.05-2.06; P = 0.02) and clipping versus EVT (30-day: OR, 2.12; 95% CI, 1.85-2.43; P < 0.000; 90-day: OR, 1.80; 95% CI, 1.59-2.03; P < 0.0001) were associated with increased readmission rates. Furthermore, frailty was associated with an increased rate of complications (surgical: OR, 2.91; 95% CI, 2.27-3.72; P < 0.0001; neurological: OR, 3.04; 95% CI, 2.43-3.81; P < 0.0001; major: OR, 2.75; 95% CI, 1.96-3.84; P < 0.0001), increased LOSs (incidence rate ratio, 3.08; 95% CI, 2.59-3.66; P < 0.0001), and an increased rate of nonroutine disposition (OR, 3.94; 95% CI, 2.91-5.34; P < 0.0001). CONCLUSIONS: Frailty was associated with an increased likelihood of 30- and 90-day readmissions after elective treatment of UCAs. Frailty was notably associated with several postoperative complications, longer LOSs, and nonroutine disposition in the treatment of UCAs.

Association of carotid endarterectomy at low-volume centers with higher likelihood of major complications and nonroutine discharge.

OBJECTIVE: Carotid artery stenosis (CAS) is associated with an annual stroke risk of 2%-5%, and revascularization with carotid endarterectomy (CEA) can reduce this risk. While studies have demonstrated that hospital CEA volume is associated with mortality and myocardial infarction, CEA volume cutoffs in studies are relatively arbitrary, and no specific analyses on broad complications and discharge disposition have been performed. In this study, the authors systematically set out to identify a cutoff at which CEA procedural volume was significantly associated with major complications and nonroutine discharge. METHODS: Asymptomatic and symptomatic CAS patients undergoing CEA were retrospectively identified in the Nationwide Readmissions Database (2010-2018). The association of CEA volume with outcomes was explored as a continuous variable using locally estimated scatterplot smoothing. The identified volume cutoff was used to generate dichotomous volume cohorts, and multivariate analyses of patient and hospital characteristics were conducted to evaluate the association of CEA volume with major complications and discharge disposition. RESULTS: Between 2010 and 2018, 308,933 asymptomatic and 32,877 symptomatic patients underwent CEA. Analysis of CEA volume with outcomes as a continuous variable demonstrated that an increase in volume was associated with a lower risk until a volume of approximately 7 cases per year (20th percentile). A total of 6702 (2.2%) asymptomatic and 1040 (3.2%) symptomatic patients were treated at the bottom 20% of hospital procedure volume. Increased rates of complications were seen at low-volume centers among asymptomatic (3.66% vs 2.77%) and symptomatic (7.4% vs 6.87%) patients. Asymptomatic patients treated at low-volume centers had an increased likelihood of major complications (OR 1.26, 95% CI 1.07-1.49; p = 0.007) and nonroutine discharge (OR 1.36, 95% CI 1.24-1.50; p < 0.0001). Symptomatic patients treated at low-volume centers were also more likely to experience major complications (OR 1.47, 95% CI 1.07-2.02; p = 0.02) and nonroutine discharge (OR 1.26, 95% CI 1.07-1.47; p = 0.005). Mortality rates were similar between low- and high-volume hospitals among asymptomatic (0.36% and 0.32%, respectively) and symptomatic (1.06% and 1.49%, respectively) patients, while volume was not significantly associated with mortality among asymptomatic (OR 1.06, 95% CI 0.67-1.65; p = 0.81) and symptomatic (OR 0.81, 95% CI 0.43-1.54; p = 0.52) patients in multivariate analysis. CONCLUSIONS: CEA patients, asymptomatic or symptomatic, are at a higher risk of major complications and nonroutine discharge at low-volume centers. Analysis of CEA as a continuous variable demonstrated a cutoff at 7 cases per year, and further study may identify factors associated with improved outcome at the lowest-volume centers.

Direct Transverse Sinus Puncture for Transvenous Coil Embolization of Vein of Galen Malformations: Innovating Existing Techniques.

BACKGROUND AND IMPORTANCE: Vein of Galen malformations (VOGMs) are complex arteriovenous malformations in neonates and young children. Recent advances in endovascular interventions have drastically improved treatment and clinical outcomes in what was previously high-morbidity, high-mortality disease. The high-flow shunt pathophysiology in VOGMs can lead to dynamic changes in the malformation angioarchitecture, and over time patients can develop jugular bulb stenosis. In the setting of inaccessible transvenous access to the malformation for endovascular embolization in cases where transarterial embolization is inadequate, a combined surgical and endovascular technique must be used. We present the first successful modern-day application of direct puncture through transverse sinus for transvenous embolization of a VOGM. CLINICAL PRESENTATION: We present 2 unique cases of complex VOGM malformations in patients who had previously undergone staged endovascular embolization for reduction of flow within the malformation. On follow-up, in both cases, there was development of severe sigmoid sinus and jugular bulb stenosis, increasing intracranial venous congestion and causing marked clinical deterioration. The stenosis prevented traditional transvenous access and treatment. We describe a direct puncture transverse sinus access using a burr hole approach for endovascular transvenous embolization in both cases with successful clinical outcomes. CONCLUSION: Direct access using burr hole craniotomy to the transverse sinus for transvenous endovascular embolization is a safe approach in the setting of severe jugular bulb stenosis for treatment of VOGMs. This technique can be done efficiently to achieve complete flow elimination in the malformation, in cases where that is called for, without significant risks or complications related to the approach.

Focal drug-resistant temporal lobe epilepsy associated with an ipsilateral anterior choroidal artery aneurysm: illustrative case.

BACKGROUND: The occurrence of both an intracranial aneurysm and epilepsy, especially drug-resistant epilepsy (DRE), is rare. Although the overall incidence of aneurysms associated with DRE is unclear, it is thought to be particularly infrequent in the pediatric population. Surgical ligation of the offending aneurysm has been reported in conjunction with resolving seizure activity, although few cases have cited a combined approach of aneurysm ligation and resection of an epileptogenic focus. OBSERVATIONS: We present the case of a 14-year-old female patient with drug-resistant temporal lobe epilepsy and an ipsilateral supraclinoid internal carotid artery aneurysm. Seizure semiology, electroencephalography monitoring, and magnetic resonance imaging all indicated a left temporal epileptogenic focus, in addition to an incidental aneurysm. The authors recommended a combined surgery involving resection of the temporal lesion and surgical clip ligation of the aneurysm. Near-total resection and successful ligation were achieved, and the patient has remained seizure free since surgery at 1 year postoperatively. LESSONS: In patients with focal DRE and an adjacent intracranial aneurysm, a combined surgical approach involving both resection and surgical ligation can be used. Several surgical timing and neuroanesthetic considerations should be made to ensure the overall safety and efficacy of this procedure.

Understanding development of jugular bulb stenosis in vein of galen malformations: identifying metrics of complex flow dynamics in the cerebral venous vasculature of infants.

Introduction: Computational fluid dynamics (CFD) assess biological systems based on specific boundary conditions. We propose modeling more advanced hemodynamic metrics, such as core line length (CL) and critical points which characterize complexity of flow in the context of cerebral vasculature, and specifically cerebral veins during the physiologically evolving early neonatal state of vein of Galen malformations (VOGM). CFD has not been applied to the study of arteriovenous shunting in Vein of Galen Malformations but could help illustrate the pathophysiology of this malformation. Methods: Three neonatal patients with VOGM at Boston Children's Hospital met inclusion criteria for this study. Structural MRI data was segmented to generate a mesh of the VOGM and venous outflow. Boundary condition flow velocity was derived from PC-MR sequences with arterial and venous dual velocity encoding. The mesh and boundary conditions were applied to model the cerebral venous flow. We computed flow variables including mean wall shear stress (WSSmean), mean OSI, CL, and the mean number of critical points (nCrPointsmean) for each patient specific model. A critical point is defined as the location where the shear stress vector field is zero (stationary point) and can be used to describe complexity of flow. Results: The division of flow into the left and right venous outflow was comparable between PC-MR and CFD modeling. A high complexity recirculating flow pattern observed on PC-MR was also identified on CFD modeling. Regions of similar WSSmean and OSImean (<1.3 fold) in the left and right venous outflow channels of a single patient have several-fold magnitude difference in higher order hemodynamic metrics (> 3.3 fold CL, > 1.7 fold nCrPointsmean). Specifically, the side which developed JBS in each model had greater nCrPointsmean compared to the jugular bulb with no stenosis (VOGM1: 4.49 vs. 2.53, VOGM2: 1.94 vs. 0, VOGM3: 1 vs. 0). Biologically, these regions had subsequently divergent development, with increased complexity of flow associating with venous stenosis. Discussion: Advanced metrics of flow complexity identified in computational models may reflect observed flow phenomena not fully characterized by primary or secondary hemodynamic parameters. These advanced metrics may indicate physiological states that impact development of jugular bulb stenosis in VOGM.

Carotid artery stenting for asymptomatic stenosis is associated with decreased 30-day readmission at very high volume centers.

Endovascular carotid artery stenting (CAS) is a common treatment for carotid artery stenosis and stroke prevention. Previous studies have shown that high procedural volume centers are associated with improved patient outcomes. Unplanned 30-day readmissions, which are associated with significant expenses, are increasingly used as a metric of patient outcome. Despite prior studies evaluating associations between procedural volume and multiple outcomes, the association between very high CAS volume and short-term (30-day) readmission has not yet been evaluated in a large multicenter study. The National Readmissions Database (NRD) was analyzed retrospectively from 2010 to 2015 to evaluate the association between hospital procedural volume and patient outcomes in asymptomatic and symptomatic CAS patients. Very high volume centers (VHVC) were defined as the top 10% hospitals in terms of procedural volume, performing >= 79 procedures a year. Univariate and multivariate analyses of patient and hospital characteristics evaluated associations with short-term (30-day) readmissions (SR), long-term (90-day) readmissions (LR), index mortality, discharge disposition, major complications, and neurological complications. A total of 36,128 asymptomatic patients and 8,390 symptomatic patients who underwent CAS were identified. Asymptomatic CAS patients treated at VHVCs were associated with decreased likelihood of SR (OR 0.88, 95% CI 0.80-0.95, p = 0.003) and LR (OR 0.91, 95% CI 0.85-0.99, p = 0.037) compared to asymptomatic patients at non-VHVCs. There was no significant difference in SR or LR between symptomatic CAS patients treated at a VHVC vs. non-VHVC. Our findings provide additional evidence to support the role of experience in improved CAS treatment outcomes.

Pediatric patients with malignant brain tumor treated at children's hospitals: association with fewer unplanned readmissions.

OBJECTIVE: Pediatric primary brain tumors are the leading cause of death among childhood cancers. Guidelines recommend specialized care with a multidisciplinary team and focused treatment protocols to optimize outcomes in this patient population. Furthermore, readmission is a key metric of patient outcomes and has been used to inform reimbursement. However, no prior study has analyzed national database-level records to evaluate the role of care in a designated children's hospital following pediatric tumor resection and its impact on readmission rates. The goal of this study was to investigate whether treatment at a children's hospital rather than a nonchildren's hospital has a significant effect on outcome. METHODS: The Nationwide Readmissions Database records from 2010 to 2018 were analyzed retrospectively to evaluate the effect of hospital designation on patient outcomes after craniotomy for brain tumor resection, and results are reported as national estimates. Univariate and multivariate regression analyses of patient and hospital characteristics were conducted to evaluate if craniotomy for tumor resection at a designated children's hospital was independently associated with 30-day readmissions, mortality rate, and length of stay. RESULTS: A total of 4003 patients who underwent craniotomy for tumor resection were identified using the Nationwide Readmissions Database, with 1258 of these cases (31.4%) treated at children's hospitals. Patients treated at children's hospitals were associated with decreased likelihood of 30-day hospital readmission (OR 0.68, 95% CI 0.48-0.97, p = 0.036) compared to patients treated at nonchildren's hospitals. There was no significant difference in index mortality between patients treated at children's hospitals and those treated at nonchildren's hospitals. CONCLUSIONS: The authors found that patients undergoing craniotomy for tumor resection at children's hospitals were associated with decreased rates of 30-day readmission, with no significant difference in index mortality. Future prospective studies may be warranted to confirm this association and identify components contributing to improved outcomes in care at children's hospitals.

Myelomeningocele repair at pediatric hospitals: association with routine discharge and shorter hospital stay.

OBJECTIVE: Postnatal repair for myelomeningocele (MMC) is a time-sensitive and technically challenging procedure. More experienced hospitals may provide improved outcomes for the complexity of care associated with these patients. No prior study has investigated the impact of MMC treatment at pediatric hospitals. The authors sought to examine the effect of pediatric hospital designation on patients undergoing postnatal MMC repair to identify factors associated with maximizing improved patient outcomes. METHODS: The Nationwide Readmissions Database records from 2010 to 2018 were analyzed retrospectively to determine the effect of hospital designation on patient outcomes after postnatal MMC repair. Univariate and multivariate regression analyses of patient and hospital characteristics were conducted to evaluate if MMC repair at a designated pediatric hospital was independently associated with patient outcomes of perinatal infection rates, discharge disposition, and length of stay. RESULTS: Of the total of 6353 pediatric patients who underwent postnatal MMC repair between 2010 and 2018, 2224 (35.0%) received care at a pediatric hospital. Those with an extreme level of disease burden as defined by the all patient refined diagnosis-related group severity of illness index were more likely to be treated at a pediatric hospital (p = 0.03). Patients undergoing repair at a pediatric hospital were also associated with a decreased likelihood of perinatal infection (OR 0.54, 95% CI 0.35-0.83, p = 0.005); greater likelihood of routine disposition (OR 4.85, 95% CI 2.34-10.06, p < 0.0001); and shorter length of stay (incidence rate ratio 0.88, 95% CI 0.77-0.995, p = 0.04). CONCLUSIONS: Pediatric patients requiring intervention for postnatal repair of MMC may benefit from the multidisciplinary subspeciality care offered at pediatric hospitals. The authors found that postnatal repair of MMC at pediatric hospitals was associated with a greater likelihood of improved patient outcomes.

Neurosurgical outcomes of pediatric cerebral venous sinus thrombosis following acute mastoiditis: a systematic review and meta-analysis.

OBJECTIVE: Neurosurgical outcomes are not well defined in the management of pediatric patients with cerebral venous sinus thrombosis (CVST) following acute mastoiditis. Specific notable sequelae are otogenic (otitic) hydrocephalus and CVST management. Correspondingly, the aim of this study was to integrate the currently published metadata to summarize these outcomes. METHODS: Electronic searches were performed using the Ovid Embase, PubMed, Scopus, and Cochrane databases from inception to November 2022 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Cohort-level data were then abstracted for analysis for appropriate pediatric patients. Outcomes were pooled by random-effects meta-analyses of proportions where possible. RESULTS: Twenty-three study cohorts describing 312 pediatric patients with otogenic CVST were included. At a cohort level, the median patient age was 6 years among 181 boys (58%) and 131 girls (42%). Modeling indicated papilledema at presentation in 46% of cases (95% CI 30%-62%). Regarding management, antibiotics were applied universally in all cases, mastoidectomy or other otologic surgery was performed in 91% (95% CI 82%-98%), and prophylactic anticoagulation was administered in 86% (95% CI 75%-95%). There was only 1 case (0.3%) of postprocedural intracranial hemorrhage, and there were no deaths reported among all studies. Although diagnostic lumbar puncture was performed in 14% (95% CI 3%-28%) at presentation, clinical otogenic hydrocephalus was ultimately suspected in 31% (95% CI 14%-49%), and acetazolamide was given in 65% (95% CI 35%-91%) overall. There were 10 cases (3%) that proceeded to permanent CSF diversion in the form of ventricular shunting. At a median follow-up of 8 months among all studies, the venous sinus was completely recanalized in 67% (95% CI 53%-79%). CONCLUSIONS: Most CVSTs following acute mastoiditis will recanalize with the standard use of antibiotics, otologic surgery, and anticoagulation, with minimal symptomatic hemorrhage risk. However, an appreciable proportion of these patients will develop symptomatic otogenic hydrocephalus, and it is imperative that the appropriate surveillance and workup is performed to fully optimize patient outcomes long-term. The possible need for permanent CSF diversion should be recognized.