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Hersh DS, Martin JE, Bristol RE, Browd SR, Grant G, Gupta N, Hankinson TC, Jackson EM, Kestle JRW, Krieger MD, Kulkarni AV, Madura CJ, Pindrik J, Pollack IF, Raskin JS, Riva-Cambrin J, Rozzelle CJ, Smith JL, Wellons JC. Hydrocephalus surveillance following CSF diversion: a modified Delphi study. J Neurosurg Pediatr 2022; 30:177-187. [PMID: 35901763 DOI: 10.3171/2022.5.peds22116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Long-term follow-up is often recommended for patients with hydrocephalus, but the frequency of clinical follow-up, timing and modality of imaging, and duration of surveillance have not been clearly defined. Here, the authors used the modified Delphi method to identify areas of consensus regarding the modality, frequency, and duration of hydrocephalus surveillance following surgical treatment. METHODS Pediatric neurosurgeons serving as institutional liaisons to the Hydrocephalus Clinical Research Network (HCRN), or its implementation/quality improvement arm (HCRNq), were invited to participate in this modified Delphi study. Thirty-seven consensus statements were generated and distributed via an anonymous electronic survey, with responses structured as a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). A subsequent, virtual meeting offered the opportunity for open discussion and modification of the statements in an effort to reach consensus (defined as ≥ 80% agreement or disagreement). RESULTS Nineteen pediatric neurosurgeons participated in the first round, after which 15 statements reached consensus. During the second round, 14 participants met virtually for review and discussion. Some statements were modified and 2 statements were combined, resulting in a total of 36 statements. At the conclusion of the session, consensus was achieved for 17 statements regarding the following: 1) the role of standardization; 2) preferred imaging modalities; 3) postoperative follow-up after shunt surgery (subdivided into immediate postoperative imaging, delayed postoperative imaging, routine clinical surveillance, and routine radiological surveillance); and 4) postoperative follow-up after an endoscopic third ventriculostomy. Consensus could not be achieved for 19 statements. CONCLUSIONS Using the modified Delphi method, 17 consensus statements were developed with respect to both clinical and radiological follow-up after a shunt or endoscopic third ventriculostomy. The frequency, modality, and duration of surveillance were addressed, highlighting areas in which no clear data exist to guide clinical practice. Although further studies are needed to evaluate the clinical utility and cost-effectiveness of hydrocephalus surveillance, the current study provides a framework to guide future efforts to develop standardized clinical protocols for the postoperative surveillance of patients with hydrocephalus. Ultimately, the standardization of hydrocephalus surveillance has the potential to improve patient care as well as optimize the use of healthcare resources.
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Affiliation(s)
- David S Hersh
- 1Division of Neurosurgery, Connecticut Children's, Hartford
- 2Department of Surgery, UConn School of Medicine, Farmington, Connecticut
| | - Jonathan E Martin
- 1Division of Neurosurgery, Connecticut Children's, Hartford
- 2Department of Surgery, UConn School of Medicine, Farmington, Connecticut
| | - Ruth E Bristol
- 3Division of Pediatric Neurosurgery, Department of Surgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Samuel R Browd
- 4Department of Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Gerald Grant
- 5Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Nalin Gupta
- 6Departments of Neurological Surgery and Pediatrics, University of California, San Francisco, California
| | - Todd C Hankinson
- 7Departments of Neurosurgery and Pediatrics, University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, Colorado
| | - Eric M Jackson
- 8Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John R W Kestle
- 9Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City
- 10Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Mark D Krieger
- 11Division of Neurological Surgery, Department of Surgery, Children's Hospital Los Angeles
- 12Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Abhaya V Kulkarni
- 13Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Casey J Madura
- 14Section of Neurosurgery, Division of Pediatric Neurosciences, Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Jonathan Pindrik
- 15Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus
- 16Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Ian F Pollack
- 17Department of Neurosurgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jeffrey S Raskin
- 18Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago
- 19Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jay Riva-Cambrin
- 20Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Curtis J Rozzelle
- 21Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham
- 22Department of Neurosurgery, Heersink School of Medicine, University of Alabama at Birmingham, Alabama
| | - Jodi L Smith
- 23Goodman Campbell Brain and Spine, Peyton Manning Children's Hospital at St. Vincent Ascension, Indianapolis, Indiana; and
| | - John C Wellons
- 24Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Pape L, Ernst G. Health care transition from pediatric to adult care: an evidence-based guideline. Eur J Pediatr 2022; 181:1951-1958. [PMID: 35084548 PMCID: PMC9056438 DOI: 10.1007/s00431-022-04385-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 12/01/2022]
Abstract
For consistent quality of treatment of young people with chronic health care needs, a structured health care transition (HCT) from pediatric medicine to adult medical care is essential. Currently, most countries have no guidelines on HCT based on systematic evidence research. To close this gap, guidance to support HCT was developed in Germany. Twenty-two experts in the management of adolescents and young adults with different chronic conditions and three patient representatives were invited to take part in the guideline group. Based on a systematic literature search recommendations for HCT were drafted. Where evidence was lacking, recommendations were developed using collective expert consensus. The consensus process was independently moderated using a Delphi approach. The final draft was reviewed and endorsed by all major German medical societies. The clinical recommendations provide guidance for all chronic somatic diseases. After assessment of HCT readiness, an individualized plan for HCT should be drawn up. Key elements here are a responsible coordinator, age-adapted patient education, involvement of caregivers, web-based interventions, joint visits, and a structured summary for the receiving physician. The aim is the gradual transfer of responsibility for disease management to the young person themselves. Conclusion: As only a few randomized controlled studies on HCT are available, evidence-based statements are possible for some but not all areas of HCT. However, this guideline may help to develop globally accepted standards. These standards should be established and implemented. The aim should be a reimbursement by individual national health systems to allow appropriate support for young people. What is Known: • Health care transition from pediatric to adult care is primarily organized in local settings, partly based on disease-specific guidelines. •There have been no national guidelines in Germany until now. What is New: • Here we present the general evidence-based guidelines of the German Association of Scientific Medical Societies for health care transition. • These might serve as a blueprint for further national or international health care transition guidelines.
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Affiliation(s)
- Lars Pape
- Society for Transition Medicine, Hannover, Germany
- Children’s Clinic II, Essen University Hospital, Univ. of Duisburg-Essen, Essen, Germany
| | - Gundula Ernst
- Society for Transition Medicine, Hannover, Germany
- Research and Teaching Unit Medical Psychology, Hannover Medical School, Hannover, Germany
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Hong MA, Sukumaran A, Riva-Cambrin J. Pediatric to Adult Hydrocephalus: A Smooth Transition. Neurol India 2021; 69:S390-S394. [PMID: 35102994 DOI: 10.4103/0028-3886.332245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Pediatric patients treated for hydrocephalus, regardless of etiology, require continuous access to care to address the long-term sequelae from the disease progression itself and from the interventions undertaken. The challenge for all pediatric neurosurgeons is providing comprehensive and coordinated care for these patients in order to achieve a smooth and seamless transition into adult health care. Methods A review of the literature was conducted regarding the overall concept of pediatric patients with chronic conditions transitioning to adult care. We also specifically reviewed the pediatric hydrocephalus literature to investigate the barriers of transition, models of success, and specific elements required in a transition policy. Results The review identified several barriers that hamper smooth and successful transition from pediatric to adult care within the hydrocephalus population. These included patient-related, cultural/society-related, healthcare provider-related, and healthcare system-related barriers. Six elements for successful transitions were noted: transition policy, tracking and monitoring, transition readiness, transition planning, transfer of care, and transition completion stemming from the Got Transition center. Conclusions A successful patient transition from pediatric neurosurgical care to adult neurosurgical care is very center-specific and depends on the available resources within that center's hospital, health system, and geo-economic environment. Six recommendations are made for transition policy implementation in resource-poor environments, including beginning the process early, preferably at age 14 years.
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Affiliation(s)
- Manilyn A Hong
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Arvind Sukumaran
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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Hersh DS, Kumar R, Klimo P, Bookland M, Martin JE. Hydrocephalus surveillance following shunt placement or endoscopic third ventriculostomy: a survey of surgeons in the Hydrocephalus Clinical Research Networks. J Neurosurg Pediatr 2021; 28:139-146. [PMID: 34020413 DOI: 10.3171/2020.12.peds20830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Late failure is a well-documented complication of cerebrospinal fluid shunt placement and, less commonly, endoscopic third ventriculostomy (ETV). However, standards regarding the frequency of clinical and radiological follow-up in these patients have not been defined. Here, the authors report on their survey of surgeons at sites for the Hydrocephalus Clinical Research Network (HCRN) or its implementation/quality improvement arm (HCRNq) to provide a cross-sectional overview of practice patterns. METHODS A 24-question survey was developed using the Research Electronic Data Capture (REDCap) platform and was distributed to the 138 pediatric neurosurgeons across 39 centers who participate in the HCRN or HCRNq. Survey questions were organized into three sections: 1) Demographics (5 questions), 2) Shunt Surveillance (12 questions), and 3) ETV Surveillance (7 questions). RESULTS A total of 122 complete responses were obtained, for an overall response rate of 88%. The majority of respondents have been in practice for more than 10 years (58%) and exclusively treat pediatric patients (79%). Most respondents consider hydrocephalus to have stabilized 1 month (21%) or 3 months (39%) after shunt surgery, and once stability is achieved, 72% then ask patients to return for routine clinical follow-up annually. Overall, 83% recommend lifelong clinical follow-up after shunt placement. Additionally, 75% obtain routine imaging studies in asymptomatic patients, although the specific imaging modality and frequency of imaging vary. The management of an asymptomatic increase in ventricle size or an asymptomatic catheter fracture also varies widely. Many respondents believe that hydrocephalus takes longer to stabilize after ETV than after shunt placement, reporting that they consider hydrocephalus to have stabilized 3 (28%), 6 (33%), or 12 (28%) months after an ETV. Although 68% of respondents have patients return annually for routine clinical follow-up after an ETV, only 56% recommend lifelong follow-up. The proportion of respondents who perform lifelong follow-up increases with greater practice experience (p = 0.01). Overall, 67% of respondents obtain routine imaging studies in asymptomatic patients after an ETV, with "rapid" MRI the study of choice for most respondents. CONCLUSIONS While there is a general consensus among pediatric neurosurgeons across North America that hydrocephalus patients should have long-term follow-up after shunt placement, radiological surveillance is characterized by considerable variety, as is follow-up after an ETV. Future work should focus on evaluating whether any one of these surveillance protocols is associated with improved outcomes.
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Affiliation(s)
- David S Hersh
- 1Division of Neurosurgery, Connecticut Children's, Hartford
- 2Department of Surgery, UConn School of Medicine, Farmington, Connecticut
| | | | - Paul Klimo
- 4Department of Neurosurgery, University of Tennessee Health Science Center, Memphis
- 5Le Bonheur Children's Hospital, Memphis; and
- 6Semmes-Murphey, Memphis, Tennessee
| | - Markus Bookland
- 1Division of Neurosurgery, Connecticut Children's, Hartford
- 2Department of Surgery, UConn School of Medicine, Farmington, Connecticut
| | - Jonathan E Martin
- 1Division of Neurosurgery, Connecticut Children's, Hartford
- 2Department of Surgery, UConn School of Medicine, Farmington, Connecticut
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