Cauda equina syndrome with surgical intervention in pregnancy during the periviable period.

INTRODUCTION: Cauda equina syndrome (CES) following lumbar disc herniation is exceedingly rare in pregnancy and there is limited literature outlining management of CES in pregnancy. There is further limited data addressing the management of periviable pregnancies complicated by CES. CASE PRESENTATION: A 38-year-old female at 22 weeks gestation presented with worsening lower back pain radiating to the right posterior lower extremity. She was initially managed with conservative therapy, but re-presented with worsening neurologic symptoms, including fasciculations and perineal numbness. Magnetic resonance imaging showed a large herniated disc at L4-5, and given concern for CES, she underwent emergent decompression surgery, which was complicated by a superficial wound dehiscence. She ultimately carried her pregnancy to term and had a cesarean delivery. The patient's residual neurologic symptoms continued to improve with physical therapy throughout the postpartum period. DISCUSSION: Cauda equina syndrome is a rare spinal condition with potentially devastating outcomes if not managed promptly. Diagnosis and management of CES in pregnancy is the same as in non-pregnant patients, however, standardization of patient positioning for surgery, surgical approach, anesthetic use, and fetal considerations is lacking. A multidisciplinary approach is critical, especially at periviable gestational ages of pregnancy. Our case and review of the literature demonstrates that patients in the second trimester can be managed surgically with prone positioning, intermittent fetal monitoring, and continued management of the pregnancy remains unchanged. Given the rarity of these cases, there is a need for a consensus on management and continued care in pregnant patients with CES.

The Effect of Health Insurance on Pediatric Cancer Survival: An Analysis of Children Evaluated for Radiation Therapy in Diverse Multicenter Health Systems.

BACKGROUND: Understanding the role of health insurance in cancer survival in a diverse population of pediatric radiation oncology patients could help to identify patients at risk of adverse outcomes. MATERIALS AND METHODS: Data were collected from cancer patients evaluated for radiation therapy, age < 19, diagnosed from January 1990 to August 2019. Predictors of recurrence-free survival (RFS) and overall survival (OS) were analyzed by univariable and multivariable Cox regression. Variables included health insurance, diagnosis type, sex, race/ethnicity, and socioeconomic status deprivation index. RESULTS: The study included 459 patients with a median diagnosis age of 9 years. Demographic breakdown was 49.5% Hispanic, 27.2% non-Hispanic White, and 20.7% non-Hispanic Black. There were 203 recurrences and 86 deaths observed over a median follow-up of 2.4 years. Five-year RFS was 59.8% (95% CI, 51.6, 67.0) versus 36.5% (95% CI, 26.6, 46.6), and 5-year OS was 87.5% (95% CI, 80.9, 91.9) versus 71.0% (95% CI, 60.3, 79.3) in private pay insurance versus Medicaid/Medicare, respectively. Multivariable showed Medicaid/Medicare patients experienced a 54% higher risk of recurrence (hazard ratio: 1.54, 95% CI, 1.08, 2.20) and 79% higher risk of death (hazard ratio: 1.79, 95% CI, 1.02, 3.14) than privately insured patients. CONCLUSIONS: Significant disadvantages in RFS and OS were identified in radiation oncology patients with Medicaid/Medicare insurance, even after adjusting for clinical and demographic variables.

Effects of Cancer Treatment on the Education and Cognition of South Florida Pediatric Cancer Survivors.

Purpose As pediatric cancer survival rates have exponentially increased in the past decade, with the vast majority surviving five years or more, the long-term impacts of treatment on the quality of survivorship must be explored. This study examines the effects of pediatric cancer treatment regimens on education outcomes among a demographically diverse regional population. The primary objective is to identify potential factors that may impact the educational and cognitive quality of life in this population.  Methods Four hundred sixty-eight pediatric oncology patients diagnosed at age <20 between January 1990 - August 2019 and treated for cancer with radiation therapy at a large public or a multi-center private hospital in South Florida were identified. A novel survey available in English and Spanish was electronically distributed at least three times to each patient from August 2020 - July 2021 via email, phone call, and text message. Variables relating to demographics, treatment, cognitive impairment, and school re-entry were collected through the survey and electronic medical record review. Descriptive statistical analysis was performed.  Results Of the patients, 10.5% responded to the survey (26 male, 21 female, two unidentified sex). The mean age was 8.9 years old (range 0-20) at diagnosis, 24.0 years old (range 8-39) at the time of survey completion, and 55.1% self-identified as Hispanic. Nearly one-quarter of respondents (22.4%) were unable to correctly identify the treatment modalities they received; Hispanic self-identifying patients were 1.75 times more likely than non-Hispanic patients to incorrectly report the treatment modalities received. One-quarter (26.5%) of respondents reported long-term cognitive deficits post-treatment, of which, over three-quarters (76.9%) identified as Hispanic.  Conclusion This study illuminates patients' perspectives on their long-term cognitive impacts after pediatric cancer treatment. Given the diverse study population, ethnic disparities in post-treatment survivorship were explored. A substantial subset of Hispanic participants was unable to correctly identify their treatment regimen, and a disproportionately large group of Hispanic patients experienced cognitive long-term cognitive deficits, suggesting that ethnic disparities play a critical role in post-treatment survivorship. Further research on prioritizing educational intervention during and after treatment is essential to improving both the quality and equity of survivorship among pediatric oncology patients.