Pediatric Neurosurgery Patients Need More than a Pediatric Neurosurgeon. Part II. A Clinical Report: In the USA Lack of Parent/Caregiver Compliance Interferes with the Patient Care Sequence.

We have previously reported on the initiation, development, and preliminary results of a comprehensive multidisciplinary team for the long-term management of children with neurosurgical conditions other than spina bifida. This report addresses the follow-up of the care of these patients and identifies limitations in the care sequence including, but not limited to, lack of parental/caregiver compliance, unmet educational needs, and medical insurance issues.

The value of head circumference measurements after 36 months of age: a clinical report and review of practice patterns.

OBJECT The cranium is documented to grow from birth through adolescence. The standard of practice in primary care is measuring head circumference and plotting growth using curves that stop at 36 months. The authors report the importance of their experience with measuring head circumference in the child and same-sex parent beyond 36 months. METHODS In the University of Florida genetics and pediatric neurosurgery clinics, head circumference is measured and plotted on growth charts through 18 years of age. Circumference and rate of growth over time are compared with those of the same-sex parent. A diagnostic workup is initiated if there is a discrepancy with the patient's head circumference or if there is significant change in the growth rate of the cranium. RESULTS Between January 2004 and December 2007, the lead author examined 190 patients referred by pediatricians and/or pediatric subspecialists because of the concerns regarding head size of the child. Neuroimaging was performed in 70% of the patients prior to referral. None of the patients had their head size compared with that of their same-sex parent prior to referral. On assessing referring physician responses as to why the same-sex parents, head measurements were not pursued prior to imaging or referral to the specialists, the results were: 1) only have head circumference sheets to 36 months of age (n = 28); 2) the American Academy of Pediatrics does not recommend it (n = 3); and 3) the head stops growing at 36 months of age (n = 2). CONCLUSIONS Pediatricians and pediatric subspecialists need instruction on head circumference measurement in children from infancy through adolescence, and when indicated, in comparison with the head size of the same-sex parent. This measurement may be an effective and inexpensive assessment tool.

Pediatric neurosurgery patients need more than a neurological surgeon: a clinical experience.

The Division of Pediatric Neurosurgery of the University of Florida College of Medicine Jacksonville initiated and developed a multidisciplinary comprehensive team for the management of patients with a neurosurgical condition other than spina bifida. This report relates the rationale and stages of development of a multidisciplinary team to facilitate the health care and special needs of these children.

Creating a working group for prenatal diagnosis and management as a venue to facilitate neurosurgery health care delivery.

BACKGROUND/AIMS: To facilitate the communication and engagement with the parents of a fetus with a neurosurgical condition, as well as subsequent care of the newborn, the Division of Pediatric Neurosurgery of the University of Florida College of Medicine Jacksonville created a multidisciplinary working group. METHODS: The University of Florida Division of Pediatric Neurosurgery performed a staged process to develop a multidisciplinary prenatal working group. Phase I: establish communications with perinatology, neonatology and radiology. Phase II: initiate clinical working sessions with neurosurgery, neonatology, perinatology, radiology. Phase III: the working sessions were progressively expanded to include other specialties of interest. RESULTS: This report addresses the development and the subsequent monthly meetings that were held between March 2004 and October 2008. There were a total of 246 pregnancies in which a significant fetal condition was present. Of these, 53 generated neurosurgical consultations on the basis of fetal imaging (ultrasound and/or MRI). Those that required postnatal surgery were able to have timely coordinated scheduled delivery and subsequent neurosurgical procedures. CONCLUSIONS: If neurosurgeons do not have access to a multidisciplinary prenatal working group, they may take the lead and facilitate the establishment of such a team approach. This can lead to better prenatal communications with the parents/families, coordination of delivery and timely postnatal neurosurgical management.

Advanced registered nurse practitioners and physician assistants in the practice of pediatric neurosurgery: a clinical report.

OBJECTIVE: This report addresses the clinical experience of the Division of Pediatric Neurosurgery with dedicated nurse practitioners and a physician assistant (PA) in outpatient and inpatient health care delivery, including surgical activities, as well as participation with the neurosurgery call schedule, quality improvement, teaching, and clinical research activities. METHODS: We report on the activities of allied health personnel in the Division of Pediatric Neurosurgery for the purpose of identifying the current and future role for health care delivery, related to the care of the child with a neurosurgical condition. This addresses the participation of 2 advanced registered nurse practitioners (ARNPs) and a PA in the outpatient and inpatient setting, call schedule, interventions in and out of the operating room, quality improvement sessions, continuing medical education, clinical research, clinical databases, presentations in meetings, teaching, and scientific publications. RESULTS: This report covers the period from September 2003 (when the division was initiated) to February 2011. The division currently consists of 3 pediatric neurosurgeons, 2 ARNPs and 1 PA. The ARNPs/PA have participated in the pediatric neurosurgery clinic held 5 half-days per week, the monthly multidisciplinary clinics (Spinal Defects Clinic, Pediatric Neurosciences Clinic, and the Fetal Diagnosis and Therapy Center working group), and inpatient care, as well as assisting in operative interventions. They participated in the on-call schedule and attended the monthly quality improvement sessions of the division in addition to presenting papers and topics in the monthly continuing medical education session. The PA maintained a computerized database of operative interventions, coding, morbidities, and outcomes. All were involved in teaching activities. They prepared preoperative and postoperative orders and practice guidelines, and they were also involved in the preparation of the database of institutional clinical research projects. They have presented posters in a total of 9 national and 2 international meetings, and have co-authored 8 manuscripts published in peer review journals. CONCLUSION: The ARNP/PA members have been active participants in all functions of the Division of Pediatric Neurosurgery. They have facilitated the work of the faculty in day-to-day activities and enhanced the scope of divisional activities, providing a team approach for the care of the patients, families, and caretakers.

Titanium screws as fiducial markers for image-guided stereotactic proton irradiation in pediatric central nervous system tumors: a technical report.

OBJECTIVES: Fiducial markers (FM) have been used to enhance the accuracy of radiation therapy in central nervous system (CNS) tumors. Recently, image-guided radiotherapy utilizing FM has been used in proton therapy of CNS tumors. We describe our surgical technique of placement of titanium screws as cranial FM in children undergoing proton therapy for CNS tumors. METHODS: Records of children undergoing cranial fiducial placement for proton therapy were reviewed. Details of the adjuvant treatment of their CNS tumors were examined. Indications for placement of the FM, the technique of placement as well as the operative data and complications were reviewed. RESULTS: Twelve children, aged 10 months to 16 years (mean: 7.6 years), underwent FM placement. When available, the patients had their proton irradiation as part of or according to Children's Oncology Group protocols. All patients had implantations of FM onto bilateral frontal and parietal bone sites, using commercial titanium screws, in a noncollinear fashion. Ten operations were performed on an outpatient basis. There were no surgery-related complications. FM facilitated the cranial alignment for targeting of proton irradiation in all patients. CONCLUSIONS: Commercially available titanium screws can be used as FM for cranial proton radiotherapy. The procedure can be done quickly and safely on an outpatient basis. Pediatric neurosurgeons can perform this procedure on their patients at their home institutions to facilitate treatment at regional proton therapy centers.