Endoscopic Versus Open Repair for Craniosynostosis in Infants Using Propensity Score Matching to Compare Outcomes: A Multicenter Study from the Pediatric Craniofacial Collaborative Group

BACKGROUND

The North American Pediatric Craniofacial Collaborative Group (PCCG) established the Pediatric Craniofacial Surgery Perioperative Registry to evaluate outcomes in infants and children undergoing craniosynostosis repair. The goal of this multicenter study was to utilize this registry to assess differences in blood utilization, intensive care unit (ICU) utilization, duration of hospitalization, and perioperative complications between endoscopic-assisted (ESC) and open repair in infants with craniosynostosis. We hypothesized that advantages of ESC from single-center studies would be validated based on combined data from a large multicenter registry.

METHODS

Thirty-one institutions contributed data from June 2012 to September 2015. We analyzed 1382 infants younger than 12 months undergoing open (anterior and/or posterior cranial vault reconstruction, modified-Pi procedure, or strip craniectomy) or endoscopic craniectomy. The primary outcomes included transfusion data, ICU utilization, hospital length of stay, and perioperative complications; secondary outcomes included anesthesia and surgical duration. Comparison of unmatched groups (ESC: N = 311, open repair: N = 1071) and propensity score 2:1 matched groups (ESC: N = 311, open repair: N = 622) were performed by conditional logistic regression analysis.

RESULTS

Imbalances in baseline age and weight are inherent due to surgical selection criteria for ESC. Quality of propensity score matching in balancing age and weight between ESC and open groups was assessed by quintiles of the propensity scores. Analysis of matched groups confirmed significantly reduced utilization of blood (26% vs 81%, P < .001) and coagulation (3% vs 16%, P < .001) products in the ESC group compared to the open group. Median blood donor exposure (0 vs 1), anesthesia (168 vs 248 minutes) and surgical duration (70 vs 130 minutes), days in ICU (0 vs 2), and hospital length of stay (2 vs 4) were all significantly lower in the ESC group (all P < .001). Median volume of red blood cell administered was significantly lower in ESC (19.6 vs 26.9 mL/kg, P = .035), with a difference of approximately 7 mL/kg less for the ESC (95% confidence interval for the difference, 3-12 mL/kg), whereas the median volume of coagulation products was not significantly different between the 2 groups (21.2 vs 24.6 mL/kg, P = .73). Incidence of complications including hypotension requiring treatment with vasoactive agents (3% vs 4%), venous air embolism (1%), and hypothermia, defined as <35°C (22% vs 26%), was similar between the 2 groups, whereas postoperative intubation was significantly higher in the open group (2% vs 10%, P < .001).

CONCLUSIONS

This multicenter study of ESC versus open craniosynostosis repair represents the largest comparison to date. It demonstrates striking advantages of ESC for young infants that may result in improved clinical outcomes, as well as increased safety.

Safety of antifibrinolytics in cranial vault reconstructive surgery: a report from the pediatric craniofacial collaborative group

BACKGROUND

Antifibrinolytic therapy significantly decreases blood loss and transfusion in pediatric cranial vault reconstructive surgery; however, concern regarding the side effects profile limits clinical use.

AIMS

The aim was to utilize the Pediatric Craniofacial Surgery Perioperative Registry database to identify the safety profile of antifibrinolytic therapy for cranial vault reconstructive surgery by reporting the incidence of adverse events as they relate to exposure to tranexamic acid and aminocaproic acid compared to no exposure to antifibrinolytics.

METHODS

The database was queried for cases of open cranial vault reconstructive surgery. Less invasive procedures such as neuro-endoscopic and spring-mediated cranioplasties were excluded. The outcomes evaluated included any perioperative neurological adverse event including seizures or seizure-like movements and thromboembolic events.

RESULTS

Thirty-one institutions reported a total of 1638 cases from 2010 to 2015. Total antifibrinolytic administration accounted for 59.5% (tranexamic acid, 36.1% and aminocaproic acid, 23.4%), with 40.5% not receiving any antifibrinolytic. The overall incidence of postoperative seizures or seizure-like movements was 0.6%. No significant difference was detected in the incidence of postoperative seizures between patients receiving tranexamic acid and those receiving aminocaproic acid [the odds ratio for seizures being 0.34 (95% confidence interval: 0.07-1.85) controlling for American Society of Anesthesia (ASA) physical class] nor in patients receiving antifibrinolytics compared to those not administered antifibrinolytics (the odds ratio for seizures being 1.02 (confidence interval 0.29-3.63) controlling for ASA physical class). One complicated patient in the antifibrinolytic group with a femoral venous catheter had a postoperative deep venous thrombosis.

CONCLUSIONS

This is the first report of an incidence of postoperative seizures of 0.6% in pediatric cranial vault reconstructive surgery. There was no significant difference in postoperative seizures or seizure-like events in those patients who received the tranexamic acid or aminocaproic acid vs those that did not. This report provides evidence of the safety profile of antifibrinolytic in children having noncardiac major surgery. Caution should prevail however in using antifibrinolytic in high-risk patients. Antifibrinolytic dosage regimes should be based on pharmacokinetic data avoiding high doses.

Placement of dementia sufferers in residential and nursing home care

BACKGROUND

Few UK studies have examined the associations of residential or nursing home placement in dementia sufferers.

METHOD

124 patients with mild to moderate dementia (according to the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised) and in contact with clinical services were evaluated with a detailed standardized assessment and followed-up at monthly intervals for 1 year.

RESULTS

25 (21.6%) of the 116 patients living at home were admitted to residential or nursing home care during the follow-up year. Institutional placement was associated with greater severity of cognitive impairment, severity of parkinsonism and the failure of carers to adopt active coping strategies.

CONCLUSION

An intervention to improve coping skills in carers may decrease the rates of residential and nursing home placement.

Randomised controlled trial of psychological debriefing for victims of acute burn trauma

BACKGROUND

Psychological debriefing (PD) is widely used following major traumatic events in an attempt to reduce psychological sequelae.

METHOD

One hundred and thirty-three adult burn trauma victims entered the study. After initial questionnaire completion, participants were randomly allocated to an individual/couple PD group or a control group who received no intervention; 110 (83%) were interviewed by an assessor blind to PD status three and 13 months later.

RESULTS

Sixteen (26%) of the PD group had PTSD at 13-month follow-up, compared with four (9%) of the control group. The PD group had higher initial questionnaire scores and more severe dimensions of burn trauma than the control group, both of which were associated with a poorer outcome.

CONCLUSION

This study seriously questions the wisdom of advocating one-off interventions post-trauma, and should stimulate research into more effective initiatives.

The prevalence, associations and symptoms of depression amongst dementia sufferers

OBJECTIVE

To examine the prevalence rates of RDC major and RDC minor depression in dementia sufferers, to compare the prevalence rates and symptoms of depression between different dementias and to look at the associations of RDC major depression.

DESIGN

Case control.

SETTING

Referrals to clinical services.

SUBJECTS

124 patients with DSM-III-R dementia.

MEASURES

The patients were assessed using the GMS/HAS package and the Cornell Depression Scale. Depression was diagnosed according to RDC criteria.

RESULTS

25.0% of patients had RDC major depression and 27.4% had RDC minor depression. Major depression occurred significantly more often and was significantly more severe in patients with vascular dementia than patients with Alzheimer's disease. Severe visual impairment was significantly associated with RDC major depression in Alzheimer's disease and physical health problems were significantly associated with depression in vascular dementia. Most symptoms of depression including suicidal thoughts were common.

CONCLUSIONS

Major depression is more common and more severe in patients with vascular dementia. The associations of depression may be different in these patients.

Associations of psychotic symptoms in dementia sufferers

BACKGROUND

Psychotic symptoms in dementia have been considered as a single category which may have masked important associations. An exploratory analysis was undertaken to look separately at delusions, visual hallucinations and delusional misidentification.

METHOD

Psychotic symptoms were assessed with the Burns' Symptom Checklist in 124 patients with DSM-III-R dementia.

RESULTS

Eighty-three (66.9%) patients had psychotic symptoms. Deafness and life events were associated with delusions and visual impairment was associated with visual hallucinations, while senile dementia of Lewy body type and older age were associated with both.

CONCLUSIONS

Differences are evident in the associations of delusions and visual hallucinations. Sensory impairments were associated with both symptoms.

Structures of histamine H1-receptor antagonists derived from the cimetidine group of histamine H2-receptor antagonists

The crystal and molecular structures of ten compounds with strong structural resemblances to the cimetidine group of histamine H2-receptor antagonists, but exhibiting selective H1-receptor antagonist activity, (1)-(7), or H1 and H2 activity (8)-(10), have been determined: (1) 2-[4-(5-Bromo-3-methyl-2-pyridyl)butylamino]-5- (6-methyl-3-pyridylmethyl)-4-pyrimidone trihydrobromide (temalastine), C21H27BrN5O3+.3Br-, M(r) = 685.09, triclinic, P1, a = 6.314 (2), b = 11.192 (2), c = 19.441 (5) A, alpha = 102.47 (2), beta = 92.77 (2), gamma = 103.28 (2) degrees, V = 1298.51 A3, Z = 2, Dx = 1.75 g cm-3, mu = 61.6 cm-1, F(000) = 672, R = 2.93% for 3208 independent reflexions. (2) 2-[4-(5-Bromo-3-methyl-2-pyridyl)butylamino]-4-pyrimidone, C14H19BrN4O2, M(r) = 355.23, monoclinic, I2/a, a = 16.359 (3), b = 10.469 (6), c = 18.339 (4) A, beta = 90.90 (2) degrees, V = 3140.49 A3, Z = 8, Dx = 1.503 g cm-3, mu = 26.0 cm-1, F(000) = 1176, R = 4.2% for 1872 independent reflexions. (3) 3-[4-(5-Bromo-3-methyl-2-pyridyl)butylamino]-4- amino-1,2,5-thiadiazole-1-oxide, C12H16BrN5OS, M(r) = 358.26, triclinic, P1, a = 14.295 (2), b = 12.447 (2), c = 9.917 (2) A, alpha = 95.77 (2), beta = 113.86 (2), gamma = 106.91 (1) degrees, V = 1495.18 A3, Z = 4, Dx = 1.59 g cm-3, mu = 50.96 cm-1, F(000) = 728, R = 5.98% for 5674 independent reflexions. (4) 3-[4-(5-Bromo-3-methyl-2-pyridyl)butylamino]-4- benzylamino-1,2,5-thiadiazole-1-oxide, C19H22BrN5OS, M(r) = 448.38, monoclinic, P2(1)/c, a = 36.293 (7), b = 4.826 (2), c = 11.528 (3) A, beta = 96.91 (2) degrees, V = 2004.27 A3, Z = 4, Dx = 1.49 g cm-3, mu = 39.2 cm-1, F(000) = 920, R = 12.1% for 1945 independent reflexions. (5) 2-[3-(N-Benzyl-N-2- pyridylamino)propylamino]-4-pyrimidone, C19H21N5O, M(r) = 335.4, orthorhombic, Pbna, a = 7.082 (1), b = 19.889 (3), c = 24.899 (3) A, V = 3507.16 A3, Z = 8, Dx = 1.27 g cm-3, mu = 6.24 cm-1, F(000) = 1424, R = 4.05% from 2470 independent reflexions. (6) 3-[3-(N-4-Fluorobenzyl-N-2- pyridylamino)propylamino]-4-ethylamino-1,2,5-thiadiazole-1-oxide, C19H23FN6OS, M(r) = 402.5, monoclinic, P2(1)/n, a = 6.686 (2), b = 14.717 (3), c = 20.850 (5) A, beta = 97.83 (2) degrees, V = 2032.47 A3, Z = 4, Dx = 1.32 g cm-3, mu = 16.41 cm-1, F(000) = 848, R = 8.5% from 2484 independent reflexions. (7) 5-(6-Methyl-3-pyridylmethyl)-2-[3-(5,6,7,8-tetrahydro-8- quinolyl)propylamino]-4-pyrimidone, C23H29N5O2, M(r) = 407.5, monoclinic, P2(1)/c, a = 14.966 (2), b = 16.075 (2), c = 9.1608 (9) A, beta = 99.158 (8) degrees, V = 2175.83 A3, Z = 4, Dx = 1.24 g cm-3, mu = 6.19 cm-1; F(000) = 872, R = 5.3% from 2784 independent reflexions. (8) 2-(4-Phenylbutylamino)-5-(3-pyridyl-methyl)-4-pyrimidone, C20H26N4O3, M(r) = 370.5, monoclinic, P2(1)/c, a = 8.040 (4), b = 21.279 (4), c = 11.404 (2) A, beta = 92.08 (5) degrees, V = 1949.68 A3, Z = 4, Dx = 1.26 g cm-3, mu = 0.93 cm-1, F(000) = 792, R = 4.05% from 3816 independent reflexions.(ABSTRACT TRUNCATED AT 400 WORDS)

Crystal and molecular structures of pyridazinone cardiovascular agents

The crystal and molecular structures of 11 6-substituted pyridazinone derivatives: 6-phenyl-3(2H)-pyridazinone-acetic acid (1/1) (1), 6-(4-aminophenyl)- 3(2H)-pyridazinone (2), 6-(4-aminophenyl)- 5-methyl-3(2H)-pyridazinone (3), 6-(4-acetamidophenyl)- 3(2H)-pyridazinone (4), 6-(4-acetamido-2- methoxyphenyl)-3(2H)-pyridazinone (5), 6-(2-aminophenyl)-3(2H)- pyridazinone (6), 6-phenyl-3(2H)- pyrazinone (7), 6-(4-aminophenyl)-4,5-dihydro- 3(2H)-pyridazinone (8), (R)-(-)-6[4-(3-bromopropionamido)phenyl]- 4,5-dihydro-5-methyl-3(2H)-pyridazinone (9), (R)-(-)-6-(4-ammoniophenyl)-4,5- dihydro-5-methyl-3(2H)-pyridazinone (-)-tartrate-dichloromethane-methanol (1/1/1) (10), 4,5-dihydro-6-methyl-3(2H)-pyridazinone (11) have been determined as part of a study to determine the relationship between their cardiovascular properties and molecular structure and dimensions. For the two optically resolved chiral derivatives (9) and (10) the absolute configuration has been determined.

Prevalence, symptom profile, and aetiology of depression in dementia sufferers

Ninety-two consecutive attenders at a day hospital for the assessment of dementia were assessed using the CAMDEX schedule. The prevalence of depression in the 58 dementia sufferers who fulfilled the entry criteria for the study was 24.1%. The prevalence of depression was similar in patients with senile dementia of Alzheimer's type and those with vascular dementia. Patients with minimal dementia were significantly more likely to suffer from depression than those with mild or moderate dementia but there was no significant association with insight. The symptom profile of patients with minimal dementia was significantly correlated to that of patients with mild dementia and both were similar to the symptom profiles previously described amongst the elderly with functional depression. Physical illness was not associated with depression in the current sample. The implications of the findings are discussed.

A prospective randomised controlled trial of antimicrobial prophylaxis in hydrocephalus shunt surgery

Despite attempts to reduce their incidence, shunt infections remain a major complication of the treatment of hydrocephalus. Various forms of antimicrobial prophylaxis are in use, but no controlled, statistically valid trial has been conducted to assess their efficacy. Such a trial was therefore carried out and its design is described here. After a 1-year retrospective and prospective study by members of the United Kingdom Hydrocephalus Group to establish feasibility and infection rates, a statistical study showed that at least 712 patients would be required. Six centres were enrolled to fulfil these requirements, and ethical committee approval was obtained at each. The chosen prophylactic regimen was 10 mg vancomycin administered into the ventricular system during surgery. Adults and children undergoing insertion or revision of ventriculoperitoneal shunts were included unless they were receiving therapeutic antimicrobials. Randomisation was by computer-generated numbers. Controls received the antimicrobial regimen, if any, currently used in that centre, the only difference between the two groups being intraventricular vancomycin in the test group. Diagnosis of shunt infection included accepted clinical and microbiological criteria reinforced by measurement of serum C-reactive protein levels. Follow-up was for at least six months. After 2.5 years only 158 patients had been enrolled in the trial, 80 controls and 78 tests. There were 5 preventable infections in the control group and 2 in the test group. In view of the small total the planned statistical analysis was not possible. Therefore, while no problems were encountered with toxicity, the trial failed to enroll enough patients to answer the question of efficacy of antimicrobial prophylaxis in shunt surgery and the reasons for this are discussed.

The influence of barbiturates on cerebral metabolism in patients with borderline cerebrovascular reserve during intraoperative transient carotid occlusion

Sixty patients with borderline or frank insufficiency of their cerebrovascular reserve undergoing carotid endarterectomy were given enough short acting barbiturates, during cross clamping of the internal carotid artery, to cause EEG burst suppression. Arterial and venous concentrations of lactate were measured in blood samples taken before, 30 min after occlusion of the artery and 10 min after reperfusion. The amount of lactate produced depended on the length of time of burst suppression; the shorter it lasted, the larger the amount of lactate produced. Only in patients with the shortest burst suppression times did the blood lactate levels rise above normal levels. The lactate levels can be used as indicators of how effective barbiturates are being in preventing ischaemia during the time of carotid artery occlusion.

Three-dimensional computed tomographic scans in the planning of procedures for reconstructive craniofacial surgery

Three-dimensional computed tomographic (3D CT) scans were used in the assessment of three cases being considered for craniofacial reconstructive surgery; the first patient had a frontal encephalocele, the second an orbital encephalocele and the third an apparent asymmetry of the face due to cervical scoliosis caused by developmental defects of the upper two cervical vertebrae. The 3D CT scans provided information which was of great help in deciding how best to manage each case.

In vitro electrical activity in human colon

Extracellular electrical activity was measured in vitro in 28 specimens of human colon taken at the time of operation. The mucosa was removed, and the muscle strips were mounted in an organ bath irrigated with oxygenated Krebs. Records were made from 3-7 silver/silver chloride electrodes placed directly on the circular muscle, for periods of 15-30 min. Data were stored on magnetic tape, digitized, analyzed by the fast Fourier transform method and plotted in three-dimensional form (signal power vs. frequency vs. time). Some plots showed a single frequency peak in the range 2-9 cpm, which was present throughout the study. However, multiple peaks were frequently seen and were of two types: (a) peaks of two or three closely related frequencies in the 2-9 cpm range, which divided and fused during the recording time. The power of the fused peak was greater than that of the components. And (b) peaks at frequencies which were integer multiples of the fundamental frequency; we interpret these to be the second and third harmonics of the fundamental frequency. When the fundamental frequency peak developed into several components, similar components also appeared at their individual harmonic frequencies, i.e., the second harmonic components were separated by twice the interval between the fundamental components. We conclude that only one fundamental frequency of electrical activity exists in any one site in human colon. Multiple frequencies are due either to the simultaneous recording from two or more poorly coupled electrical oscillators or to harmonics of the fundamental frequency.