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Hawkes MT, McAlpine A, Barton M, Ranger A, Balamohan A, Davies HD, Skar G, Lefebvre MA, Almadani A, Freire D, Saux NL, Bowes J, Srigley JA, Passarelli P, Bradley J, Khan S, Purewal R, Viel-Thériault I, Robinson JL. Association of cerebrospinal fluid parameters with treatment and complications among children with cerebrospinal fluid shunt infections: a multicenter study. J Neurosurg Pediatr 2024; 33:35-43. [PMID: 37856380 DOI: 10.3171/2023.8.peds23348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/22/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE Cerebrospinal fluid (CSF) white blood cell (WBC) count, neutrophil percentage, protein concentration, and glucose level are typically measured at diagnosis and serially during the treatment of CSF shunt infections. The objective of this retrospective cohort study was to describe the longitudinal profile of CSF parameters in children with CSF shunt infections and assess their association with treatment and outcome. METHODS Participants were children treated at 11 tertiary pediatric hospitals in Canada and the United States for CSF shunt infection, from July 1, 2013, through June 30, 2019, with hardware removal, external ventricular drain placement, intravenous antibiotics, and subsequent permanent shunt reinsertion. The relationship between CSF parameters and a complicated course (a composite outcome representing children with at least one of the following: contiguous soft-tissue infection, worsening hydrocephalus, CSF leak, intracranial bleed, brain abscess, venous thrombosis, reinfection after insertion of the new shunt, other complication, ICU admission, or death) was analyzed. RESULTS A total of 109 children (median age 2.8 years, 44% female) were included in this study. CSF pleocytosis, elevated protein, and hypoglycorrhachia had sensitivities of 69%, 47%, and 38% for the diagnosis of culture-confirmed CSF shunt infection, respectively. The longitudinal profile of the neutrophil percentage followed a monotonic trend, decreasing by 1.5% (95% CI 1.0%-2.0%, p < 0.0001) per day over the course of treatment. The initial WBC count differed significantly between pathogens (p = 0.011), but the proportion of neutrophils, protein concentration, and glucose level did not, and was lowest with Cutibacterium acnes. The duration of antibiotic treatment and the time to shunt reinsertion were longer in patients with a higher initial neutrophil percentage. Fifty-eight patients (53%) had one or more complications during their admission. A neutrophil percentage > 44% (Youden index) in the initial CSF sample was associated with a 1.8-fold (95% CI 1.2- to 2.8-fold) higher relative risk of a complicated course. In a random-intercept, random-slope linear mixed-effects model, the longitudinal neutrophil trajectory differed significantly between patients with and without complications (p = 0.030). CONCLUSIONS A higher proportion of neutrophils in the CSF at diagnosis was associated with a complicated clinical course. Other CSF parameters were associated with treatment and outcome; however, wide variability in values may limit their clinical utility.
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Affiliation(s)
- Michael T Hawkes
- 1Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Alastair McAlpine
- 2Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michelle Barton
- 3Department of Pediatrics, London, Health Sciences Centre, Western University, London, Ontario, Canada
| | - Adrianna Ranger
- 3Department of Pediatrics, London, Health Sciences Centre, Western University, London, Ontario, Canada
| | - Archana Balamohan
- 4Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - H Dele Davies
- 5Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska
| | - Gwenn Skar
- 5Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Ahmed Almadani
- 6Department of Pediatrics, McGill University, Montréal, Québec, Canada
| | - Dolores Freire
- 1Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Nicole Le Saux
- 7Department of Pediatrics, University of Ottawa, Ontario, Canada
| | - Jennifer Bowes
- 7Department of Pediatrics, University of Ottawa, Ontario, Canada
| | - Jocelyn A Srigley
- 8Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Patrick Passarelli
- 9Department of Pediatrics, UC San Diego School of Medicine, San Diego, California
| | - John Bradley
- 9Department of Pediatrics, UC San Diego School of Medicine, San Diego, California
| | - Sarah Khan
- 10Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Rupeena Purewal
- 11Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; and
| | | | - Joan L Robinson
- 1Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Cheng S, McLaughlin JR, Brown MC, Al-Sawaihey H, Rutka J, Bouffet E, Hawkins C, Cairney AE, Ranger A, Fleming AJ, Johnston D, Greenberg M, Malkin D, Hung RJ. Correction: Maternal and childhood medical history and the risk of childhood brain tumours: a case-control study in Ontario, Canada. Br J Cancer 2023; 129:1362. [PMID: 37704791 PMCID: PMC10575968 DOI: 10.1038/s41416-023-02415-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Affiliation(s)
- Sierra Cheng
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - John R McLaughlin
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - M Catherine Brown
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Hamad Al-Sawaihey
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada
| | - James Rutka
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Eric Bouffet
- Division of Hematology/Oncology, The Hospital for Sick Children Toronto, Toronto, ON, Canada
| | - Cynthia Hawkins
- Division of Pathology, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Adrianna Ranger
- Children's Hospital, London Health Sciences Centre, London, ON, Canada
| | - Adam J Fleming
- McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Donna Johnston
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Mark Greenberg
- Division of Hematology/Oncology, The Hospital for Sick Children Toronto, Toronto, ON, Canada
- Pediatric Oncology Group of Ontario, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - David Malkin
- Division of Hematology/Oncology, The Hospital for Sick Children Toronto, Toronto, ON, Canada
- Department of Pediatrics, University of University of Toronto, Toronto, ON, Canada
| | - Rayjean J Hung
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada.
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
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Cheng S, McLaughlin JR, Brown MC, Al-Sawaihey H, Rutka J, Bouffet E, Hawkins C, Cairney AE, Ranger A, Fleming AJ, Johnston D, Greenberg M, Malkin D, Hung RJ. Maternal and childhood medical history and the risk of childhood brain tumours: a case-control study in Ontario, Canada. Br J Cancer 2023; 129:318-324. [PMID: 37165200 PMCID: PMC10338441 DOI: 10.1038/s41416-023-02281-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/04/2023] [Accepted: 04/14/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Studies to date have yielded inconclusive results as to whether maternal medical history during pregnancy, and a child's early-life medical history contribute to the development of childhood brain tumours (CBTs). This study examined associations between maternal and childhood medical history and the risk of CBTs. METHODS The Childhood Brain Tumour Epidemiology Study of Ontario (CBREO) examined children 0-15 years of age with newly diagnosed CBTs from 1997 to 2003. Multivariable logistic regression analysis determined associations for prenatal medications and childhood medical history, adjusted for child's demographics, and maternal education. Analyses were stratified by histology. A latency period analysis was conducted using 12- and 24-month lead times. RESULTS Maternal intake of immunosuppressants during the prenatal period was significantly associated with glial tumours (OR 2.73, 95% CI 1.17-6.39). Childhood intake of anti-epileptics was significantly associated with CBTs overall, after accounting for 12-month (OR 8.51, 95% CI 3.35-21.63) and 24-month (OR 6.04, 95% CI 2.06-17.70) lead time before diagnosis. No associations for other medications were found. CONCLUSIONS This study underscores the need to examine potential carcinogenic effects of the medication classes highlighted and of the indication of medication use. Despite possible reverse causality, increased CBT surveillance for children with epilepsy might be warranted.
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Affiliation(s)
- Sierra Cheng
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - John R McLaughlin
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - M Catherine Brown
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Hamad Al-Sawaihey
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada
| | - James Rutka
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Eric Bouffet
- Division of Hematology/Oncology, The Hospital for Sick Children Toronto, Toronto, ON, Canada
| | - Cynthia Hawkins
- Division of Pathology, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Adrianna Ranger
- Children's Hospital, London Health Sciences Centre, London, ON, Canada
| | - Adam J Fleming
- McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Donna Johnston
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Mark Greenberg
- Division of Hematology/Oncology, The Hospital for Sick Children Toronto, Toronto, ON, Canada
- Pediatric Oncology Group of Ontario, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - David Malkin
- Division of Hematology/Oncology, The Hospital for Sick Children Toronto, Toronto, ON, Canada
- Department of Pediatrics, University of University of Toronto, Toronto, ON, Canada
| | - Rayjean J Hung
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada.
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
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Ranger A, Girardin S. A22 USING INTESTINAL ORGANOIDS TO CHARACTERIZE THE NAIP-NLRC4 INFLAMMASOME RESPONSE IN THE INTESTINAL EPITHELIUM. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991125 DOI: 10.1093/jcag/gwac036.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background The NAIP-NLRC4 inflammasome is an important innate defence mechanism in intestinal epithelial cells (IECs) that protects the gut from invasive pathogens. NAIP-NLRC4 activation triggers pyroptotic cell death, releases active interleukin (IL)-18, and promotes the expulsion of infected enterocytes. Dysregulated inflammasomes result in exaggerated inflammation of the intestinal mucosa which is characterisitic of inflammatory bowel disease (IBD). There is increasing evidence that inflammasomes in IEC behave differently than in immune cells. However, a majority of inflammasome pathway characterization is studied immune cells. In addition, NAIP-NLRC4 activity in macrophages has been shown to be important for regulating the expression of nitric oxide (Nos2). The potential transcriptomic impact of NAIP-NLRC4 activity in IECs has yet to be explored. Purpose We will use intestinal orgnaoids to systematically characterize the NAIP-NLRC4 inflammasome pathway and identify the transcriptomic impact of NAIP-NLRC4 activity in IECs. To better define the role of NAIP-NLRC4 activity during a physiological infection, we have developed a novel ex vivo model of Shigella infection in 3D organoids. Method Organoids were derived from the ileal crypts of wild type (WT) and Nlrc4-/-, Casp1-/-, Pycard-/-, or Tlr5-/- mice and stimulated with Pam3CSk4, LPS, or flagellin. Inflammasome activation was assessed by Western blot (WB) and propidium iodide uptake. WT and Nlrc4-/- organoids were infected with WT or a non-invasive Shigella mutant and the inflammasome response was evaluated by WB and a colony forming unit assay. WT and Nlrc4-/- organoids were stimulated with flagellin and gene expression was assessed by RT-qPCR. Result(s) Basolateral organoid stimulation with bacterial ligands revealed a novel response of IECs to bacterial flagellin that results in pyroptosis and IL-18 processing. Basolateral internalization of flagellin occurred in a TLR5-independent manner. Inflammasome activation by flagellin was fully abrogated in Nlrc4-/- and Casp1-/- organoids while only IL-18 processing was affected in Pycard-/- organoids. Infection with only WT Shigella induced inflammasome activation in an NLRC4-dependent manner. Interestingly, flagellin stimulation of WT but not Nlrc4-/- organoids led to increased expression of Nos2. Furthermore, Nlrc4-/- organoids had significantly lower expression levels of cytokine genes Ccl20, Cxcl1, and Tnf following inflammasome activation. Conclusion(s) Our study demonstrates an integral role for epithelial NAIP-NLRC4 inflammasomes in the response to bacterial flagellin and Shigella infection. We have uncovered a novel response of IECs to basolateral flagellin stimulation and revealed that NAIP-NLRC4 is important for the transcriptional regulation of inflammatory genes. Further work will examine how NAIP-NLRC4 activation controls inflammation and epithelial integrity by analyzing the NLRC4-dependent transcriptome and the effects on cell proliferation, differentiation, and barrier integrity. Please acknowledge all funding agencies by checking the applicable boxes below CCC, CIHR Disclosure of Interest None Declared
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Affiliation(s)
- A Ranger
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - S Girardin
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
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Ranger A, Dunlop A, Hansen VN, Princewill G, Landeg S, Donovan EM, Harris EJ, McNair HA, Haviland J, Kirby AM. A Randomised Phase II Clinical Trial Comparing the Deliverability and Acute Toxicity of Wide Tangent versus Volumetric Modulated Arc Therapy to the Breast and Internal Mammary Chain. Clin Oncol (R Coll Radiol) 2022; 34:526-533. [PMID: 35597698 DOI: 10.1016/j.clon.2022.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 02/18/2022] [Accepted: 03/28/2022] [Indexed: 11/03/2022]
Abstract
AIMS Inclusion of the internal mammary chain in the radiotherapy target volume (IMC-RT) improves disease-free and overall survival in higher risk breast cancer patients, but increases radiation doses to heart and lungs. Dosimetric data show that either modified wide-tangential fields (WT) or volumetric modulated arc therapy (VMAT) together with [AQ1]voluntary deep inspiration breath hold (vDIBH) keep mean heart doses below 4 Gy in most patients. However, the impact on departmental resources has not yet been documented. This phase II clinical trial compared the time taken to deliver IMC-RT using either WT and vDIBH or VMAT and vDIBH, together with planning time, dosimetry, set-up reproducibility and toxicity. MATERIALS AND METHODS Left-sided breast cancer patients requiring IMC-RT were randomised to receive either WT(vDIBH) or VMAT radiotherapy. The primary outcome was treatment time, powered to detect a minimum difference of 75 min (5 min/fraction) between techniques. The population mean displacement, systematic error and random error for cone beam computed tomography chest wall matches in three directions of movement were calculated. Target volume and organ at risk doses were compared between groups. Side-effects, including skin (Radiation Therapy Oncology Group), lung and oesophageal toxicity (Common Terminology Criteria for Adverse Events v 4.03) rates, were compared between the groups over 3 months. Patient-reported outcome measures, including shoulder toxicity at baseline, 6 months and 1 year, were compared. RESULTS Twenty-one patients were recruited from a single UK centre between February 2017 and January 2018. The mean (standard deviation) total treatment time per fraction for VMAT treatments was 13.2 min (1.7 min) compared with 28.1 min (3.3 min) for WT(vDIBH). There were no statistically significant differences in patient set-up errors in between groups. The average mean heart dose for WT(vDIBH) was 2.6 Gy compared with 3.4 Gy for VMAT(vDIBH) (P = 0.13). The mean ipsilateral lung V17Gy was 32.8% in the WT(vDIBH) group versus 34.4% in the VMAT group (P = 0.2). The humeral head (mean dose 16.8 Gy versus 2.8 Gy), oesophagus (maximum dose 37.3 Gy versus 20.1 Gy) and thyroid (mean dose 22.0 Gy versus 11.2 Gy) all received a statistically significantly higher dose in the VMAT group. There were no statistically significant differences in skin, lung or oesophageal toxicity within 3 months of treatment. Patient-reported outcomes of shoulder toxicity, pain, fatigue, breathlessness and breast symptoms were similar between groups at 1 year. CONCLUSION VMAT(vDIBH) and WT(vDIBH) are feasible options for locoregional breast radiotherapy including the IMC. VMAT improves nodal coverage and delivers treatment more quickly, resulting in less breath holds for the patient. This is at the cost of increased dose to some non-target tissues. The latter does not appear to translate into increased toxicity in this small study.
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Affiliation(s)
- A Ranger
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK.
| | - A Dunlop
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - V N Hansen
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - G Princewill
- The Royal Marsden NHS Foundation Trust, London, UK
| | - S Landeg
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | - E J Harris
- The Institute of Cancer Research, London, UK
| | - H A McNair
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - J Haviland
- The Institute of Cancer Research, London, UK
| | - A M Kirby
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
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McAlpine A, Robinson JL, Barton M, Balamohan A, Davies HD, Skar G, Lefebvre MA, Almadani A, Freire D, Le Saux N, Bowes J, Srigley JA, Passarelli P, Bradley J, Khan S, Purewal R, Viel-Thériault I, Ranger A, Hawkes MT. Cerebrospinal Fluid Shunt Infections: A Multicenter Pediatric Study. Pediatr Infect Dis J 2022; 41:449-454. [PMID: 35389956 DOI: 10.1097/inf.0000000000003513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infections complicate 5%-10% of cerebrospinal fluid (CSF) shunts. We aimed to describe the characteristics and contemporary pathogens of shunt infections in children in Canada and the United States. METHODS Descriptive case series at tertiary care hospitals in Canada (N = 8) and the United States (N = 3) of children up to 18 years of age with CSF shunt infections from July 1, 2013, through June 30, 2019. RESULTS There were 154 children (43% female, median age 2.7 years, 50% premature) with ≥1 CSF shunt infections. Median time between shunt placement and infection was 54 days (interquartile range, 24 days-2.3 years). Common pathogens were coagulase-negative staphylococci (N = 42; 28%), methicillin-susceptible Staphylococcus aureus (N = 24; 16%), methicillin-resistant S. aureus (N = 9; 5.9%), Pseudomonas aeruginosa (N = 9; 5.9%) and other Gram-negative bacilli (N = 14; 9.0%). Significant differences between pathogens were observed, including timing of infection (P = 0.023) and CSF leukocyte count (P = 0.0019); however, differences were not sufficient to reliably predict the causative organism based on the timing of infection or discriminate P. aeruginosa from other pathogens based on clinical features. Empiric antibiotic regimens, which included vancomycin (71%), cefotaxime or ceftriaxone (29%) and antipseudomonal beta-lactams (33%), were discordant with the pathogen isolated in five cases. There was variability between sites in the distribution of pathogens and choice of empiric antibiotics. Nine children died; 4 (44%) deaths were attributed to shunt infection. CONCLUSIONS Staphylococci remain the most common cause of CSF shunt infections, although antibiotic resistant Gram-negative bacilli occur and cannot be reliably predicted based on clinical characteristics.
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Affiliation(s)
- Alastair McAlpine
- From the Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joan L Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle Barton
- Department of Pediatrics, London, Health Sciences Centre, Western University, London, Ontario, Canada
| | - Archana Balamohan
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - H Dele Davies
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska
| | - Gwenn Skar
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Ahmed Almadani
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Dolores Freire
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Nicole Le Saux
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Jennifer Bowes
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Jocelyn A Srigley
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Patrick Passarelli
- Department of Pediatrics UC San Diego School of Medicine, San Diego, California
| | - John Bradley
- Department of Pediatrics UC San Diego School of Medicine, San Diego, California
| | - Sarah Khan
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Rupeena Purewal
- Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Adrianna Ranger
- Department of Clinical Neurological Sciences (Neurosurgery), London, Health Sciences Centre, Western University, London, Ontario, Canada
| | - Michael T Hawkes
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Nabi Z, Butt R, Mir R, Hills J, Tsang Y, Wheatley D, Bhattacharya I, Ranger A, Cramp S, Hammonds N, Goyal A. PO-1835 A glimpse at breast internal mammary chain radiotherapy practice in the United Kingdom. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)03798-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Butt R, Nabi Z, Mir R, Hills J, Wheatley D, Bhattacharya I, Ranger A, Cramp S, Hammonds N, Goyal A, Tsang Y. MO-0644 Practice patterns for outlining the axilla and IMC, findings of the RTQA for the ATNEC trial. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)02402-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Cheng S, McLaughlin JR, Brown MC, Al-Sawaihey H, Rutka J, Bouffet E, Hawkins C, Cairney AE, Ranger A, Fleming AJ, Johnston D, Greenberg M, Malkin D, Hung RJ. Childhood head trauma and the risk of childhood brain tumours: A case-control study in Ontario, Canada. Int J Cancer 2021; 150:795-801. [PMID: 34520575 DOI: 10.1002/ijc.33805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/07/2021] [Accepted: 08/04/2021] [Indexed: 11/10/2022]
Abstract
Head trauma in early childhood has been hypothesized as a potential risk factor for childhood brain tumours (CBTs). However, head trauma has not been extensively studied in the context of CBTs and existing studies have yielded conflicting results. A population-based and hospital-based case-control study of children 0 to 15 years with newly diagnosed CBTs from 1997 to 2003 recruited across Ontario through paediatric oncology centres was conducted. Controls were frequency-matched with cases by age, sex and geographical region. The association was assessed based on multivariable logistic regressions, accounting for child's age, sex, ethnicity, highest level of maternal education and maternal pack-years of smoking during the pregnancy. Analyses were conducted separately based on age of first head trauma, sex and histology. A latency period analysis was conducted. Overall, based on 280 cases and 919 controls, CBTs were not significantly associated with previous history of head trauma (OR 1.34, 95% CI 0.96, 1.86), head trauma severity, number of head injuries, or head or neck X-rays or computed tomography (CT) examinations. Results were consistent across sexes and histological subtypes. However, head trauma within the first year of life was significantly associated with CBTs (OR 2.00, 95% CI 1.01, 3.98), but the association diminished when adjusted for X-ray or CT occurring during the same time period (OR 1.62, 95% CI 0.75, 3.49), albeit limited sample size. Overall, no association was observed between head trauma and CBTs among all children, while head trauma occurring within first year of life may warrant further investigation in future research.
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Affiliation(s)
- Sierra Cheng
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - John R McLaughlin
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - M Catherine Brown
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada.,Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Hamad Al-Sawaihey
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
| | - James Rutka
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Eric Bouffet
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cynthia Hawkins
- Division of Pathology, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Adrianna Ranger
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Adam J Fleming
- McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Donna Johnston
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Mark Greenberg
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Pediatric Oncology Group of Ontario, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - David Malkin
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Rayjean J Hung
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Vivekanandan A, Santyr B, Ranger A. Effects of systemic corticosteroid treatment on pseudotumoral hemicerebellitis: a case report and literature review. Childs Nerv Syst 2021; 37:2105-2113. [PMID: 33219391 DOI: 10.1007/s00381-020-04970-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/10/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Pseudotumoral hemicerebellitis is an acute, unilateral inflammation of the cerebellum that typically affects the pediatric population. The purpose of this paper is to review cases of pseudotumoral hemicerebellitis in the literature and evaluate if treatment with systemic corticosteroids reduces length of time to symptomatic recovery. METHODS We present a case report of a 12-year-old male with pseudotumoral hemicerebellitis and unilateral cerebellar dysfunction. Additionally, we review the thirty-five reported cases of pseudotumoral hemicerebellitis with respect to length of time to symptomatic recovery with or without systemic corticosteroid treatment. RESULTS Thirty cases reported length of time to symptomatic recovery. Including our case, the mean time to recovery for those treated with systemic corticosteroids (n = 20) was 48.05 days (SE = 16.3). The mean time to recovery for those treated without (n = 10) was 86.7 days (SE = 29.3). CONCLUSIONS Treatment with systemic corticosteroids was associated with a faster time to symptomatic recovery compared to without. Regardless of etiology, reducing inflammation and mass effect involved in pseudotumoral hemicerebellitis may be integral to a more rapid return to neurological baseline.
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Affiliation(s)
- Amirti Vivekanandan
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.
| | - Brendan Santyr
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Adrianna Ranger
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Paediatric Neurosurgery, Children's Hospital, London Health Sciences Centre, Victoria Campus, London, Ontario, Canada
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11
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Settatree S, Brand D, Ranger A, Dunlop A, Harris E, Gulliford S, Kirby A. Estimating Contralateral Breast Cancer Risk from Photons versus Protons in Patients Undergoing Internal Mammary Nodal Breast Cancer Radiotherapy. Clin Oncol (R Coll Radiol) 2020; 32:342. [PMID: 31948769 DOI: 10.1016/j.clon.2019.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/13/2019] [Indexed: 11/22/2022]
Affiliation(s)
- S Settatree
- The Royal Marsden Hospital, London, UK; The Institute Cancer Research, London, UK
| | - D Brand
- The Royal Marsden Hospital, London, UK; The Institute Cancer Research, London, UK
| | - A Ranger
- The Royal Marsden Hospital, London, UK; The Institute Cancer Research, London, UK
| | - A Dunlop
- The Royal Marsden Hospital, London, UK; The Institute Cancer Research, London, UK
| | - E Harris
- The Institute Cancer Research, London, UK
| | - S Gulliford
- University College London Hospital, London, UK
| | - A Kirby
- The Royal Marsden Hospital, London, UK; The Institute Cancer Research, London, UK
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12
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Huang LY, Fan HZ, Maltchevski M, Ranger A. Fueling Machine Model for Simulation of Spent Fuel Behavior in Postulated Fuel Handling Accidents. Journal of Nuclear Engineering and Radiation Science 2020. [DOI: 10.1115/1.4044459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
On-power fueling is an important feature of the CANDU® reactor. Fueling is a routine operation with a large number of channel fueling visits made each year with the fueling machines acting as the key system. Hence, safety analysis must consider fueling machine events typically when the fueling machine is in transit toward the spent fuel port. This paper presents a model of fueling machine containing spent fuel with complex configuration and multiprocess mechanisms. Using an integral approach with fuel and fueling machine, this model tends to improve previous modeling method, which only takes account of a slice of fuel or fueling machine. This fueling machine model is developed for simulations of the fueling machine coolant thermal hydraulics behavior, the spent fuel behavior, and potential fission product release during postulated loss of heat removal accidents. An example of its application is also presented in this paper.
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Affiliation(s)
- L. Y. Huang
- Candu Energy, Inc., Mississauga, ON L5K 1B2, Canada
| | - H. Z. Fan
- Candu Energy, Inc., Mississauga, ON L5K 1B2, Canada
| | | | - A. Ranger
- Candu Energy, Inc., Mississauga, ON L5K 1B2, Canada
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13
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Cameron S, Gillio-Meina C, Ranger A, Choong K, Fraser DD. Collection and Analyses of Cerebrospinal Fluid for Pediatric Translational Research. Pediatr Neurol 2019; 98:3-17. [PMID: 31280949 DOI: 10.1016/j.pediatrneurol.2019.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/23/2019] [Accepted: 05/27/2019] [Indexed: 12/18/2022]
Abstract
Cerebrospinal fluid sample collection and analysis is imperative to better elucidate central nervous system injury and disease in children. Sample collection methods are varied and carry with them certain ethical and biologic considerations, complications, and contraindications. Establishing best practices for sample collection, processing, storage, and transport will ensure optimal sample quality. Cerebrospinal fluid samples can be affected by a number of factors including subject age, sampling method, sampling location, volume extracted, fraction, blood contamination, storage methods, and freeze-thaw cycles. Indicators of sample quality can be assessed by matrix-associated laser desorption/ionization time-of-flight mass spectrometry and include cystatin C fragments, oxidized proteins, prostaglandin D synthase, and evidence of blood contamination. Precise documentation of sample collection processes and the establishment of meticulous handling procedures are essential for the creation of clinically relevant biospecimen repositories. In this review we discuss the ethical considerations and best practices for cerebrospinal fluid collection, as well as the influence of preanalytical factors on cerebrospinal fluid analyses. Cerebrospinal fluid biomarkers in highly researched pediatric diseases or disorders are discussed.
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Affiliation(s)
| | | | - Adrianna Ranger
- Pediatrics, Western University, London, Ontario, Canada; Clinical Neurological Sciences, Western University, London, Ontario, Canada
| | - Karen Choong
- Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Douglas D Fraser
- Pediatrics, Western University, London, Ontario, Canada; Children's Health Research Institute, London, Ontario, Canada; Clinical Neurological Sciences, Western University, London, Ontario, Canada; Physiology and Pharmacology, Western University, London, Ontario, Canada; Translational Research Centre, London, Ontario, Canada.
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14
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Ranger A, Dunlop A, Donovan E, Harris E, DeSouza N, McNair H, Kirby A. EP-1323 HeartSpare Plus: A comparison of the feasibility and acute toxicity of internal mammary chain RT. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)31743-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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15
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Blasiak-Wal I, Dunlop A, Colgan R, Ranger A, Kirby A. EP-1889 Evaluation of organ-motion based robust optimisation for RT of the breast, axilla, and IMC. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)32309-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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16
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O'Callaghan KM, Shin J, Cheung AS, Cheema T, Judge C, Ranger A, Huet HA, Ettenberg SA, Sachs J, Vasconcelles M, Motz G. Abstract OT2-07-06: Antibody-coupled T cell receptor (ACTR) engineered autologous T cells in combination with trastuzumab for the treatment of HER2-positive malignancies. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-ot2-07-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Antibody-Coupled T cell Receptor (ACTR) is an autologous engineered T cell therapy developed to combine with tumor-targeting antibodies to exert potent anti-tumor immune responses and tumor cell killing. The ACTR construct is composed of the extracellular domain of CD16 fused to CD3ζ signaling and T cell co-stimulatory domains. ACTR-expressing T cells are universal in that they can be paired with a therapeutic antibody to target specific antigens on tumors. Unum has two ACTR constructs, ACTR087 and ACTR707, currently in clinical testing. ACTR087 and ACTR707 are being tested in combination with rituximab in subjects with CD20+ B cell lymphoma in two separate trials (NCT02776813 and NCT03189836, respectively). Preliminary data with ACTR087 + rituximab has demonstrated clinical proof-of-concept and a dose-response relationship in subjects with relapsed/refractory B cell lymphoma. ACTR087 is also being tested in combination with a novel BCMA-targeting antibody in subjects with multiple myeloma (NCT03266692).
While T cell therapies, such as chimeric antigen receptor (CAR) T cells, have demonstrated clinical activity in hematological cancers, the therapeutic potential of this approach has yet to be established in solid tumors. Challenges associated with targeting solid tumors with CAR-T cells include tumor antigen heterogeneity and antigen expression on normal tissues. HER2 is a well-established therapeutic target that is over-expressed in a number of cancer indications. HER2 is also expressed at low levels on normal epithelial cells, creating a risk for on-target/off-tumor toxicities of HER2-targeted CAR-T cells. Here we present nonclinical studies demonstrating that ACTR T cells in combination with trastuzumab have antigen density-dependent activity on HER2-expressing tumor cell lines, while trastuzumab-based CAR-T cells do not. We observed that ACTR + trastuzumab had robust activity against HER2-amplified tumor cells and more modest activity against non-amplified tumor cells, whereas HER2-targeting CAR-T cells had comparable activity against HER2-amplified and non-amplified tumor cells. On normal human primary cells, ACTR + trastuzumab had minimal activity in comparison to HER2 CAR-T cells, suggesting that ACTR + trastuzumab may exhibit a superior clinical therapeutic index. Furthermore, the activity of ACTR T cells against HER2-amplified tumor cells was titratable with antibody concentration, allowing for control of ACTR activity by modulation of trastuzumab concentration. Together, these data demonstrate the specificity of the ACTR T cell therapeutic approach to target HER2-amplified tumors and support clinical testing in combination with trastuzumab.
A phase 1, multicenter, single-arm, open-label dose escalation study, ATTCK-34-01, is proposed to evaluate ACTR T cells in combination with trastuzumab in subjects with advanced HER2-positive malignancies. The primary study objectives are to assess the safety and tolerability of the combination, and to define the recommended phase 2 dose combination for further study. Additional objectives include assessment of anti-tumor activity, ACTR T cell persistence and trastuzumab pharmacokinetics. Enrollment is expected to commence in early 2019.
Citation Format: O'Callaghan KM, Shin J, Cheung AS, Cheema T, Judge C, Ranger A, Huet HA, Ettenberg SA, Sachs J, Vasconcelles M, Motz G. Antibody-coupled T cell receptor (ACTR) engineered autologous T cells in combination with trastuzumab for the treatment of HER2-positive malignancies [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-07-06.
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Affiliation(s)
| | - J Shin
- Unum Therapeutics Inc., Cambridge, MA
| | - AS Cheung
- Unum Therapeutics Inc., Cambridge, MA
| | - T Cheema
- Unum Therapeutics Inc., Cambridge, MA
| | - C Judge
- Unum Therapeutics Inc., Cambridge, MA
| | - A Ranger
- Unum Therapeutics Inc., Cambridge, MA
| | - HA Huet
- Unum Therapeutics Inc., Cambridge, MA
| | | | - J Sachs
- Unum Therapeutics Inc., Cambridge, MA
| | | | - G Motz
- Unum Therapeutics Inc., Cambridge, MA
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17
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Ranger A, Dunlop A, Shah P, Amin K, Henderson D, Bartlett FR, Knowles C, Brigden B, Lacey C, Donovan E, Harris E, Kirby AM. Evaluation of a Novel Field-placement Algorithm for Locoregional Breast Cancer Radiotherapy Including the Internal Mammary Chain. Clin Oncol (R Coll Radiol) 2019; 31:25-33. [PMID: 30078523 DOI: 10.1016/j.clon.2018.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 06/18/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
AIMS Irradiation of the internal mammary chain (IMC) is increasing following recently published data, but the need for formal delineation of lymph node volumes is slowing implementation in some healthcare settings. A field-placement algorithm for irradiating locoregional lymph nodes including the IMC could reduce the resource impact of introducing irradiation of the IMC. This study describes the development and evaluation of such an algorithm. MATERIALS AND METHODS An algorithm was developed in which six points representing lymph node clinical target volume borders (based on European Society for Radiotherapy and Oncology consensus nodal contouring guidelines) were placed on computed tomography-defined anatomical landmarks and used to place tangential and nodal fields. Single-centre testing in 20 cases assessed the success of the algorithm in covering planning target volumes (PTVs) and adequately sparing organs at risk. Plans derived using the points algorithm were also compared with plans generated following formal delineation of nodal PTVs, using the Wilcoxon signed rank test. Timing data for point placement were collected. Multicentre testing using the same methods was then carried out to establish whether the technique was transferable to other centres. RESULTS Single-centre testing showed that 95% of cases met the nodal PTV coverage dose constraints (binomial probability confidence interval 75.1-99.9%) with no statistically significant reduction in mean heart dose or ipsilateral lung V17Gy associated with formal nodal delineation. In multicentre testing, 69% of cases met nodal PTV dose constraints and there was a statistically significant difference in IMC PTV coverage using the points algorithm when compared with formally delineated nodal volumes (P < 0.01). However, there was no difference in axillary level 1-4 PTV coverage (P = 0.11) with all cases meeting target volume constraints. CONCLUSIONS The optimal strategy for breast and locoregional lymph node radiotherapy is target volume delineation. However, use of this novel points-based field-placement algorithm results in dosimetrically acceptable plans without the need for formal lymph node contouring in a single-centre setting and for the breast and level 1-4 axilla in a multicentre setting. Further quality assurance measures are needed to enable implementation of the algorithm for irradiation of the IMC in a multicentre setting.
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Affiliation(s)
- A Ranger
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK.
| | - A Dunlop
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | - P Shah
- The Royal Marsden NHS Foundation Trust, London, UK
| | - K Amin
- The Royal Marsden NHS Foundation Trust, London, UK
| | - D Henderson
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - C Knowles
- The Royal Marsden NHS Foundation Trust, London, UK
| | - B Brigden
- The Royal Marsden NHS Foundation Trust, London, UK
| | - C Lacey
- The Royal Marsden NHS Foundation Trust, London, UK
| | - E Donovan
- CVSSP, University of Surrey, Guildford, UK
| | - E Harris
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | - A M Kirby
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
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18
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Ranger A, Helmert E, Bott TS, Ostermann T, Als H, Bassler D, Hautzinger M, Vagedes J. Physiological and emotional effects of pentatonic live music played for preterm neonates and their mothers in the Newborn Intensive Care Unit: A randomized controlled trial. Complement Ther Med 2018; 41:240-246. [PMID: 30477847 DOI: 10.1016/j.ctim.2018.07.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 07/16/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE Despite attempts to increase calmness in the Newborn Intensive Care Unit (NICU), preterm neonates still experience stress. The question arises how to further promote the infants' wellbeing. Therefore, the immediate effects of pentatonic live music on preterm infants and their mothers were examined. DESIGN AND METHODS In a two-centre randomized controlled trial with crossover design preterm infants were exposed sequentially to two conditions: live pentatonic harp music (LPHM) used in Anthroposophic Medicine or standard care. The order of the conditions was randomized within each subject. The primary outcome was change of the number of oxygen desaturations < 90%/h, whereas secondary outcomes were: heart rate, respiratory rate, oxygen saturation, heart rate variability (HRV), the perfusion index, pulse-transit-time and maternal anxiety and others not reported on in this article. RESULTS 21 preterm infants were randomized (14 girls), mean gestational age at measurement 35 + 0 weeks (SD 1 week). The primary outcome parameter showed no significant changes. Regarding the secondary outcomes the comparison of the pre-post-differences between the conditions showed significant effects for the HRV parameters pNN50 (ΔpNN50 = 1.46%, z = -2.47, p = .001) and SDNN (ΔSDNN=-0.06 ms, z = -2.25, p = .002). The music intervention significantly increased the values of pNN50 (Mdn 1.2% vs. 2.6%, p = 0.04) and marginally those of SDNN (Mdn 31.7 ms vs. 36.4 ms, p = 0.05). No changes were found in the other parameters. CONCLUSIONS While the use of music in the NICU had no effect on the number of oxygen desaturations, it increased two HRV parameters indicative of infants' parasympathetic tone.
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Affiliation(s)
- A Ranger
- ARCIM Institute, Fidlerstadt, Germany
| | - E Helmert
- ARCIM Institute, Fidlerstadt, Germany
| | - T S Bott
- Department of Pediatric Surgery Olgahospital, Stuttgart, Germany
| | - T Ostermann
- Department of Psychology, University of Witten-Herdecke, Germany
| | - H Als
- Department of Psychiatry, Boston Children`s Hospital and Harvard Medical School, Boston, MA, USA
| | - D Bassler
- Department of Neonatology, Zurich University Hospital, Zurich, Switzerland
| | - M Hautzinger
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, University of Tübingen, Germany
| | - J Vagedes
- ARCIM Institute, Fidlerstadt, Germany; University Hospital, Department of Neonatology, University of Tuebingen, Germany.
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Ranger A, Dunlop A, Hutchinson K, Convery H, Maclennan MK, Chantler H, Twyman N, Rose C, McQuaid D, Amos RA, Griffin C, deSouza NM, Donovan E, Harris E, Coles CE, Kirby A. A Dosimetric Comparison of Breast Radiotherapy Techniques to Treat Locoregional Lymph Nodes Including the Internal Mammary Chain. Clin Oncol (R Coll Radiol) 2018; 30:346-353. [PMID: 29483041 DOI: 10.1016/j.clon.2018.01.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 10/17/2022]
Abstract
AIMS Radiotherapy target volumes in early breast cancer treatment increasingly include the internal mammary chain (IMC). In order to maximise survival benefits of IMC radiotherapy, doses to the heart and lung should be minimised. This dosimetry study compared the ability of three-dimensional conformal radiotherapy, arc therapy and proton beam therapy (PBT) techniques with and without breath-hold to achieve target volume constraints while minimising dose to organs at risk (OARs). MATERIALS AND METHODS In 14 patients' datasets, seven IMC radiotherapy techniques were compared: wide tangent (WT) three-dimensional conformal radiotherapy, volumetric-modulated arc therapy (VMAT) and PBT, each in voluntary deep inspiratory breath-hold (vDIBH) and free breathing (FB), and tomotherapy in FB only. Target volume coverage and OAR doses were measured for each technique. These were compared using a one-way ANOVA with all pairwise comparisons tested using Bonferroni's multiple comparisons test, with adjusted P-values ≤ 0.05 indicating statistical significance. RESULTS One hundred per cent of WT(vDIBH), 43% of WT(FB), 100% of VMAT(vDIBH), 86% of VMAT(FB), 100% of tomotherapy FB and 100% of PBT plans in vDIBH and FB passed all mandatory constraints. However, coverage of the IMC with 90% of the prescribed dose was significantly better than all other techniques using VMAT(vDIBH), PBT(vDIBH) and PBT(FB) (mean IMC coverage ± 1 standard deviation = 96.0% ± 4.3, 99.8% ± 0.3 and 99.0% ± 0.2, respectively). The mean heart dose was significantly reduced in vDIBH compared with FB for both the WT (P < 0.0001) and VMAT (P < 0.0001) techniques. There was no advantage in target volume coverage or OAR doses for PBT(vDIBH) compared with PBT(FB). CONCLUSIONS Simple WT radiotherapy delivered in vDIBH achieves satisfactory coverage of the IMC while meeting heart and lung dose constraints. However, where higher isodose coverage is required, VMAT(vDIBH) is the optimal photon technique. The lowest OAR doses are achieved by PBT, in which the use of vDIBH does not improve dose statistics.
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Affiliation(s)
- A Ranger
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK.
| | - A Dunlop
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - K Hutchinson
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - H Convery
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | | | - H Chantler
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - N Twyman
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - C Rose
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - D McQuaid
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - R A Amos
- University College London, London, UK
| | - C Griffin
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - N M deSouza
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - E Donovan
- CVSSP, University of Surrey, Guildford, UK
| | - E Harris
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - C E Coles
- University of Cambridge, Cambridge, UK
| | - A Kirby
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
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Ranger A, Perotti C, Dunlop A, Donovan E, McNair H, Harris E, Kirby A. EP-1283: Lung sparing techniques for internal mammary chain radiotherapy in right breast cancer patients. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)31593-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Ranger A, Dunlop A, Maclennan M, Donovan E, Harris E, Brigden B, Knowles C, Carr K, Henegan E, Francis J, Bartlett F, Somiah N, Locke I, Coles C, Kirby A. OC-0452: Evaluation of a novel field placement algorithm for tangential internal mammary chain radiotherapy. Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)30894-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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22
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Staudt MD, Morgenstern JD, Neufeld A, Ranger A. Macrocephaly and right arm disuse in a 7-month-old boy. J Clin Neurosci 2016. [DOI: 10.1016/j.jocn.2016.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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23
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Ranger A, Kirby A, Dunlop A, Maclennan M, Coles C. Coverage of axillary lymph node levels using standard radiotherapy fields for breast cancer patients – what are we actually treating? Clin Oncol (R Coll Radiol) 2016. [DOI: 10.1016/j.clon.2016.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ranger A, Allaire N, Colman P, Wager C, Li H, Thai A, Cullen P, Otoul C, Czerkowicz J, Roberts C, Chamberlain C, Burkly L, Johnston G. OP0040 Peripheral Blood Transcriptional Changes Elicited by Treatment of Systemic Lupus Erythematosus (SLE) Patients with Dapirolizumab Pegol (A Pegylated Anti-CD40L Fab'). Ann Rheum Dis 2016. [DOI: 10.1136/annrheumdis-2016-eular.1292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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25
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Steinbok P, Gopalakrishnan CV, Hengel AR, Vitali AM, Poskitt K, Hawkins C, Drake J, Lamberti-Pasculli M, Ajani O, Hader W, Mehta V, McNeely PD, McDonald PJ, Ranger A, Vassilyadi M, Atkinson J, Ryall S, Eisenstat DD, Hukin J. Pediatric thalamic tumors in the MRI era: a Canadian perspective. Childs Nerv Syst 2016; 32:269-80. [PMID: 26597682 DOI: 10.1007/s00381-015-2968-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 11/17/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Thalamic gliomas are rare. The natural history is unpredictable, and the optimal management of these tumors in children is poorly defined. The aim was to identify outcomes, prognostic factors, and response to various modalities of treatment in a relatively large population of pediatric thalamic tumors from many centers within a fairly homogeneous health care system. METHODS We performed a Canadian multicenter retrospective review of pediatric thalamic tumors presenting during the MRI era (1989-2012). Radiology and pathology were reviewed by central independent reviewers. Paraffin shavings for RNA extraction were taken and tested for fusion events involving KIAA1549:BRAF. Tumors were classified as unilateral or bithalamic based on their origin on imaging. Univariate and multivariate analyses on factors influencing survival were performed. RESULTS Seventy-two thalamic tumors were identified from 11 institutions. Females represented 53% of the study population, and the mean age at presentation was 8.9 years. Sixty-two tumors were unilateral and 10 bithalamic. Unilateral tumors had a greater propensity to grow inferiorly towards the brainstem. These tumors were predominantly low grade in comparison to bithalamic tumors which were high-grade astrocytomas. The 5-year overall survival was 61 ± 13% for unithalamic tumors compared to 37 ± 32% for bithalamic tumors (p = 0.097). Multivariate analysis indicated tumor grade as the only significant prognostic factor for unithalamic tumors. Six unilateral tumors, all low grade, were BRAF fusion positive. CONCLUSION Unilateral and bilateral thalamic tumors behave differently. Surgical resection is an appropriate treatment option in unilateral tumors, most of which are low grade, but outcome is not related to extent of resection (EOR). Bilateral thalamic tumors have a poorer prognosis, but the occasional patient does remarkably well. The efficacy of chemotherapy and radiotherapy has not been clearly demonstrated. Novel therapeutic approaches are required to improve the prognosis for malignant unilateral thalamic tumors and bilateral thalamic tumors.
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Affiliation(s)
- Paul Steinbok
- Division of Pediatric Neurosurgery, Department of Surgery, University of British Columbia & British Columbia Children's Hospital, 4480 Oak St., Room K3-159, V6H 3V4, Vancouver, BC, Canada.
| | - Chittur Viswanathan Gopalakrishnan
- Division of Pediatric Neurosurgery, Department of Surgery, University of British Columbia & British Columbia Children's Hospital, 4480 Oak St., Room K3-159, V6H 3V4, Vancouver, BC, Canada
| | - Alexander R Hengel
- Division of Pediatric Neurosurgery, Department of Surgery, University of British Columbia & British Columbia Children's Hospital, 4480 Oak St., Room K3-159, V6H 3V4, Vancouver, BC, Canada
| | | | - Ken Poskitt
- Department of Radiology, University of British Columbia & British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Cynthia Hawkins
- Division of Pathology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - James Drake
- Division of Pediatric Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Maria Lamberti-Pasculli
- Division of Pediatric Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Olufemi Ajani
- Division of Neurosurgery, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Walter Hader
- Division of Neurosurgery, Alberta Children's Hospital, Calgary, AB, Canada
| | - Vivek Mehta
- Division of Neurosurgery, Stollery Children's Hospital, Edmonton, AB, Canada
| | - P Daniel McNeely
- Division of Neurosurgery, IWK Health Centre, Halifax, NS, Canada
| | - Patrick J McDonald
- Section of Neurosurgery, Winnipeg's Children's Hospital, Winnipeg, MB, Canada
| | - Adrianna Ranger
- Division of Neurosurgery, Children's Hospital, London Health Sciences Center, London, ON, Canada
| | - Michael Vassilyadi
- Division of Neurosurgery, University of Ottawa & Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Jeff Atkinson
- Division of Paediatric Neurosurgery, McGill University Health Centre, Montreal, QC, Canada
| | - Scott Ryall
- The Arthur and Sonia Labatt Brain Tumour Research Centre, the Hospital for Sick Children, Toronto, ON, Canada
| | - David D Eisenstat
- Division of Hematology, Oncology and Palliative Care, Department of Pediatrics, University of Alberta & Stollery Children's Hospital, Edmonton, AB, Canada
| | - Juliette Hukin
- Division of Neurology and Oncology, Department of Pediatrics, University of British Columbia & British Columbia Children's Hospital, Vancouver, BC, Canada
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Grigenas O, Labib M, Avery M, Lownie S, Ranger A. Cavernous hemangioma presenting during pregnancy: A detailed literature review. J Pediatr Neurol 2015. [DOI: 10.3233/jpn-2012-0523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Orest Grigenas
- Department of Clinical Neurological Sciences, Division of Neurosurgery, London Health Sciences Center, University of Western Ontario, London, ON, Canada
| | - Mohamed Labib
- Department of Clinical Neurological Sciences, Division of Neurosurgery, London Health Sciences Center, University of Western Ontario, London, ON, Canada
| | - Michael Avery
- Schulich School of Medicine and Dentistry, London Health Sciences Center, University of Western Ontario, London, ON, Canada
| | - Stephen Lownie
- Department of Clinical Neurological Sciences, Division of Neurosurgery, London Health Sciences Center, University of Western Ontario, London, ON, Canada
| | - Adrianna Ranger
- Department of Clinical Neurological Sciences, Division of Neurosurgery, London Health Sciences Center, University of Western Ontario, London, ON, Canada
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Hochstadter E, Stewart TC, Alharfi IM, Ranger A, Fraser DD. Subarachnoid hemorrhage prevalence and its association with short-term outcome in pediatric severe traumatic brain injury. Neurocrit Care 2015; 21:505-13. [PMID: 24798696 DOI: 10.1007/s12028-014-9986-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is an independent prognostic indicator of outcome in adult severe traumatic brain injury (sTBI). There is a paucity of investigations on SAH in pediatric sTBI. The goal of this study was to determine in pediatric sTBI patients SAH prevalence, associated factors, and its relationship to short-term outcome. METHODS We retrospectively analyzed 171 sTBI patients (pre-sedation GCS ≤8 and head MAIS ≥4) who underwent CT head imaging within the first 24 h of hospital admission. Data were analyzed with both univariate and multivariate techniques. RESULTS SAH was found in 42 % of sTBI patients (n = 71/171), and it was more frequently associated with skull fractures, cerebral edema, diffuse axonal injury, contusion, and intraventricular hemorrhage (p < 0.05). Patients with SAH had higher Injury Severity Scores (p = 0.032) and a greater frequency of fixed pupil(s) on admission (p = 0.001). There were no significant differences in etiologies between sTBI patients with and without SAH. Worse disposition occurred in sTBI patients with SAH, including increased mortality (p = 0.009), increased episodes of central diabetes insipidus (p = 0.002), greater infection rates (p = 0.002), and fewer ventilator-free days (p = 0.001). In sTBI survivors, SAH was associated with increased lengths of stay (p < 0.001) and a higher level of care required on discharge (p = 0.004). Despite evidence that SAH is linked to poorer outcomes on univariate analyses, multivariate analysis failed to demonstrate an independent association between SAH and mortality (p = 0.969). CONCLUSION SAH was present in almost half of pediatric sTBI patients, and it was indicative of TBI severity and a higher level of care on discharge. SAH in pediatric patients was not independently associated with increased risk of mortality.
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Zollars E, Fang H, Bienkowska J, Czerkowicz J, Ranger A, Allaire N, Thai A, Browning J, Magder L, Petri M. A6.44 Only BAFF mRNA, not BAFF protein level in blood, is associated with SLE activity over one year. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-207259.170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Ranger A, Diosy D. Seizures in children with dysembryoplastic neuroepithelial tumors of the brain--A review of surgical outcomes across several studies. Childs Nerv Syst 2015; 31:847-55. [PMID: 25795072 PMCID: PMC4445255 DOI: 10.1007/s00381-015-2675-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 02/27/2015] [Indexed: 01/22/2023]
Abstract
PURPOSE In children and adolescents, dysembryoplastic neuroepithelial tumors (DNETs) of the brain present with seizures almost 100% of the time, potentially creating significant long-term morbidity and disability despite the generally indolent course of the lesion. These tumors also tend to be quite resistant to anti-epileptic drugs which, themselves, can be associated with long-term side effects and resultant disability. Many clinicians advocate early surgical resection of these lesions, but how effective this approach is, and how aggressive tumor removal should be, continues to be debated. METHODS We performed a systematic review of the relevant literature to identify all reports of DNET resections in pediatric patients published over the past 20 years. In all, over 3000 MEDLINE abstracts were reviewed, ultimately resulting in 13 studies with 185 pediatric DNET patients to review. RESULTS Surgical resection of the lesion was effective at improving seizures in over 98% of patients and at achieving long-term seizure freedom in 86%. Surgical resection of DNETs also appeared to be quite safe, with no reported perioperative deaths and an overall rate of postoperative complications of 12%; the vast majority of these complications were transient. CONCLUSIONS Total gross resection of the lesion was the only factor statistically correlated with long-term seizure freedom (r = 0.63, p = 0.03). However, data remain lacking regarding whether this translates into more extensive procedures-like brain mapping and partial lobectomies-being any more effective than simple lesionectomies alone. Further research is clearly needed to address this and other crucial questions.
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Affiliation(s)
- Adrianna Ranger
- Department of Clinical Neurological Sciences, Division of Neurosurgery (Pediatric Neurosurgery), Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada,
| | - David Diosy
- Department of Clinical Neurological Sciences, Division of Neurology (Epilepsy), Schulich School of Medicine and Dentistry, Western University, London, Ontario Canada
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Abstract
ABSTRACT:Objective:To determine physical and cognitive outcomes of full-term infants who suffered intracranial hemorrhage (ICH) at birth.Methods:A retrospective hospital-based, follow-up study of infants treated in London, Ontario between 1985 and 1996. Follow-up was conducted by telephone interviews and clinic visits. Outcome was measured according to physical and cognitive scales. Perinatal risk factors and hemorrhage characteristics were correlated with final outcome.Results:For this study 66 infants with ICH were identified, of which seven died during the first week of life. We obtained follow-up in all but ten cases (median = 3-years; range 1.0 to 10.9 years). Overall, 57% of infants had no physical or cognitive deficits at follow-up. Death occurred most frequently among those with primarily subarachnoid hemorrhage (19%) and the most favorable outcomes occurred among those with subdural hemorrhage (80% had no disability). In univariate models, thrombocytopenia (platelet count ≤ 70 x 109/L), increasing overall hemorrhage severity, frontal location and spontaneous vaginal delivery as opposed to forceps-assisted delivery increased risk for poor outcome. In multivariate models, all these factors tended towards increased risk, but only thrombocytopenia remained significant for physical disability (OR = 7.6; 95% CI = 1.02 – 56.6); thrombocytopenia was borderline significant in similar models for cognitive disability (OR = 4.6; 95% CI = 0.9 – 23.9).Conclusion:Although forceps-assisted delivery may contribute to ICH occurrence, our study found better outcomes among these infants than those who had ICH following a spontaneous vaginal delivery. Hemorrhage in the frontal lobe was the most disabling hemorrhage location and if multiple compartments were involved, disability was also more likely to occur. However, in this report we found that the factor that was most likely to contribute to poor outcome was thrombocytopenia and this remained important in multivariate analysis.
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Affiliation(s)
- Balraj S Jhawar
- Division of Neurosurgery, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
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Magder L, Zollars E, Bienkowska J, Stebbins C, Wager C, Burkly L, Wisniacki N, Ranger A, Petri M. OP0214 Identification of Gene Transcripts and Proteins That Independently PREDICT SLE Disease Activity over the Next Year. Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2014-eular.4539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Hochstadter E, Stewart TC, Alharfi IM, Ranger A, Fraser DD. 24: Subarachnoid Hemorrhage is not Independently Associated with Mortality in Pediatric Severe Traumatic Brain Injury. Paediatr Child Health 2014. [DOI: 10.1093/pch/19.6.e35-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ranger A, Buckley H, Bhuva N, Koay J, Anand G. Palliative Whole Brain Radiotherapy in Primary Lung Cancer – Are We Doing Too Much? Clin Oncol (R Coll Radiol) 2014. [DOI: 10.1016/j.clon.2014.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Maciel TT, Merle E, Fricot A, Monteiro R, Moura IC, Seleznik G, Seeger H, Papandile A, Fu K, Poreci U, Czerkowicz J, Rabah D, Ranger A, Cohen CD, Lindenmeyer M, Chen J, Edenhofer I, Anders HJ, Lech M, Wuthrich RP, Ruddle NH, Moeller MJ, Regele H, Kozakowski N, Bauer J, Heikenwalder M, Browning JL, Segerer S, Kirsch AH, Artinger K, Rho E, Wolf AM, Cornez I, Eller P, Wolf D, Rosenkranz AR, Eller K, Rho E, Artinger K, Kirsch AH, Schaubettl C, Aringer I, Rosenkranz AR, Eller P, Eller K, Grande JP, Hartono SP, Kashyap S, Knudsen B. PATHOLOGY INFLAMMATION. Nephrol Dial Transplant 2014. [DOI: 10.1093/ndt/gfu119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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35
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Wisniacki N, Stebbins C, Bienkowska J, Gawlak S, Bennett D, Xiang Y, Dearth A, Ranger A, Burkly L, Petri M. FRI0295 Urinary tweak predicts renal disease activity in patients with systemic lupus erythematosus over a 1 year period. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.1422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
Type 2B von Willebrand disease (VWD) is a rare, inherited bleeding disorder resulting from a qualitative defect in von Willebrand factor (VWF). There is very little published information on how to quantify bleeding risk and manage haemostasis in type 2B VWD patients during pregnancy. This article presents the changes in VWF parameters and details of patient management and delivery outcomes for four pregnancies in three women with two different mutations causing type 2B VWD. We report an unexpected rise in the VWF:Ag at 37 weeks gestation in two sisters with R1306W associated with significant thrombocytopenia. These patients were supported with platelet transfusions as well as intermediate purity VWF-FVIII plasma concentrates during the peri- and postpartum periods. No thrombocytopenia was observed in our third case with a mutation encoding an R1308C substitution; haemostatic support was with intermediate purity VWF-FVIII plasma concentrates alone. No adverse bleeding events occurred and in all cases a live healthy infant was delivered. One patient was readmitted post partum with bleeding symptoms due to retained placenta; no further haemostatic support was given at this time. This case series is the first to detail the progression of laboratory parameters, management and outcomes of pregnancy in patients with type 2B VWD. The cases illustrate some of the challenges posed by the increased production of a VWF variant with a gain-of-function effect. The rapid coagulation changes observed in this series illustrate the need for continual monitoring of VWF parameters and platelet count throughout pregnancy in women with type 2B VWD.
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Affiliation(s)
- A Ranger
- Department of Haematology, Imperial College Academic Health Care Trust, Hammersmith Hospital, London, UK
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Abstract
In most instances, initial surgery to untether a tethered spinal cord is successful. But what happens when it is not? The authors describe the case of a now 18-year-old woman with spina bifida in whom surgery for tethered cord was required on two occasions. In both instances, due to the extent of her underlying lesion and fibrous tissue, only partial detethering was possible without acutely sacrificing significant neurological function. The authors detail the patient's course and review the peer-reviewed scientific literature on outcomes in patients in whom only partial cord detethering is achieved. In their review of all case series and clinical studies pertaining to the surgical treatment of tethered cord syndrome identified during an online search of 2184 scientific abstracts and 2 major neurosurgery textbooks, excluding the present case, the authors identified 53 confirmed or presumed cases of incomplete detethering in eight articles, incorporating 390 patients, for an overall prevalence of roughly 13.6%. Although no investigators have reported statistical comparisons of outcomes in those in whom just partial and complete detethering has been achieved, the evidence generally suggests poorer outcomes in the former. Prospective multicenter studies addressing this important issue clearly are warranted. To date, the authors believe that incomplete detethering is grossly underreported in the medical literature.
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Affiliation(s)
- Adrianna Ranger
- Department of Neurosurgery, Children's Hospital London Health Sciences Center, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.
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Ranger A, Szymczak A, Levin S, Salvadori M, Fraser DD. Osmotic myelinolysis with malignant cerebellar edema occurring after DDAVP-induced hyponatremia in a child. Pediatr Neurosurg 2010; 46:318-23. [PMID: 21196800 DOI: 10.1159/000320146] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Accepted: 08/10/2010] [Indexed: 01/13/2023]
Abstract
Central pontine myelinolysis (CPM) and extrapontine myelinolysis (EPM) are dire neurological disorders, characterized by severe damage to the myelin sheath of neurons, which typically result from rapid correction or overcorrection of systemic hyponatremia. For many years, both conditions have been considered universally fatal, though survivors have been reported more recently. Pediatric cases are rare. We present a 13-year-old boy with panhypopituitarism secondary to repair of a nasofrontal encephalocele in infancy, managed on long-term corticosteroid, deamino arginine vasopressin and thyroid hormone. He presented with severe hyponatremia (116 mEq/l), which during correction rapidly and unexpectedly increased to 176 mEq/l, resulting in profoundly impaired consciousness. Brain imaging revealed multiple bilateral changes in the basal ganglia, thalamus, pons and cerebral white matter, consistent with both CPM and EPM. Malignant cerebellar edema necessitated emergent suboccipital craniectomy, with subsequent improvement in level of consciousness and imaging postoperatively. However, he succumbed to acute cardiorespiratory arrest 8 weeks later. Nine similar cases from the literature are reviewed.
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Affiliation(s)
- Adrianna Ranger
- Pediatric Neurosurgery, Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont., Canada.
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Ranger A, Szymczak A. DO INTRACRANIAL NEOPLASMS DIFFER IN OLLIER DISEASE AND MAFFUCCI SYNDROME? AN IN-DEPTH ANALYSIS OF THE LITERATURE. Neurosurgery 2009; 65:1106-13; discussion 1113-5. [DOI: 10.1227/01.neu.0000356984.92242.d5] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Ranger A, Szymczak A, Hammond RR, Zelcer S. Pediatric thalamic glioblastoma associated with Ollier disease (multiple enchondromatosis): a rare case of concurrence. J Neurosurg Pediatr 2009; 4:363-7. [PMID: 19795968 DOI: 10.3171/2009.5.peds08422] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ollier disease and Maffucci syndrome are rare syndromes in which there is deforming dysplasia of cartilage, primarily but not exclusively involving the metaphyses and diaphyses of long bones. In a minority of patients, dysplasia can lead to sarcomatous degeneration, producing chondrosarcomas. There also appears to be an association with other neoplasms. Little has been written about the association between Ollier disease and intracranial tumors, and these papers have largely consisted of case reports in adults. The authors present the case of a 6-year-old girl with left arm osseous changes consistent with Ollier disease and a biopsy-proven thalamic glioblastoma multiforme. They then examine the co-occurrence of brain tumors in conjunction with a dyschondroplasia syndrome in children and adolescents to assess the presentation, treatment offered, and disease course of similar cases. Eight other such cases were identified, 6 in patients with Ollier disease (ranging in age from 7 to 18 years), and 2 with Maffucci syndrome (both in late adolescence). Including our own patient, 7 of the 9 cases of comorbid dyschondroplasia and intracranial malignancy occurred in girls. Some patients presented soon after the acute onset of symptoms, and others had a more subtle, protracted course over as many as 2 years. Some tumors were deemed resectable and others not. In only 1 instance was follow-up beyond 1 year reported.
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Affiliation(s)
- Adrianna Ranger
- Department of Neurosurgery, Children's Hospital, London, Ontario, Canada.
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Ranger A, McDonald W, Moore E, Delmaestro R. The invasiveness of five medulloblastoma cell lines in collagen gels. J Neurooncol 2009; 96:181-9. [PMID: 19847623 DOI: 10.1007/s11060-009-9962-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 07/06/2009] [Indexed: 10/20/2022]
Abstract
Local recurrence continues to limit survival in medulloblastoma patients, largely related to the persistence of invasive cells at the site of tumour resection and leptomeningeal dissemination. Given the relative dearth of understanding of causative mechanisms behind the invasiveness of medulloblastomas, and a general lack of validated in vitro models with which to study them, our objectives were (1) to obtain quantitative data on the invasiveness of five distinct medulloblastoma cell lines within a 3-dimensional in vitro collagen-based model; and (2) to characterize some of the mechanisms behind invasion, specifically striving to identify proteolytic processes that occur as medulloblastoma cells disrupt and thereby invade the normal tissue surrounding them, and specific inhibitors of these proteolytic enzymes. Five different medulloblastoma cell lines (UW228-1, 2 and 3; Daoy, and Madsen) were implanted onto a 3-dimensional, type I collagen gel assay to assess tumour invasion distance and mean doubling time over 5 days. Proteolytic activity was assessed against collagen types I and IV by measuring the degradation of 3H-collagen I and IV to products soluble in 100% w/v trichloroacetic acid; and general (neutral) proteolytic activity evaluated by measuring the degradation of 3H-albumin. In other experiments, cells were pre-exposed to a variety of protease inhibitors, including inhibitors of metalloproteinases and cysteine, serine and aspartic proteases, and then plated to identify any inhibition of invasion. Inter-group differences in mean invasion distance were assessed by means of Student's t-tests for non-paired subjects, with P < 0.05 set as the threshold for statistical significance. For the inhibitor studies, an inhibition index, called the inhibitory concentration 50, IC-50, was calculated by performing a regression analysis for each inhibitor tested over a range of concentrations, for each cell line. Within hours of implantation, individual cells readily detached from the surface of the cell aggregates and invaded the collagen matrix, to distances of up to 1,200 mum and at rates of up to 300-mum per day; the UW228-1 cell line clearly was less invasive than the other four cell lines. Proteolytic activity was identified against collagen type I, but not against collagen type IV or albumin; but there was no apparent correlation between invasion distance and either cell doubling time or the amount of collagen type I proteolytic activity. Both metalloproteinase inhibitors suppressed tumour invasion, as did one of two cysteine protease inhibitors; but there was no tumour suppression with either serine or aspartic protease inhibition. MMP-1 and 2, and TIMP-1 and 2 all were detectable by Western blot analysis. Medulloblastoma cell invasiveness within the 3-dimensional model used here appears to depend upon a combination of metalloproteinase and cysteine protease activity, a finding that may suggest areas for potential future clinical investigation and therapy.
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Affiliation(s)
- Adrianna Ranger
- Brain Research Laboratories, Experimental Research Unit, Division of Neurosurgery, London Health Sciences Centre, University of Western Ontario, London, ON N6A4G5, Canada.
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Ranger A, Szymczak A. The association between intracranial tumours and multiple dyschondroplasia (Ollier's disease or Maffucci's syndrome): do children and adults differ? J Neurooncol 2009; 95:165-173. [PMID: 19506814 DOI: 10.1007/s11060-009-9924-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2008] [Accepted: 05/24/2009] [Indexed: 11/26/2022]
Abstract
In Ollier's disease (OD) and Maffucci's syndrome (MS), there is deforming dysplasia of cartilage, primarily but not exclusively involving the metaphyses and diaphyses of long bones. In a minority of patients with either of these rare syndromes, dysplasia can lead to sarcomatous degeneration, producing chondrosarcomas. There also appears to be an association with other neoplasms, which can include intracranial tumours. The primary objective of the current paper was to compare children/adolescents who have either OD or MS and an intracranial malignancy with their adult counterparts. All relevant cases in the medical literature were identified by electronically searching PubMed, SciSearch, Scientific Commons, Springer Link, and Google. Translate DotNet and Babelfish were used to translate non-English text. Non-parametric Pearson chi-square analyses were used to compare youths versus adults with respect to gender and geographic distribution (by continent), tumour histology and site of lesion, and the underlying enchondromatosis syndrome (OD vs. MS). All tests were 2-tailed, and P < 0.05 represented a statistically-significant difference. Forty-six patients with 47 intra-cranial malignancies were identified, with nine of the patients being 18 years old or less and categorized as youths. The incidence of intracranial chondrosarcomas peaked in the fourth decade of life, in parallel with the peak number of MS cases; conversely, both non-sarcomas and OD peaked in the third decade of life. Six of nine youths (67%) versus 17 of 36 adults with gender data (47%) were female (P = 0.30). There was no difference in geographic distribution by continent (P = 0.82). Four youths (44%) versus 16 adults (43%) had a chondrosarcoma (P = 0.95), and there was no statistically significant difference by tumour site (P = 0.42). However, seven (77%) of the youths had Ollier's disease as their underlying enchondromatosis syndrome, versus just 17 (46%) of the adults, a difference that approached statistical significance (P = 0.086). The association between enchondromatosis and intracranial malignancy seems to be roughly the same in youths versus adults, though Ollier's disease cases appear to predominate among youths.
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Affiliation(s)
- Adrianna Ranger
- Department of Neurosurgery, Children's Hospital London Health Sciences Center, 800 Commissioners Road East, London, ON, Canada.
| | - Artur Szymczak
- Department of Neurosurgery, Children's Hospital London Health Sciences Center, 800 Commissioners Road East, London, ON, Canada
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Abstract
A 15 year old male presented with hydrocephalus from a tectal mass obstructing the cerebral aqueduct and upper fourth ventricle. The solid-cystic partly enhancing mass proved to be a pigmented pleomorphic xanthoastrocytoma, the third such example reported. The lesion revealed typical features of a PXA with the unusual addition of intracytoplasmic melanin in select lesional cells. Melanin pigment production is uncommon in glial tumors and of uncertain significance. The present case is recurrence-free one year post-operatively.
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Affiliation(s)
- Erin M Chapman
- Department of Clinical Neurologic Sciences, London Health Sciences Center and Schlich School of Medicine and Dentistry, London, Ontario, Canada
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45
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Ranger A, Szymczak A, Fraser D, Salvadori M, Jardine L. Bilateral decompressive craniectomy for refractory intracranial hypertension in a child with severe ITP-related intracerebral haemorrhage. Pediatr Neurosurg 2009; 45:390-5. [PMID: 19940538 DOI: 10.1159/000260910] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Accepted: 07/20/2009] [Indexed: 11/19/2022]
Abstract
We report a 13-month-old infant who developed acutely elevated intracranial pressure (ICP) as a result of a spontaneous intracerebral haemorrhage (ICH), secondary to idiopathic thrombocytopenic purpura (ITP). Her ICP remained severely elevated despite aggressive medical measures, with persistent obtundation, right hemiparesis and a dilated left pupil. Bilateral decompressive craniectomies (DCs) were performed, which resulted in a rapid decline in ICP. Ultimately, the patient regained consciousness and went on to complete neurological recovery. Tragically, she died of non-neurological, ITP-related complications 9 months later. In our review, we identified no other instances of bilateral DCs reported in the management of an infant with ITP and/or an ICH. We addressed three central questions: (1) Is there any value of DCs in children, and especially in infants, with elevated ICP? (2) Is there any value of DCs in the setting of non-traumatic ICH? And (3) is there any rationale for the use of bilateral versus unilateral DCs?
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Affiliation(s)
- Adrianna Ranger
- Department of Pediatric Neurosurgery, London Health Sciences Center, London, ON N6A 5W9, Canada.
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Chik CL, Arnason TG, Dukewich WG, Price DM, Ranger A, Ho AK. Histone H3 phosphorylation in the rat pineal gland: adrenergic regulation and diurnal variation. Endocrinology 2007; 148:1465-72. [PMID: 17185373 DOI: 10.1210/en.2006-1454] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In this study, we investigated phosphorylation of Ser10 in histone H3 by norepinephrine (NE) in the rat pineal gland. In whole-animal studies, we demonstrated a marked increase in histone H3 phosphorylation in the rat pineal gland during the first half of the dark period. Exposure to light during this period caused a rapid decline in histone H3 phosphorylation with an estimated t1/2 of less than 15 min, indicating a high level of dephosphorylation activity. Corresponding studies in cultured pineal cells revealed that treatment with NE produced an increase in histone H3 phosphorylation that peaked between 2 and 3 h and declined rapidly by 4 h. The NE-induced histone H3 phosphorylation was blocked by cotreatment with propranolol or KT5720, a protein kinase A inhibitor, but not by prazosin or other kinase inhibitors. Moreover, only treatment with dibutyryl cAMP but not other kinase activators mimicked the effect of NE on histone H3 phosphorylation. The NE-stimulated H3 phosphorylation was markedly increased by cotreatment with a serine/threonine phosphatase inhibitor, tautomycin or okadaic acid, supporting a high level of ongoing histone H3 dephosphorylation activity. Together, our results indicate that histone H3 phosphorylation is a naturally occurring event at night in the rat pineal gland that is driven almost exclusively by a NE-->beta-adrenergic-->cAMP/protein kinase A signaling mechanism. This transient histone H3 phosphorylation probably reflects the nocturnal activation of multiple adrenergic-regulated genes in the rat pineal gland.
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Affiliation(s)
- C L Chik
- Department of Physiology, 7-26 Medical Sciences Building, Edmonton, Alberta, Canada T6G 2H7
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Abstract
An 11-month-old girl was admitted for a 2-month history of regression of motor milestones and lateralizing neurologic findings. Tests for hypercoagulability were all within normal limits except for a moderately elevated fibrinogen level. Urine and blood cultures were negative for growth. Complete MRI of the spine revealed a well-defined extradural inhomogeneous signal intensity extending from C(4) to T(3) suggestive of a subacute hematoma with evidence of evolving hemorrhagic change. There was no evidence of underlying arterial venous fistula or malformation. She underwent a cervicothoracic laminoplasty and evacuation of the hematoma. The clot was confirmed to be a hematoma on pathologic investigation. She made an uneventful recovery with gradual return of neurologic function. This case represents the longest known duration between initial symptoms and definitive management of spontaneous spinal epidural hematoma.
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Affiliation(s)
- N Poonai
- Children's Hospital of Western Ontario, University of Western Ontario, London, Ont., Canada
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Megyesi JF, Ranger A, MacDonald W, Del Maestro RF. Suturing technique and the integrity of dural closures: an in vitro study. Neurosurgery 2005; 55:950-4; discussion 954-5. [PMID: 15458604 DOI: 10.1227/01.neu.0000138441.07112.1b] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2003] [Accepted: 03/04/2004] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The watertight closure of the dura mater is fundamental to intracranial procedures in neurosurgery. Nevertheless, for any given operator and type of suture, it is still not certain which suturing technique affords the most watertight dural closure. We have developed a laboratory model that allows us to compare the pressures at which dural closures leak when different suturing techniques are used. METHODS Human cadaveric dura was secured to a glass cylinder filled with colored saline. By application of force to a bag of saline attached to the cylinder, the pressure at which sutured dural incisions leak can be recorded. Using this method, we have compared the closure of 2-cm dural incisions with 3-0 silk using the following techniques (10 per group): 1) interrupted simple, 2) running simple, 3) running locked, and 4) interrupted vertical mattress. We have also compared the closure of 1- x 3-cm dural windows with cadaveric dura and 3-0 silk using the same suturing techniques (10 per group). RESULTS The pressure at which 2-cm linear dural incisions leaked was significantly higher when they were closed with the interrupted simple suturing technique (P < 0.05). There was no significant difference among the different suturing techniques when they were used to close a 1- x 3-cm dural window with a duraplasty. Overall, the pressures at which sutured linear dural incisions leaked were higher than the pressures at which sutured dural windows closed with duraplasties leaked. CONCLUSION In the experimental model described, an interrupted simple suturing technique affords the most watertight dural closure for linear incisions, whereas no suturing technique proved advantageous for the closure of a duraplasty.
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Affiliation(s)
- Joseph F Megyesi
- Brain Research Laboratory, Experimental Research Unit, Division of Neurosurgery, University of Western Ontario, London, Ontario, Canada.
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Jhawar BS, Ranger A, Steven D, Del Maestro RF. Risk factors for intracranial hemorrhage among full-term infants: a case-control study. Neurosurgery 2003; 52:581-90; discussion 588-90. [PMID: 12590682 DOI: 10.1227/01.neu.0000047819.33177.72] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2002] [Accepted: 10/18/2002] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To investigate the cause of intracranial hemorrhage among full-term infants. METHODS A retrospective, hospital-based, matched case-control study was conducted at London Health Sciences Center, in southwestern Ontario, for the period from January 1, 1985, to December 31, 1996. Cases were diagnosed with magnetic resonance imaging, computed tomography, or ultrasonography within 7 days after birth. Control subjects were matched with respect to year of birth, sex, and, for nontransferred case patients only, obstetrician. RESULTS Sixty-six full-term infants with intracranial hemorrhage were identified, and 104 control subjects were matched. Each factor was independently associated with increased risk of intracranial hemorrhage, as follows: forceps assistance (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.2-15.1), compared with spontaneous vaginal delivery; 1-minute Apgar scores of 1 through 4 (OR, 110; 95% CI, 5.0-2400) and 5 through 8 (OR, 4.9; 95% CI, 1.3-18.3), compared with scores of 9 or 10 (corresponding 5-min Apgar scores were also statistically significant); and requirements for resuscitation (OR, 5.1; 95% CI, 1.8-14.1), compared with no resuscitation requirements. Of the 52 case patients for whom platelet counts were recorded within 48 hours after birth, 30.8% (95% CI, 18.3-43.3%) exhibited counts of less than 70 x 10(9)/L. Platelet counts of less than 50 x 10(9)/L were specifically associated with intraparenchymal hemorrhage and a more severe radiological grade. Forceps-associated hemorrhage was more frequently subarachnoid and subdural and less frequently intraparenchymal. Such hemorrhage also tended to be more caudal in location. CONCLUSION Thrombocytopenia seems to be an important cause of intraparenchymal hemorrhage, and the use of forceps is more likely to be associated with subarachnoid and subdural hemorrhage.
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Affiliation(s)
- Balraj S Jhawar
- Department of Neurosurgery, London Health Sciences Center, University of Western Ontario, London, Ontario, Canada.
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Affiliation(s)
- C Downs
- The Mid Argyll Hospital, Lochgilphead, Argyll PA31 8LU, UK.
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