Video Diversion Improves Success Rate of Fundoscopic Examination in Children: A Prospective Randomized Controlled Trial.

BACKGROUND: Fundoscopy is an important component of the neurological examination as it can detect pathologies such as high intracranial pressure. However, the examination can be challenging in young children. This study evaluated whether playing a video during eye examination improves the success, duration, and ease of pediatric fundoscopy. MATERIALS AND METHODS: This was a prospective, multipractitioner, multiclinic, randomized controlled trial. Patients aged one to four years were recruited in the emergency department, neurology clinic, spinal cord clinic, and general pediatric clinic. Eye examination was randomized to video or non-video-assisted fundoscopy. Successful examinations were defined as visualizing the fundus within 60 seconds. Time to visualize optic disc was recorded and difficulty of examination was assessed using a 10-point Likert scale. RESULTS: We recruited 101 subjects with a mean age of 2.8 years. Overall, there was a 20% absolute improvement in the success rate of visualizing the optic disc in the video versus non-video group (P < 0.001, 95%CI: 7.8% to 31%). Time to visualize optic disc was also improved (Δ5.3 seconds, P < 0.01, 95%CI: 1.4 to 9.1 seconds). Practitioners and caregivers noticed a 33% (P < 0.01, 95%CI: 21% to 44%) and 42% (P < 0.01, 95%CI: 30% to 56%) relative improvement in the ease of examination with video, respectively. CONCLUSIONS: The use of videos improved the ease, duration, and, most importantly, the success of fundoscopy in younger children. This simple, inexpensive adjunct has great potential to improve the ease and efficacy of this aspect of the neurological examination and allow fundoscopic examination to be effectively performed earlier in the age-appropriate vision screening protocols.

Spinal extradural arachnoid cyst presenting as recurrent abdominal pain.

INTRODUCTION: Spinal arachnoid cysts are an infrequently reported cause of abdominal pain in children. In this report, we describe the unusual case of an extradural arachnoid cyst presenting as recurrent abdominal pain in a pediatric patient without any signs of cord or nerve root compression. CASE REPORT: A 14-year-old girl with recurrent abdominal pain as the only symptom of a spinal extradural arachnoid cyst is reported. The patient was incidentally diagnosed with an intraspinal mass on abdominal computed tomography (CT) during the course of investigating her abdominal pain. Magnetic resonance (MR) imaging confirmed the diagnosis of a T11-L2 extradural arachnoid cyst. After resection of the T11-L2 arachnoid cyst, the patient's abdominal pain resolved. To our knowledge, this is the first report describing abdominal pain as the sole presenting feature of a spinal arachnoid cyst in the pediatric population. CONCLUSION: This case illustrates that abdominal pain may be the first and only presentation of spinal arachnoid cysts in children. Spinal pathology should be considered in the differential diagnosis of unexplained abdominal pain, even when there are no other symptoms of spinal disease.

Long-term outcome after selective dorsal rhizotomy in children with spastic cerebral palsy.

PURPOSE: The purpose of this study is to evaluate long-term outcomes after selective dorsal rhizotomy (SDR) for children with spastic cerebral palsy. METHODS: This is a retrospective review of a prospective database of patients who underwent SDR at British Columbia Children's Hospital. Hip adductor spasticity, hip range of motion (ROM), quadriceps strength, and motor function were assessed pre-operatively, at 6 months to 5 years and more than 10 years postoperatively. Patients were stratified by Gross Motor Function Classification System (GMFCS) level into group 1 (GMFCS II and III) and group 2 (GMFCS IV and V). RESULTS: Forty-four patients, with mean age at SDR of 4.5 years (range 2.9-7.7), were followed for a mean 14.4 years. Spasticity (Modified Ashworth Scale) decreased 1.5 (p < 0.0001) by early postoperative evaluation with further decrease at late evaluation of 0.8 (p < 0.0001). Early improvement in hip ROM of 13.7 degrees (p < 0.0001) was not sustained at late assessment. Motor function improved in both groups at early assessment but was only sustained in group 1. Group 1 increased 10.0 points (p < 0.0001) at early evaluation with subsequent decrease of 3.5, resulting in an overall increase of 6.6 (p = 0.04) from baseline. Group 2 patients had an initial increase of 8.3 [2.0, 14.6] (p = 0.01) but then declined to 4.9 below baseline (p = 0.3). CONCLUSIONS: SDR yields durable reduction in spasticity after 10 years. Early improvements in motor function are present, but at long-term follow-up, these improvements were attenuated in GMFCS II and III and were not sustained in GMFCS IV and V.

Video diversion during fundoscopic examination in children: a randomized controlled trial.

Fundoscopy is an important aspect of a neurological examination but can be challenging in uncooperative children. This study explored whether viewing a video during examination improves the success, duration, and ease of pediatric fundoscopy. This single-practitioner, randomized study involved 60 patients aged 1 to 8 years. Patients were randomized (by eye examined) to the treatment group (video-assisted) or control group (no video). A caregiver and the practitioner ranked the level of difficulty of each examination. There was a 28% improvement in the success rate of visualizing the optic disc (P < .001). Further analysis showed a 48% improvement in the success rate in children aged 1 to 4 years (P < .001) but no difference in children aged 5 to 8 years (P = .23). Time needed to visualize the optic disc also improved (Δ16.3 s, P < .001). Improvement in the ease of examination (P < .001) was noted by both the practitioner and caregiver. This simple adjunct has the potential to improve the efficacy of this aspect of the pediatric neurological examination.

Evaluating the benefits of second-eye cataract surgery among the elderly.

UNLABELLED: The aim of this systematic review was to synthesize and appraise the evidence of benefits of second-eye cataract extraction for visual function, patient-reported quality of life, falls, and driving ability among the elderly. We conducted a comprehensive search in MEDLINE using "surgery," "cataract extraction," "second eye," and "bilateral." Ten studies met the inclusion and quality criteria. We found "moderate" evidence supporting improvement in stereopsis, stereoacuity, and anisometropia over and above the benefits of first-eye surgery. We also found "moderate" evidence supporting improvement in visual acuity, contrast sensitivity, and self-reported visual functioning. Studies included in the review do not provide definitive evidence of second-eye surgery benefits on health-related quality of life, visual fields, falls prevention, and driving performance. However, the heterogeneity of outcome measures and the limited number of studies likely contributed to our findings. The findings have implications for clinicians and policymakers in the health-care industry and emphasize the need for additional trials examining this important and widely performed clinical procedure. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Neurological morbidity of surgical resection of pediatric cerebellar astrocytomas.

BACKGROUND: Review of children with low-grade cerebellar astrocytoma (LGCA) prior to 1992 showed a 98% rate of gross total resection (GTR) but a concerning incidence of permanent neurological dysfunction. The purpose of this study was to determine the rate of GTR of LGCA since 1992 and frequency of neurologic injury. METHODS: Retrospective review of children with LGCA was performed. CT/MR scans were rereviewed to assess extent of resection. Primary outcomes included incidence of GTR and incidence of permanent new neurological deficits. Other outcomes included late effects severity score (LESS), Bloom score for functional status, and educational assessment. RESULTS: Of 50 LGCA, GTR was achieved in 38 (76%) compared to 43 of 44 (98%) prior to 1992 (p < 0.004). Permanent new neurologic deficits from surgery occurred in 16% compared to 18% in the prior era (p = 0.61). For 35 patients operated on by the 2 surgeons in the prior study, 74% had GTR, with permanent neurological deficits in 8.6%. At latest follow-up, all patients were alive, 16% with residual tumor. LESS was two or less (mild or no deficit) in 94%. Bloom score was one or two (no or mild disability) in 90%. Eighty-six percent attended normal school. CONCLUSIONS: Less aggressive resection of LGCA in children may reduce postoperative neurologic deficits in the hands of the same surgeons as in the prior study but not overall at our institution. The good long-term outcomes suggest that it may be appropriate to do incomplete resection rather than risk additional neurological deficit.

Polo-like kinase 1 inhibition kills glioblastoma multiforme brain tumor cells in part through loss of SOX2 and delays tumor progression in mice.

Glioblastoma multiforme (GBM) ranks among the deadliest types of cancer and given these new therapies are urgently needed. To identify molecular targets, we queried a microarray profiling 467 human GBMs and discovered that polo-like kinase 1 (PLK1) was highly expressed in these tumors and that it clustered with the proliferative subtype. Patients with PLK1-high tumors were more likely to die from their disease suggesting that current therapies are inactive against such tumors. This prompted us to examine its expression in brain tumor initiating cells (BTICs) given their association with treatment failure. BTICs isolated from patients expressed 110-470 times more PLK1 than normal human astrocytes. Moreover, BTICs rely on PLK1 for survival because the PLK1 inhibitor BI2536 inhibited their growth in tumorsphere cultures. PLK1 inhibition suppressed growth, caused G(2) /M arrest, induced apoptosis, and reduced the expression of SOX2, a marker of neural stem cells, in SF188 cells. Consistent with SOX2 inhibition, the loss of PLK1 activity caused the cells to differentiate based on elevated levels of glial fibrillary acidic protein and changes in cellular morphology. We then knocked glial fibrillary acidic protein (GFAP) down SOX2 with siRNA and showed that it too inhibited cell growth and induced cell death. Likewise, in U251 cells, PLK1 inhibition suppressed cell growth, downregulated SOX2, and induced cell death. Furthermore, BI2536 delayed tumor growth of U251 cells in an orthotopic brain tumor model, demonstrating that the drug is active against GBM. In conclusion, PLK1 level is elevated in GBM and its inhibition restricts the growth of brain cancer cells.

Bull bars and vulnerable road users.

OBJECTIVES: Pedestrian injuries are a leading cause of the global death and injury burden, accounting for 65 percent of the 1.2 million annual road deaths. The purpose of this brief literature review is to examine whether bull bars, a rigid aftermarket accessory fitted to the front end of passenger vehicles, increase the risk of severe and fatal injuries to vulnerable road users in the event of a collision. METHODS: Applicable peer-reviewed research, review papers, and grey literature were identified from a search of MEDLINE; the Transportation Research Board (TRB) database composed of Transportation Research Information Services (TRIS) and International Transport Research Documentation (TRID) databases; the Cochrane Database of Systematic Reviews; and Google Scholar. The following search terms were used: "bull bars" OR "nudge bars" OR "sahara bars" AND "pedestrians" OR "vulnerable road users" for 1948 to March 1, 2011. A secondary set of search terms was also included "bull bars" OR "nudge bars" OR "sahara bars" OR "vehicle frontal protective systems" AND "pedestrians" OR "vulnerable road users" for 1948 to March 1, 2011. RESULTS: Neither the MEDLINE search nor the Cochrane Review search returned any relevant literature. The TRID search returned 19 research articles, 9 of which were included. Searches using Google Scholar returned 110 items, of which 21 were included in the present review after excluding patents and citations. Seven of the articles from TRID were also found in the Google Scholar search, resulting in 23 unique articles being included in this review. The studies used included 12 real-world studies, 3 computer modeling studies, and 8 laboratory testing studies. Very few studies examined the road safety of pedal-cyclists and motorcyclists; therefore, we focused solely on studies examining pedestrian safety. CONCLUSIONS: The literature reviewed in this study indicates that vehicles fitted with bull bars, particularly those without deformable padding, concentrate crash forces over a smaller area of vulnerable road users during collisions compared to vehicles not fitted with a bull bar. Rigid bull bars, such as those made from steel or aluminum, stiffen the front end of vehicles and interfere with the vital shock absorption systems designed in vehicle fronts. These devices therefore significantly alter the collision dynamics of vehicles, resulting in an increased risk of pedestrian injury and mortality in crashes. This literature review shows that bull bars do indeed increase the severity of injuries to vulnerable road users in the event of a collision and highlights the need for current traffic safety policies to reflect the safety concerns surrounding the use of bull bars.

Natural history of untreated syringomyelia in pediatric patients.

OBJECT: The natural history of syringomyelia in pediatric patients remains uncertain. Although symptomatic and operative cases of syringomyelia are well studied, there are fewer articles in the literature on the nonoperative syrinx and its clinical and radiological course. The purpose of this research was to analyze the natural history of untreated syringomyelia in pediatric patients presenting with minimal neurological symptoms. METHODS: A review of the neurosurgery database at British Columbia's Children's Hospital identified all pediatric patients (< 18 years of age) with syringes identified on MR imaging. Patients were included in this study if they had at least 2 MR images of the spine, at least 1 year apart, while receiving nonoperative treatment. Magnetic resonance imaging was used to determine changes in the size of the syrinx over time. Clinic notes were analyzed to establish demographic and clinical features and to determine any clinical changes over time. RESULTS: A total of 17 patients were included in the study. Symptoms at presentation were often mild and included limb numbness (3 cases), headaches (2 cases), mild sensory deficits (2 cases), mild motor deficits (3 cases), and intermittent incontinence (7 cases). The consultant neurosurgeon believed that the syrinx was not contributing to the symptoms in these 17 patients. The syrinx either remained unchanged (7 cases) or diminished in size (8 cases) in a total of 15 patients (88%). In the remaining 2 patients the authors noted an increase in syrinx size, in 1 of whom the clinical course also worsened. Both of these patients had a Chiari malformation and subsequently underwent craniocervical decompression. Overall, the mean change was -0.7 mm of maximal axial diameter (range -2.6 to +2.7 mm). Sixteen patients (94%) exhibited no worsening of symptoms over time. CONCLUSIONS: Syringomyelia often remains stable in patients receiving nonoperative treatment. However, given that 2 (12%) of 17 syringes in this series enlarged, it is likely appropriate to include periodic imaging in the follow-up of these cases.