Comparative study between ventriculosubgaleal shunt and external ventricular drain for management of post infective hydrocephalus among pediatrics.

PURPOSE: Post infective hydrocephalus (PIH) is a type of hydrocephalus which occurs after an infection of the brain or cerebrospinal fluid (CSF). Treatment of PIH requires temporary measures such as external ventricular drain (EVD) and ventriculosubgaleal shunt (VSGS) until CSF becomes clear and ready to implement VP shunt. Limited research has been done to explore the tradeoff between these approaches particularly in pediatric PIH patients. Our study compares the complications, mortality rates, and the cost of used resources of both procedures. METHODS: A prospective study was conducted for 18 months in which we compared between VSGS and EVD for management of PIH involving 42 randomized cases with 21 patients in group A operated by VSGS and 21 patients in group B operated by EVD. RESULTS: Our results show a statistically significant difference between both groups in the duration of implementation of VSGS/EVD until resolution of infection occurs. Additionally, a higher rate of pediatric intensive care unit (PICU) admission and a longer length of hospital stay (LOS) were recorded among the EVD group. No statistically significant difference between the number of complications that happened in both despite variations in their forms. Moreover, both groups showed nearly similar mortality rates. CONCLUSION: There is no significant difference in the rate of complications between VSGS and EVD for PIH. Based on that, VSGS emerges as a favorable and cost-effective option for the management of PIH which leads to less economic burden on patients and the country's health resources, especially in developing countries.

Toxoplasma gondii: Seroprevalence and association with childhood brain tumors in Egypt.

BACKGROUND: Childhood brain tumors are a significant global health challenge, yet the etiology of these tumors remains elusive. While research has identified potential risk factors, recent studies have explored the involvement of infectious agents, particularly Toxoplasma gondii (T. gondii), in brain tumor development. METHODS: This study aimed to explore the prevalence of T. gondii infection in children diagnosed with brain tumors and to investigate the potential association between T. gondii infection and childhood brain tumors in Egypt. A total of 64 children with brain tumors and 92 healthy controls were enrolled in this study. Demographics and risk factors data were collected using structured questionnaires. Serological assay using ELISA technique was performed to detect anti-T. gondii antibodies in both cases and control groups. RESULTS: This study revealed a significantly higher seroprevalence of T. gondii infection in brain tumor cases (62.5 %) compared to healthy controls (38 %). Furthermore, a strong association was observed between T. gondii seropositivity and childhood brain tumors (odds ratio: 2.7). Notably, the consumption of unwashed vegetables emerged as a significant risk factor for T. gondii infection in Egypt. Analysis of T. gondii seroprevalence across different subtypes of brain tumors revealed varying rates, with glioma cases displaying a striking 100 % seroprevalence. CONCLUSIONS: These findings support the hypothesis that T. gondii infection may be a risk factor for childhood brain tumors and emphasize the need for further research in this area. The study also highlights the potential implications of control of T. gondii infection for prevention and treatment of childhood brain tumors.

Diagnostic and prognostic utility of TROP-2, SLP-2, and CXCL12 expression in papillary thyroid carcinoma.

BACKGROUND: Papillary thyroid carcinoma (PTC) is the most frequent thyroid malignancy. Histopathological examination is widely accepted as the gold standard test for the diagnosis of PTC. However, the histopathological examination sometimes can't differentiate PTC from other thyroid diseases. Differentiating PTC from other thyroid diseases is essential for a therapeutic approach and prognosis. OBJECTIVES: The current study was performed to investigate the utility of TROP-2, SPL-2, and CXCL12 mRNA and protein expression in discriminating PTC from other thyroid diseases that mimic PTC. METHODS: The current study was performed on 75 cases of surgically resected thyroid glands. The cases were distributed in two groups: the PTC group and the non-PTC group. The PTC group consisted of 35 cases (25 patients of the classic PTC variant and 10 patients of the PTC follicular variant). The non-PTC group consisted of 40 cases (10 cases were multinodular goiter, 5 cases were Graves' disease, 5 cases were Hashimoto thyroiditis, 15 patients were follicular adenoma (FA) and 5 cases were follicular carcinoma). TROP-2, SPL-2, and CXCL12 mRNA expression were estimated by qRT-PCR, and protein expression was estimated by immunohistochemistry. RESULTS: There were upregulated TROP-2, SPL-2, and CXCL12 mRNA and protein expressions in PTC compared to non-PTC (P< 0.001, for each). There was a statistically significant upregulation in the mRNA expression of the three genes among PTC cases with larger tumor sizes (P< 0.001, for each), those with tumor stages III and IV (P= 0.008, 0.002 and < 0.001 respectively), and those with LN metastasis (P< 0.001, for each). Moreover, there was a statistically significant upregulation in CXCL-12 gene expression among PTC cases with extra-thyroid extension (P< 0.001). CONCLUSION: mRNA expression of TROP-2, SPL-2, and CXCL12 among PTC cases increased in larger tumor size, tumor stages III and IV, and LN metastasis. Moreover, there was an increase in CXCL-12 gene expression among PTC cases with extra-thyroid extension. Thus, TROP-2, SPL-2, and CXCL12 expressions could be possible diagnostic and prognostic markers in PTC.

Preterm infants with positive conjunctival swab culture: risk factors and association with late-onset sepsis-a retrospective cohort study.

Introduction: Purulent conjunctival discharge in hospitalized preterm infants may indicate conjunctivitis and warrant treatment. The purpose of this study was to examine the relationship between positive conjunctival swab (CS) culture and late-onset sepsis (LOS) in preterm infants. Methods: A retrospective cohort study was conducted to determine the relationship between positive CS culture growth results (CSP) obtained in preterm infants ≤34 weeks' gestation and the development of LOS within 120 h of obtaining CS compared with those who had negative CS culture results (CSN). Electronic medical records were reviewed from January 2015 until December 2019 for preterm infants presenting with purulent conjunctival discharge and underwent CS culture testing due to suspected conjunctivitis. Results: Of the 234 CS cultures obtained during the study period, 145 (61.9%) were CSP compared to 89 (38.1%) CSN cultures. Gram-negative organisms accounted for 70% of all CSP cultures, with the remaining 30% being Gram-positive. Patients with CSP were smaller, younger, had lower 1-minute APGAR scores, and required respiratory support more frequently than those with CSN. Infants with CSP received antibiotics for longer periods, both topically and systemically. Infants who developed LOS were more likely to require invasive ventilation (adjusted odds ratio, 33.5; 95% CI, 2.52-446.5, p = 0.008). The incidence of LOS between the two groups was similar, with 6.2% observed in the CSP group compared to 3.4% in the CSN group (p = 0.543). Similarly, the rates of bacteremia were similar in both groups. Of the CSP patients who were presented with bacteremia, four out of seven (57%) exhibited bacteremia caused by the same organism found in their CS cultures. Similarly, within the entire cohort, respiratory cultures were performed on nine intubated patients within two weeks of obtaining CS cultures. Of these, in the CSP group, five out of six (83%) showed an organism identical to that found in the CS cultures. Conclusion: The study found a significant proportion of positive CS cultures in preterm infants, with distinct patient characteristics and treatment compared to negative cultures. While the incidence of LOS was not significantly different between the two groups, some CSP patients demonstrated bacteremia with the same CS organism, suggesting a possible connection between conjunctival or respiratory colonization and bacteremia.

Does the antimicrobial-impregnated peripherally inserted central catheter decrease the CLABSI rate in neonates? Results from a retrospective cohort study.

Background: The use of antimicrobial-impregnated peripherally inserted central catheters (PICCs) has been introduced in the last few years to neonatal units aiming to reduce central line-associated bloodstream infection (CLABSI). Methods: This retrospective observational study aimed to compare the CLABSI rates and other catheter-related parameters including the insertion success rates and catheter-related complications in the antimicrobial-impregnated and conventional (ordinary) PICCs in NICU between 2017 and 2020. Results: Our dedicated PICC team including physicians and nurses inserted 1,242 conventional (PremiCath and NutriLine) and 791 antimicrobial-impregnated PICCs (PremiStar) over the study period from 2017 to 2020. Of those 1,242 conventional PICCs, 1,171 (94.3%) were 1 Fr single lumen and only 71 (5.7%) were 2 Fr double lumen. The mean ± SD [median (IQR)] for the birth weight in all babies who had a PICC line was 1,343.3 ± 686.75 [1,200 (900, 1,500)] g, while the mean ± SD for the gestational age was 29.6 ± 4.03 [29 (27, 31)] weeks. The mean ± SD [median (IQR)] age at the time of insertion for all catheters was 9.3 ± 21.47 [2 (1, 9)] days, while the mean ± SD [median (IQR)] dwell time was 15.7 ± 14.03 [12 (8, 17)] days. The overall success rate of the PICC insertion is 1,815/2,033 (89.3%), while the first attempt success rate is 1,290/2,033 (63.5%). The mean ± SD [median (IQR)] gestational age, birth weight, age at catheter insertion, and catheter dwell time were 28.8 ± 3.24 [29, (26, 31)] weeks, 1,192.1 ± 410.3 [1,150, (900, 1,450)] g, 6.3 ± 10.85 [2, (1, 8)] days, and 17.73 ± 17.532 [13, (9, 18)] days in the antimicrobial-impregnated catheter compared with 30.1 ± 4.39 [29, (27, 32)] weeks (P < 0.001), 1,439.5 ± 800.8 [1,240, (920, 1,520)] g (P < 0.001), 11.1 ± 25.9 [1, (1, 9)] days (P < 0.001), and 14.30 ± 10.964 [12, (8, 17)] days (P < 0.001), respectively, in the conventional PICCs. The use of the antimicrobial-impregnated catheter was not associated with any significant reduction in the CLABSI rate (per 1,000 days dwell time), either the overall [P = 0.11, risk ratio (RR) (95% CI): 0.60 (0.32, 1.13)] or the yearly CLABSI rates. Conclusions: The use of miconazole and rifampicin-impregnated PICCs did not reduce the CLABSI rate in neonates compared with conventional PICCs. However, it has a higher overall rate of elective removal after completion of therapy and less extravasation/infiltration, occlusion, and phlebitis compared with the conventional PICCs. Further large RCTs are recommended to enrich the current paucity of evidence and to reduce the risk of bias. Neonatal PICCs impregnation by other antimicrobials is a recommendation for vascular access device manufacturers.

Ventriculosubgaleal shunt as a proposed technique for post-infectious hydrocephalus.

BACKGROUND: The management of post-infectious hydrocephalus (PIH) remains challenging for neurosurgeons. It requires a temporary diversion procedure till the normalization of CSF parameters prior to the permanent one. Ventriculosubgaleal shunt (VSGS) was widely used in pediatric cases with post-hemorrhagic hydrocephalus (PHH). However, its role in PIH is still lacking. This study was done to elucidate the safety and efficacy of VSGS as a temporary CSF diversion procedure before the permanent one in patients with PIH. PATIENTS AND METHODS: This retrospective investigation analyzed the data of 50 consecutive cases who underwent VSGS for PIH. RESULTS: The age of the included patients ranged between 1 and 10 months. Twenty-six cases had meningitis and or ventriculitis (52%), while the remaining had shunt infection. At follow-up, arresting of hydrocephalus was noted in ten patients (20%), while another 36 cases required the permanent diversion procedure within 35 days. Regarding the shunt complications, scalp infection, tissue breakdown, and shunt exposure were encountered in ten cases (20%), while CSF leakage was noted in 12 cases (24%). Shunt migration was noted in only two patients (4%). Shunt revision was needed in 16 cases (32%). Mortality was encountered in four cases (8%) because of sepsis. Risk factors for morbimortality included younger age, lower weight, male gender, and meningitis and or ventriculitis. CONCLUSION: VSGS is a safe and effective procedure in infants awaiting definitive VPS for postinfectious hydrocephalus. It was proven that VSGS has shortened the hospital stay and the economic burden on the country.

The Use of a Hemi Glabellar Flap for Reconstruction of Medial Canthus Defects.

BACKGROUND:  Medial canthal reconstruction is a challenging task due to its complex anatomy. The glabellar flap is a common viable technique; however, this results in narrowing of the eyebrows, bulky nasal dorsum horizontal scarring, which is aesthetically displeasing, and possible injury of the supratrochlear artery. Multiple variations have been proposed in the literature, which is often complex. In this paper, the senior author (AK) has developed an intuitive, simple technique by utilising half of the glabellar skin in 12 patients with good clinical outcomes. MATERIALS AND METHODS:  A rotational advancement flap involving the upper lateral nasal wall with the hemi glabellar was formed and transferred to the medial canthal defect. The donor site was closed in a V-Y manner. Complete closure of defect was achieved in all patients. RESULTS:  Reconstruction using the hemi glabellar technique was performed on 12 patients following resection of basal cell carcinoma (BCC) in or near the medial canthus area. Superficial cellulitis was noted in two patients; they were managed on oral antibiotics. Bruising was reported in seven patients which resolved spontaneously in 4-7 days. All patients had a good outcome at two months and six months follow up; there was no flap loss, and all patients were satisfied with the aesthetic outcome. CONCLUSION:  The technique highlighted in this article can be performed quickly and applies to the reconstruction of medial canthus defects with excellent aesthetic outcomes, an inconspicuous scar and supple skin with matching colour.

Efficiency of decompressive craniectomy as a line of management of severe cerebral venous thrombosis.

OBJECTIVE: Cerebral venous thrombosis (CVT) is a rare pathology with life threatening consequences, most of these fatal complications are due to raised intracranial pressure due to venous infarction and cerebral swelling, the purpose of this study is to evaluate the efficiency of decompressive craniectomy for favorable outcome. METHODS: A retrospective analysis of clinical, radiological and surgical data of patients who underwent decompressive craniectomy for CVT in a tertiary referral hospital between the years 2016 through 2020. RESULTS: The study included 7 patients, female predominance was noted (5/7), mean age was 18.14 years. Mean Glasgow coma score (GCS) at surgery was 8.26, good clinical outcome was achieved for the majority of cases 71.4%, and one case of mortality 14.28%. CONCLUSIONS: Decompressive craniectomy is a life saving procedure for patients with severe brain swelling as a sequela of CVT, majority of patients (71.4%) showed favorable functional outcome by 6 months postoperatively.

Effect of Optimizing Oxygen Saturation Targets on the Incidence of Retinopathy of Prematurity in a Quaternary NICU.

Introduction: Retinopathy of prematurity (ROP) is a multifactorial disease and a preventable cause of blindness in childhood. Hyperoxia and hypoxia can cause retinal neovascularization resulting in retinal detachment and blindness if left untreated. Besides oxygen treatment, other reasons for ROP development are well known. We prospectively adopt various strategies to keep oxygen saturation (SpO2) within targets, between 91 and 95% for those on supplemental oxygen. By adapting this, we postulated that the incidence of severe ROP might be reduced. Methods: 2018-2019 provided pre-intervention and 2020 post-intervention data for the project. For all babies (≤32 weeks, ≤1,500 g with FiO2 >0.21), target SpO2 between 91 and 95% was measured as a percentage of time spent within and outside target SpO2 during 1-4 weeks of life. Results: 112 and 60 preterm neonates were screened for ROP during the pre- and post-intervention phase. Twenty neonates (18.3%) during pre-intervention and 16 (26.7%) in the post-intervention phase developed severe ROP requiring treatment. Despite a statistically significant increase of 10 percent points in time spent within target SpO2 (91-95%) in the post-intervention phase (p < 0.05), the incidence of severe ROP did not decline. Using a multivariate model, odds of ROP development decreased with gestational age (25%) while increasing with PDA requiring treatment (4.33 times) and glucose ≥10 mg/dL (4.15 times), considering one variable at a time, keeping others constant. Conclusion: Our QI project showed successful attainment of maximum time; the SpO2 remained within targets during supplemental oxygen; however, the incidence of severe ROP had not declined. Factors other than SpO2 might be responsible for a high incidence of ROP in our neonatal intensive care unit.

Reintubation rates after extubation to different non-invasive ventilation modes in preterm infants.

INTRODUCTION: Respiratory Distress Syndrome (RDS) is a common cause of neonatal morbidity and mortality in premature newborns. In this study, we aim to compare the reintubation rate in preterm babies with RDS who were extubated to Nasal Continuous Positive Airway Pressure (NCPAP) versus those extubated to Nasal Intermittent Positive Pressure Ventilation (NIPPV). METHODS: This is a retrospective study conducted in the Neonatal Intensive Care Unit (NICU) of Women's Wellness and Research Center (WWRC), Doha, Qatar. The medical files (n = 220) of ventilated preterm infants with gestational age ranging between 28 weeks 0 days and 36 weeks + 6 days gestation and extubated to non-invasive respiratory support (whether NCPAP, NIPPV, or Nasal Cannula) during the period from January 2016 to December 2017 were reviewed. RESULTS: From the study group of 220 babies, n = 97 (44%) babies were extubated to CPAP, n = 77 (35%) were extubated to NIPPV, and n = 46 (21%) babies were extubated to Nasal Cannula (NC). Out of the n = 220 babies, 18 (8.2%) were reintubated within 1 week after extubation. 14 of the 18 (77.8%) were reintubated within 48 h of extubation. Eleven babies needed reintubation after being extubated to NCPAP (11.2%) and seven were reintubated after extubation to NIPPV (9.2%), none of those who were extubated to NC required reintubation (P = 0.203). The reintubation rate was not affected by extubation to any form of non-invasive ventilation (P = 0.625). The mode of ventilation before extubation does not affect the reintubation rate (P = 0.877). The presence of PDA and NEC was strongly associated with reintubation which increased by two and four-folds respectively in those morbidities. There is an increased risk of reintubation with babies suffering from NEC and BPD and this was associated with an increased risk of hospital stay with a P-value ranging (from 0.02-0.003). Using multivariate logistic regression, NEC the NEC (OR = 5.52, 95% CI 1.26, 24.11, P = 0.023) and the vaginal delivery (OR = 0.23, 95% CI 0.07, 0.78, P = 0.018) remained significantly associated with reintubation. CONCLUSION: Reintubation rates were less with NIPPV when compared with NCPAP, however, this difference was not statistically significant. This study highlights the need for further research studies with a larger number of neonates in different gestational ages birth weight categories. Ascertaining this information will provide valuable data for the factors that contribute to re-intubation rates and influence the decision-making and management of RDS patients in the future.

Verbal Dominant Memory Impairment and Low Risk for Post-operative Memory Worsening in Both Left and Right Temporal Lobe Epilepsy Associated with Hippocampal Sclerosis.

Post-operative memory changes after temporal lobe surgery have been established mainly by group analysis of cognitive outcome. This study investigated individual patient-based memory outcome in surgically-treated patients with mesial temporal lobe epilepsy (TLE). This study included 84 consecutive patients with intractable TLE caused by unilateral hippocampal sclerosis (HS) who underwent epilepsy surgery (47 females, 41 left [Lt] TLE). Memory functions were evaluated with the Wechsler Memory Scale-Revised before and at 1 year after surgery. Pre-operative memory function was classified into three patterns: verbal dominant memory impairment (Verb-D), visual dominant impairment (Vis-D), and no material-specific impairment. Post-operative changes in verbal and visual memory indices were classified into meaningful improvement, worsening, or no significant changes. Pre-operative patterns and post-operative changes in verbal and visual memory function were compared between the Lt and right (Rt) TLE groups. Pre-operatively, Verb-D was the most common type of impairment in both the Lt and Rt TLE groups (65.9 and 48.8%), and verbal memory indices were lower than visual memory indices, especially in the Lt compared with Rt TLE group. Vis-D was observed only in 11.6% of Rt and 7.3% of Lt TLE patients. Post-operatively, meaningful improvement of memory indices was observed in 23.3-36.6% of the patients, and the memory improvement was equivalent between Lt and Rt TLE groups and between verbal and visual materials. In conclusion, Verb-D is most commonly observed in patients with both the Lt and Rt TLE associated with HS. Hippocampectomy can improve memory indices in such patients regardless of the side of surgery and the function impaired.