Ventriculoperitoneal shunt complications in an adult population: A comparison of various shunt designs to prevent overdrainage.

BACKGROUND: Overdrainage after cerebrospinal fluid diversion remains a significant morbidity. The hydrostatic, gravitational force in the upright position can aggravate this. Siphon control (SC) mechanisms, as well as programmable and flow regulating devices, were developed to counteract this. However, limited studies have evaluated their safety and efficacy. In this study, direct comparisons of the complication rates between siphon control (SC) and non-SC (NSC), fixed versus programmable, and flow- versus pressure regulating valves are undertaken. METHODS: A retrospective chart review was performed over all shunt implantations from January 2011 to December 2016 within the Houston Methodist Hospital system. Complication rates within 6 months of the operative date, including infection, subdural hematoma, malfunction, and any other shunt-related complication, were analyzed via Fisher's exact test, with P < 0.05 regarded as significant. Subgroup analyses based on diagnoses - normal pressure hydrocephalus (HCP), pseudotumor cerebri, or other HCP - were also performed. RESULTS: The overall shunt-related complication rate in this study was 19%. Overall rates of infection, shunt failure, and readmission within 180 days were 3%, 11%, and 34%, respectively. No difference was seen between SC and NSC groups in any complication rate overall or on subgroup analyses. When comparing fixed versus programmable and flow- versus pressure-regulating valves, the latter in each analysis had significantly lower malfunction and total complication rates. CONCLUSIONS: Programmable and pressure regulating devices may lead to lower shunt malfunction and total complication rates. Proper patient selection should guide valve choice. Future prospective studies may further elucidate the difference in complication rates between these various shunt designs.

Who Needs What? Perceptions of Patients and Caregivers in Oncology Phase 1 Trials.

BACKGROUND: The study design and nature of oncology phase 1 clinical trials create a uniquely vulnerable patient population yet little research has been conducted to identify the added burden these trials create for both cancer patients and their caregiver(s). OBJECTIVE: Examining the perceptions and needs of patients and their caregivers participating in phase 1 oncology clinical trials, the investigators tested the hypothesis that the caregiver will exhibit a higher level of burden and/or distress than the patient. METHOD: A mixed-methods exploratory process utilizing patient and caregiver interviews and quality-of-life questionnaires was used to assess the psychosocial burdens associated with oncology clinical trial participation. A qualitative and quantitative analysis of the responses were 8 performed. RESULT: Both patients and caregivers reported similar themes identifying the burdens and benefits related to phase 1 clinical trial participation. However, the caregivers' expressed burden exceeded that of the patients' validating the study's hypothesis. CONCLUSION: The need for ongoing additional support services for not only the patient but also the caregiver was identified.

Symptomatic, left-sided deep brain stimulation lead edema 6 h after bilateral subthalamic nucleus lead placement.

BACKGROUND: Deep brain stimulation (DBS) lead edema can be a serious, although rare, complication in the postoperative period. Of the few cases that have been reported, the range of presentation has been 33 h-120 days after surgery. CASE DESCRIPTION: We report a case of a 75-year-old male with a history of Parkinson's disease who underwent bilateral placement of subthalamic nucleus DBS leads that resulted in symptomatic, left-sided lead edema 6 h after surgery, which is the earliest reported case. CONCLUSIONS: DBS lead edema is noted to be a self-limiting phenomenon. It is critical to recognize the possibility of lead edema as a cause of postoperative encephalopathy even in the acute phase after surgery. Although it is important to rule out other causes of postoperative changes in the patient examination, the recognition of lead edema can help to avoid extraneous diagnostic tests or DBS lead revision or removal.

The health belief model and factors associated with adherence to treatment recommendations for positional plagiocephaly.

OBJECTIVE This study aimed to examine factors associated with adherence to recommended treatment among pediatric patients with positional skull deformity by reviewing a single-institution experience (2007-2014) with the treatment of positional plagiocephaly. METHODS A retrospective chart review was conducted. Risk factors, treatment for positional head shape deformity, and parent-reported adherence were recorded. Univariate and multivariate analyses were used to assess the impact of patient clinical and demographic characteristics on adherence. RESULTS A total of 991 patients under age 12 months were evaluated for positional skull deformity at the Texas Children's Hospital Cranial Deformity Clinic between 2007 and 2014. According to an age- and risk factor-based treatment algorithm, patients were recommended for repositioning, physical therapy, or cranial orthosis therapy or crossover from repositioning/physical therapy into cranial orthosis therapy. The patients' average chronological age at presentation was 6.2 months; 69.3% were male. The majority were white (40.7%) or Hispanic (32.6%); 38.7% had commercial insurance and 37.9% had Medicaid. The most common initial recommended treatment was repositioning or physical therapy; 85.7% of patients were adherent to the initial recommended treatment. Univariate analysis showed differences in adherence rates among subgroups. Children's families with Medicaid were less likely to be adherent to treatment recommendations (adherence rate, 80.2%). Families with commercial insurance were more likely to be adherent to the recommended treatment (89.6%). Multivariate logistic regression confirmed that factors associated with parent-reported adherence to recommended treatment included primary insurance payer, diagnosis (plagiocephaly vs brachycephaly), and the nature of the recommended treatment. Families were less likely to be adherent if they had Medicaid, a child with a diagnosis of brachycephaly, or were initially recommended for cranial orthosis therapy than families with commercial insurance, a child with a diagnosis of plagiocephaly, or an initial recommendation for repositioning or physical therapy. Factors associated with treatment completion included corrected age, insurance, diagnosis, recommended treatment, and distance to provider from patient's residence. Patients with commercial insurance (OR 1.49, 95% CI 1.10-2.02, p = 0.009), those diagnosed with both brachycephaly and plagiocephaly (OR 2.26, 95% CI 1.31-3.90, p = 0.003), those recommended for treatment with cranial orthosis (OR 4.55, 95% CI = 3.24-6.38, p < 0.001), and those living in proximity to the provider (OR 1.40, 95% CI 1.00-1.96, p = 0.047) were more likely to complete treatment. CONCLUSIONS Insurance type, degree of head shape deformity, and types of recommended treatment appear to affect rates of adherence to recommended treatments for positional skull deformation.

Factors influencing outcomes of the treatment of positional plagiocephaly in infants: a 7-year experience.

OBJECTIVE Following institution of the Back to Sleep Campaign, the incidence of sudden infant death syndrome decreased while the prevalence of positional skull deformation increased dramatically. The management of positional deformity is controversial, and treatment recommendations and outcomes reporting are variable. The authors reviewed their institutional experience (2008-2014) with the treatment of positional plagiocephaly to explore factors associated with measured improvement. METHODS A retrospective chart review was conducted with risk factors and treatment for positional head shape deformity recorded. Univariate and multivariate analyses were used to assess the impact of these variables on the change in measured oblique diagonal difference (ODD) on head shape surface scanning pre- and posttreatment. RESULTS A total of 991 infants aged less than 1 year were evaluated for cranial positional deformity in a dedicated clinical program. The most common deformity was occipital plagiocephaly (69.5%), followed by occipital brachycephaly (18.4%) or a combination of both deformities (12.1%). Recommended treatment included repositioning (RP), physical therapy (PT) if indicated, or orthotic treatment with a customized cranial orthosis (CO) according to an age- and risk factor-dependent algorithm that the authors developed for this clinic. Of the 991 eligible patients, 884 returned for at least 1 follow-up appointment. A total of 552 patients were followed to completion of their treatment and had a full set of records for analysis: these patients had pre- and posttreatment 2D surface scanner evaluations. The average presenting age was 6.2 months (corrected for prematurity for treatment considerations). Of the 991 patients, 543 (54.8%) had RP or PT as first recommended treatment. Of these 543 patients, 137 (25.2%) transitioned to helmet therapy after the condition did not improve over 4-8 weeks. In the remaining cases, RP/PT had already failed before the patients were seen in this program, and the starting treatment recommendation was CO. At the end of treatment, the measured improvements in ODD were 36.7%, 33.5%, and 15.1% for patients receiving CO, RP/PT/CO, and RP/PT, respectively. Univariate analysis showed that sex, race, insurance, diagnosis, sleep position preference, torticollis history, and multiple gestation were not significantly associated with magnitude of ODD change during treatment. On multivariate analysis, corrected age at presentation and type of treatment received were significantly associated with magnitude of ODD change. Orthotic treatment corresponded with the largest ODD change, while the RP/PT group had the least change in ODD. Earlier age at presentation corresponded with larger ODD change. CONCLUSIONS Earlier age at presentation and type of treatment impact the degree of measured deformational head shape correction in positional plagiocephaly. This retrospective study suggests that treatment with a custom CO can result in more improvement in objective measurements of head shape.

Massive sialadenitis resulting in critical airway after elective craniotomy: case report.

The authors report an unusual case of acute, rapidly progressive, unilateral neck swelling following extubation after elective left anterior temporal lobectomy with amygdalohippocampectomy. Due to severe neck swelling, the patient developed critical airway compromise, brachial plexopathy, and Horner's syndrome. After critical airway management and appropriate rehabilitation, the patient recovered completely and remains seizure free at 1.5 years of follow-up. This case highlights the importance of early recognition of acute postoperative sialadenitis and the steps needed to prevent serious morbidity and possible mortality from this rare complication.

Acute spinal cord injury associated with multilevel pediatric idiopathic intervertebral disc calcification: case report.

Pediatric idiopathic intervertebral disc calcification (PIIVDC) is a rare condition; most cases are reported to be selflimited with conservative management. In this study, we describe a case of PIIVDC presenting with acute incomplete spinal cord injury with Brown-Séquard-plus syndrome that was treated with surgery and demonstrate the subsequent rehabilitation time course.

Pre-ischemic exercise preserves cerebral blood flow during reperfusion in stroke.

INTRODUCTION: The neuroprotective nature of exercise has been well established and the mechanisms of this protection are still a subject of much research. This study aims to determine if cerebral blood flow is constituently higher during the ischemia or reperfusion events in stroke. MATERIALS AND METHODS: Adult male Sprague-Dawley rats were randomly assigned into exercise or non-exercise (control) groups. Exercised rats underwent 30 minutes of running on a treadmill for 3 weeks. A 2 hour unilateral middle cerebral artery occlusion using an intraluminal filament was performed to induce ischemic stroke, followed by a 24 hour reperfusion. A sham control without exercise and middle cerebral artery occlusion was used. Laser Doppler flowmetry (LDF) and (15)O-H(2)O positron emission tomography (PET) were used to determine cerebral blood flow, respectively. (18)F-fluorodeoxy-D-glucose was used to determine cerebral metabolism in some animals. Histological analysis determined infarct volume in the same animal after blood flow examination. RESULTS: LDF and PET both indicated that middle cerebral artery occlusion significantly (p<0.05) reduced cerebral blood flow during ischemia and reperfusion in association with reduced cerebral metabolism after stroke. However, pre-ischemic exercise significantly (p<0.05) improved cerebral blood flow during reperfusion, although cerebral blood flow remained at a similar level to that of the non-exercise stroke group during the middle cerebral artery occlusion. This improved cerebral blood flow during reperfusion was associated with decreased brain infarct volume. CONCLUSIONS: This study revealed that pre-ischemic exercise in rats improved cerebral blood flow during reperfusion, suggesting that exercise provides neuroprotection by partially ameliorating the 'no reflow' phenomenon in stroke.