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Kelly KA, Guidry BS, Wong GW, Thomas HC, Girgis M, Shannon CN, Wellons JC, Cools MJ. The role of traditional social determinants of health in referral patterns, timing of surgery, and Chiari Health Index for Pediatrics-determined quality of life in children with symptomatic Chiari type I malformation. J Neurosurg Pediatr 2023; 32:686-691. [PMID: 37877946 DOI: 10.3171/2023.7.peds22114] [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: 04/02/2022] [Accepted: 07/20/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE Understanding the impact of the social determinants of health on the utilization of healthcare resources is an important step in eliminating inequalities. The goal of this study was to determine the role of social determinants of health in referral patterns, timing of consultation/intervention, and quality of life in children with Chiari malformation type I (CM-I). METHODS A retrospective study was conducted of children aged 0 to 18 years who underwent surgical treatment for CM-I at a single pediatric facility from 2015 to 2019. The variables included demographic and socioeconomic characteristics, referral patterns, timing, and quality of life data based on the Chiari Health Index for Pediatrics (CHIP). RESULTS The cohort consisted of 103 surgically treated CM-I patients. No differences were seen in race, sex, insurance, or household income when evaluating referral source (community, specialist, or emergency department) or when comparing patients with incidental versus symptomatic findings. In the evaluation of timing from initial evaluation to surgery, no statistical differences were seen between racial, sex, insurance status, or income groups. Children from households of lower median family income were significantly more likely to report pain at the time of consultation (pain group median [interquartile range] $46,660 [$41,004-$50,367] vs nonpain group $53,604 [$41,427-$59,828], p = 0.004). Those in the lower-income group also reported lower CHIP scores corresponding to increased symptomatology in the nonpain physical symptoms (p = 0.004) and psychosocial domains (p = 0.018). CONCLUSIONS There was no evidence of a difference in referral patterns or a delay in time from clinic presentation to surgery based on the traditional social determinants of health categories. Children from households in the lower-income group were associated with increased severity of pain and nonpain symptoms.
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Affiliation(s)
- Katherine A Kelly
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
- 2Vanderbilt University School of Medicine, Nashville, Tennessee
- 3Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | - Bradley S Guidry
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
- 2Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gunther W Wong
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
- 2Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Harrison C Thomas
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
- 2Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mariam Girgis
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Chevis N Shannon
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
- 2Vanderbilt University School of Medicine, Nashville, Tennessee
- 4Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John C Wellons
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
- 2Vanderbilt University School of Medicine, Nashville, Tennessee
- 4Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael J Cools
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
- 2Vanderbilt University School of Medicine, Nashville, Tennessee
- 4Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Dewan MC, Isaacs AM, Cools MJ, Yengo-Kahn A, Naftel RP, Jensen H, Reeder RW, Holubkov R, Haizel-Cobbina J, Riva-Cambrin J, Jafrani RJ, Pindrik JA, Jackson EM, Judy BF, Kurudza E, Pollack IF, Mcdowell MM, Hankinson TC, Staulcup S, Hauptman J, Hall K, Tamber MS, Cheong A, Warsi NM, Rocque BG, Saccomano BW, Snyder RI, Kulkarni AV, Kestle JRW, Wellons JC. Treatment of hydrocephalus following posterior fossa tumor resection: a multicenter collaboration from the Hydrocephalus Clinical Research Network. J Neurooncol 2023; 163:123-132. [PMID: 37129738 DOI: 10.1007/s11060-023-04316-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Persistent hydrocephalus following posterior fossa brain tumor (PFBT) resection is a common cause of morbidity in pediatric brain tumor patients, for which the optimal treatment is debated. The purpose of this study was to compare treatment outcomes between VPS and ETV in patients with persistent hydrocephalus following surgical resection of a PFBT. METHODS A post-hoc analysis was performed of the Hydrocephalus Clinical Research Network (HCRN) prospective observational study evaluating VPS and ETV for pediatric patients. Children who experienced hydrocephalus secondary to PFBT from 2008 to 2021 were included. Primary outcomes were VPS/ETV treatment failure and time-to-failure (TTF). RESULTS Among 241 patients, the VPS (183) and ETV (58) groups were similar in age, extent of tumor resection, and preoperative ETV Success Score. There was no difference in overall treatment failure between VPS and ETV (33.9% vs 31.0%, p = 0.751). However, mean TTF was shorter for ETV than VPS (0.45 years vs 1.30 years, p = 0.001). While major complication profiles were similar, compared to VPS, ETV patients had relatively higher incidence of minor CSF leak (10.3% vs. 1.1%, p = 0.003) and pseudomeningocele (12.1% vs 3.3%, p = 0.02). No ETV failures were identified beyond 3 years, while shunt failures occurred beyond 5 years. Shunt infections occurred in 5.5% of the VPS cohort. CONCLUSIONS ETV and VPS offer similar overall success rates for PFBT-related postoperative hydrocephalus. ETV failure occurs earlier, while susceptibility to VPS failure persists beyond 5 years. Tumor histology and grade may be considered when selecting the optimal means of CSF diversion.
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Affiliation(s)
- Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Neurological Surgery, Division of Pediatric Neurological Surgery, Vanderbilt Children's Hospital, 2200 Children's Way, 9226 Doctors Office Tower, Nashville, TN, 37232-9557, USA.
| | - Albert M Isaacs
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael J Cools
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aaron Yengo-Kahn
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert P Naftel
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hailey Jensen
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Joseline Haizel-Cobbina
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Ryan J Jafrani
- Department of Neurosurgery, St. Louis Children's Hospital, Washington University, St. Louis, MO, USA
| | - Jonathan A Pindrik
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brendan F Judy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elena Kurudza
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Ian F Pollack
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael M Mcdowell
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Hankinson
- Department of Neurosurgery, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Susan Staulcup
- Department of Neurosurgery, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Jason Hauptman
- Department of Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Koko Hall
- Department of Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Mandeep S Tamber
- Department of Surgery, Division of Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Alex Cheong
- Department of Surgery, Division of Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Nebras M Warsi
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Benjamin W Saccomano
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Rita I Snyder
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Abhaya V Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - John R W Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - John C Wellons
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Cools MJ, Tang AR, Pruthi S, Koh TH, Braun SA, Bennett KA, Wellons JC. A comparison of MRI appearance and surgical detethering rates between intrauterine and postnatal myelomeningocele closures: a single-center pilot matched cohort study. Childs Nerv Syst 2023; 39:647-653. [PMID: 35927592 DOI: 10.1007/s00381-022-05627-z] [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: 06/05/2022] [Accepted: 07/25/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Intrauterine myelomeningocele repair (IUMR) and postnatal myelomeningocele repair (PNMR) differ in terms of both setting and surgical technique. A simplified technique in IUMR, in which a dural onlay is used followed by skin closure, has been adopted at our institution. The goal of this study was to compare the rates of clinical tethering in IUMR and PNMR patients, as well as to evaluate the appearance on MRI. METHODS We conducted a retrospective review of 36 patients with MMC repaired at our institution, with 2:1 PNMR to IUMR matching based on lesion level. A pediatric neuroradiologist blinded to the clinical details reviewed the patients' lumbar spine MRIs for the distance from neural tissue to skin and the presence or absence of a syrinx. An EMR review was then done to evaluate for detethering procedures and need for CSF diversion. RESULTS Mean age at MRI was 4.0 years and mean age at last follow-up was 6.1 years, with no significant difference between the PNMR and IUMR groups. There was no significant difference between groups in the distance from neural tissue to skin (PNMR 13.5 mm vs IUMR 17.6 mm; p = 0.5). There was no difference in need for detethering operations between groups (PNMR 12.5% vs IUMR 16.7%; RR 0.75; CI 0.1-5.1). CONCLUSIONS There was no significant difference between postnatal- and intrauterine-repaired myelomeningocele on MRI or in need for detethering operations. These results imply that a more straightforward and time-efficient IUMR closure technique does not lead to an increased rate of tethering when compared to the multilayered PNMR.
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Affiliation(s)
- Michael J Cools
- Department of Neurological Surgery, Vanderbilt University Medical Center, 1161 21st Ave S, Suite T-4224, Nashville, TN, USA.
- Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
| | - Alan R Tang
- Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sumit Pruthi
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tae Ho Koh
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephane A Braun
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelly A Bennett
- The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John C Wellons
- Department of Neurological Surgery, Vanderbilt University Medical Center, 1161 21st Ave S, Suite T-4224, Nashville, TN, USA
- Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
- The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA
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Cools MJ, Wellons JC, Iskandar BJ. The Nomenclature of Chiari Malformations. Neurosurg Clin N Am 2022; 34:1-7. [DOI: 10.1016/j.nec.2022.08.003] [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: 11/07/2022]
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Allen JH, Yengo-Kahn AM, Cools MJ, Greeno A, Ghani MOA, Unni P, Martus JE, Lovvorn HN, Bonfield CM. Pediatric spinal injury patterns and management in all-terrain vehicle and dirt bike crashes, 2010-2019. J Neurosurg Pediatr 2022; 30:1-8. [PMID: 35962971 DOI: 10.3171/2022.7.peds22178] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric spinal injuries in all-terrain vehicle (ATV) and dirt bike crashes are relatively uncommon but may be associated with significant morbidity. There are no recent studies examining these injuries, their management, and outcomes. Therefore, a retrospective study was performed to characterize pediatric spinal injuries related to ATV and dirt bike crashes over the last decade. METHODS Data on all patients involved in ATV or dirt bike crashes evaluated at a regional level 1 pediatric trauma center over a 10-year period (2010-2019) were analyzed. Descriptive statistics were analyzed and chi-square, Fisher exact, and Mann-Whitney U-tests were performed comparing the demographics, injury characteristics, and clinical outcomes in patients with versus those without spinal injuries. RESULTS Of 680 patients evaluated, 35 (5.1%) were diagnosed with spinal injuries. Over the study period, both spinal injuries and emergency department visits related to ATV or dirt bike crashes increased in frequency. All spinal injuries were initially diagnosed on CT scans, and 57.9% underwent spinal MRI. Injuries were most commonly thoracic (50%), followed by cervical (36.8%). The injuries of most patients were classified as American Spinal Injury Association (ASIA) grade E on presentation (86.8%), while 2 (5.3%) had complete spinal cord injuries (ASIA grade A) and 3 patients (8.6%) were ASIA grade B-D. Operative management was required for 13 patients (28.9%). Nonoperative management was used in 71.1% of injuries, including bracing in 33% of all injuries. Patients with spinal injuries were older than those without (13.4 ± 3.35 vs 11.5 ± 3.79 years, p = 0.003). Spinal injuries occurred via similar crash mechanisms (p = 0.48) and in similar locations (p = 0.29) to nonspinal injuries. Patients with spinal injuries more frequently required admission to the intensive care unit (ICU; 34.2% vs 14.6%, p = 0.011) and had longer hospital stays (mean 4.7 ± 5.5 vs 2.7 ± 4.0 days, p = 0.0025). CONCLUSIONS Although infrequent among young ATV and dirt bike riders, spinal injuries are associated with longer hospital stays, increased ICU use, and required operative intervention in 29%. Increasing awareness among ATV and dirt bike riders about the severity of riding-related injuries may encourage safer riding behaviors.
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Affiliation(s)
| | | | | | - Amber Greeno
- 3Pediatric Surgery, Vanderbilt University Medical Center; and
| | | | - Purnima Unni
- 3Pediatric Surgery, Vanderbilt University Medical Center; and
| | - Jeffrey E Martus
- 4Department of Orthopedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
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Castellano AK, Powell JR, Cools MJ, Walton SR, Barnett RR, DeLellis SM, Goldberg RL, Kane SF, Means GE, Zamora CA, Depenbrock PJ, Mihalik JP. Relationship between Anterior Pituitary Volume and IGF-1 Serum Levels in Soldiers with Mild Traumatic Brain Injury History. Med Sci Sports Exerc 2022; 54:1364-1370. [PMID: 35838301 PMCID: PMC9287595 DOI: 10.1249/mss.0000000000002892] [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] [Indexed: 11/21/2022]
Abstract
PURPOSE A high mild traumatic brain injury (mTBI) incidence rate exists in military and sport. Hypopituitarism is an mTBI sequela; however, few studies have examined this phenomenon in those with an mTBI history. This cross-sectional study of Special Operations Forces combat soldiers aimed 1) to relate anterior pituitary gland volumes (actual and normalized) to insulin-like growth factor 1 (IGF-1) concentrations, 2) to examine the effect of mTBI history on anterior pituitary gland volumes (actual and normalized) and IGF-1 concentrations, and 3) to measure the odds of demonstrating lower anterior pituitary gland volumes (actual and normalized) or IGF-1 concentrations if self-reporting mTBI history. METHODS Anterior pituitary gland volumes were manually segmented from T1-weighted 3D brain MRI sequences; IGF-1 serum concentrations were quantified using commercial enzyme-linked immunosorbent assays. Correlations and linear regression were used to determine the association between IGF-1 serum concentration and anterior pituitary gland volume (n = 74). Independent samples t-tests were used to compare outcomes between mTBI groups and logistic regression models were fit to test the odds of demonstrating IGF-1 concentration or anterior pituitary volume less than sample median based on mTBI group (n = 54). RESULTS A significant linear relationship between the subjects' anterior pituitary gland volumes and IGF-1 concentrations (r72 = 0.35, P = 0.002) was observed. Soldiers with mTBI history had lower IGF-1 concentrations (P < 0.001) and lower anterior pituitary gland volumes (P = 0.037) and were at greater odds for IGF-1 serum concentrations less than the sample median (odds ratio = 5.73; 95% confidence interval = 1.77-18.55). CONCLUSIONS Anterior pituitary gland volume was associated with IGF-1 serum concentrations. Mild TBI history may be adversely associated with anterior pituitary gland volumes and IGF-1 concentrations. Longitudinal IGF-1 and anterior pituitary gland monitoring may be indicated in those who report one or more mTBI.
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Affiliation(s)
- Anna K. Castellano
- Matthew Gfeller Center, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jacob R. Powell
- Matthew Gfeller Center, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael J. Cools
- Matthew Gfeller Center, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Samuel R. Walton
- Matthew Gfeller Center, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Randaline R. Barnett
- Matthew Gfeller Center, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Richard L. Goldberg
- Department of Applied Physical Sciences, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Shawn F. Kane
- Department of Family Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Gary E. Means
- United States Army Special Operations Command, Fort Bragg, NC
| | - Carlos A. Zamora
- Department of Radiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Jason P. Mihalik
- Matthew Gfeller Center, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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Northam WT, Cools MJ, Chandran A, Alexander A, Mihalik JP, Guskiewicz KM, Carneiro KA. Sports Medicine Fellowship Training Improves Sport-related Concussion Evaluation. Curr Sports Med Rep 2020; 19:272-276. [PMID: 32692063 DOI: 10.1249/jsr.0000000000000730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Evaluating acute sport-related concussion (SRC) differs among providers, who apply international consensus and national guidelines variably. Retrospective medical record review was completed for 889 outpatients aged 7 to 18 years, diagnosed with SRC from 2014 to 2017. Associations between board-certified sports medicine fellowship (SMF) training status and assessment of concussion-specific history and physical examination items were tested using nonparametric χ tests. Differential odds (by fellowship training status) of using history and physical examination items were assessed using multivariable logistic regression modeling. Each SRC history and physical examination items were assessed in higher proportions by SMFs, as compared with non-SMFs, statistically significant for all tested items with the exception of headache history. SMFs demonstrated higher odds of detailed neurologic examinations and clinical cognitive testing compared with non-SMFs, after adjusting for patient and physician characteristics. Physicians caring for concussed patients should seek continuing education opportunities aligning them with training provided to sports medicine fellows.
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Affiliation(s)
| | | | | | | | | | - Kevin M Guskiewicz
- Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Department of Exercise and Sport Science, University of North Carolina, Chapel Hill, NC
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Reed SW, Cools MJ, Quinsey CS, Elton SW. Neonatal Hydrocephalus Treatment with Ultrasmall Valve Implantation. World Neurosurg 2019; 133:e397-e400. [PMID: 31526889 DOI: 10.1016/j.wneu.2019.09.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 07/08/2019] [Accepted: 09/06/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Neonatal hydrocephalus remains a difficult condition to manage, due to high failure rates among all management strategies. Neurosurgeons commonly manage hydrocephalus with ventriculoperitoneal shunt (VPS) implantation, and valves of variable sizes and profiles are available for implantation. This study examines primary ventricular shunt valve implantation complication rates based on valve profiles in pediatric patients with hydrocephalus. METHODS This study retrospectively reviews pediatric patients younger than 1 year of age who underwent ventricular shunt placement at a single institution from January 2001 to January 2017. Patients were classified by valve profile and categorized as either ultrasmall valves or regular-sized valves. Time until complication and type of complication were studied. RESULTS A total of 156 patients met the inclusion criteria. Forty-eight (31%) patients received an ultrasmall shunt valve, while 108 patients received a regular valve. On average, patients undergoing ultrasmall valve placement were younger (2.1 months) than patients undergoing placement of regular valves (3.1 months) (P = 0.03). The overall complication rate within 2 years of VPS placement was 37.5% in patients with the ultrasmall valve and 41.7% in the regular valve population. There was no difference in 1-year shunt survival rate between the 2 cohorts. CONCLUSION Our review did not find a significant difference in complication rates between ultrasmall and regular valves in patients under 1 year of age. However, the etiology of shunt malfunction did differ between the groups. This work further supports evidence suggesting a surgeon's preference for shunt hardware alone does not significantly impact outcome.
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Affiliation(s)
- Samuel W Reed
- Department of Neurosurgery, University of North Carolina at Chapel Hill, North Carolina, USA.
| | - Michael J Cools
- Department of Neurosurgery, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Carolyn S Quinsey
- Department of Neurosurgery, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Scott W Elton
- Department of Neurosurgery, University of North Carolina at Chapel Hill, North Carolina, USA
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Northam WT, Cools MJ, Boyd M, Mihalik JP, Guskiewicz KM, Carneiro KA. Evaluating Acute Sport-related Concussion In The Primary Care Setting: Are We Dropping The Ball? Med Sci Sports Exerc 2019. [DOI: 10.1249/01.mss.0000562709.36183.5f] [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: 11/21/2022]
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Cools MJ, Quinsey CS, Elton SW. Chiari decompression outcomes using ligamentum nuchae harvest and duraplasty in pediatric patients with Chiari malformation type I. J Neurosurg Pediatr 2018; 22:47-51. [PMID: 29652242 DOI: 10.3171/2018.1.peds17670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The choice of graft material for duraplasty in decompressions of Chiari malformations remains a matter of debate. The authors present a detailed technique for harvesting ligamenta nuchae, as well as the clinical and radiographic outcomes of this technique, in a case series. METHODS The authors conducted a retrospective study evaluating the outcomes of Chiari malformation type I decompression and duraplasty in children aged 0-18 years at a single institution from 2013 to 2016. They collected both intraoperative and postoperative variables and compared them qualitatively to published data. RESULTS During the study period, the authors performed 25 Chiari malformation decompressions with ligamentum nuchae graft duraplasties. Of the 25 patients, 10 were females, and the mean age at surgery was 8.6 years (range 13 months to 18 years). The median operative time was 163 minutes (IQR 152-187 minutes), with approximately 10 minutes needed by a resident surgeon to harvest the graft. The mean length of stay was 3 nights (range 2-6 nights), and the mean follow-up was 12.6 months (range 0.5-43.5 months). One patient (4%) developed a CSF leak that was repaired using an oversewing patch. There were no postoperative pseudomeningoceles or infections. Of the 19 patients presenting with a syrinx, imaging showed improvement in 10 (53%) and 8 (42%) had stable syrinx size on imaging. Of 16 patients presenting with a symptomatic Chiari malformation, 14 (87.5%) experienced resolution of symptoms and in 1 (4%) symptoms remained the same. One patient (4%) presented with worsening syrinx and symptoms 1.5 months after initial surgery and underwent repeat decompression. CONCLUSIONS The authors describe a series of clinical and imaging outcomes of patients who underwent Chiari malformation decompression and duraplasty with a harvested ligamentum nuchae. The rates of postoperative CSF leak are similar to established techniques of autologous and artificial grafts, with similarly successful outcomes. Further study will be needed with larger patient cohorts to more directly compare duraplasty graft outcomes.
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Ford CB, Cools MJ, DeLellis SM, Kane SF, Lutz RH, Lynch JH, Mihalik JP. Concussion History Moderates Relationships Between Neural and Clinical Outcomes in Special Operations Forces Personnel. Med Sci Sports Exerc 2018. [DOI: 10.1249/01.mss.0000538717.21606.6c] [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: 11/21/2022]
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Mihalik JP, Ford CB, Cools MJ, DeLellis SM, Kane SF, Lutz RH, Lynch JH. Concussion History Predicts Reduced Cortical Thickness in Special Operations Forces Personnel. Med Sci Sports Exerc 2018. [DOI: 10.1249/01.mss.0000538718.21606.88] [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: 11/21/2022]
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Cools MJ, Mihalik J, Carneiro K. Head Injury - Trampoline. Med Sci Sports Exerc 2018. [DOI: 10.1249/01.mss.0000536399.34521.31] [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: 11/21/2022]
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Cools MJ, Carneiro KA. Facial nerve palsy following mild mastoid trauma on trampoline. Am J Emerg Med 2018; 36:1522.e1-1522.e3. [PMID: 29861376 DOI: 10.1016/j.ajem.2018.04.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 04/12/2018] [Accepted: 04/17/2018] [Indexed: 11/27/2022] Open
Abstract
We present a case report of a 14-year-old boy who was jumping on a trampoline when he struck his right mastoid on a support pole. The following day, he developed a right-sided facial droop and inability to close his right eye. He presented to the emergency department, where CT of his temporal bone was negative and he was started on prednisone. Over the next month, he had spontaneous recovery of his facial nerve (FN) function. In cases of traumatic FN palsy, urgent referral to otolaryngology is needed, even without a fracture of the temporal bone, as edema within the facial nerve could require decompressive surgery. Steroids, while used in this patient, are of questionable benefit in the limited data available. Patient's with traumatic FN palsies should be instructed to use eye lubricant frequently and tape his eye closed at night, as corneal drying could lead to permanent damage. Proper evaluation, management, and referral are needed in cases of traumatic FN palsy to prevent long-term morbidity.
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Affiliation(s)
- Michael J Cools
- Department of Neurosurgery, University of North Carolina, 170 Manning Drive, Campus Box 7060, Chapel Hill, NC 27599, USA.
| | - Kevin A Carneiro
- Department of Neurosurgery, University of North Carolina, 170 Manning Drive, Campus Box 7060, Chapel Hill, NC 27599, USA.
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Cools MJ, Al-Holou WN, Stetler WR, Wilson TJ, Muraszko KM, Ibrahim M, La Marca F, Garton HJL, Maher CO. Filum terminale lipomas: imaging prevalence, natural history, and conus position. J Neurosurg Pediatr 2014; 13:559-67. [PMID: 24628511 DOI: 10.3171/2014.2.peds13528] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [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] [Indexed: 11/06/2022]
Abstract
OBJECT Filum terminale lipomas (FTLs) are being identified with increasing frequency due to the increasing utilization of MRI. Although an FTL may be associated with tethered cord syndrome (TCS), in many cases FTLs are diagnosed incidentally in patients without any symptoms of TCS. The natural history of FTLs is not well defined. METHODS The authors searched the clinical and imaging records at a single institution over a 14-year interval to identify patients with FTLs. For patients with an FTL, the clinical records were reviewed for indication for imaging, presenting symptoms, perceived need for surgery, and clinical outcome. A natural history analysis was performed using all patients with more than 6 months of clinical follow-up. RESULTS A total of 436 patients with FTL were identified. There were 217 males and 219 females. Of these patients, 282 (65%) were adults and 154 (35%) were children. Symptoms of TCS were present in 22 patients (5%). Fifty-two patients underwent surgery for FTL (12%). Sixty-four patients (15%) had a low-lying conus and 21 (5%) had a syrinx. The natural history analysis included 249 patients with a mean follow-up time of 3.5 years. In the follow-up period, only 1 patient developed new symptoms. CONCLUSIONS Filum terminale lipomas are a common incidental finding on spinal MRI, and most patients present without associated symptoms. The untreated natural history is generally benign for asymptomatic patients.
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Cools MJ, Al-Holou WN, Stetler WR, La Marca F, Valdivia-Valdivia JM. Anterior sacral pseudomeningocele following minimal trauma. J Neurosurg Spine 2013; 19:384-8. [DOI: 10.3171/2013.6.spine12956] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Sacral fractures are rare and seldom result in formation of a sacral pseudomeningocele. Treatment of these pseudomeningoceles usually consists of conservative management with flat bedrest or open operative management. The authors describe the case of a 55-year-old woman with an anterior sacral pseudomeningocele that was successfully treated using a lumbar drain for temporary continuous CSF drainage. The patient first presented to an outside institution several days after sacral trauma from an ice skating fall. Initial symptoms included throbbing headaches relieved by lying flat. Head and cervical spine CT demonstrated no abnormality. As symptoms worsened, she presented to another institution where MRI of the lumbar spine indicated sacral fracture with pseudomeningocele. The patient subsequently transferred to the authors' facility, where symptoms included headaches and occasional mild sacral pain. Given her headaches and the authors' concern for CSF leak, another head CT scan was performed. This revealed no subdural hematoma or other abnormality. A subsequent CT myelogram revealed an anterior sacral pseudomeningocele at S3–4 with an anterior irregular linear filling defect, likely representing torn dura. Treatment included placement of a lumbar drain (10 ml/hr) and flat bedrest. Resolution of the CSF leak occurred on postprocedure Day 9. At the 4-week follow-up visit, the patient had no clinical symptoms of CSF leak and no neurological complaints. To our knowledge, this is the first description of temporary continuous CSF drainage used to treat a posttraumatic sacral pseudomeningocele. This technique may reduce the need for potentially complicated surgical repair of sacral fractures associated with CSF leak in select patients.
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Jacobsen JPR, Siesser WB, Sachs BD, Peterson S, Cools MJ, Setola V, Folgering JHA, Flik G, Caron MG. Deficient serotonin neurotransmission and depression-like serotonin biomarker alterations in tryptophan hydroxylase 2 (Tph2) loss-of-function mice. Mol Psychiatry 2012; 17:694-704. [PMID: 21537332 PMCID: PMC3536482 DOI: 10.1038/mp.2011.50] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Probably the foremost hypothesis of depression is the 5-hydroxytryptamine (5-HT, serotonin) deficiency hypothesis. Accordingly, anomalies in putative 5-HT biomarkers have repeatedly been reported in depression patients. However, whether such anomalies in fact reflect deficient central 5-HT neurotransmission remains unresolved. We employed a naturalistic model of 5-HT deficiency, the tryptophan hydroxylase 2 (Tph2) R439H knockin mouse, to address this question. We report that Tph2 knockin mice have reduced basal and stimulated levels of extracellular 5-HT (5-HT(Ext)). Interestingly, cerebrospinal fluid (CSF) 5-hydroxyindoleacetic acid (5-HIAA) and fenfluramine-induced plasma prolactin levels are markedly diminished in the Tph2 knockin mice. These data seemingly confirm that low CSF 5-HIAA and fenfluramine-induced plasma prolactin reflects chronic, endogenous central nervous system (CNS) 5-HT deficiency. Moreover, 5-HT(1A) receptor agonist-induced hypothermia is blunted and frontal cortex 5-HT(2A) receptors are increased in the Tph2 knockin mice. These data likewise parallel core findings in depression, but are usually attributed to anomalies in the respective receptors rather than resulting from CNS 5-HT deficiency. Further, 5-HT(2A) receptor function is enhanced in the Tph2 knockin mice. In contrast, 5-HT(1A) receptor levels and G-protein coupling is normal in Tph2 knockin mice, indicating that the blunted hypothermic response relates directly to the low 5-HT(Ext). Thus, we show that not only low CSF 5-HIAA and a blunted fenfluramine-induced prolactin response, but also blunted 5-HT(1A) agonist-induced hypothermia and increased 5-HT(2A) receptor levels are bona fide biomarkers of chronic, endogenous 5-HT deficiency. Potentially, some of these biomarkers could identify patients likely to have 5-HT deficiency. This could have clinical research utility or even guide pharmacotherapy.
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Affiliation(s)
- JPR Jacobsen
- Department of Cell Biology, Duke University, Durham, NC, USA
| | - WB Siesser
- Department of Cell Biology, Duke University, Durham, NC, USA
| | - BD Sachs
- Department of Cell Biology, Duke University, Durham, NC, USA
| | - S Peterson
- Department of Cell Biology, Duke University, Durham, NC, USA
| | - MJ Cools
- Department of Cell Biology, Duke University, Durham, NC, USA
| | - V Setola
- Department of Pharmacology, University of North Carolina, Chapel Hill, NC, USA
| | | | - G Flik
- BrainsOnline, Groningen, The Netherlands
| | - MG Caron
- Department of Cell Biology, Duke University, Durham, NC, USA,Department of Neurobiology, Duke University Medical Center, Durham, NC, USA
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