A multicenter study of factors influencing cerebrospinal fluid shunt survival in infants and children.

OBJECTIVES: To identify factors influencing the duration of cerebrospinal fluid shunt survival after initial placement and after subsequent revisions. METHODS: We conducted a retrospective cohort study using the Pediatric Health Information System database, which contains resource use data from 37 tertiary care children's hospitals. Children younger than 18 years who underwent initial cerebrospinal fluid placement between January 1, 2000, and December 31, 2005, were eligible. RESULTS: During the study period, 20.2, 7.5, and 6.9% of 7399 patients required one, two, or three or more shunt revisions, respectively. Shunt survival rates were lower with each subsequent shunt revision. In multivariable Cox proportional hazards analysis, children undergoing shunt placement in the Northeast census region had a longer duration of shunt survival between initial placement and both the first (adjusted hazard ratio, 0.74; 95% confidence interval, 0.55-0.99) and second (adjusted hazard ratio, 0.66; 95% confidence interval, 0.51-0.86) revisions. Young age and a principal diagnosis of obstructive hydrocephalus were also associated with a higher risk of failure after initial placement; age-related variation in shunt survival persisted after the first but not the second revision. Among patients with multiple shunt revisions, those with early revision (i.e., revision <60 d after placement) had a shorter shunt survival time after subsequent revisions (adjusted hazard ratio for second revision, 1.30; 95% confidence interval, 1.11-1.52). CONCLUSIONS: Regional variation in the risk of ventricular shunt revision exists, and young infants are at the highest risk for shunt failure. Risk factors for the duration of shunt survival differ between the initial and subsequent revisions.

Toxicity profile of delayed high dose sodium thiosulfate in children treated with carboplatin in conjunction with blood-brain-barrier disruption.

PURPOSE: To assess the safety of delayed high dose intravenous (i.v.) sodium thiosulfate (STS) in a case series of 12 children with malignant brain tumors who were treated with intraarterial (i.a.) carboplatin in conjunction with blood-brain-barrier disruption (BBBD). METHODS: Twelve children ages 17 months-12 years underwent a total of 132 BBBD chemotherapy treatments and also received delayed high dose STS (i.v.). Dose 1 of STS (10-16 g/m(2)) was administered 2 or 4 hr after carboplatin, and a second STS dose was administered 4 hr after dose 1 if the child had impaired baseline hearing. Toxicity data were graded in accordance with the National Cancer Institute Common Toxicity Criteria (Version 2). Audiologic monitoring to evaluate the otoprotective potential of STS was performed on 11 children. Ototoxicity was defined in accordance with the American Speech-Language-Hearing Association (ASHA) criteria. Baseline and end of treatment hearing status were graded using Brock's criteria. RESULTS: Nausea and vomiting were well controlled with anti-emetics administered approximately 30 min prior to STS infusion. Analogous to results in adult patients, there was mild transient hypernatremia and a trend for improved protection from ototoxicity in children who received STS delayed to 4 hr post-treatment versus 2 hr. Tumor responses were seen in heavily pre-treated patients with relatively chemo-resistant tumors, suggesting that STS did not protect the tumor from platinum cytotoxicity. CONCLUSION: High dose STS is well tolerated in children under 12 years of age. Further studies of STS in children are warranted to assess otoprotection and the impact of STS on platinum mediated efficacy.

Vagus nerve stimulator implantation in children.

BACKGROUND: Vagus nerve stimulation was approved in 1997 as an adjunctive treatment of partial-onset seizures refractory to medical therapy. Subsequent to the initial clinical trials, few studies have been published specifically addressing perioperative management issues. OBJECTIVES: To review the operative technique and perioperative management of patients undergoing vagus nerve stimulator implantation and to analyze complications and their management. DESIGN: Retrospective medical record review and survey of patients who underwent implantation. SETTING: A tertiary care pediatric hospital in Kansas City, Mo. PATIENTS: One hundred two patients aged 21 months to 40 years. INTERVENTION: Vagus nerve stimulator implantation and lead placement. MAIN OUTCOME MEASURES: The surgical technique of vagus nerve stimulator implantation is presented in detail. Perioperative complications are enumerated, and strategies for their management are described. A subjective patient survey addresses some quality-of-life issues and the effect on swallowing and voice. RESULTS: One hundred two patients successfully underwent vagus nerve stimulator implantation. Three patients experienced infection of the chest wound holding the generator and required explantation. These 3 patients underwent reimplantation within 2 months after the infection had cleared. Most patients experience some degree of hoarseness when the generator is activated, but this symptom usually does not significantly affect the ability to communicate. Responses to questions regarding quality of life are positive. CONCLUSIONS: Vagus nerve stimulator implantation has a low incidence of serious complications. Quality of life seems to be improved for most patients. Modifications to the surgical procedure must be considered when performing the implantation on a young patient.