Pediatric Intracranial Hypotension and Post-Dural Puncture Headache.

Pediatric intracranial hypotension can occur acutely following iatrogenic dural puncture for diagnostic or therapeutic purposes, or chronically from cerebrospinal fluid leak. The incidence of intracranial hypotension in children is not fully known. However, many steps can be taken to reduce the risk of a child developing a post-dural puncture headache. Other causes of intracranial hypotension, such as spontaneous intracranial hypotension or CSF fistulas, are rare and with little pediatric data to guide evaluation and management. This manuscript reviews the risk factors, diagnostic evaluations, and treatments for post-dural puncture headache, as well as a limited discussion of spontaneous intracranial hypotension as it may pertain to children and adolescents.

In-circuit high-frequency jet ventilation to reduce organ motion in a child undergoing sarcoma ablation.

Patients with primary or metastatic solid tumours can be treated with minimally invasive image-guided procedures as an alternative to surgical resection. Reducing organ motion during these procedures is crucial so that tumours can be accurately targeted and treatment delivered within a small margin, limiting potential damage to adjacent structures. As ventilation is the main cause of motion, there has been a shift from conventional ventilation towards the use of in-circuit high-frequency jet ventilation techniques for these procedures. We present the case of a 7-year-old who required computed tomography-guided microwave ablation of a right lung metastatic nodule under general anaesthesia. The patient's lungs were ventilated with in-circuit high-frequency jet ventilation in order to provide optimum conditions for ablation. The treatment was successfully completed and she was discharged home the following day. High-frequency jet ventilation is regularly used in our institution for adult computed tomography-guided treatments and to our knowledge, this application has not been described yet in a child this young. Our experience suggests that this technique can be safely used in paediatric patients, though further investigation of the optimum parameters for in-circuit high-frequency jet ventilation in this population is warranted.

Transition guidelines: An important step in the future care for childhood cancer survivors. A comprehensive definition as groundwork.

Evidence-based clinical practice guidelines are essential to ensure that childhood cancer survivors at risk of chronic health conditions receive effective long-term follow-up care. However, adult survivors of childhood cancer are not always engaged in recommended health promotion and follow-up practices, as many centres do not have a formal transition programme that prepares survivors and their families for successful transfer from child-centred to adult-oriented healthcare. The need for a specific pan-European guideline for the transition of care for childhood cancer survivors has been recognised. The first step is to define the concept of transition of care for survivors of childhood cancer based on existing evidence.

Recommendations of the OARSI FDA Osteoarthritis Devices Working Group.

Osteoarthritis (OA) is the most common type of arthritis and a major cause of chronic musculoskeletal pain and functional disability. While both pharmacologic and non-pharmacologic modalities are recommended in the management of OA, when patients with hip or knee OA do not obtain adequate pain relief and/or functional improvement, joint replacement surgery or other surgical interventions should be considered. Total joint arthroplasties are reliable and cost-effective treatments for patients with significant OA of the hip and knee. Evidence from cohort and observational studies has confirmed substantial improvements in pain relief with cumulative revision rates at 10 years following total hip (THA) and total knee arthroplasties (TKA) at 7% and 10%, respectively. Joint replacements have been used in most every synovial joint, although results for joints other than hip and knee replacement have not been as successful. The evolution of new device designs and surgical techniques highlights the need to better understand the risk to benefit ratio for different joint replacements and to identify the appropriate methodology for evaluating the efficacy and optimal outcomes of these new devices, designed to treat OA joints.

Cerebrospinal fluid eosinophilia in dogs.

BACKGROUND: Marked eosinophilic meningitis or meningoencephalomyelitis (EME) is rarely reported in dogs and the cause is usually undetermined. Long-term prognosis for dogs with cerebrospinal fluid (CSF) eosinophilia is variable. ANIMALS: Twenty-three client-owned dogs. METHODS: Retrospective case series. Dogs with eosinophilic CSF, defined as total nucleated cell count (TNCC) >3 cells/microL with >20% eosinophils, were identified by a computerized search of all dogs having cisternal and/or lumbar CSF analyzed as part of the diagnostic workup between 1992 and 2007. RESULTS: TNCC in CSF ranged from 4 to 4,740 cells/microL (median 84 cells/microL, reference range

Lumbar cerebrospinal fluid in dogs with type I intervertebral disc herniation.

BACKGROUND: Cerebrospinal fluid (CSF) in dogs with Hansen type I intervertebral disc herniation (IVDH) is classically described as normal or mildly inflammatory with a predominance of large mononuclear cells or neutrophils in severe acute herniations. However, we have observed a moderate to marked pleocytosis with a predominance of lymphocytes in some dogs with IVDH. HYPOTHESIS: Moderate to marked CSF pleocytosis occurs more commonly in dogs with type I IVDH than is reported in the literature. Lymphocytic predominance is more common than nonlymphocytic pleocytosis in dogs with chronic IVDH. ANIMALS: Four hundred twenty-three client-owned dogs with type I IVDH. METHODS: Retrospective study. Lumbar CSF of dogs with surgically confirmed type I IVDH was evaluated cytologically. Information obtained from medical records included signalment, prior clinical history, time from onset of signs to presentation, neurologic status, and intraoperative findings. Dogs with prior history and/or intraoperative evidence consistent with chronic IVDH before an acute herniation were termed acute-on-chronic (AOC). RESULTS: Pleocytosis (> 5 cells/uL) was present in 51% of dogs, including 23% with cervical IVDH and 61% with thoracolumbar IVDH. Moderate or marked inflammation (> or = 20 cells/uL) was identified in the CSF of 51% of dogs with thoracolumbar IVDH and pleocytosis. A predominance of lymphocytes was significantly more common in dogs examined > 7 days from onset of signs (P= .032) and in dogs with AOC IVDH (P= .0013). CONCLUSIONS AND CLINICAL IMPORTANCE: Moderate to marked CSF pleocytosis in dogs with type I IVDH is more common than previously reported. Lymphocytic pleocytosis is most common in dogs with chronic progression or AOC IVDH. Lymphocytic inflammation in the CSF of some dogs might suggest an immune-mediated response to chronically herniated disc material.

Questionnaire study of canine neutering techniques taught in UK veterinary schools and those used in practice.

OBJECTIVES: To gather information about the different techniques employed in general practice and to compare this with current undergraduate teaching. This would provide an insight into any areas of discrepancy and influences on technique in practice. METHODS: A questionnaire was composed and distributed to 407 practices throughout the UK, using a commercial mailing list. Fifty further questionnaires were distributed by final-year students to their foster practices and five were sent to practices on request. A second questionnaire was composed and sent to the members of staff responsible for teaching surgical neutering techniques at each of the UK veterinary schools. RESULTS: Completed questionnaires were received from 183 respondents. These were compared with seven questionnaires from university teachers. Only areas in which the teachers reached a consensus of opinion were directly compared. CLINICAL SIGNIFICANCE: Several areas of discrepancy between current teaching and techniques in practice were identified. A study of complications compared with technique would provide further information. There is a lack of published material or an evidence base in many aspects of surgical neutering to support one technique over another.

Standardizing contact investigation protocols.

SETTING: The State of Alabama Department of Public Health Division of Tuberculosis Control. OBJECTIVE: To standardize contact investigation protocols and implement an intervention to increase TB field worker adherence to the protocols with the goal of promoting efficiency and effectiveness in contact investigations. DESIGN: A process evaluation of existing data collection and management systems and protocols was performed. Standardized protocols and an intervention to increase TB field worker adherence to the protocols were created and pilot tested. These were then implemented and formative evaluation data were collected. RESULTS: The process evaluation revealed considerable variance among field workers with regard to protocols and definitions of variables related to contact investigations. Protocols were standardized and an intervention targeted at TB field workers was developed. The intervention consisted of a training workshop and the development of a computer-based contact investigation module. This was successfully implemented throughout the state. CONCLUSIONS: To perform effective contact investigations and conduct studies to improve the effectiveness of these investigations, TB control programs must pay careful attention to precisely defining variables and concepts related to the contact investigation. Furthermore, protocols must be standardized and resources devoted to training of TB field workers to ensure adherence to protocols.

The Knee Society Index of Severity for failed total knee arthroplasty: development and validation.

Compared with primary knee replacement, total knee arthroplasty revision surgery is a more complex procedure and accounts for greater expenditures of healthcare resources at each clinical stage. Overall, patients having revision procedures have poorer functional outcomes and higher complication rates than patients having primary arthroplasty. Despite the expanded scope of revision problems and the rapidly emerging technology in revision surgery, the long-term success of any method remains in question. Because there is little consensus on the timing of revision surgery, optimal surgical reconstruction, and the type of prosthesis to be implanted, the Knee Society began development of an Index of Severity for Failed Total Knee Arthroplasty. Fifty-four percent of Knee Society members completed an 82-item questionnaire that determined their clinical impression about potential risk factors for the outcomes of revision surgery for failed total knee replacements. Using these results, a consensus group developed the final version of the index. The result of the nominal group process was the Knee Society Index of Severity, which was based on eight distinct domains. Each domain was divided into attributes and weights based on the questionnaire responses and consensus meeting. Actual case scenarios from five institutions were used to test interrater reliability and validity. The interrater reliability of the average score of all ratings was 0.95; the correlation of the criterion rating with the mean rating was 0.77. When three outliers were not included, the Pearson product correlation increased to 0.92. These data support the application of the Knee Society Index of Severity as a critical component of risk factor studies, effectiveness research, and cost-effectiveness analysis involving revisions of total knee replacements.

The Knee Society Index of Severity for failed total knee arthroplasty: practical application.

Previous classifications of severity for total knee arthroplasty revisions have been based largely on bone loss of the femur and tibia. These approaches failed to address the more technically difficult issues in revision surgery such as surgical exposure, contractures, extremity alignment, implant removal, soft tissue stability (in the anteroposterior and in the sagittal planes), extensor mechanism integrity, and patellar revisability. Through the Knee Society, the authors developed a severity index that incorporated these latter factors into one measure. The current authors describe the application of the Knee Society Index of Severity for failed total knee arthroplasty and its method of scoring.

Alterations in the patella after a high tibial or distal femoral osteotomy.

Knee osteotomies realign the knee in an attempt to better distribute forces across the knee. The anatomic and physiologic function of the extensor mechanism, which includes the quadriceps tendon, patella, and patella ligament, may be altered during this procedure. An understanding of these changes is important especially when additional surgery becomes necessary, such as a conversion to a total knee arthroplasty. The current authors discuss patella mechanics and changes in the patella associated with osteotomies about the knee and the influence on normal patella biomechanics. Although patella changes are uncommon after a distal femoral osteotomy, poor total knee arthroplasty outcomes after a high tibial osteotomy attributable to patella alterations exist. Surgical technique during the primary high tibial osteotomy and the conversion to the total knee arthroplasty can reliably improve the final outcome. Rigid internal fixation with early knee mobilization after high tibial osteotomy reduces the incidence of patella baja and improves total knee arthroplasty outcome after a high tibial osteotomy, whereas while patella changes after a distal femoral osteotomy are minimal and largely ignored.

Total knee arthroplasty after open reduction and internal fixation of fractures of the tibial plateau: a minimum five-year follow-up study.

BACKGROUND: There is little information in the literature regarding the outcome of total knee arthroplasty following open reduction and internal fixation of fractures of the tibial plateau. The goal of this study was to evaluate the results of such procedures after a minimum of five years of follow-up. METHODS: We retrospectively analyzed the outcomes of fifteen total knee arthroplasties performed at an average of 38.6 months (range, eight months to eleven years) after open reduction and internal fixation of a fracture of the tibial plateau in fifteen consecutive patients. The average duration of follow-up after the total knee arthroplasty procedures was 6.2 years (range, 5.4 to 11.1 years). The average age of the patients was fifty-six years (range, thirty-seven to sixty-eight years) at the time of the arthroplasty. We evaluated the outcomes on the basis of the Hospital for Special Surgery knee score, the Short Form-36 score, and radiographs of the knees. RESULTS: The average Hospital for Special Surgery knee score was 51 points (range, 20 to 74 points) before the arthroplasty, and it increased to 80 points (range, 44 to 91 points) postoperatively. Four knees were scored as excellent, eight had a good result, one was rated as fair, and two had a poor result. The average Short Form-36 scores were 58.0 points for general health, 72.4 points for bodily pain, 72.1 points for mental health, 58.3 points for physical functioning, 84.6 points for physical role functioning, 81.0 points for social functioning, and 57.7 points for vitality. The average active postoperative arc of motion was 105 degrees (range, 70 degrees to 135 degrees ) compared with 87 degrees (range, 20 degrees to 125 degrees ) preoperatively. Incomplete radiolucencies were noted on all of the postoperative radiographs made after the total knee arthroplasties. There was a high rate of infection (three patients), patellar tendon disruption (two patients), and postoperative secondary procedures (three patients required closed manipulation). The patients with infection were considered to have a failure of treatment: two required arthrodesis, and one required a two-stage exchange. CONCLUSION: On the basis of our results, we concluded that total knee arthroplasty after open reduction and internal fixation of a fracture of the tibial plateau decreases pain and improves knee function, but the procedure is technically demanding and is associated with a high failure rate (five of fifteen).

Evaluation of school-based HIV prevention education programs in New Jersey.

This paper presents results from a process evaluation conducted by the New Jersey Department of Education (NJDOE). Representative samples of middle and high school superintendents, principals, lead health teachers, and HIV teachers provided information assessing whether local district policy content was consistent with the state's policy code, the dynamics of local policy development, and school district staff perceptions and practices regarding HIV education policies. NJDOE also was interested in determining: if inservice training was accessible to teachers assigned to provide HIV education; the scope and impact of HIV inservice programs; and the training needs of staff assigned to teach the HIV curriculum. Finally, NJDOE was interested in determining: local curricula scope, sequence, and approach; the extent to which local curricula were skills-based; and local expectations for instructional outcomes. As a result of the evaluation, program staff identified areas needing remediation and planned for program improvement in new areas.