OBJECT The rate of CSF shunt failure remains unacceptably high. The Hydrocephalus Clinical Research Network (HCRN) conducted a comprehensive prospective observational study of hydrocephalus ...management, the aim of which was to isolate specific risk factors for shunt failure. METHODS The study followed all first-time shunt insertions in children younger than 19 years at 6 HCRN centers. The HCRN Investigator Committee selected, a priori, 21 variables to be examined, including clinical, radiographic, and shunt design variables. Shunt failure was defined as shunt revision, subsequent endoscopic third ventriculostomy, or shunt infection. Important a priori-defined risk factors as well as those significant in univariate analyses were then tested for independence using multivariate Cox proportional hazard modeling. RESULTS A total of 1036 children underwent initial CSF shunt placement between April 2008 and December 2011. Of these, 344 patients experienced shunt failure, including 265 malfunctions and 79 infections. The mean and median length of follow-up for the entire cohort was 400 days and 264 days, respectively. The Cox model found that age younger than 6 months at first shunt placement (HR 1.6 95% CI 1.1-2.1), a cardiac comorbidity (HR 1.4 95% CI 1.0-2.1), and endoscopic placement (HR 1.9 95% CI 1.2-2.9) were independently associated with reduced shunt survival. The following had no independent associations with shunt survival: etiology, payer, center, valve design, valve programmability, the use of ultrasound or stereotactic guidance, and surgeon experience and volume. CONCLUSIONS This is the largest prospective study reported on children with CSF shunts for hydrocephalus. It confirms that a young age and the use of the endoscope are risk factors for first shunt failure and that valve type has no impact. A new risk factor-an existing cardiac comorbidity-was also associated with shunt failure.
INTRODUCTION A 2003–2011 National Inpatient Sample (NIS) study revealed that low socioeconomic status (SES) patients were less likely to receive timely-reperfusion during acute ischemic stroke (AIS) ...treatment. Mechanical thrombectomy (MT) allows a wider treatment window which may improve access to timely treatment. METHODS Patients with primary ICD-9-diagnosis code for AIS were identified from 2012–2015 NIS. Primary outcomes were timely-treatment (admission day MT/tPA), timely-MT (admission day MT), and functional outcome (“bad” = death or long-term facility disposition). Primary variable was zip code median income quartile (“4” = highest income). Covariates included age, race, gender, distance to hospital (home rurality versus hospital rurality), comorbidities, stroke severity, hospital size/region, payer, and transfer status. Multiple logistic regression was utilized to model timely-treatment and timely-MT within overall population, and functional outcome within MT-treated subset. RESULTS Total of 40,935 AIS patients were included (median age 70, 47.4% female, 73.3% White). Total of 25,402 (62.1%) patients received timely-treatment, while 4,126 (10.1%) received timely-MT. Income quartile-4 (OR = 1.21.0-1.3, P = .007) was associated with timely-treatment after adjustment. Income quartile-4 was associated with timely-MT (OR = 1.21.1-1.3, P = .002), but lost significance after adjustment with distance to hospital. Within both populations, low SES groups had > 4-fold increased rate of rural-to-urban hospital travel (P < .001). Within MT cohort, income quartile-3 was associated with better functional outcome (OR = 1.21.0-1.5, P = .047), but lost significance after adjustment. CONCLUSION Low SES was associated with lower rate of any timely-treatment, but was not associated with timely-MT or functional outcomes after adjustment. With increasing MT utilization, improving transfer rules, and “Get With the Guidelines” efforts, it will be important to continue measuring nationwide changes in SES disparities within AIS treatment.
Diaphragm paralysis (DP) complicates the postoperative course of neonates and infants undergoing cardiac surgery. Events causing DP remain poorly understood, and preventive strategies remain elusive. ...This retrospective cohort analysis aims to test the hypothesis that chest tubes in contact with the phrenic nerve in the pleural apex may cause pressure palsy.
In late 2018, the chest tube positioning strategy was changed so as to avoid a putative “danger zone” configuration, defined as (1) the chest tube looping apicomedially at the level of the second right intercostal space, and (2) wedging of chest tube tip against pericardium. A preintervention and postintervention analysis of 531 patients from 2012 to 2019 was performed to evaluate any association of chest tube position or duration in place with DP. Univariable and multivariable analyses were carried out, with significance set a priori at P < .05.
The preintervention group comprised 488 patients, of whom 32 (6.6%) had RDP. The postintervention group comprised 43 patients, none of whom had DP. Multivariable analysis of the entire cohort revealed chest tube positioning in the danger zone as the only significant association with RDP (odds ratio, 4.22; 95% confidence interval, 1.57-11.33; P < .05).
Chest tubes that occupy the right superior pleural space are associated with increased risk of DP.
531 patients underwent univariate and multivariate analysis to determine the risk factors of diaphragm paralysis. Display omitted
Abstract
BACKGROUND
Although many clinical risk factors of spastic cerebral palsy (CP) have been identified, the genetic basis of spastic CP is largely unknown. Here, using whole-genome genetic ...information linked to a deidentified electronic health record (BioVU) with replication in the UK Biobank and FinnGen, we perform the first genome-wide association study (GWAS) for spastic CP.
OBJECTIVE
To define the genetic basis of spastic CP.
METHODS
Whole-genome data were obtained using the multi-ethnic genotyping array (MEGA) genotyping array capturing single-nucleotide polymorphisms (SNPs), minor allele frequency (MAF) > 0.01, and imputation quality score (r2) > 0.3, imputed based on the 1000 genomes phase 3 reference panel. Threshold for genome-wide significance was defined after Bonferroni correction for the total number of SNPs tested (P < 5.0 × 10–8). Replication analysis (defined as P < .05) was performed in the UK Biobank and FinnGen.
RESULTS
We identify 1 SNP (rs78686911) reaching genome-wide significance with spastic CP. Expression quantitative trait loci (eQTL) analysis suggests that rs78686911 decreases expression of GRIK4, a gene that encodes a high-affinity kainate glutamatergic receptor of largely unknown function. Replication analysis in the UK Biobank and FinnGen reveals additional SNPs in the GRIK4 loci associated with CP.
CONCLUSION
To our knowledge, we perform the first GWAS of spastic CP. Our study indicates that genetic variation contributes to CP risk.
INTRODUCTION Intracranial atherosclerotic disease (ICAD) is responsible for 8–10% of acute ischemic stroke (AIS). Angioplasty and stenting have unproven efficacy for ICAD. Antiplatelet medical ...therapy is the mainstay, but resistance is highly prevalent. CYP2C19 gene loss-of-function (up to 45% of patients) causes clopidogrel resistance. METHODS From deidentified database of all medical records, patients were selected with ICD-9/10 code for ICAD, availability of CYP2C19 genotype, clopidogrel exposure, and established patient care. Dual-antiplatelet therapy patients were included. Patients with intracranial angioplasty/stenting, other primary neurovascular condition, prior ischemic stroke, or observation time <1 month were excluded. Time-to-event analysis using Cox regression was conducted to model first-time ischemic stroke events based on CYP2C19 loss-of-function allele and adjusted for age, gender, race, length of aspirin, length of concurrent antiplatelet/anticoagulant treatment, diabetes, coagulopathy, hypertension, heart disease, atrial fibrillation, and lipid disorder. RESULTS A total of 340 patients were included (median age 68, 58% male, 88% Caucasian, 26% CYP2C19 loss-of-function). A total of 37 patients (10.9%) suffered a first-time ischemic stroke during observation period. Median observation time was 2.82 IQR 1.13-5.25 years. Median length of concurrent aspirin use was 99% 96-100 of observation period. CYP2C19 loss-of-function allele was associated with ischemic stroke event (HR 2.2, 95% CI 1.1-4.3, P = .020) after adjustment. CONCLUSION CYP2C19 loss-of-function is associated with 2.2-fold increased risk of first-time ischemic stroke for ICAD patients during clopidogrel exposure. This genetic risk may have interacted with results of previous clinical trials, making it difficult to clearly interpret differences between medical and procedural management. These results may indicate a need for increased CYP2C19 testing to inform patient-specific selection of antiplatelet agent for ICAD. For ICAD patients with already-established CYP2C19 loss-of-function, clinicians should consider antiplatelet alternatives to clopidogrel for primary stroke prevention.
Recently, more neurosurgical residency programs have transitioned from a postgraduate year (PGY)-7 to a PGY-6 chief year. There has not been a national analysis of resident and program director ...perceptions regarding the timing of chief year conductance and its influence on overall program satisfaction.
An online survey was distributed to all North American PGY 4–7 residents and program directors. Data regarding program size, protected research timing, chief year timing (PGY-6 vs. PGY-7), and resident and program director perceptions of the influence of neurosurgical chief year timing on program satisfaction and ability of residents to practice were recorded. Survey results were summarized descriptively.
A total of 134 respondents completed the survey. Thirty-five percent of respondents reported a recent program transition from a PGY-7 to PGY-6 chief year while 44% of respondents at programs conducting a PGY-7 chief year reported they were interested in transitioning to a PGY-6 chief year. The large majority (76%) of respondents at PGY-6 chief year programs stated they were overall satisfied with this. A large percentage of all respondents reported that a PGY-6 chief year provided increased opportunity for subspecialty focus, enfolded fellowships and career planning.
Program directors and residents at PGY-6 chief year programs report a high level of satisfaction with close to half of those at PGY-7 programs desiring to make this transition. Most PGY-6 chief year respondents report that this model allows for greater subspecialty focus and career planning during the PGY-7 year.
OBJECTIVE Up to one-third of patients with a posterior fossa brain tumor (PFBT) will experience persistent hydrocephalus mandating permanent CSF diversion. The optimal hydrocephalus treatment ...modality is unknown; the authors sought to compare the durability between endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) therapy in the pediatric population. METHODS The authors conducted a systematic review of articles indexed in PubMed between 1986 and 2016 describing ETV and/or VPS treatment success/failure and time-to-failure rate in patients < 19 years of age with hydrocephalus related to a PFBT. Additionally, the authors conducted a retrospective review of their institutional series of PFBT patients requiring CSF diversion. Patient data from the systematic review and from the institutional series were aggregated and a time-to-failure analysis was performed comparing ETV and VPS using the Kaplan-Meier method. RESULTS A total of 408 patients were included from 12 studies and the authors' institutional series: 284 who underwent ETV and 124 who underwent VPS placement. The analysis included uncontrolled studies with variable method and timing of CSF diversion and were subject to surgeon bias. No significant differences between cohorts were observed with regard to age, sex, tumor grade or histology, metastatic status, or extent of resection. The cumulative failure rate of ETV was 21%, whereas that of VPS surgery was 29% (p = 0.105). The median time to failure was earlier for ETV than for VPS surgery (0.82 IQR 0.2-1.8 vs 4.7 months IQR 0.3-5.7, p = 0.03). Initially the ETV survival curve dropped sharply and then stabilized around 2 months. The VPS curve fell gradually but eventually crossed below the ETV curve at 5.7 months. Overall, a significant survival advantage was not demonstrated for one procedure over the other (p = 0.21, log-rank). However, postoperative complications were higher following VPS (31%) than ETV (17%) (p = 0.012). CONCLUSIONS ETV failure occurred sooner than VPS failure, but long-term treatment durability may be higher for ETV. Complications occurred more commonly with VPS than with ETV. Limited clinical conclusions are drawn using this methodology; the optimal treatment for PFBT-related hydrocephalus warrants investigation through prospective studies.
SARS-CoV-2 COVID-19, coronavirus, has created unique challenges for the medical community after national guidelines called for the cancellation of all elective surgery. While there are clear cases of ...elective surgery (benign cranial cosmetic defect) and emergency surgery (hemorrhage, fracture, trauma, etc.), there is an unchartered middle ground in pediatric neurosurgery. Children, unlike adults, have dynamic anatomy and are still developing neural networks. Delaying seemingly elective surgery can affect a child’s already vulnerable health state by further impacting their neurocognitive development, neurologic functioning, and potential long-term health states. The purpose of this paper is to demonstrate that “elective” pediatric neurosurgery should be risk-stratified, and multi-institutional informed guidelines established.
To examine the recent literature on psychologic comorbidities prevalent in youth living with adolescent idiopathic scoliosis (AIS)—including body image, eating behaviors, and mood disorders—to ...improve patient outcomes.
A comprehensive literature review was performed using the PubMed database. Eligible studies were extracted based on defined inclusion criteria, and the effects of AIS on psychologic comorbidities were evaluated. Studies were categorized and analyzed based on 3 recurrent themes: body image, eating behaviors, and mood.
Body image presents the most important link between psychosocial difficulties and AIS. Self-reported body image is a significant factor for successful treatment outcomes in AIS. As such, specific patient-reported outcome measures have recently been developed and validated to aid in the treatment of AIS. Although patients with AIS consistently demonstrate altered anthropometry compared with their healthy counterparts, links between these factors and pathologic behaviors, such as abnormal fear of gaining weight or disordered eating, are not clear. Equally unclear is the association between AIS and altered moods, notably depression and anxiety, because of the wide variety of disparate instruments used to measure mood disorders in patients with AIS.
Patients with AIS undergoing treatment often face psychosocial difficulties. Together, the current literature points to a growing understanding and appreciation of the psychosocial aspects of AIS, but a clear need for more study is needed to optimize treatment of these patients.
•Patients with AIS have significant issues with perceptions of body image.•Patients with AIS consistently demonstrate lower BMI without eating disorders.•Patients with AIS are at higher risk for mood disorders.•Patient-related outcome instruments have the potential to improve outcomes in AIS.
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