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Podkovik S, Zhou C, Coffin SE, Hall M, Hauptman JS, Kronman MP, Mangano FT, Pollack IF, Sedano S, Vega J, Schaffzin JK, Thorell E, Warf BC, Whitlock KB, Simon TD. Antibiotic impregnated catheters and intrathecal antibiotics for CSF shunt infection prevention in children undergoing low-risk CSF shunt surgery. BMC Pediatr 2024; 24:325. [PMID: 38734598 PMCID: PMC11088062 DOI: 10.1186/s12887-024-04798-9] [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: 12/13/2023] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) shunts allow children with hydrocephalus to survive and avoid brain injury (J Neurosurg 107:345-57, 2007; Childs Nerv Syst 12:192-9, 1996). The Hydrocephalus Clinical Research Network implemented non-randomized quality improvement protocols that were shown to decrease infection rates compared to pre-operative prophylactic intravenous antibiotics alone (standard care): initially with intrathecal (IT) antibiotics between 2007-2009 (J Neurosurg Pediatr 8:22-9, 2011), followed by antibiotic impregnated catheters (AIC) in 2012-2013 (J Neurosurg Pediatr 17:391-6, 2016). No large scale studies have compared infection prevention between the techniques in children. Our objectives were to compare the risk of infection following the use of IT antibiotics, AIC, and standard care during low-risk CSF shunt surgery (i.e., initial CSF shunt placement and revisions) in children. METHODS A retrospective observational cohort study at 6 tertiary care children's hospitals was conducted using Pediatric Health Information System + (PHIS +) data augmented with manual chart review. The study population included children ≤ 18 years who underwent initial shunt placement between 01/2007 and 12/2012. Infection and subsequent CSF shunt surgery data were collected through 12/2015. Propensity score adjustment for regression analysis was developed based on site, procedure type, and year; surgeon was treated as a random effect. RESULTS A total of 1723 children underwent initial shunt placement between 2007-2012, with 1371 subsequent shunt revisions and 138 shunt infections. Propensity adjusted regression demonstrated no statistically significant difference in odds of shunt infection between IT antibiotics (OR 1.22, 95% CI 0.82-1.81, p = 0.3) and AICs (OR 0.91, 95% CI 0.56-1.49, p = 0.7) compared to standard care. CONCLUSION In a large, observational multicenter cohort, IT antibiotics and AICs do not confer a statistically significant risk reduction compared to standard care for pediatric patients undergoing low-risk (i.e., initial or revision) shunt surgeries.
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Affiliation(s)
- Stacey Podkovik
- Department of Neurological Surgery, Riverside University Health Sciences Medical Center, Riverside, CA, USA
| | - Chuan Zhou
- Center for Child Health, Seattle Children's Research Institute, Behavior, and Development, Seattle, WA, USA
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA
| | - Susan E Coffin
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Matthew Hall
- Children's Hospital Association, Lenexa, KS, USA
| | - Jason S Hauptman
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Matthew P Kronman
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA
| | - Francesco T Mangano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ian F Pollack
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sabrina Sedano
- Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd,, MS 94, Los Angeles, CA, 90027, USA
| | - Joaquin Vega
- Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd,, MS 94, Los Angeles, CA, 90027, USA
| | | | - Emily Thorell
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Harvard School of Medicine, Boston, MA, USA
| | | | - Tamara D Simon
- Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd,, MS 94, Los Angeles, CA, 90027, USA.
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.
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Mukherjee SK, Papadakis JE, Arman DM, Islam J, Azim M, Rahman A, Ekramullah SM, Suchanda HS, Farooque A, Warf BC, Mazumdar M. The importance of neurosurgical intervention and surgical timing for management of pediatric patients with myelomeningoceles in Bangladesh. World Neurosurg 2024:S1878-8750(24)00718-6. [PMID: 38685347 DOI: 10.1016/j.wneu.2024.04.144] [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: 12/29/2023] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVE Reports on the management and survival of children with myelomeningocele defects in Bangladesh are limited. This study describes the characteristics and outcomes of these children, focusing on the timing of surgical repair and factors affecting survival. METHODS We enrolled patients with myelomeningoceles in a case-control study on arsenic exposure and spina bifida in Bangladesh. Cases were subsequently followed at regular intervals to assess survival. Demographic, clinical, and surgical characteristics were reviewed. Univariate tests identified factors affecting survival. RESULTS Between 2016-2022, we enrolled 272 patients with myelomeningocele. Postnatal surgical repair was performed in 63% of cases. However, surgery within 5 days after birth was infrequent (<10%) due to delayed presentation, and there was a high rate (29%) of preoperative deaths. Surgical repair significantly improved patient survival (p<0.0001). Older age at time of surgery was also associated with improved survival rates, which most likely represents that those who survived to older ages prior to surgery accommodated better with their lesions. Patients who presented with ruptured lesions had lower survival rates. CONCLUSIONS Timely neurosurgical repair of myelomeningoceles in Bangladesh is hindered by late patient presentation, resulting in a high preoperative patient death rate. Neurosurgical intervention remains a significant predictor of survival. Increased access to neurosurgical care and education of families and non-neurosurgical providers on the need for timely surgical intervention are important for improving the survival of infants with myelomeningoceles.
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Affiliation(s)
- Sudipta Kumer Mukherjee
- Department of Paediatric Neurosurgery, National Institute of Neurosciences & Hospital (NINS), Dhaka, Bangladesh
| | - Joanna E Papadakis
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - D M Arman
- Department of Paediatric Neurosurgery, National Institute of Neurosciences & Hospital (NINS), Dhaka, Bangladesh
| | - Joynul Islam
- Department of Paediatric Neurosurgery, National Institute of Neurosciences & Hospital (NINS), Dhaka, Bangladesh
| | | | - Asifur Rahman
- Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | - Sheikh Muhammad Ekramullah
- Department of Paediatric Neurosurgery, National Institute of Neurosciences & Hospital (NINS), Dhaka, Bangladesh
| | - Hafiza Sultana Suchanda
- Paediatric Neurosurgery Research Committee, National Institute of Neurosciences & Hospital (NINS), Dhaka, Bangladesh
| | - Afifah Farooque
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Maitreyi Mazumdar
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Podkovik S, Zhou C, Coffin SE, Hall M, Hauptman JS, Kronman MP, Mangano FT, Pollack IF, Sedano S, Schaffzin JK, Thorell E, Warf BC, Whitlock KB, Simon TD. Utilization trends in cerebrospinal fluid shunt infection prevention techniques in the United States from 2007 to 2015. J Neurosurg Pediatr 2024; 33:349-358. [PMID: 38181501 PMCID: PMC10810681 DOI: 10.3171/2023.11.peds2337] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 11/03/2023] [Indexed: 01/07/2024]
Abstract
OBJECTIVE The objective of this study was to describe trends in the utilization of infection prevention techniques (standard care, intrathecal [IT] antibiotics, antibiotic-impregnated catheters [AICs], and combination of IT antibiotics and AICs) among participating hospitals over time. METHODS This retrospective cohort study at six large children's hospitals between 2007 and 2015 included children ≤ 18 years of age who underwent initial shunt placement between 2007 and 2012. Pediatric Health Information System + (PHIS+) data were augmented with chart review data for all shunt surgeries that occurred prior to the first shunt infection. The Pearson chi-square test was used to test for differences in outcomes. RESULTS In total, 1723 eligible children had initial shunt placement between 2007 and 2012, with 3094 shunt surgeries through 2015. Differences were noted between hospitals in gestational age, etiology of hydrocephalus, and race and ethnicity, but not sex, weight at surgery, and previous surgeries. Utilization of infection prevention techniques varied across participating hospitals. Hydrocephalus Clinical Research Network hospitals used more IT antibiotics in 2007-2011; after 2012, increasing adoption of AICs was observed in most hospitals. CONCLUSIONS A consistent trend of decreasing IT antibiotic use and increased AIC utilization was observed after 2012, except for hospital B, which consistently used AICs.
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Affiliation(s)
- Stacey Podkovik
- Department of Neurological Surgery, Riverside University Health Sciences Medical Center, Riverside, California
| | - Chuan Zhou
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
- Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Susan E. Coffin
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | | | - Matthew P. Kronman
- Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | | | - Ian F. Pollack
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sabrina Sedano
- Department of Hospital Medicine, Children’s Hospital Los Angeles, California
| | | | - Emily Thorell
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Benjamin C. Warf
- Department of Neurosurgery, Harvard School of Medicine, Boston, Massachusetts; and
| | - Kathryn B. Whitlock
- Department of Hospital Medicine, Children’s Hospital Los Angeles, California
| | - Tamara D. Simon
- Department of Hospital Medicine, Children’s Hospital Los Angeles, California
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California
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Tindula G, Issac B, Mukherjee SK, Ekramullah SM, Arman DM, Islam J, Suchanda HS, Sun L, Rockowitz S, Christiani DC, Warf BC, Mazumdar M. Genome-wide analysis of spina bifida risk variants in a case-control study from Bangladesh. Birth Defects Res 2024; 116:e2331. [PMID: 38526198 PMCID: PMC10963057 DOI: 10.1002/bdr2.2331] [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: 11/01/2023] [Revised: 03/07/2024] [Accepted: 03/09/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Human studies of genetic risk factors for neural tube defects, severe birth defects associated with long-term health consequences in surviving children, have predominantly been restricted to a subset of candidate genes in specific biological pathways including folate metabolism. METHODS In this study, we investigated the association of genetic variants spanning the genome with risk of spina bifida (i.e., myelomeningocele and meningocele) in a subset of families enrolled from December 2016 through December 2022 in a case-control study in Bangladesh, a population often underrepresented in genetic studies. Saliva DNA samples were analyzed using the Illumina Global Screening Array. We performed genetic association analyses to compare allele frequencies between 112 case and 121 control children, 272 mothers, and 128 trios. RESULTS In the transmission disequilibrium test analyses with trios only, we identified three novel exonic spina bifida risk loci, including rs140199800 (SULT1C2, p = 1.9 × 10-7), rs45580033 (ASB2, p = 4.2 × 10-10), and rs75426652 (LHPP, p = 7.2 × 10-14), after adjusting for multiple hypothesis testing. Association analyses comparing cases and controls, as well as models that included their mothers, did not identify genome-wide significant variants. CONCLUSIONS This study identified three novel single nucleotide polymorphisms involved in biological pathways not previously associated with neural tube defects. The study warrants replication in larger groups to validate findings and to inform targeted prevention strategies.
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Affiliation(s)
- Gwen Tindula
- Department of Neurology, Boston Children’s Hospital, Boston, MA, 02115, United States
- Department of Neurology, Harvard Medical School, Boston, MA, 02115, United States
| | - Biju Issac
- Research Computing, Information Technology, Boston Children’s Hospital, Boston, MA, 02115, United States
| | - Sudipta Kumer Mukherjee
- Department of Paediatric Neurosurgery, National Institute of Neurosciences and Hospital (NINS), Sher-e-Bangla Nagar, Agargoan, Dhaka-1207, Bangladesh
| | - Sheikh Muhammad Ekramullah
- Department of Paediatric Neurosurgery, National Institute of Neurosciences and Hospital (NINS), Sher-e-Bangla Nagar, Agargoan, Dhaka-1207, Bangladesh
| | - DM Arman
- Department of Paediatric Neurosurgery, National Institute of Neurosciences and Hospital (NINS), Sher-e-Bangla Nagar, Agargoan, Dhaka-1207, Bangladesh
| | - Joynul Islam
- Department of Clinical Neurosurgery, National Institute of Neurosciences and Hospital (NINS), Sher-e-Bangla Nagar, Agargoan, Dhaka-1207, Bangladesh
| | - Hafiza Sultana Suchanda
- Pediatric Neurosurgery Research Committee, National Institute of Neurosciences and Hospital (NINS), Sher-e-Bangla Nagar, Agargoan, Dhaka-1207, Bangladesh
| | - Liang Sun
- Research Computing, Information Technology, Boston Children’s Hospital, Boston, MA, 02115, United States
| | - Shira Rockowitz
- Research Computing, Information Technology, Boston Children’s Hospital, Boston, MA, 02115, United States
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, 02115, United States
- The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, United States
| | - David C. Christiani
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, United States
| | - Benjamin C. Warf
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA, 02115, United States
| | - Maitreyi Mazumdar
- Department of Neurology, Boston Children’s Hospital, Boston, MA, 02115, United States
- Department of Neurology, Harvard Medical School, Boston, MA, 02115, United States
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, United States
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Wei CF, Mukherjee SK, Ekramullah SM, Arman DM, Islam MJ, Azim M, Rahman A, Rahman MN, Ziauddin M, Tindula G, Suchanda HS, Gomberg DF, Weisskopf MG, Liang L, Warf BC, Christiani DC, Mazumdar M. Arsenic modifies the effect of folic acid in spina bifida prevention, a large hospital-based case-control study in Bangladesh. Res Sq 2024:rs.3.rs-3989039. [PMID: 38464105 PMCID: PMC10925447 DOI: 10.21203/rs.3.rs-3989039/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Background Spina bifida, a developmental malformation of the spinal cord, is associated with high rates of mortality and disability. Although folic acid-based preventive strategies have been successful in reducing rates of spina bifida, some areas continue to be at higher risk because of chemical exposures. Bangladesh has high arsenic exposures through contaminated drinking water and high rates of spina bifida. Methods We conducted a hospital-based case-control study at the National Institute of Neurosciences & Hospital (NINS&H) in Dhaka, Bangladesh, between December 2016 and December 2022. Cases were infants under age one year with spina bifida and further classified using data from observations by neurosurgeons and available imaging. Controls were drawn from children who presented to NINS&H or Dhaka Shishu Hospital (DSH) during the same study period. Mothers reported folic acid use during pregnancy, and we assessed folate status with serum assays. Arsenic exposure was estimated in drinking water using graphite furnace atomic absorption spectrophotometry (GF-AAS) and in toenails using inductively coupled plasma mass spectrometry (ICP-MS). Results We evaluated data from 294 cases of spina bifida and 163 controls. We did not find a main effect of mother's arsenic exposure on spina bifida risk. However, in stratified analyses, folic acid use was associated with lower odds of spina bifida (adjusted odds ratio [OR]: 0.50, 95% confidence interval [CI]: 0.25-1.00, p = 0.05) among women with toenail arsenic concentrations below the median, and no association was seen among mothers with toenail arsenic concentrations higher than median (adjusted OR: 1.09, 95% CI: 0.52-2.29, p = 0.82). Conclusions Mother's arsenic exposure modified the protective association of folic acid with spina bifida. Increased surveillance and additional preventive strategies, such as folic acid fortification and reduction of arsenic, are needed in areas of high arsenic exposure.
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Chen JA, Bernstock JD, Essayed WI, Do W, Demehri FR, Proctor M, Warf BC. Syndrome of anterior neural stalk, vertebral abnormality, enteric duplication cyst, and diaphragmatic hernia related to persistent ventral neurenteric canal: report of two cases. Childs Nerv Syst 2023; 39:3341-3348. [PMID: 37776334 PMCID: PMC10842521 DOI: 10.1007/s00381-023-06169-8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/26/2023] [Indexed: 10/02/2023]
Abstract
PURPOSE Abnormalities in notochordal development can cause a range of developmental malformations, including the split notochord syndrome and split cord malformations. We describe two cases that appear related to unusual notochordal malformations, in a female and a male infant diagnosed in the early postnatal and prenatal periods, which were treated at our institution. These cases were unusual from prior cases given a shared constellation of an anterior cervicothoracic meningocele with a prominent "neural stalk," which coursed ventrally from the spinal cord into the thorax in proximity to a foregut duplication cyst. METHODS Two patients with this unusual spinal cord anomaly were assessed clinically, and with neuroimaging and genetics studies. RESULTS We describe common anatomical features (anterior neural stalk arising from the spinal cord, vertebral abnormality, enteric duplication cyst, and diaphragmatic hernia) that support a common etiopathogenesis and distinguish these cases. In both cases, we opted for conservative neurosurgical management in regards to the spinal cord anomaly. We proposed a preliminary theory of the embryogenesis that explains these findings related to a persistence of the ventral portion of the neurenteric canal. CONCLUSION These cases may represent a form of spinal cord malformation due to a persistent neurenteric canal and affecting notochord development that has rarely been described. Over more than 1 year of follow-up while managed conservatively, there was no evidence of neurologic dysfunction, so far supporting a treatment strategy of observation.
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Affiliation(s)
- Jason A Chen
- Department of Neurosurgery, Boston Children's Hospital, Boston, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | - Joshua D Bernstock
- Department of Neurosurgery, Boston Children's Hospital, Boston, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | - Walid Ibn Essayed
- Department of Neurosurgery, Boston Children's Hospital, Boston, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | - Woo Do
- Department of Surgery, Boston Children's Hospital, Boston, USA
| | | | - Mark Proctor
- Department of Neurosurgery, Boston Children's Hospital, Boston, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Boston, USA.
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Sedano S, Kronman MP, Whitlock KB, Zhou C, Coffin SE, Hauptman JS, Heller E, Mangano FT, Pollack IF, Schaffzin JK, Thorell E, Warf BC, Simon TD. Associations of Standard Care, Intrathecal Antibiotics, and Antibiotic-Impregnated Catheters With Cerebrospinal Fluid Shunt Infection Organisms and Resistance. J Pediatric Infect Dis Soc 2023; 12:504-512. [PMID: 37681670 PMCID: PMC10848219 DOI: 10.1093/jpids/piad064] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/07/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Infection prevention techniques used during cerebrospinal fluid (CSF) shunt surgery include: (1) standard perioperative intravenous antibiotics, (2) intrathecal (IT) antibiotics, (3) antibiotic-impregnated catheter (AIC) shunt tubing, or (4) Both IT and AIC. These techniques have not been assessed against one another for their impact on the infecting organisms and patterns of antimicrobial resistance. METHODS We performed a retrospective longitudinal observational cohort study of children with initial CSF shunt placement between January 2007 and December 2012 at 6 US hospitals. Data were collected electronically from the Pediatric Health Information Systems+ (PHIS+) database, and augmented with standardized chart review. Only subjects with positive CSF cultures were included in this study. RESULTS Of 1,723 children whose initial shunt placement occurred during the study period, 196 (11%) developed infection, with 157 (80%) having positive CSF cultures. Of these 157 subjects, 69 (44%) received standard care, 28 (18%) received AIC, 55 (35%) received IT antibiotics, and 5 (3%) received Both at the preceding surgery. The most common organisms involved in monomicrobial infections were Staphylococcus aureus (38, 24%), coagulase-negative staphylococci (36, 23%), and Cutibacterium acnes (6, 4%). Compared with standard care, the other infection prevention techniques were not significantly associated with changes to infecting organisms; AIC was associated with decreased odds of methicillin resistance among coagulase-negative staphylococci. CONCLUSIONS Because no association was found between infection prevention technique and infecting organisms when compared to standard care, other considerations such as tolerability, availability, and cost should inform decisions about infection prevention during CSF shunt placement surgery.
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Affiliation(s)
- Sabrina Sedano
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Matthew P Kronman
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington, USA
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
| | | | - Chuan Zhou
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington, USA
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Susan E Coffin
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jason S Hauptman
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington, USA
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Evan Heller
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Francesco T Mangano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ian F Pollack
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joshua K Schaffzin
- Department of Pediatrics, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Emily Thorell
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Harvard School of Medicine, Boston, Massachusetts, USA
| | - Tamara D Simon
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California, USA
- The Saban Research Institute, Los Angeles, California, USA
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8
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Morton SU, Hehnly C, Burgoine K, Ssentongo P, Ericson JE, Kumar MS, Hagmann C, Fronterre C, Smith J, Movassagh M, Streck N, Bebell LM, Bazira J, Kumbakumba E, Bajunirwe F, Mulondo R, Mbabazi-Kabachelor E, Nsubuga BK, Natukwatsa D, Nalule E, Magombe J, Erickson T, Ngonzi J, Ochora M, Olupot-Olupot P, Onen J, Ssenyonga P, Mugamba J, Warf BC, Kulkarni AV, Lane J, Whalen AJ, Zhang L, Sheldon K, Meier FA, Kiwanuka J, Broach JR, Paulson JN, Schiff SJ. Paenibacillus spp infection among infants with postinfectious hydrocephalus in Uganda: an observational case-control study. Lancet Microbe 2023; 4:e601-e611. [PMID: 37348522 PMCID: PMC10529524 DOI: 10.1016/s2666-5247(23)00106-4] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/02/2023] [Accepted: 03/15/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Paenibacillus thiaminolyticus is a cause of postinfectious hydrocephalus among Ugandan infants. To determine whether Paenibacillus spp is a pathogen in neonatal sepsis, meningitis, and postinfectious hydrocephalus, we aimed to complete three separate studies of Ugandan infants. The first study was on peripartum prevalence of Paenibacillus in mother-newborn pairs. The second study assessed Paenibacillus in blood and cerebrospinal fluid (CSF) from neonates with sepsis. The third study assessed Paenibacillus in CSF from infants with hydrocephalus. METHODS In this observational study, we recruited mother-newborn pairs with and without maternal fever (mother-newborn cohort), neonates (aged ≤28 days) with sepsis (sepsis cohort), and infants (aged ≤90 days) with hydrocephalus with and without a history of neonatal sepsis and meningitis (hydrocephalus cohort) from three hospitals in Uganda between Jan 13, 2016 and Oct 2, 2019. We collected maternal blood, vaginal swabs, and placental samples and the cord from the mother-newborn pairs, and blood and CSF from neonates and infants. Bacterial content of infant CSF was characterised by 16S rDNA sequencing. We analysed all samples using quantitative PCR (qPCR) targeting either the Paenibacillus genus or Paenibacillus thiaminolyticus spp. We collected cranial ultrasound and computed tomography images in the subset of participants represented in more than one cohort. FINDINGS No Paenibacillus spp were detected in vaginal, maternal blood, placental, or cord blood specimens from the mother-newborn cohort by qPCR. Paenibacillus spp was detected in 6% (37 of 631 neonates) in the sepsis cohort and, of these, 14% (5 of 37 neonates) developed postinfectious hydrocephalus. Paenibacillus was the most enriched bacterial genera in postinfectious hydrocephalus CSF (91 [44%] of 209 patients) from the hydrocephalus cohort, with 16S showing 94% accuracy when validated by qPCR. Imaging showed progression from Paenibacillus spp-related meningitis to postinfectious hydrocephalus over 1-3 months. Patients with postinfectious hydrocephalus with Paenibacillus spp infections were geographically clustered. INTERPRETATION Paenibacillus spp causes neonatal sepsis and meningitis in Uganda and is the dominant cause of subsequent postinfectious hydrocephalus. There was no evidence of transplacental transmission, and geographical evidence was consistent with an environmental source of neonatal infection. Further work is needed to identify routes of infection and optimise treatment of neonatal Paenibacillus spp infection to lessen the burden of morbidity and mortality. FUNDING National Institutes of Health and Boston Children's Hospital Office of Faculty Development.
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Affiliation(s)
- Sarah U Morton
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Christine Hehnly
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Kathy Burgoine
- Neonatal Unit, Department of Paediatrics and Child Health, Mbale Regional Referral Hospital, Mbale, Uganda; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Mbale Clinical Research Institute, Mbale Regional Referral Hospital, Mbale, Uganda; Busitema University, Busitema, Uganda
| | - Paddy Ssentongo
- Department of Medicine, The Pennsylvania State University College of Medicine, Hershey, PA, USA; Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Jessica E Ericson
- Division of Pediatric Infectious Disease, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - M Senthil Kumar
- Department of Biostatistics, Harvard T H Chan School of Public Health and Department of Data Sciences, Dana Farber Cancer Institute, Boston, MA, USA
| | - Cornelia Hagmann
- Department of Neonatology and Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
| | - Claudio Fronterre
- Centre for Health Informatics, Computing, and Statistics, Lancaster University, Lancaster, UK
| | - Jasmine Smith
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Mercedeh Movassagh
- Department of Biostatistics, Harvard T H Chan School of Public Health and Department of Data Sciences, Dana Farber Cancer Institute, Boston, MA, USA
| | - Nicholas Streck
- Department of Pathology and Laboratory Medicine Division of Clinical Pathology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Lisa M Bebell
- Division of Infectious Diseases, Department of Medicine, Center for Global Health, and Medical Practice Evaluation Center and Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Joel Bazira
- Department of Microbiology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elias Kumbakumba
- Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Francis Bajunirwe
- Department of Epidemiology, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | | | | | | | | | - Tim Erickson
- CURE Children's Hospital of Uganda, Mbale, Uganda
| | - Joseph Ngonzi
- Department of Obstetrics and Gynaecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Moses Ochora
- Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Peter Olupot-Olupot
- Neonatal Unit, Department of Paediatrics and Child Health, Mbale Regional Referral Hospital, Mbale, Uganda; Mbale Clinical Research Institute, Mbale Regional Referral Hospital, Mbale, Uganda; Busitema University, Busitema, Uganda
| | - Justin Onen
- CURE Children's Hospital of Uganda, Mbale, Uganda; Mulago National Referral Hospital, Makerere University, Kampala, Uganda
| | - Peter Ssenyonga
- CURE Children's Hospital of Uganda, Mbale, Uganda; Mulago National Referral Hospital, Makerere University, Kampala, Uganda
| | - John Mugamba
- CURE Children's Hospital of Uganda, Mbale, Uganda
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA, USA; Department of Neurosurgery, Harvard Medical School, Boston, MA, USA
| | - Abhaya V Kulkarni
- Division of Neurosurgery, Department of Surgery, Hospital for Sick Children, University of Toronto, ON, Canada
| | - Jessica Lane
- Department of Neurosurgery, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Andrew J Whalen
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Lijun Zhang
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Kathryn Sheldon
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Frederick A Meier
- Department of Pathology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Julius Kiwanuka
- Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - James R Broach
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Joseph N Paulson
- Department of Data Sciences, N-Power Medicine, Redwood City, CA, USA
| | - Steven J Schiff
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
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9
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Sadegh C, Xu H, Sutin J, Fatou B, Gupta S, Pragana A, Taylor M, Kalugin PN, Zawadzki ME, Alturkistani O, Shipley FB, Dani N, Fame RM, Wurie Z, Talati P, Schleicher RL, Klein EM, Zhang Y, Holtzman MJ, Moore CI, Lin PY, Patel AB, Warf BC, Kimberly WT, Steen H, Andermann ML, Lehtinen MK. Choroid plexus-targeted NKCC1 overexpression to treat post-hemorrhagic hydrocephalus. Neuron 2023; 111:1591-1608.e4. [PMID: 36893755 PMCID: PMC10198810 DOI: 10.1016/j.neuron.2023.02.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [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: 08/16/2022] [Revised: 01/17/2023] [Accepted: 02/13/2023] [Indexed: 03/11/2023]
Abstract
Post-hemorrhagic hydrocephalus (PHH) refers to a life-threatening accumulation of cerebrospinal fluid (CSF) that occurs following intraventricular hemorrhage (IVH). An incomplete understanding of this variably progressive condition has hampered the development of new therapies beyond serial neurosurgical interventions. Here, we show a key role for the bidirectional Na-K-Cl cotransporter, NKCC1, in the choroid plexus (ChP) to mitigate PHH. Mimicking IVH with intraventricular blood led to increased CSF [K+] and triggered cytosolic calcium activity in ChP epithelial cells, which was followed by NKCC1 activation. ChP-targeted adeno-associated viral (AAV)-NKCC1 prevented blood-induced ventriculomegaly and led to persistently increased CSF clearance capacity. These data demonstrate that intraventricular blood triggered a trans-choroidal, NKCC1-dependent CSF clearance mechanism. Inactive, phosphodeficient AAV-NKCC1-NT51 failed to mitigate ventriculomegaly. Excessive CSF [K+] fluctuations correlated with permanent shunting outcome in humans following hemorrhagic stroke, suggesting targeted gene therapy as a potential treatment to mitigate intracranial fluid accumulation following hemorrhage.
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Affiliation(s)
- Cameron Sadegh
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA; Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Huixin Xu
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Jason Sutin
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Benoit Fatou
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Suhasini Gupta
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Aja Pragana
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Milo Taylor
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA; Harvard College, Harvard University, Cambridge, MA 02138, USA
| | - Peter N Kalugin
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA; Harvard/MIT MD-PhD Program, Harvard Medical School, Boston, MA 02115, USA; Graduate Program in Neuroscience, Harvard Medical School, Boston, MA 02115, USA
| | - Miriam E Zawadzki
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA; Harvard/MIT MD-PhD Program, Harvard Medical School, Boston, MA 02115, USA; Graduate Program in Biological and Biomedical Sciences, Harvard Medical School, Boston, MA 02115, USA
| | - Osama Alturkistani
- Cellular Imaging Core, Boston Children's Hospital, Boston, MA 02115, USA
| | - Frederick B Shipley
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA; Graduate Program in Biophysics, Harvard University, Cambridge, MA 02138, USA
| | - Neil Dani
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Ryann M Fame
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Zainab Wurie
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Pratik Talati
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Riana L Schleicher
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Eric M Klein
- Carney Institute for Brain Science, Brown University, Providence, RI 02912, USA
| | - Yong Zhang
- Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, MO, 63110, USA
| | - Michael J Holtzman
- Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, MO, 63110, USA
| | - Christopher I Moore
- Carney Institute for Brain Science, Brown University, Providence, RI 02912, USA
| | - Pei-Yi Lin
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA 02115, USA
| | - W Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Hanno Steen
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA; Precision Vaccines Program, Boston Children's Hospital, Boston, MA 02115, USA
| | - Mark L Andermann
- Graduate Program in Neuroscience, Harvard Medical School, Boston, MA 02115, USA; Graduate Program in Biophysics, Harvard University, Cambridge, MA 02138, USA; Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Maria K Lehtinen
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA; Graduate Program in Neuroscience, Harvard Medical School, Boston, MA 02115, USA; Graduate Program in Biological and Biomedical Sciences, Harvard Medical School, Boston, MA 02115, USA; Graduate Program in Biophysics, Harvard University, Cambridge, MA 02138, USA.
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10
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Warf BC, Weber DS, Day EL, Riordan CP, Staffa SJ, Baird LC, Fehnel KP, Stone SSD. Endoscopic third ventriculostomy with choroid plexus cauterization: predictors of long-term success and comparison with shunt placement for primary treatment of infant hydrocephalus. J Neurosurg Pediatr 2023:1-13. [PMID: 37178026 DOI: 10.3171/2023.4.peds2310] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/07/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) can avoid ventriculoperitoneal shunt (VPS) dependence in very young hydrocephalic children, although long-term success as a primary treatment in North America has not been previously reported. Moreover, optimal age at surgery, impact of preoperative ventriculomegaly, and relationship to prior cerebrospinal fluid (CSF) diversion remain poorly defined. The authors compared ETV/CPC and VPS placement for averting reoperation, and they evaluated preoperative predictors for reoperation and shunt placement after ETV/CPC. METHODS All patients under 12 months of age who underwent initial hydrocephalus treatment via ETV/CPC or VPS placement at Boston Children's Hospital between December 2008 and August 2021 were reviewed. Analyses included Cox regression for independent outcome predictors, and both Kaplan-Meier and log-rank rank tests for time-to-event outcomes. Cutoff values for age and preoperative frontal and occipital horn ratio (FOHR) were determined with receiver operating characteristic curve analysis and Youden's J index. RESULTS In total, 348 children (150 females) were included with principal etiologies of posthemorrhagic hydrocephalus (26.7%), myelomeningocele (20.1%), and aqueduct stenosis (17.0%). Of these, 266 (76.4%) underwent ETV/CPC and 82 (23.6%) underwent VPS placement. Treatment choice largely reflected surgeon preferences before practice shifted toward endoscopy, with endoscopy not considered for > 70% of initial VPS cases. ETV/CPC patients trended toward fewer reoperations, and Kaplan-Meier analysis estimated that 59% of patients would achieve long-term shunt freedom through 11 years (median 42 months of actual follow-up). Among all patients, corrected age < 2.5 months (p < 0.001), prior temporizing CSF diversion (p = 0.003), and excess intraoperative bleeding (p < 0.001) independently predicted reoperation. Among ETV/CPC patients, corrected age < 2.5 months (p = 0.031), prior CSF diversion (p = 0.001), preoperative FOHR > 0.613 (p = 0.011), and excessive intraoperative bleeding (p = 0.001) independently predicted ultimate conversion to VPS. The actual VPS insertion rates remained low in patients who were ≥ 2.5 months old at ETV/CPC either with prior CSF diversion (2/10 [20.0%]) or without prior CSF diversion (24/123 [19.5%]); however, the actual VPS insertion rates increased in patients who were < 2.5 months old at ETV/CPC with prior CSF diversion (19/26 [73.1%]) or without prior CSF diversion (44/107 [41.1%]). CONCLUSIONS ETV/CPC successfully treated hydrocephalus in most patients younger than 1 year irrespective of etiology, averting observed shunt dependence in 80% of patients ≥ 2.5 months of age regardless of prior CSF diversion and in 59% of those < 2.5 months of age without prior CSF diversion. For infants aged < 2.5 months with prior CSF diversion, particularly those with severe ventriculomegaly, ETV/CPC was unlikely to succeed unless safely delayed.
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Affiliation(s)
| | | | | | | | - Steven J Staffa
- 2Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
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11
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Rolle ML, Bhebhe A, Munkondya A, Kharbat AF, Kaskie N, McLellan R, Nahed BV, Warf BC, Kunda H, Sichizya K. Qualitative and Quantitative Analysis of Pediatric Post Neurosurgical Care in a Lower Middle-Income Country: The Zambian Experience. World Neurosurg 2022; 167:e784-e788. [PMID: 36049724 DOI: 10.1016/j.wneu.2022.08.098] [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: 06/08/2022] [Revised: 08/19/2022] [Accepted: 08/20/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Pediatric postoperative neurosurgical care is an essential component of a child's treatment pathway. It is important to better understand how neurosurgeons in lower middle-income countries (LMICs) have been able to address socioeconomic and systemic factors to improve their patients' access to quality pediatric postoperative neurosurgical care. We aim to characterize the pediatric neurosurgical postoperative system in place in Zambia and to discuss how these efforts have been implemented to improve outcomes and address socioeconomic barriers to accessing health care. METHODS We acquired a patient list of 90 tenants of House of Hope (HOH)-an out-of-hospital center caring for children awaiting surgery, as well as those recovering from surgery. Of the patient list, 44 patients qualified for our study. Survey responses and occurrence of demographic and clinical characteristics were calculated. Non-normally distributed variables (age) were reported by median and interquartile range (IQR). Dichotomous variables were presented as percentages. Fisher's Exact test was applied to compare categorical data and hospital re-admission. A P-value of <0.05 was considered significant. RESULTS Our study demonstrates two key findings: (1) low 30-day hospital re-admission rate of 9% and (2) favorable postoperative experience by patient families. Of the 44 patients, a majority were 1-year-old children (n = 31, 70%) and female (n = 24, 55%) (IQR 1-2 years). Presenting conditions included: hydrocephalus only (n = 35, 80%), hydrocephalus and myelomeningocele (n = 5, 11%), myelomeningocele only (n = 2, 5%), cerebral palsy (n = 1, 2%), and encephalocele (n = 1, 2%). Half (n = 22, 50%) of the patients lived in east Zambia, 8 (18%) lived in central, 8 (18%) in north, 5 (11%) in south, and 1 (2%) in west Zambia. CONCLUSIONS We report the first qualitative and quantitative analysis of postoperative care for LMIC pediatric neurosurgical patients in the academic literature. Quality, patient-centered postoperative pediatric neurosurgical care that is rooted in addressing socioeconomic determinants of health produces good outcomes in LMICs.
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Affiliation(s)
- Myron L Rolle
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Arnold Bhebhe
- Department of Neurosurgery, University Teaching Hospital, Lusaka, Zambia
| | - Aaron Munkondya
- Department of Neurosurgery, University Teaching Hospital, Lusaka, Zambia
| | - Abdurrahman F Kharbat
- Division of Neurosurgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA.
| | - Natasha Kaskie
- Department of Neurosurgery, University Teaching Hospital, Lusaka, Zambia
| | - Rachel McLellan
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Humphrey Kunda
- Department of Neurosurgery, University Teaching Hospital, Lusaka, Zambia
| | - Kachinga Sichizya
- Department of Neurosurgery, University Teaching Hospital, Lusaka, Zambia
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12
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Tirrell TF, Demehri FR, Lillehei CW, Borer JG, Warf BC, Dickie BH. Hindgut Duplication in an Infant with Omphalocele-Exstrophy-Imperforate Anus-Spinal Defects (OEIS) Complex. European J Pediatr Surg Rep 2022; 10:e45-e48. [PMID: 35282303 PMCID: PMC8913173 DOI: 10.1055/s-0041-1742154] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 10/16/2020] [Indexed: 10/28/2022] Open
Abstract
Introduction The congenital anomaly of omphalocele, cloacal exstrophy, imperforate anus, and spinal abnormalities (OEIS complex) is rare but well recognized. Hindgut duplications are also uncommon and are not known to be associated with OEIS. We describe a neonate with OEIS who was found to have fully duplicated blind-ending hindguts. Case Report A premature infant boy with OEIS underwent first-stage closure on day of life 6, which included excision of the omphalocele sac, separation of the cecal plate and bladder halves, tubularization of the cecal plate, hindgut rescue with end colostomy, and joining of the bladder halves. Cecal plate inspection revealed two hindgut structures that descended distally, one descended midline into the pelvis along the sacrum and the second laterally along the left border of the sacrum. Both lumens connected to the cecal plate and had separate mesenteries. In an effort to maximize the colonic mucosal surface area, the hindgut segments were unified through a side-to-side anastomosis, creating a larger caliber hindgut. The cecal plate was tubularized and an end colostomy was created. Bowel function returned and he was discharged home on full enteral feeds. Discussion This case represents a cooccurrence of two extremely rare and complex congenital anomalies. The decision to unify the distinct hindguts into a single lumen was made in an effort to combine the goals of management for both OEIS and alimentary duplications. The hindgut is abnormal in OEIS and should be assessed carefully during repair.
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Affiliation(s)
- Timothy F Tirrell
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Craig W Lillehei
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Joseph G Borer
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Belinda H Dickie
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, United States
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13
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Vadset TA, Rajaram A, Hsiao CH, Kemigisha Katungi M, Magombe J, Seruwu M, Kaaya Nsubuga B, Vyas R, Tatz J, Playter K, Nalule E, Natukwatsa D, Wabukoma M, Neri Perez LE, Mulondo R, Queally JT, Fenster A, Kulkarni AV, Schiff SJ, Grant PE, Mbabazi Kabachelor E, Warf BC, Sutin JDB, Lin PY. Improving Infant Hydrocephalus Outcomes in Uganda: A Longitudinal Prospective Study Protocol for Predicting Developmental Outcomes and Identifying Patients at Risk for Early Treatment Failure after ETV/CPC. Metabolites 2022; 12:78. [PMID: 35050201 PMCID: PMC8781620 DOI: 10.3390/metabo12010078] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/09/2022] [Accepted: 01/11/2022] [Indexed: 01/06/2023] Open
Abstract
Infant hydrocephalus poses a severe global health burden; 80% of cases occur in the developing world where patients have limited access to neurosurgical care. Surgical treatment combining endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC), first practiced at CURE Children's Hospital of Uganda (CCHU), is as effective as standard ventriculoperitoneal shunt (VPS) placement while requiring fewer resources and less post-operative care. Although treatment focuses on controlling ventricle size, this has little association with treatment failure or long-term outcome. This study aims to monitor the progression of hydrocephalus and treatment response, and investigate the association between cerebral physiology, brain growth, and neurodevelopmental outcomes following surgery. We will enroll 300 infants admitted to CCHU for treatment. All patients will receive pre/post-operative measurements of cerebral tissue oxygenation (SO2), cerebral blood flow (CBF), and cerebral metabolic rate of oxygen consumption (CMRO2) using frequency-domain near-infrared combined with diffuse correlation spectroscopies (FDNIRS-DCS). Infants will also receive brain imaging, to monitor tissue/ventricle volume, and neurodevelopmental assessments until two years of age. This study will provide a foundation for implementing cerebral physiological monitoring to establish evidence-based guidelines for hydrocephalus treatment. This paper outlines the protocol, clinical workflow, data management, and analysis plan of this international, multi-center trial.
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Affiliation(s)
- Taylor A. Vadset
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (T.A.V.); (A.R.); (C.-H.H.); (R.V.); (J.T.); (K.P.); (L.E.N.P.); (P.E.G.); (J.D.B.S.)
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Ajay Rajaram
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (T.A.V.); (A.R.); (C.-H.H.); (R.V.); (J.T.); (K.P.); (L.E.N.P.); (P.E.G.); (J.D.B.S.)
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Chuan-Heng Hsiao
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (T.A.V.); (A.R.); (C.-H.H.); (R.V.); (J.T.); (K.P.); (L.E.N.P.); (P.E.G.); (J.D.B.S.)
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Miriah Kemigisha Katungi
- CURE Children’s Hospital of Uganda, Mbale P.O. Box 903, Uganda; (M.K.K.); (J.M.); (M.S.); (B.K.N.); (E.N.); (D.N.); (M.W.); (R.M.); (E.M.K.)
| | - Joshua Magombe
- CURE Children’s Hospital of Uganda, Mbale P.O. Box 903, Uganda; (M.K.K.); (J.M.); (M.S.); (B.K.N.); (E.N.); (D.N.); (M.W.); (R.M.); (E.M.K.)
| | - Marvin Seruwu
- CURE Children’s Hospital of Uganda, Mbale P.O. Box 903, Uganda; (M.K.K.); (J.M.); (M.S.); (B.K.N.); (E.N.); (D.N.); (M.W.); (R.M.); (E.M.K.)
| | - Brian Kaaya Nsubuga
- CURE Children’s Hospital of Uganda, Mbale P.O. Box 903, Uganda; (M.K.K.); (J.M.); (M.S.); (B.K.N.); (E.N.); (D.N.); (M.W.); (R.M.); (E.M.K.)
| | - Rutvi Vyas
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (T.A.V.); (A.R.); (C.-H.H.); (R.V.); (J.T.); (K.P.); (L.E.N.P.); (P.E.G.); (J.D.B.S.)
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Julia Tatz
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (T.A.V.); (A.R.); (C.-H.H.); (R.V.); (J.T.); (K.P.); (L.E.N.P.); (P.E.G.); (J.D.B.S.)
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Katharine Playter
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (T.A.V.); (A.R.); (C.-H.H.); (R.V.); (J.T.); (K.P.); (L.E.N.P.); (P.E.G.); (J.D.B.S.)
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Esther Nalule
- CURE Children’s Hospital of Uganda, Mbale P.O. Box 903, Uganda; (M.K.K.); (J.M.); (M.S.); (B.K.N.); (E.N.); (D.N.); (M.W.); (R.M.); (E.M.K.)
| | - Davis Natukwatsa
- CURE Children’s Hospital of Uganda, Mbale P.O. Box 903, Uganda; (M.K.K.); (J.M.); (M.S.); (B.K.N.); (E.N.); (D.N.); (M.W.); (R.M.); (E.M.K.)
| | - Moses Wabukoma
- CURE Children’s Hospital of Uganda, Mbale P.O. Box 903, Uganda; (M.K.K.); (J.M.); (M.S.); (B.K.N.); (E.N.); (D.N.); (M.W.); (R.M.); (E.M.K.)
| | - Luis E. Neri Perez
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (T.A.V.); (A.R.); (C.-H.H.); (R.V.); (J.T.); (K.P.); (L.E.N.P.); (P.E.G.); (J.D.B.S.)
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Ronald Mulondo
- CURE Children’s Hospital of Uganda, Mbale P.O. Box 903, Uganda; (M.K.K.); (J.M.); (M.S.); (B.K.N.); (E.N.); (D.N.); (M.W.); (R.M.); (E.M.K.)
| | - Jennifer T. Queally
- Department of Psychiatry, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Aaron Fenster
- Robarts Research Institute, Western University, London, ON N6A 3K7, Canada;
| | | | - Steven J. Schiff
- Center for Neural Engineering, Center for Infectious Disease Dynamics, Departments of Engineering Science and Mechanics, Neurosurgery, and Physics, The Pennsylvania State University, University Park, PA 16802, USA;
| | - Patricia Ellen Grant
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (T.A.V.); (A.R.); (C.-H.H.); (R.V.); (J.T.); (K.P.); (L.E.N.P.); (P.E.G.); (J.D.B.S.)
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Edith Mbabazi Kabachelor
- CURE Children’s Hospital of Uganda, Mbale P.O. Box 903, Uganda; (M.K.K.); (J.M.); (M.S.); (B.K.N.); (E.N.); (D.N.); (M.W.); (R.M.); (E.M.K.)
| | - Benjamin C. Warf
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Jason D. B. Sutin
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (T.A.V.); (A.R.); (C.-H.H.); (R.V.); (J.T.); (K.P.); (L.E.N.P.); (P.E.G.); (J.D.B.S.)
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Pei-Yi Lin
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (T.A.V.); (A.R.); (C.-H.H.); (R.V.); (J.T.); (K.P.); (L.E.N.P.); (P.E.G.); (J.D.B.S.)
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
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14
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Lane JR, Ssentongo P, Peterson MR, Harper JR, Mbabazi-Kabachelor E, Mugamba J, Ssenyonga P, Onen J, Donnelly R, Levenbach J, Cherukuri V, Monga V, Kulkarni AV, Warf BC, Schiff SJ. Preoperative risk and postoperative outcome from subdural fluid collections in African infants with postinfectious hydrocephalus. J Neurosurg Pediatr 2022; 29:31-39. [PMID: 34598146 PMCID: PMC9078082 DOI: 10.3171/2021.7.peds21209] [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: 04/19/2021] [Accepted: 07/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study investigated the incidence of postoperative subdural collections in a cohort of African infants with postinfectious hydrocephalus. The authors sought to identify preoperative factors associated with increased risk of development of subdural collections and to characterize associations between subdural collections and postoperative outcomes. METHODS The study was a post hoc analysis of a randomized controlled trial at a single center in Mbale, Uganda, involving infants (age < 180 days) with postinfectious hydrocephalus randomized to receive either an endoscopic third ventriculostomy plus choroid plexus cauterization or a ventriculoperitoneal shunt. Patients underwent assessment with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III; sometimes referred to as BSID-III) and CT scans preoperatively and then at 6, 12, and 24 months postoperatively. Volumes of brain, CSF, and subdural fluid were calculated, and z-scores from the median were determined from normative curves for CSF accumulation and brain growth. Linear and logistic regression models were used to characterize the association between preoperative CSF volume and the postoperative presence and size of subdural collection 6 and 12 months after surgery. Linear regression and smoothing spline ANOVA were used to describe the relationship between subdural fluid volume and cognitive scores. Causal mediation analysis distinguished between the direct and indirect effects of the presence of a subdural collection on cognitive scores. RESULTS Subdural collections were more common in shunt-treated patients and those with larger preoperative CSF volumes. Subdural fluid volumes were linearly related to preoperative CSF volumes. In terms of outcomes, the Bayley-III cognitive score was linearly related to subdural fluid volume. The distribution of cognitive scores was significantly different for patients with and those without subdural collections from 11 to 24 months of age. The presence of a subdural collection was associated with lower cognitive scores and smaller brain volume 12 months after surgery. Causal mediation analysis demonstrated evidence supporting both a direct (76%) and indirect (24%) effect (through brain volume) of subdural collections on cognitive scores. CONCLUSIONS Larger preoperative CSF volume and shunt surgery were found to be risk factors for postoperative subdural collection. The size and presence of a subdural collection were negatively associated with cognitive outcomes and brain volume 12 months after surgery. These results have suggested that preoperative CSF volumes could be used for risk stratification for treatment decision-making and that future clinical trials of alternative shunt technologies to reduce overdrainage should be considered.
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Affiliation(s)
- Jessica R. Lane
- Department of Neurosurgery, Penn State College of Medicine, Hershey
| | - Paddy Ssentongo
- Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park,Department of Public Health Sciences, Penn State College of Medicine, Hershey
| | - Mallory R. Peterson
- Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park
| | - Joshua R. Harper
- Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park
| | | | | | - Peter Ssenyonga
- CURE Children’s Hospital of Uganda, Mbale,Mulago National Referral Hospital, Kampala, Uganda
| | - Justin Onen
- CURE Children’s Hospital of Uganda, Mbale,Mulago National Referral Hospital, Kampala, Uganda
| | - Ruth Donnelly
- Division of Neurosurgery, University of Toronto, Hospital for Sick Children, Toronto
| | - Jody Levenbach
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Venkateswararao Cherukuri
- School of Electrical Engineering and Computer Science, The Pennsylvania State University, University Park
| | - Vishal Monga
- School of Electrical Engineering and Computer Science, The Pennsylvania State University, University Park
| | - Abhaya V. Kulkarni
- Division of Neurosurgery, University of Toronto, Hospital for Sick Children, Toronto
| | - Benjamin C. Warf
- Department of Neurosurgery, Boston Children’s Hospital and Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Steven J. Schiff
- Department of Neurosurgery, Penn State College of Medicine, Hershey,Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park,Department of Physics, The Pennsylvania State University, University Park, Pennsylvania
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15
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Tindula G, Mukherjee SK, Ekramullah SM, Arman DM, Biswas SK, Islam J, Obrycki JF, Christiani DC, Liang L, Warf BC, Mazumdar M. Parental metal exposures as potential risk factors for spina bifida in Bangladesh. Environ Int 2021; 157:106800. [PMID: 34358915 PMCID: PMC9008873 DOI: 10.1016/j.envint.2021.106800] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 07/08/2021] [Accepted: 07/26/2021] [Indexed: 06/11/2023]
Abstract
BACKGROUND Neural tube defects are a pressing public health concern despite advances in prevention from folic acid-based strategies. Numerous chemicals, in particular arsenic, have been associated with neural tube defects in animal models and could influence risk in humans. OBJECTIVES We investigated the relationship between parental exposure to arsenic and 17 metals and risk of neural tube defects (myelomeningocele and meningocele) in a case control study in Bangladesh. METHODS Exposure assessment included analysis of maternal and paternal toenail samples using inductively coupled plasma mass spectrometry (ICP-MS). A total of 278 participants (155 cases and 123 controls) with data collected from 2016 to 2020 were included in the analysis. RESULTS In the paternal models, a one-unit increase in the natural logarithm of paternal toenail arsenic was associated with a 74% (odds ratio: 1.74, 95% confidence interval: 1.26-2.42) greater odds of having a child with spina bifida, after adjusting for relevant covariates. Additionally, paternal exposure to aluminum, cobalt, chromium, iron, selenium, and vanadium was associated with increased odds of having a child with spina bifida in the adjusted models. In the maternal models, a one-unit increase in the natural logarithm of maternal toenail selenium and zinc levels was related to a 382% greater (odds ratio: 4.82, 95% confidence interval: 1.32-17.60) and 89% lower (odds ratio: 0.11, 95% confidence interval: 0.03-0.42) odds of having a child with spina bifida in the adjusted models, respectively. Results did not suggest an interaction between parental toenail metals and maternal serum folate. DISCUSSION Parental toenail levels of numerous metals were associated with increased risk of spina bifida in Bangladeshi infants. Paternal arsenic exposure was positively associated with neural tube defects in children and is of particular concern given the widespread arsenic poisoning of groundwater resources in Bangladesh and the lack of nutritional interventions aimed to mitigate paternal arsenic exposure. The findings add to the growing body of literature of the impact of metals, especially paternal environmental factors, on child health.
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Affiliation(s)
- Gwen Tindula
- Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, United States; Department of Neurology, Harvard Medical School, 25 Shattuck St, Boston, MA, United States
| | - Sudipta Kumer Mukherjee
- Department of Paediatric Neurosurgery, National Institute of Neurosciences and Hospital (NINS), Sher-e-Bangla Nagar, Agargoan, Dhaka 1207, Bangladesh
| | - Sheikh Muhammad Ekramullah
- Department of Paediatric Neurosurgery, National Institute of Neurosciences and Hospital (NINS), Sher-e-Bangla Nagar, Agargoan, Dhaka 1207, Bangladesh
| | - D M Arman
- Department of Paediatric Neurosurgery, National Institute of Neurosciences and Hospital (NINS), Sher-e-Bangla Nagar, Agargoan, Dhaka 1207, Bangladesh
| | - Subrata Kumar Biswas
- Department of Biochemistry and Molecular Biology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka 1000, Bangladesh
| | - Joynul Islam
- Department of Clinical Neurosurgery, National Institute of Neurosciences and Hospital (NINS), Sher-e-Bangla Nagar, Agargoan, Dhaka 1207, Bangladesh
| | - John F Obrycki
- Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, United States; Department of Neurology, Harvard Medical School, 25 Shattuck St, Boston, MA, United States
| | - David C Christiani
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, United States; Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, United States
| | - Liming Liang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, United States; Department of Biostatistics, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, United States
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, United States
| | - Maitreyi Mazumdar
- Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, United States; Department of Neurology, Harvard Medical School, 25 Shattuck St, Boston, MA, United States; Department of Environmental Health, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, United States.
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16
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Harper JR, Cherukuri V, O'Reilly T, Yu M, Mbabazi-Kabachelor E, Mulando R, Sheth KN, Webb AG, Warf BC, Kulkarni AV, Monga V, Schiff SJ. Assessing the utility of low resolution brain imaging: treatment of infant hydrocephalus. Neuroimage Clin 2021; 32:102896. [PMID: 34911199 PMCID: PMC8646178 DOI: 10.1016/j.nicl.2021.102896] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/27/2021] [Accepted: 11/22/2021] [Indexed: 11/21/2022]
Abstract
As low-field MRI technology is being disseminated into clinical settings around the world, it is important to assess the image quality required to properly diagnose and treat a given disease and evaluate the role of machine learning algorithms, such as deep learning, in the enhancement of lower quality images. In this post hoc analysis of an ongoing randomized clinical trial, we assessed the diagnostic utility of reduced-quality and deep learning enhanced images for hydrocephalus treatment planning. CT images of post-infectious infant hydrocephalus were degraded in terms of spatial resolution, noise, and contrast between brain and CSF and enhanced using deep learning algorithms. Both degraded and enhanced images were presented to three experienced pediatric neurosurgeons accustomed to working in low- to middle-income countries (LMIC) for assessment of clinical utility in treatment planning for hydrocephalus. In addition, enhanced images were presented alongside their ground-truth CT counterparts in order to assess whether reconstruction errors caused by the deep learning enhancement routine were acceptable to the evaluators. Results indicate that image resolution and contrast-to-noise ratio between brain and CSF predict the likelihood of an image being characterized as useful for hydrocephalus treatment planning. Deep learning enhancement substantially increases contrast-to-noise ratio improving the apparent likelihood of the image being useful; however, deep learning enhancement introduces structural errors which create a substantial risk of misleading clinical interpretation. We find that images with lower quality than is customarily acceptable can be useful for hydrocephalus treatment planning. Moreover, low quality images may be preferable to images enhanced with deep learning, since they do not introduce the risk of misleading information which could misguide treatment decisions. These findings advocate for new standards in assessing acceptable image quality for clinical use.
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Affiliation(s)
- Joshua R Harper
- Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA, USA
| | - Venkateswararao Cherukuri
- School of Electrical Engineering and Computer Science, The Pennsylvania State University, University Park, PA, USA
| | - Tom O'Reilly
- Gorter Center for High Field MRI, Leiden University Medical Center, Leiden, NL, the Netherlands
| | - Mingzhao Yu
- School of Electrical Engineering and Computer Science, The Pennsylvania State University, University Park, PA, USA
| | | | | | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew G Webb
- Gorter Center for High Field MRI, Leiden University Medical Center, Leiden, NL, the Netherlands
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Abhaya V Kulkarni
- Department of Surgery, Hospital for Sick Children, University of Toronto, CA, USA
| | - Vishal Monga
- School of Electrical Engineering and Computer Science, The Pennsylvania State University, University Park, PA, USA
| | - Steven J Schiff
- Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA, USA; Departments of Neurosurgery, and Physics, The Pennsylvania State University, University Park, PA, USA.
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17
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Hulsbergen AFC, Siddi F, McAvoy M, Lynch BT, Karsten MB, Stopa BM, Ashby J, McNulty J, Broekman MLD, Gormley WB, Stone SSD, Warf BC, Proctor MR. The low utility of routine cranial imaging after pediatric shunt revision. J Neurosurg Pediatr 2021:1-7. [PMID: 34798615 DOI: 10.3171/2021.9.peds21261] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Postoperative routine imaging is common after pediatric ventricular shunt revision, but the benefit of scanning in the absence of symptoms is questionable. In this study, the authors aimed to assess how often routine scanning results in a change in clinical management after shunt revision. METHODS The records of a large, tertiary pediatric hospital were retrospectively reviewed for all consecutive cases of pediatric shunt revision between July 2013 and July 2018. Postoperative imaging was classified as routine (i.e., in the absence of symptoms, complications, or other direct indications) or nonroutine. Reinterventions within 30 days were assessed in these groups. RESULTS Of 387 included shunt revisions performed in 232 patients, postoperative imaging was performed in 297 (77%), which was routine in 244 (63%) and nonroutine in 53 (14%). Ninety revisions (23%) underwent any shunt-related procedure after postoperative imaging, including shunt reprogramming (n = 35, 9%), shunt tap (n = 10, 3%), and a return to the operating room (OR; n = 58, 15%). Of the 244 cases receiving routine imaging, 241 did not undergo a change in clinical management solely based on routine imaging findings. The remaining 3 cases returned to the OR, accounting for 0.8% (95% CI 0.0%-1.7%) of all cases or 1.2% (95% CI 0.0%-2.6%) of cases that received routine imaging. Furthermore, 27 of 244 patients in this group returned to the OR for other reasons, namely complications (n = 12) or recurrent symptoms (n = 15); all arose after initial routine imaging. CONCLUSIONS The authors found a low yield to routine imaging after pediatric shunt revision, with only 0.8% of cases undergoing a change in management based on routine imaging findings without corresponding clinical findings. Moreover, routine imaging without abnormal findings was no guarantee of an uneventful postoperative course. Clinical monitoring can be considered as an alternative in asymptomatic, uncomplicated patients.
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Affiliation(s)
- Alexander F C Hulsbergen
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,4Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Francesca Siddi
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,2Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,5Department of Neurological Surgery, University of Padua, Padua, Italy
| | - Malia McAvoy
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,2Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,6Harvard-MIT Health Sciences and Technology, Harvard Medical School, Massachusetts Institute of Technology, Cambridge, Massachusetts; and
| | - Benjamin T Lynch
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Madeline B Karsten
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brittany M Stopa
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,2Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joanna Ashby
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,2Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jack McNulty
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,2Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,7Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Marike L D Broekman
- 2Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,4Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - William B Gormley
- 2Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scellig S D Stone
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin C Warf
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark R Proctor
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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18
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Schiff SJ, Kulkarni AV, Mbabazi-Kabachelor E, Mugamba J, Ssenyonga P, Donnelly R, Levenbach J, Monga V, Peterson M, Cherukuri V, Warf BC. Brain growth after surgical treatment for infant postinfectious hydrocephalus in Sub-Saharan Africa: 2-year results of a randomized trial. J Neurosurg Pediatr 2021:1-9. [PMID: 34243157 PMCID: PMC8742836 DOI: 10.3171/2021.2.peds20949] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 12/04/2020] [Accepted: 02/17/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Hydrocephalus in infants, particularly that with a postinfectious etiology, is a major public health burden in Sub-Saharan Africa. The authors of this study aimed to determine whether surgical treatment of infant postinfectious hydrocephalus in Uganda results in sustained, long-term brain growth and improved cognitive outcome. METHODS The authors performed a trial at a single center in Mbale, Uganda, involving infants (age < 180 days old) with postinfectious hydrocephalus randomized to endoscopic third ventriculostomy plus choroid plexus cauterization (ETV+CPC; n = 51) or ventriculoperitoneal shunt (VPS; n = 49). After 2 years, they assessed developmental outcome with the Bayley Scales of Infant Development, Third Edition (BSID-III), and brain volume (raw and normalized for age and sex) with CT scans. RESULTS Eighty-nine infants were assessed for 2-year outcome. There were no significant differences between the two surgical treatment arms in terms of BSID-III cognitive score (p = 0.17) or brain volume (p = 0.36), so they were analyzed together. Raw brain volumes increased between baseline and 2 years (p < 0.001), but this increase occurred almost exclusively in the 1st year (p < 0.001). The fraction of patients with a normal brain volume increased from 15.2% at baseline to 50.0% at 1 year but then declined to 17.8% at 2 years. Substantial normalized brain volume loss was seen in 21.3% patients between baseline and year 2 and in 76.7% between years 1 and 2. The extent of brain growth in the 1st year was not associated with the extent of brain volume changes in the 2nd year. There were significant positive correlations between 2-year brain volume and all BSID-III scores and BSID-III changes from baseline. CONCLUSIONS In Sub-Saharan Africa, even after successful surgical treatment of infant postinfectious hydrocephalus, early posttreatment brain growth stagnates in the 2nd year. While the reasons for this finding are unclear, it further emphasizes the importance of primary infection prevention and mitigation strategies along with optimizing the child's environment to maximize brain growth potential.
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Affiliation(s)
- Steven J. Schiff
- Center for Neural Engineering; The Pennsylvania State University, State College, Pennsylvania;,Department of Neurosurgery, The Pennsylvania State University, State College, Pennsylvania;,Department of Engineering Science and Mechanics, The Pennsylvania State University, State College, Pennsylvania;,Department of Physics, The Pennsylvania State University, State College, Pennsylvania
| | - Abhaya V. Kulkarni
- Department of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - John Mugamba
- CURE Children’s Hospital of Uganda, Mbale, Uganda
| | | | - Ruth Donnelly
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jody Levenbach
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vishal Monga
- Center for Neural Engineering; The Pennsylvania State University, State College, Pennsylvania
| | - Mallory Peterson
- Center for Neural Engineering; The Pennsylvania State University, State College, Pennsylvania
| | | | - Benjamin C. Warf
- Department of Neurosurgery, Boston Children’s Hospital, Boston, Massachusetts
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19
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Peterson MR, Cherukuri V, Paulson JN, Ssentongo P, Kulkarni AV, Warf BC, Monga V, Schiff SJ. Normal childhood brain growth and a universal sex and anthropomorphic relationship to cerebrospinal fluid. J Neurosurg Pediatr 2021; 28:458-468. [PMID: 34243147 PMCID: PMC8594737 DOI: 10.3171/2021.2.peds201006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/19/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The study of brain size and growth has a long and contentious history, yet normal brain volume development has yet to be fully described. In particular, the normal brain growth and cerebrospinal fluid (CSF) accumulation relationship is critical to characterize because it is impacted in numerous conditions of early childhood in which brain growth and fluid accumulation are affected, such as infection, hemorrhage, hydrocephalus, and a broad range of congenital disorders. The authors of this study aim to describe normal brain volume growth, particularly in the setting of CSF accumulation. METHODS The authors analyzed 1067 magnetic resonance imaging scans from 505 healthy pediatric subjects from birth to age 18 years to quantify component and regional brain volumes. The volume trajectories were compared between the sexes and hemispheres using smoothing spline ANOVA. Population growth curves were developed using generalized additive models for location, scale, and shape. RESULTS Brain volume peaked at 10-12 years of age. Males exhibited larger age-adjusted total brain volumes than females, and body size normalization procedures did not eliminate this difference. The ratio of brain to CSF volume, however, revealed a universal age-dependent relationship independent of sex or body size. CONCLUSIONS These findings enable the application of normative growth curves in managing a broad range of childhood diseases in which cognitive development, brain growth, and fluid accumulation are interrelated.
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Affiliation(s)
- Mallory R. Peterson
- Center for Neural Engineering, The Pennsylvania State University, University Park,Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park,The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Venkateswararao Cherukuri
- Center for Neural Engineering, The Pennsylvania State University, University Park,School of Electrical Engineering and Computer Science, The Pennsylvania State University, University Park
| | - Joseph N. Paulson
- Department of Biostatistics, Product Development, Genentech Inc., South San Francisco, California
| | - Paddy Ssentongo
- Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park
| | - Abhaya V. Kulkarni
- Department of Neurosurgery, University of Toronto,Department of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Benjamin C. Warf
- Department of Neurosurgery, Harvard Medical School,Department of Neurosurgery, Boston Children’s Hospital, Boston, Massachusetts
| | - Vishal Monga
- School of Electrical Engineering and Computer Science, The Pennsylvania State University, University Park
| | - Steven J. Schiff
- Center for Neural Engineering, The Pennsylvania State University, University Park,Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park,Department of Neurosurgery, The Pennsylvania State University, University Park,Department of Physics, The Pennsylvania State University, University Park
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20
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Paulson JN, Williams BL, Hehnly C, Mishra N, Sinnar SA, Zhang L, Ssentongo P, Mbabazi-Kabachelor E, Wijetunge DSS, von Bredow B, Mulondo R, Kiwanuka J, Bajunirwe F, Bazira J, Bebell LM, Burgoine K, Couto-Rodriguez M, Ericson JE, Erickson T, Ferrari M, Gladstone M, Guo C, Haran M, Hornig M, Isaacs AM, Kaaya BN, Kangere SM, Kulkarni AV, Kumbakumba E, Li X, Limbrick DD, Magombe J, Morton SU, Mugamba J, Ng J, Olupot-Olupot P, Onen J, Peterson MR, Roy F, Sheldon K, Townsend R, Weeks AD, Whalen AJ, Quackenbush J, Ssenyonga P, Galperin MY, Almeida M, Atkins H, Warf BC, Lipkin WI, Broach JR, Schiff SJ. Paenibacillus infection with frequent viral coinfection contributes to postinfectious hydrocephalus in Ugandan infants. Sci Transl Med 2021; 12:12/563/eaba0565. [PMID: 32998967 DOI: 10.1126/scitranslmed.aba0565] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 05/06/2020] [Indexed: 12/14/2022]
Abstract
Postinfectious hydrocephalus (PIH), which often follows neonatal sepsis, is the most common cause of pediatric hydrocephalus worldwide, yet the microbial pathogens underlying this disease remain to be elucidated. Characterization of the microbial agents causing PIH would enable a shift from surgical palliation of cerebrospinal fluid (CSF) accumulation to prevention of the disease. Here, we examined blood and CSF samples collected from 100 consecutive infant cases of PIH and control cases comprising infants with non-postinfectious hydrocephalus in Uganda. Genomic sequencing of samples was undertaken to test for bacterial, fungal, and parasitic DNA; DNA and RNA sequencing was used to identify viruses; and bacterial culture recovery was used to identify potential causative organisms. We found that infection with the bacterium Paenibacillus, together with frequent cytomegalovirus (CMV) coinfection, was associated with PIH in our infant cohort. Assembly of the genome of a facultative anaerobic bacterial isolate recovered from cultures of CSF samples from PIH cases identified a strain of Paenibacillus thiaminolyticus This strain, designated Mbale, was lethal when injected into mice in contrast to the benign reference Paenibacillus strain. These findings show that an unbiased pan-microbial approach enabled characterization of Paenibacillus in CSF samples from PIH cases, and point toward a pathway of more optimal treatment and prevention for PIH and other proximate neonatal infections.
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Affiliation(s)
- Joseph N Paulson
- Department of Biostatistics, Product Development, Genentech Inc., South San Francisco, CA 94080, USA
| | - Brent L Williams
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY 10032, USA.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA
| | - Christine Hehnly
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Nischay Mishra
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY 10032, USA.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA
| | - Shamim A Sinnar
- Center for Neural Engineering, Pennsylvania State University, University Park, PA 16802, USA.,Department of Medicine, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Lijun Zhang
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Paddy Ssentongo
- Center for Neural Engineering, Pennsylvania State University, University Park, PA 16802, USA.,Department of Engineering Science and Mechanics, Pennsylvania State University, University Park, PA 16802, USA.,Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | | | - Dona S S Wijetunge
- Department of Pathology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Benjamin von Bredow
- Department of Pathology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Ronnie Mulondo
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - Julius Kiwanuka
- Department of Pediatrics, Mbarara University of Science and Technology, P.O. Box 1410 Mbarara, Uganda
| | - Francis Bajunirwe
- Department of Epidemiology, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Joel Bazira
- Department of Microbiology, Mbarara University of Science and Technology, P.O. Box 1410 Mbarara, Uganda
| | - Lisa M Bebell
- Division of Infectious Disease, Massachusetts Genereal Hospital, Harvard Medical School, 55 Fruit St, GRJ-504, Boston, MA 02114, USA
| | - Kathy Burgoine
- Neonatal Unit, Department of Paediatrics and Child Health, Mbale Regional Referral Hospital, Plot 29-33 Pallisa Road, P.O. Box 1966, Mbale, Uganda.,Mbale Clinical Research Institute, Mbale Regional Referral Hospital, Plot 29-33 Pallisa Road, P.O. Box 1966 Mbale, Uganda.,University of Liverpool, Liverpool, L69 3BX, UK
| | - Mara Couto-Rodriguez
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY 10032, USA.,Biotia, 100 6th avenue, New York, NY 10013, USA
| | - Jessica E Ericson
- Division of Pediatric Infectious Disease, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Tim Erickson
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - Matthew Ferrari
- Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA 16802, USA.,Department of Biology, Pennsylvania State University, University Park, PA 16802, USA.,Department of Statistics, Pennsylvania State University, University Park, PA 16802, USA
| | - Melissa Gladstone
- Institute for Translational Medicine, University of Liverpool, Liverpool, L12 2AP, UK
| | - Cheng Guo
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Murali Haran
- Department of Statistics, Pennsylvania State University, University Park, PA 16802, USA
| | - Mady Hornig
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA
| | - Albert M Isaacs
- Department of Neuroscience, Washington University School of Medicine, St. Louis, MO 63130, USA
| | - Brian Nsubuga Kaaya
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - Sheila M Kangere
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - Abhaya V Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, M5G 1X8, Canada
| | - Elias Kumbakumba
- Department of Pediatrics, Mbarara University of Science and Technology, P.O. Box 1410 Mbarara, Uganda
| | - Xiaoxiao Li
- Institute for Translational Medicine, University of Liverpool, Liverpool, L12 2AP, UK
| | - David D Limbrick
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63130, USA
| | - Joshua Magombe
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - Sarah U Morton
- Division of Newborn Medicine, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston MA 02115, USA
| | - John Mugamba
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - James Ng
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Peter Olupot-Olupot
- Mbale Clinical Research Institute, Mbale Regional Referral Hospital, Plot 29-33 Pallisa Road, P.O. Box 1966 Mbale, Uganda.,Busitema University, Mbale Campus, Plot 29-33 Pallisa Road, P.O. Box 1966, Mbale, Uganda
| | - Justin Onen
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - Mallory R Peterson
- Center for Neural Engineering, Pennsylvania State University, University Park, PA 16802, USA.,Department of Engineering Science and Mechanics, Pennsylvania State University, University Park, PA 16802, USA
| | - Farrah Roy
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Kathryn Sheldon
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Reid Townsend
- Department of Medicine, Washington University School of Medicine , St. Louis, MO 63130, USA
| | - Andrew D Weeks
- Sanyu Research Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool L8 7SS, UK
| | - Andrew J Whalen
- Department of Mechanical Engineering, Pennsylvania State University, University Park, PA 16802, USA
| | - John Quackenbush
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Peter Ssenyonga
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - Michael Y Galperin
- National Center for Biotechnology Information, National Library of Medicine, National Institutes of Health, Bethesda, MD 20894, USA
| | - Mathieu Almeida
- Université Paris-Saclay, INRAE, MGP, Jouy-en-Josas, 78350, France
| | - Hannah Atkins
- Department of Comparative Medicine, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - W Ian Lipkin
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY 10032, USA.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA
| | - James R Broach
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Steven J Schiff
- Center for Neural Engineering, Pennsylvania State University, University Park, PA 16802, USA. .,Department of Engineering Science and Mechanics, Pennsylvania State University, University Park, PA 16802, USA.,Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA 16802, USA.,Department of Neurosurgery, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.,Department of Physics, Pennsylvania State University, University Park, PA 16802, USA
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21
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Isaacs AM, Morton SU, Movassagh M, Zhang Q, Hehnly C, Zhang L, Morales DM, Sinnar SA, Ericson JE, Mbabazi-Kabachelor E, Ssenyonga P, Onen J, Mulondo R, Hornig M, Warf BC, Broach JR, Townsend RR, Limbrick DD, Paulson JN, Schiff SJ. Immune activation during Paenibacillus brain infection in African infants with frequent cytomegalovirus co-infection. iScience 2021; 24:102351. [PMID: 33912816 PMCID: PMC8065213 DOI: 10.1016/j.isci.2021.102351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/24/2021] [Accepted: 03/19/2021] [Indexed: 12/16/2022] Open
Abstract
Inflammation during neonatal brain infections leads to significant secondary sequelae such as hydrocephalus, which often follows neonatal sepsis in the developing world. In 100 African hydrocephalic infants we identified the biological pathways that account for this response. The dominant bacterial pathogen was a Paenibacillus species, with frequent cytomegalovirus co-infection. A proteogenomic strategy was employed to confirm host immune response to Paenibacillus and to define the interplay within the host immune response network. Immune activation emphasized neuroinflammation, oxidative stress reaction, and extracellular matrix organization. The innate immune system response included neutrophil activity, signaling via IL-4, IL-12, IL-13, interferon, and Jak/STAT pathways. Platelet-activating factors and factors involved with microbe recognition such as Class I MHC antigen-presenting complex were also increased. Evidence suggests that dysregulated neuroinflammation propagates inflammatory hydrocephalus, and these pathways are potential targets for adjunctive treatments to reduce the hazards of neuroinflammation and risk of hydrocephalus following neonatal sepsis. There is a characteristic immune response to Paenibacillus brain infection There is a characteristic immune response to CMV brain infection The matching immune response validates pathogen genomic presence The combined results support molecular infection causality
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Affiliation(s)
- Albert M Isaacs
- Department of Neuroscience, Washington University School of Medicine, St. Louis, MO 63110, USA.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Sarah U Morton
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Mercedeh Movassagh
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Qiang Zhang
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Christine Hehnly
- Institute for Personalized Medicine, Pennsylvania State University, Hershey, PA 17033, USA.,Department of Biochemistry and Molecular Biology, Pennsylvania State University, State College, PA 16801, USA
| | - Lijun Zhang
- Institute for Personalized Medicine, Pennsylvania State University, Hershey, PA 17033, USA
| | - Diego M Morales
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Shamim A Sinnar
- Center for Neural Engineering, Pennsylvania State University, State College, PA 16801, USA.,Department of Medicine, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Jessica E Ericson
- Department of Pediatrics, Pennsylvania State College of Medicine, Hershey, PA 17033, USA
| | | | | | - Justin Onen
- CURE Children's Hospital of Uganda, Mbale, Uganda
| | | | - Mady Hornig
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Harvard Medical School, Boston, MA 02115, USA
| | - James R Broach
- Institute for Personalized Medicine, Pennsylvania State University, Hershey, PA 17033, USA.,Department of Biochemistry and Molecular Biology, Pennsylvania State University, State College, PA 16801, USA
| | - R Reid Townsend
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - David D Limbrick
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Joseph N Paulson
- Department of Biostatistics, Product Development, Genentech Inc., South San Francisco, CA 94080, USA
| | - Steven J Schiff
- Center for Neural Engineering, Pennsylvania State University, State College, PA 16801, USA.,Center for Infectious Disease Dynamics, Departments of Neurosurgery, Engineering Science and Mechanics, and Physics, The Pennsylvania State University, University Park, PA 16802, USA
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22
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Xu H, Fame RM, Sadegh C, Sutin J, Naranjo C, Della Syau, Cui J, Shipley FB, Vernon A, Gao F, Zhang Y, Holtzman MJ, Heiman M, Warf BC, Lin PY, Lehtinen MK. Choroid plexus NKCC1 mediates cerebrospinal fluid clearance during mouse early postnatal development. Nat Commun 2021; 12:447. [PMID: 33469018 PMCID: PMC7815709 DOI: 10.1038/s41467-020-20666-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 12/10/2020] [Indexed: 12/14/2022] Open
Abstract
Cerebrospinal fluid (CSF) provides vital support for the brain. Abnormal CSF accumulation, such as hydrocephalus, can negatively affect perinatal neurodevelopment. The mechanisms regulating CSF clearance during the postnatal critical period are unclear. Here, we show that CSF K+, accompanied by water, is cleared through the choroid plexus (ChP) during mouse early postnatal development. We report that, at this developmental stage, the ChP showed increased ATP production and increased expression of ATP-dependent K+ transporters, particularly the Na+, K+, Cl-, and water cotransporter NKCC1. Overexpression of NKCC1 in the ChP resulted in increased CSF K+ clearance, increased cerebral compliance, and reduced circulating CSF in the brain without changes in intracranial pressure in mice. Moreover, ChP-specific NKCC1 overexpression in an obstructive hydrocephalus mouse model resulted in reduced ventriculomegaly. Collectively, our results implicate NKCC1 in regulating CSF K+ clearance through the ChP in the critical period during postnatal neurodevelopment in mice.
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Affiliation(s)
- Huixin Xu
- Department of Pathology, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Ryann M Fame
- Department of Pathology, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Cameron Sadegh
- Department of Pathology, Boston Children's Hospital, Boston, MA, 02115, USA
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Jason Sutin
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Christopher Naranjo
- Summer Honors Undergraduate Research Program, Division of Medical Sciences, Harvard Medical School, Boston, MA, 02115, USA
| | - Della Syau
- Summer Honors Undergraduate Research Program, Division of Medical Sciences, Harvard Medical School, Boston, MA, 02115, USA
| | - Jin Cui
- Department of Pathology, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Frederick B Shipley
- Department of Pathology, Boston Children's Hospital, Boston, MA, 02115, USA
- Graduate Program in Biophysics, Harvard University, Cambridge, MA, 02138, USA
| | - Amanda Vernon
- Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA
- Picower Institute for Learning and Memory, Cambridge, MA, 02139, USA
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Fan Gao
- Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA
- Picower Institute for Learning and Memory, Cambridge, MA, 02139, USA
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
- Bioinformatics Resource Center in the Beckman Institute at Caltech, Pasadena, CA, 91125, USA
| | - Yong Zhang
- Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, MO, 63110, USA
| | - Michael J Holtzman
- Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, MO, 63110, USA
| | - Myriam Heiman
- Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA
- Picower Institute for Learning and Memory, Cambridge, MA, 02139, USA
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Pei-Yi Lin
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Maria K Lehtinen
- Department of Pathology, Boston Children's Hospital, Boston, MA, 02115, USA.
- Graduate Program in Biophysics, Harvard University, Cambridge, MA, 02138, USA.
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23
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Tirrell TF, Demehri FR, Henry OS, Cullen L, Lillehei CW, Warf BC, Gates RL, Borer JG, Dickie BH. Safety of delayed surgical repair of omphalocele-exstrophy-imperforate anus-spinal defects (OEIS) complex in infants with significant comorbidities. Pediatr Surg Int 2021; 37:93-99. [PMID: 33231719 DOI: 10.1007/s00383-020-04779-w] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Management of infants with OEIS complex is challenging and not standardized. Expeditious surgery after birth has been recommended to limit soilage of the urinary tract and optimize intestinal function. However, clinical instability secondary to comorbidities is common in this population and early operation carries risk. We sought to define the risk/benefit profile of delaying repair. METHODS All newborn patients with OEIS managed by our institution between Sep 2017 and Oct 2019 were reviewed. Comorbidities were evaluated, including cardiopulmonary pathologies and associated malformations. RESULTS Ten patients with OEIS were managed. Patients underwent early (2 patients, repair at 0-2 days) or delayed (6 patients, repair at 6-87 days) first-stage exstrophy repair. Two patients died prior to repair (progressive respiratory failure, severe genetic anomalies). Repairs were delayed secondary to cardiac conditions, neurosurgical interventions, medical disease, and/or delayed transfer. Delayed repair patients had longer lengths of stay and use of parenteral nutrition. No patients experienced urinary tract infections prior to repair. CONCLUSIONS Delaying first-stage exstrophy repair to allow physiologic optimization is safe. All repaired patients were discharged home, without parenteral nutrition or supplemental oxygen.
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Affiliation(s)
- Timothy F Tirrell
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Fegan 3, Boston, MA, 02115, USA
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Fegan 3, Boston, MA, 02115, USA
| | - Owen S Henry
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Fegan 3, Boston, MA, 02115, USA
| | - Lauren Cullen
- Department of Urology, Boston Children's Hospital, 300 Longwood Ave, Hunnewell 3, Boston, MA, 02115, USA
| | - Craig W Lillehei
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Fegan 3, Boston, MA, 02115, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Robert L Gates
- Department of Surgery, Prisma Health, 48 Cross Park Court, Greenville, SC, 29605, USA
| | - Joseph G Borer
- Department of Urology, Boston Children's Hospital, 300 Longwood Ave, Hunnewell 3, Boston, MA, 02115, USA
| | - Belinda H Dickie
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Fegan 3, Boston, MA, 02115, USA.
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24
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Sadegh C, Xu H, Sutin J, Benedict M, Shipley F, Warf BC, Andermann M, Lehtinen MK. Disrupted Choroid Plexus Calcium Signaling Generates Decompensated Hydrocephalus in Mouse Models of Pediatric IVH. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_574] [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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25
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Kahle KT, Reeves B, Karimy JK, Zhang J, Schiff SJ, Limbrick DD, Alper S, Warf BC, Simard JM. A Shared, Targetable Inflammatory Mechanism Drives Hemorrhagic and Infectious Hydrocephalus. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_264] [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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26
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Phan D, Jin SC, Weise S, Marini C, Dong W, Kundishora A, Torres-Fernandez L, Cuevas E, Hao L, Furey CG, Zeng X, Jux B, Sousa A, Liu F, Kim SK, Li M, Yang Y, Takeo Y, Foster D, Nelson-Williams C, Allocco AA, Smith H, Dunbar A, Sullivan W, Ha Y, Selvaganesan K, Sheth A, DeSpenza T, Reeves B, Goto J, Marlier A, Warf BC, Moreno-De-Luca A, Lake E, Constable T, Sestan N, Lin H, Alper S, Slack F, Wulczyn FG, Kolanus W, Lifton RP, Kahle KT. TRIM71 Mutations Cause Human and Murine Congenital Hydrocephalus by Impairing Prenatal Neural Stem Cell Regulation. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_576] [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: 11/13/2022] Open
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27
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Panchagnula S, Jin SC, Dong W, Kundishora A, Moreno-De-Luca A, Furey CG, Allocco AA, Walker R, Nelson-Williams C, Smith H, Dunbar A, Conine SB, Lu Q, Zen X, Sierant M, Knight J, Sullivan W, Phan D, DeSpenza T, Reeves B, Karimy JK, Marlier A, Castaldi C, Tikhonova I, Li B, Peña; H, Broach J, Kabachelor EM, Ssenyonga P, Hehnly C, Ge L, Keren B, Timberlake AT, Goto J, Mangano FT, Johnston JM, Butler W, Warf BC, Smith ER, Schiff SJ, Limbrick DD, Heuer GG, Jackson EM, Iskandar BJ, Mane S, Haider S, Guclu B, Bayri Y, Sahin Y, Duncan CC, Apuzzo ML, DiLuna ML, Hoffman E, Sestan N, Ment L, Alper S, Bilguvar K, Geschwind D, Günel M, Lifton RP, Kahle KT. Integrative Genomics Implicates Genetic Disruption of Prenatal Neurogenesis in Congenital Hydrocephalus. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_572] [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: 11/12/2022] Open
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28
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Jin SC, Dong W, Kundishora AJ, Panchagnula S, Moreno-De-Luca A, Furey CG, Allocco AA, Walker RL, Nelson-Williams C, Smith H, Dunbar A, Conine S, Lu Q, Zeng X, Sierant MC, Knight JR, Sullivan W, Duy PQ, DeSpenza T, Reeves BC, Karimy JK, Marlier A, Castaldi C, Tikhonova IR, Li B, Peña HP, Broach JR, Kabachelor EM, Ssenyonga P, Hehnly C, Ge L, Keren B, Timberlake AT, Goto J, Mangano FT, Johnston JM, Butler WE, Warf BC, Smith ER, Schiff SJ, Limbrick DD, Heuer G, Jackson EM, Iskandar BJ, Mane S, Haider S, Guclu B, Bayri Y, Sahin Y, Duncan CC, Apuzzo MLJ, DiLuna ML, Hoffman EJ, Sestan N, Ment LR, Alper SL, Bilguvar K, Geschwind DH, Günel M, Lifton RP, Kahle KT. Exome sequencing implicates genetic disruption of prenatal neuro-gliogenesis in sporadic congenital hydrocephalus. Nat Med 2020; 26:1754-1765. [PMID: 33077954 PMCID: PMC7871900 DOI: 10.1038/s41591-020-1090-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 09/02/2020] [Indexed: 01/08/2023]
Abstract
Congenital hydrocephalus (CH), characterized by enlarged brain ventricles, is considered a disease of excessive cerebrospinal fluid (CSF) accumulation and thereby treated with neurosurgical CSF diversion with high morbidity and failure rates. The poor neurodevelopmental outcomes and persistence of ventriculomegaly in some post-surgical patients highlight our limited knowledge of disease mechanisms. Through whole-exome sequencing of 381 patients (232 trios) with sporadic, neurosurgically treated CH, we found that damaging de novo mutations account for >17% of cases, with five different genes exhibiting a significant de novo mutation burden. In all, rare, damaging mutations with large effect contributed to ~22% of sporadic CH cases. Multiple CH genes are key regulators of neural stem cell biology and converge in human transcriptional networks and cell types pertinent for fetal neuro-gliogenesis. These data implicate genetic disruption of early brain development, not impaired CSF dynamics, as the primary pathomechanism of a significant number of patients with sporadic CH.
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Affiliation(s)
- Sheng Chih Jin
- Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | - Weilai Dong
- Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
| | - Adam J Kundishora
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Shreyas Panchagnula
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Andres Moreno-De-Luca
- Autism & Developmental Medicine Institute, Genomic Medicine Institute, Department of Radiology, Geisinger, Danville, PA, USA
| | - Charuta G Furey
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - August A Allocco
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Rebecca L Walker
- Department of Neurology, Center for Autism Research and Treatment, Semel Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Hannah Smith
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Ashley Dunbar
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Sierra Conine
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Qiongshi Lu
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - Xue Zeng
- Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
| | - Michael C Sierant
- Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
| | - James R Knight
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
- Yale Center for Genome Analysis, Yale University, New Haven, CT, USA
| | - William Sullivan
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Phan Q Duy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Tyrone DeSpenza
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Jason K Karimy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Arnaud Marlier
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | | | - Irina R Tikhonova
- Yale Center for Genome Analysis, Yale University, New Haven, CT, USA
| | - Boyang Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Helena Perez Peña
- Department of Pharmaceutical and Biological Chemistry, University College London School of Pharmacy, London, UK
| | - James R Broach
- Institute for Personalized Medicine, The Penn State College of Medicine, Hershey, PA, USA
| | | | | | - Christine Hehnly
- Departments of Neurosurgery, Engineering Science & Mechanics, and Physics; Center for Neural Engineering and Infectious Disease Dynamics, The Pennsylvania State University, University Park, PA, USA
| | - Li Ge
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - Boris Keren
- Département de Génétique, Centre de Référence Déficiences Intellectuelles de Causes Rares, Groupe Hospitalier Pitié Salpêtrière et GHUEP Hôpital Trousseau, Sorbonne Université, GRC "Déficience Intellectuelle et Autisme", Paris, France
| | - Andrew T Timberlake
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, NY, USA
| | - June Goto
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Francesco T Mangano
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - James M Johnston
- Department of Neurosurgery, University of Alabama School of Medicine, Birmingham, AL, USA
| | - William E Butler
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven J Schiff
- Departments of Neurosurgery, Engineering Science & Mechanics, and Physics; Center for Neural Engineering and Infectious Disease Dynamics, The Pennsylvania State University, University Park, PA, USA
| | - David D Limbrick
- Department of Neurological Surgery and Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Gregory Heuer
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Bermans J Iskandar
- Department of Neurological Surgery, University of Wisconsin Medical School, Madison, WI, USA
| | - Shrikant Mane
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
- Yale Center for Genome Analysis, Yale University, New Haven, CT, USA
| | - Shozeb Haider
- Department of Pharmaceutical and Biological Chemistry, University College London School of Pharmacy, London, UK
| | - Bulent Guclu
- Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Yasar Bayri
- Department of Neurosurgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Yener Sahin
- Department of Neurosurgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Charles C Duncan
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Michael L J Apuzzo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Michael L DiLuna
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Ellen J Hoffman
- Yale Child Study Center, Yale University School of Medicine, New Haven, CT, USA
| | - Nenad Sestan
- Department of Neuroscience and Kavli Institute for Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Laura R Ment
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Seth L Alper
- Division of Nephrology and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Kaya Bilguvar
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
- Yale Center for Genome Analysis, Yale University, New Haven, CT, USA
| | - Daniel H Geschwind
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Murat Günel
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Richard P Lifton
- Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
| | - Kristopher T Kahle
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA.
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA.
- Department of Cellular & Molecular Physiology, Yale University School of Medicine, New Haven, CT, USA.
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Bernstock JD, Tafel I, Segar DJ, Dowd R, Kappel A, Chen JA, Aglan O, Montaser A, Gupta S, Johnston B, Judge J, Fehnel K, Stone S, Warf BC. Complex Management of Hydrocephalus Secondary To Choroid Plexus Hyperplasia. World Neurosurg 2020; 141:101-109. [PMID: 32497849 DOI: 10.1016/j.wneu.2020.05.211] [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: 05/01/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hyperplasia of the choroid plexus represents a rare cause of communicating hydrocephalus in children. Recent work has associated such disease with genetic abnormalities (such as perturbations in chromosome 9). Given such extensive cerebrospinal fluid (CSF) overproduction, patients with choroid plexus hyperplasia often fail CSF diversion and therefore require adjuvant interventions. CASE DESCRIPTION We present the case of a male infant with a ventriculoperitoneal shunt and radiographic choroid hyperplasia who presented to our institution with a massive abdominal hydrocele caused by an inability to absorb the significant amount of CSF drainage into the abdomen. CONCLUSION The child was treated with an endoscopic third ventriculostomy and choroid plexus coagulation; however, he still required CSF diversion via a ventriculoatrial shunt. A genetic workup showed tetraploidy of chromosome 9. We discuss criteria for selection of treatment strategies, including endoscopic third ventriculostomy with choroid plexus coagulation and/or CSF diversion, that may prevent the need for re-operation in select patients with hydrocephalus due to choroid plexus hyperplasia.
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Affiliation(s)
- Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ian Tafel
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David J Segar
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard Dowd
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ari Kappel
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason A Chen
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Osama Aglan
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alaa Montaser
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Saksham Gupta
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin Johnston
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer Judge
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Katie Fehnel
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Scellig Stone
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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30
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Hameed MQ, Zurakowski D, Proctor MR, Stone SSD, Warf BC, Smith ER, Goumnerova LC, Swoboda M, Anor T, Madsen JR. Noninvasive Thermal Evaluation of Ventriculoperitoneal Shunt Patency and Cerebrospinal Fluid Flow Using a Flow Enhancing Device. Neurosurgery 2020; 85:240-249. [PMID: 29917093 DOI: 10.1093/neuros/nyy246] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 07/10/2017] [Accepted: 05/29/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND While a noninvasive flow determination would be desirable in the diagnosis of cerebrospinal fluid shunt malfunction, existing studies have not yet defined a role for thermal flow detection. OBJECTIVE To evaluate a revised test protocol using a micropumper designed to transiently enhance flow during thermal testing to determine whether thermal detection of flow is associated with progression to shunt revision surgery. METHODS Eighty-two unique tests were performed in 71 shunts. The primary outcome, need for revision within 7 d of testing, was compared with results of micropumper-augmented thermal flow detection. Statistical analysis was based on blind interpretation of test results and raw temperature data recorded during testing. RESULTS The test was sensitive (73%) and specific (68%) in predicting need for revision, with 5.6-fold higher probability of revision when flow was not detected. Negative predictive value in our sample was 94.2%. The probability of not requiring revision increased with increasing total temperature drop. Analysis of various possible thresholds showed that the optimal temperature cutoff may be lower than suggested by the manufacturer (0.125°C vs 0.2°C). CONCLUSION This is the first study to report a strong association between thermal flow evaluation and a clinical impression that a shunt is not malfunctioning. The current recommended threshold may increase the false positive rate unnecessarily, and as clinicians gain experience with the method, they may find value in examining the temperature curves themselves. Multicenter studies are suggested to further define a role for this diagnostic test.
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Affiliation(s)
- Mustafa Q Hameed
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Zurakowski
- Department of Anesthesiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark R Proctor
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scellig S D Stone
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Liliana C Goumnerova
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marek Swoboda
- Drexel University, School of Biomedical Engineering, Science and Health Systems, Philadelphia, Pennsylvania
| | - Tomer Anor
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph R Madsen
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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31
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Karimy JK, Reeves BC, Damisah E, Duy PQ, Antwi P, David W, Wang K, Schiff SJ, Limbrick DD, Alper SL, Warf BC, Nedergaard M, Simard JM, Kahle KT. Inflammation in acquired hydrocephalus: pathogenic mechanisms and therapeutic targets. Nat Rev Neurol 2020; 16:285-296. [PMID: 32152460 DOI: 10.1038/s41582-020-0321-y] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2020] [Indexed: 12/11/2022]
Abstract
Hydrocephalus is the most common neurosurgical disorder worldwide and is characterized by enlargement of the cerebrospinal fluid (CSF)-filled brain ventricles resulting from failed CSF homeostasis. Since the 1840s, physicians have observed inflammation in the brain and the CSF spaces in both posthaemorrhagic hydrocephalus (PHH) and postinfectious hydrocephalus (PIH). Reparative inflammation is an important protective response that eliminates foreign organisms, damaged cells and physical irritants; however, inappropriately triggered or sustained inflammation can respectively initiate or propagate disease. Recent data have begun to uncover the molecular mechanisms by which inflammation - driven by Toll-like receptor 4-regulated cytokines, immune cells and signalling pathways - contributes to the pathogenesis of hydrocephalus. We propose that therapeutic approaches that target inflammatory mediators in both PHH and PIH could address the multiple drivers of disease, including choroid plexus CSF hypersecretion, ependymal denudation, and damage and scarring of intraventricular and parenchymal (glia-lymphatic) CSF pathways. Here, we review the evidence for a prominent role of inflammation in the pathogenic mechanism of PHH and PIH and highlight promising targets for therapeutic intervention. Focusing research efforts on inflammation could shift our view of hydrocephalus from that of a lifelong neurosurgical disorder to that of a preventable neuroinflammatory condition.
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Affiliation(s)
- Jason K Karimy
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Eyiyemisi Damisah
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Phan Q Duy
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Prince Antwi
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Wyatt David
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Kevin Wang
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Steven J Schiff
- Departments of Neurosurgery, Engineering Science & Mechanics, and Physics; Center for Neural Engineering, The Pennsylvania State University, University Park, PA, USA
| | - David D Limbrick
- Departments of Neurosurgery and Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Seth L Alper
- Division of Nephrology and Vascular Biology Research Center, Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Maiken Nedergaard
- Center for Translational Neuromedicine, University of Rochester Medical Center, Rochester, NY, USA.,Center for Translational Neuromedicine, Faculty of Medical and Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kristopher T Kahle
- Departments of Neurosurgery, Pediatrics, and Cellular & Molecular Physiology and Yale-Rockefeller NIH Centers for Mendelian Genomics, Yale School of Medicine, New Haven, CT, USA.
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Lepard JR, Dewan MC, Chen SH, Bankole OB, Mugamba J, Ssenyonga P, Kulkarni AV, Warf BC. The CURE Protocol: evaluation and external validation of a new public health strategy for treating paediatric hydrocephalus in low-resource settings. BMJ Glob Health 2020; 5:e002100. [PMID: 32133193 PMCID: PMC7042585 DOI: 10.1136/bmjgh-2019-002100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/07/2019] [Accepted: 12/23/2019] [Indexed: 11/05/2022] Open
Abstract
Introduction Managing paediatric hydrocephalus with shunt placement is especially risky in resource-limited settings due to risks of infection and delayed life-threatening shunt obstruction. This study evaluated a new evidence-based treatment algorithm to reduce shunt-dependence in this context. Methods A prospective cohort design was used. The CURE Protocol employs preoperative and intraoperative data to choose between endoscopic treatment and shunt placement. Data were prospectively collected for 730 children in Uganda (managed by local neurosurgeons highly experienced in the protocol) and, for external validation, 96 children in Nigeria (managed by a local neurosurgeon trained in the protocol). Results The age distribution was similar between Uganda and Nigeria, but there were more cases of postinfectious hydrocephalus in Uganda (64.2% vs 26.0%, p<0.001). Initial treatment of hydrocephalus was similar at both centres and included either a shunt at first operation or endoscopic management without a shunt. The Nigerian cohort had a higher failure rate for endoscopic cases (adjusted HR 2.5 (95% CI 1.6 to 4.0), p<0.001), but not for shunt cases (adjusted HR 1.3 (0.5 to 3.0), p=0.6). Despite the difference in endoscopic failure rates, a similar proportion of the entire cohort was successfully treated without need for shunt at 6 months (55.2% in Nigeria vs 53.4% in Uganda, p=0.74). Conclusion Use of the CURE Protocol in two centres with different populations and surgeon experience yielded similar 6-month results, with over half of all children remaining shunt-free. Where feasible, this could represent a better public health strategy in low-resource settings than primary shunt placement.
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Affiliation(s)
- Jacob R Lepard
- Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Program for Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Michael C Dewan
- Program for Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA.,Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephanie H Chen
- Neurological Surgery, University of Miami Health System, Miami, Florida, USA
| | | | - John Mugamba
- Neurosurgery, CURE Children's Hospital of Uganda, Mbale, Uganda
| | - Peter Ssenyonga
- Neurosurgery, CURE Children's Hospital of Uganda, Mbale, Uganda
| | | | - Benjamin C Warf
- Program for Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA.,Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Pricola Fehnel K, Klein J, Warf BC, Smith ER, Orbach DB. Reversible intracranial hypertension following treatment of an extracranial vascular malformation: case report. J Neurosurg Pediatr 2019; 23:369-373. [PMID: 30611152 DOI: 10.3171/2018.10.peds18235] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 10/11/2018] [Indexed: 11/06/2022]
Abstract
Pediatric hydrocephalus is a well-studied and still incompletely understood entity. One of the physiological means by which hydrocephalus and intracranial hypertension evolve is through perturbations to normal vascular dynamics. Here the authors report a unique case of an extracranial vascular anomaly resulting in persistently elevated intracranial pressures (ICPs) independent of CSF diversion in a patient with a Joubert syndrome-related disorder. The patient developed worsening intracranial hypertension after successful CSF diversion of Dandy-Walker malformation-associated hydrocephalus via endoscopic third ventriculostomy-choroid plexus cauterization (ETV/CPC). Vascular workup and imaging revealed an extracranial arteriovenous fistula of the superficial temporal artery at the site of a prior scalp intravenous catheter. Following microsurgical obliteration of the lesion, ICP normalized from > 30 cm H2O preoperatively to 11 cm H2O postoperatively. A repeat lumbar puncture at 4 months postoperatively again demonstrated normal pressure, and the patient remained asymptomatic for 9 months. Recurrent symptoms at 9 months were attributed to inadequate CSF diversion, and the patient underwent ventriculoperitoneal shunt placement. This is the first report of an extracranial-to-extracranial vascular anastomosis resulting in intracranial hypertension. This case report demonstrates the need to consider extracranial vascular anomalies as potential sources of persistently elevated ICP in the syndromic pediatric population.
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Affiliation(s)
| | | | | | - Edward R Smith
- 1Vascular Biology Program.,2Department of Neurosurgery, and
| | - Darren B Orbach
- 3Neurointerventional Radiology, Boston Children's Hospital, Boston, Massachusetts
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Mbabazi-Kabachelor E, Shah M, Vaughan KA, Mugamba J, Ssenyonga P, Onen J, Nalule E, Kapur K, Warf BC. Infection risk for Bactiseal Universal Shunts versus Chhabra shunts in Ugandan infants: a randomized controlled trial. J Neurosurg Pediatr 2019; 23:397-406. [PMID: 30611153 DOI: 10.3171/2018.10.peds18354] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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] [Received: 06/07/2018] [Accepted: 10/04/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Clinical and economic repercussions of ventricular shunt infections are magnified in low-resource countries. The efficacy of antibiotic-impregnated shunts in this setting is unclear. A previous retrospective cohort study comparing the Bactiseal Universal Shunt (BUS) and the Chhabra shunt provided clinical equipoise; thus, the authors conducted this larger randomized controlled trial in Ugandan children requiring shunt placement for hydrocephalus to determine whether there was, in fact, any advantage of one shunt over the other. METHODS Between April 2013 and September 2016, the authors randomly assigned children younger than 16 years of age without evidence of ventriculitis to either BUS or Chhabra shunt implantation in this single-blind randomized controlled trial. The primary outcome was shunt infection, and secondary outcomes included reoperation and death. The minimum follow-up was 6 months. Time to outcome was assessed using the Kaplan-Meier method. The significance of differences was tested using Wilcoxon rank-sum, chi-square, Fisher’s exact, and t-tests. RESULTS Of the 248 patients randomized, the BUS was implanted in 124 and the Chhabra shunt in 124. There were no differences between the groups in terms of age, sex, or hydrocephalus etiology. Within 6 months of follow-up, there were 14 infections (5.6%): 6 BUS (4.8%) and 8 Chhabra (6.5%; p = 0.58). There were 14 deaths (5.6%; 5 BUS [4.0%] vs 9 Chhabra [7.3%], p = 0.27) and 30 reoperations (12.1%; 15 BUS vs 15 Chhabra, p = 1.00). There were no significant differences in the time to primary or secondary outcomes at 6 months’ follow-up (p = 0.29 and 0.17, respectively, Wilcoxon rank-sum test). CONCLUSIONS Among Ugandan infants, BUS implantation did not result in a lower incidence of shunt infection or other complications. Any recommendation for a more costly standard of care in low-resource countries must have contextually relevant, evidence-based support. Clinical trial registration no.: PACTR201804003240177 (http://www.pactr.org/)
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Affiliation(s)
| | - Meghal Shah
- 2Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.,4Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Kerry A Vaughan
- 2Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.,3Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | - Kush Kapur
- 6Department of Neurology, Harvard Medical School, Harvard University; and.,7Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts
| | - Benjamin C Warf
- 1CURE Children's Hospital, Mbale, Uganda.,2Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.,5Department of Neurosurgery, Boston Children's Hospital
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Sims-Williams HJ, Sims-Williams HP, Mbabazi Kabachelor E, Magombe J, Warf BC. Children with spina bifida in Eastern Uganda report a reasonable quality of life relative to their healthy school-attending peers. Arch Dis Child 2019; 104:101-102. [PMID: 29748330 DOI: 10.1136/archdischild-2018-315044] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Helen J Sims-Williams
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Hugh P Sims-Williams
- Department of Neurosurgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Benjamin C Warf
- Department of Neurosurgery, Children's Hospital Boston, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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36
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Dewan MC, Baticulon RE, Rattani A, Johnston JM, Warf BC, Harkness W. Pediatric neurosurgical workforce, access to care, equipment and training needs worldwide. Neurosurg Focus 2018; 45:E13. [DOI: 10.3171/2018.7.focus18272] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe presence and capability of existing pediatric neurosurgical care worldwide is unknown. The objective of this study was to solicit the expertise of specialists to quantify the geographic representation of pediatric neurosurgeons, access to specialist care, and equipment and training needs globally.METHODSA mixed-question survey was sent to surgeon members of several international neurosurgical and general pediatric surgical societies via a web-based platform. Respondents answered questions on 5 categories: surgeon demographics and training, hospital and practice details, surgical workforce and access to neurosurgical care, training and equipment needs, and desire for international collaboration. Responses were anonymized and analyzed using Stata software.RESULTSA total of 459 surgeons from 76 countries responded. Pediatric neurosurgeons in high-income and upper-middle-income countries underwent formal pediatric training at a greater rate than surgeons in low- and lower-middle-income countries (89.5% vs 54.4%). There are an estimated 2297 pediatric neurosurgeons in practice globally, with 85.6% operating in high-income and upper-middle-income countries. In low- and lower-middle-income countries, roughly 330 pediatric neurosurgeons care for a total child population of 1.2 billion. In low-income countries in Africa, the density of pediatric neurosurgeons is roughly 1 per 30 million children. A higher proportion of patients in low- and lower-middle-income countries must travel > 2 hours to seek emergency neurosurgical care, relative to high-income countries (75.6% vs 33.6%, p < 0.001). Vast basic and essential training and equipment needs exist, particularly low- and lower-middle-income countries within Africa, South America, the Eastern Mediterranean, and South-East Asia. Eighty-nine percent of respondents demonstrated an interest in international collaboration for the purposes of pediatric neurosurgical capacity building.CONCLUSIONSWide disparity in the access to pediatric neurosurgical care exists globally. In low- and lower-middle-income countries, wherein there exists the greatest burden of pediatric neurosurgical disease, there is a grossly insufficient presence of capable providers and equipped facilities. Neurosurgeons across income groups and geographic regions share a desire for collaboration and partnership.
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Affiliation(s)
- Michael C. Dewan
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ronnie E. Baticulon
- 2Department of Neurosurgery, University of the Philippines College of Medicine, Mabani, Ermita, Manila, Philippines
| | - Abbas Rattani
- 3Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - James M. Johnston
- 4Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Benjamin C. Warf
- 5Department of Neurological Surgery, Boston Children’s Hospital, Boston, Massachusetts; and
| | - William Harkness
- 6Department of Neurosciences, Institute for Child Health, London, United Kingdom
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Dewan MC, Onen J, Bow H, Ssenyonga P, Howard C, Warf BC. Subspecialty pediatric neurosurgery training: a skill-based training model for neurosurgeons in low-resourced health systems. Neurosurg Focus 2018; 45:E2. [DOI: 10.3171/2018.7.focus18249] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
There is inadequate pediatric neurosurgical training to meet the growing burden of disease in low- and middle-income countries (LMIC). Subspecialty expertise in the management of hydrocephalus and spina bifida—two of the most common pediatric neurosurgical conditions—offers a high-yield opportunity to mitigate morbidity and avoid unnecessary death. The CURE Hydrocephalus and Spina Bifida (CHSB) fellowship offers an intensive subspecialty training program designed to equip surgeons from LMIC with the state-of-the-art surgical skills and equipment to most effectively manage common neurosurgical conditions of childhood. Prospective fellows and their home institution undergo a comprehensive evaluation before being accepted for the 8-week training period held at CURE Children’s Hospital of Uganda (CCHU) in Mbale, Uganda. The fellowship combines anatomy review, treatment paradigms, a flexible endoscopic simulation lab, daily ward and ICU rounds, radiology rounds, and clinic exposure. The cornerstone of the fellowship is the unique operative experience that includes a high volume of endoscopic third ventriculostomy with choroid plexus cauterization, myelomeningocele closure, and ventriculoperitoneal shunting, among many other procedures performed at CCHU. Upon completion, fellows return to their home institution to establish or rejuvenate a robust pediatric practice as part of a worldwide network of CHSB trainees committed to the care of underserved children. To date, the fellowship has graduated 33 surgeons from 20 different LMIC who are independently performing thousands of hydrocephalus and spina bifida operations each year.
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Affiliation(s)
- Michael C. Dewan
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- 2Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Justin Onen
- 3CURE Children’s Hospital of Uganda, Mbale, Uganda; and
| | - Hansen Bow
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Benjamin C. Warf
- 2Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- 4Department of Neurological Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Furey CG, Jin SC, Timberlake AT, Choi J, Zeng X, Nelson-Williams C, Mansuri M, Lu Q, Duran D, Panchagnula S, Alloco A, Karimy JK, Gaillard J, Khanna A, Butler W, Smith ER, Warf BC, Limbrick DD, Storm PB, Heuer GG, Iskandar B, Johnston JM, Alper S, Guclu B, Bayri Y, Sahin Y, Duncan CC, DiLuna ML, Gunel M, Lifton RP, Kahle KT. 125 De Novo Mutations in Genes Regulating Neural Stem Cell Fate in Human Congenital Hydrocephalus. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy303.125] [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: 11/12/2022] Open
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Furey CG, Choi J, Jin SC, Zeng X, Timberlake AT, Nelson-Williams C, Mansuri MS, Lu Q, Duran D, Panchagnula S, Allocco A, Karimy JK, Khanna A, Gaillard JR, DeSpenza T, Antwi P, Loring E, Butler WE, Smith ER, Warf BC, Strahle JM, Limbrick DD, Storm PB, Heuer G, Jackson EM, Iskandar BJ, Johnston JM, Tikhonova I, Castaldi C, López-Giráldez F, Bjornson RD, Knight JR, Bilguvar K, Mane S, Alper SL, Haider S, Guclu B, Bayri Y, Sahin Y, Apuzzo MLJ, Duncan CC, DiLuna ML, Günel M, Lifton RP, Kahle KT. De Novo Mutation in Genes Regulating Neural Stem Cell Fate in Human Congenital Hydrocephalus. Neuron 2018; 99:302-314.e4. [PMID: 29983323 DOI: 10.1016/j.neuron.2018.06.019] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [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: 02/13/2018] [Revised: 04/03/2018] [Accepted: 06/12/2018] [Indexed: 12/30/2022]
Abstract
Congenital hydrocephalus (CH), featuring markedly enlarged brain ventricles, is thought to arise from failed cerebrospinal fluid (CSF) homeostasis and is treated with lifelong surgical CSF shunting with substantial morbidity. CH pathogenesis is poorly understood. Exome sequencing of 125 CH trios and 52 additional probands identified three genes with significant burden of rare damaging de novo or transmitted mutations: TRIM71 (p = 2.15 × 10-7), SMARCC1 (p = 8.15 × 10-10), and PTCH1 (p = 1.06 × 10-6). Additionally, two de novo duplications were identified at the SHH locus, encoding the PTCH1 ligand (p = 1.2 × 10-4). Together, these probands account for ∼10% of studied cases. Strikingly, all four genes are required for neural tube development and regulate ventricular zone neural stem cell fate. These results implicate impaired neurogenesis (rather than active CSF accumulation) in the pathogenesis of a subset of CH patients, with potential diagnostic, prognostic, and therapeutic ramifications.
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Affiliation(s)
- Charuta Gavankar Furey
- Department of Genetics, Yale University School of Medicine, New Haven, CT 06510, USA; Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Jungmin Choi
- Department of Genetics, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Sheng Chih Jin
- Department of Genetics, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Xue Zeng
- Department of Genetics, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Andrew T Timberlake
- Department of Genetics, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Carol Nelson-Williams
- Department of Genetics, Yale University School of Medicine, New Haven, CT 06510, USA
| | - M Shahid Mansuri
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Qiongshi Lu
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison, WI 53706, USA
| | - Daniel Duran
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Shreyas Panchagnula
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - August Allocco
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Jason K Karimy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Arjun Khanna
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Jonathan R Gaillard
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Tyrone DeSpenza
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Prince Antwi
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Erin Loring
- Department of Genetics, Yale University School of Medicine, New Haven, CT 06510, USA
| | - William E Butler
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jennifer M Strahle
- Department of Neurological Surgery and Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - David D Limbrick
- Department of Neurological Surgery and Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Phillip B Storm
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA; Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Gregory Heuer
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA; Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Bermans J Iskandar
- Department of Neurological Surgery, University of Wisconsin Medical School, Madison, WI 53726, USA
| | - James M Johnston
- Department of Neurosurgery, University of Alabama School of Medicine, Birmingham, AL 35233, USA
| | - Irina Tikhonova
- Yale Center for Genome Analysis, Yale University, New Haven, CT 06510, USA
| | | | | | - Robert D Bjornson
- Yale Center for Genome Analysis, Yale University, New Haven, CT 06510, USA
| | - James R Knight
- Department of Genetics, Yale University School of Medicine, New Haven, CT 06510, USA; Yale Center for Genome Analysis, Yale University, New Haven, CT 06510, USA
| | - Kaya Bilguvar
- Yale Center for Genome Analysis, Yale University, New Haven, CT 06510, USA
| | - Shrikant Mane
- Yale Center for Genome Analysis, Yale University, New Haven, CT 06510, USA
| | - Seth L Alper
- Division of Nephrology and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA 02215, USA
| | - Shozeb Haider
- Department of Pharmaceutical and Biological Chemistry, University College London School of Pharmacy, London WC1N 1AX, UK
| | - Bulent Guclu
- Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul 34860, Turkey
| | - Yasar Bayri
- Acibadem Mehmet Ali Aydinlar University, School of Medicine, Department of Neurosurgery, Division of Pediatric Neurosurgery, Istanbul 34752, Turkey
| | - Yener Sahin
- Acibadem Mehmet Ali Aydinlar University, School of Medicine, Department of Neurosurgery, Division of Pediatric Neurosurgery, Istanbul 34752, Turkey
| | - Michael L J Apuzzo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Charles C Duncan
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Michael L DiLuna
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Murat Günel
- Department of Genetics, Yale University School of Medicine, New Haven, CT 06510, USA; Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Richard P Lifton
- Department of Genetics, Yale University School of Medicine, New Haven, CT 06510, USA; Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY 10065, USA
| | - Kristopher T Kahle
- Department of Genetics, Yale University School of Medicine, New Haven, CT 06510, USA; Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA; Department of Cellular & Molecular Physiology, Yale University School of Medicine, New Haven, CT 06510, USA.
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Abstract
OBJECTIVE While there is a long history of interest in measuring brain growth, as of yet there is no definitive model for normative human brain volume growth. The goal of this study was to analyze a variety of candidate models for such growth and select the model that provides the most statistically applicable fit. The authors sought to optimize clinically applicable growth charts that would facilitate improved treatment and predictive management for conditions such as hydrocephalus. METHODS The Weibull, two-term power law, West ontogenic, and Gompertz models were chosen as potential models. Normative brain volume data were compiled from the NIH MRI repository, and the data were fit using a nonlinear least squares regression algorithm. Appropriate statistical measures were analyzed for each model, and the best model was characterized with prediction bound curves to provide percentile estimates for clinical use. RESULTS Each model curve fit and the corresponding statistics were presented and analyzed. The Weibull fit had the best statistical results for both males and females, while the two-term power law generated the worst scores. The statistical measures and goodness of fit parameters for each model were provided to assure reproducibility. CONCLUSIONS The authors identified the Weibull model as the most effective growth curve fit for both males and females. Clinically usable growth charts were developed and provided to facilitate further clinical study of brain volume growth in conditions such as hydrocephalus. The authors note that the homogenous population from which the normative MRI data were compiled limits the study. Gaining a better understanding of the dynamics that underlie childhood brain growth would yield more predictive growth curves and improved neurosurgical management of hydrocephalus.
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Affiliation(s)
- Mallory Peterson
- The Center for Neural Engineering, The Pennsylvania State University, University Park, Pennsylvania,Departments of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania
| | - Benjamin C. Warf
- Department of Neurosurgery, Boston Children’s Hospital and Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Steven J. Schiff
- The Center for Neural Engineering, The Pennsylvania State University, University Park, Pennsylvania,Departments of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania,Engineering Science and Mechanics, Neurosurgery, and Physics, The Pennsylvania State University, University Park, Pennsylvania
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Dewan MC, Rattani A, Baticulon RE, Faruque S, Johnson WD, Dempsey RJ, Haglund MM, Alkire BC, Park KB, Warf BC, Shrime MG. Operative and consultative proportions of neurosurgical disease worldwide: estimation from the surgeon perspective. J Neurosurg 2018:1-9. [PMID: 29749918 DOI: 10.3171/2017.10.jns17347] [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: 02/08/2018] [Accepted: 10/18/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe global magnitude of neurosurgical disease is unknown. The authors sought to estimate the surgical and consultative proportion of diseases commonly encountered by neurosurgeons, as well as surgeon case volume and perceived workload.METHODSAn electronic survey was sent to 193 neurosurgeons previously identified via a global surgeon mapping initiative. The survey consisted of three sections aimed at quantifying surgical incidence of neurological disease, consultation incidence, and surgeon demographic data. Surgeons were asked to estimate the proportion of 11 neurological disorders that, in an ideal world, would indicate either neurosurgical operation or neurosurgical consultation. Respondent surgeons indicated their confidence level in each estimate. Demographic and surgical practice characteristics-including case volume and perceived workload-were also captured.RESULTSEighty-five neurosurgeons from 57 countries, representing all WHO regions and World Bank income levels, completed the survey. Neurological conditions estimated to warrant neurosurgical consultation with the highest frequency were brain tumors (96%), spinal tumors (95%), hydrocephalus (94%), and neural tube defects (92%), whereas stroke (54%), central nervous system infection (58%), and epilepsy (40%) carried the lowest frequency. Similarly, surgery was deemed necessary for an average of 88% cases of hydrocephalus, 82% of spinal tumors and neural tube defects, and 78% of brain tumors. Degenerative spine disease (42%), stroke (31%), and epilepsy (24%) were found to warrant surgical intervention less frequently. Confidence levels were consistently high among respondents (lower quartile > 70/100 for 90% of questions), and estimates did not vary significantly across WHO regions or among income levels. Surgeons reported performing a mean of 245 cases annually (median 190). On a 100-point scale indicating a surgeon's perceived workload (0-not busy, 100-overworked), respondents selected a mean workload of 75 (median 79).CONCLUSIONSWith a high level of confidence and strong concordance, neurosurgeons estimated that the vast majority of patients with central nervous system tumors, hydrocephalus, or neural tube defects mandate neurosurgical involvement. A significant proportion of other common neurological diseases, such as traumatic brain and spinal injury, vascular anomalies, and degenerative spine disease, demand the attention of a neurosurgeon-whether via operative intervention or expert counsel. These estimates facilitate measurement of the expected annual volume of neurosurgical disease globally.
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Affiliation(s)
- Michael C Dewan
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine.,2Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
| | - Abbas Rattani
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine.,3Meharry Medical College, School of Medicine, Nashville, Tennessee
| | - Ronnie E Baticulon
- 4University of the Philippines College of Medicine-Philippine General Hospital, Manila, Republic of the Philippines
| | - Serena Faruque
- 5Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Walter D Johnson
- 6Emergency & Essential Surgical Care Programme Lead, World Health Organization, Geneva, Switzerland
| | - Robert J Dempsey
- 7Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; and
| | - Michael M Haglund
- 8Division of Global Neurosurgery and Neurology, Department of Neurosurgery and Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Blake C Alkire
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine.,9Office of Global Surgery and Health
| | - Kee B Park
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine
| | - Benjamin C Warf
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine.,10Department of Neurological Surgery, Boston Children's Hospital, Harvard Medical School
| | - Mark G Shrime
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine.,11Department of Otolaryngology, Massachusetts Eye and Ear Infirmary
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Dewan MC, Rattani A, Fieggen G, Arraez MA, Servadei F, Boop FA, Johnson WD, Warf BC, Park KB. Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change. J Neurosurg 2018:1-10. [PMID: 29701548 DOI: 10.3171/2017.11.jns171500] [Citation(s) in RCA: 190] [Impact Index Per Article: 31.7] [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: 06/21/2017] [Accepted: 11/10/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Worldwide disparities in the provision of surgical care result in otherwise preventable disability and death. There is a growing need to quantify the global burden of neurosurgical disease specifically, and the workforce necessary to meet this demand. METHODS Results from a multinational collaborative effort to describe the global neurosurgical burden were aggregated and summarized. First, country registries, third-party modeled data, and meta-analyzed published data were combined to generate incidence and volume figures for 10 common neurosurgical conditions. Next, a global mapping survey was performed to identify the number and location of neurosurgeons in each country. Finally, a practitioner survey was conducted to quantify the proportion of disease requiring surgery, as well as the median number of neurosurgical cases per annum. The neurosurgical case deficit was calculated as the difference between the volume of essential neurosurgical cases and the existing neurosurgical workforce capacity. RESULTS Every year, an estimated 22.6 million patients suffer from neurological disorders or injuries that warrant the expertise of a neurosurgeon, of whom 13.8 million require surgery. Traumatic brain injury, stroke-related conditions, tumors, hydrocephalus, and epilepsy constitute the majority of essential neurosurgical care worldwide. Approximately 23,300 additional neurosurgeons are needed to address more than 5 million essential neurosurgical cases-all in low- and middle-income countries-that go unmet each year. There exists a gross disparity in the allocation of the surgical workforce, leaving large geographic treatment gaps, particularly in Africa and Southeast Asia. CONCLUSIONS Each year, more than 5 million individuals suffering from treatable neurosurgical conditions will never undergo therapeutic surgical intervention. Populations in Africa and Southeast Asia, where the proportion of neurosurgeons to neurosurgical disease is critically low, are especially at risk. Increasing access to essential neurosurgical care in low- and middle-income countries via neurosurgical workforce expansion as part of surgical system strengthening is necessary to prevent severe disability and death for millions with neurological disease.
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Affiliation(s)
- Michael C Dewan
- 1Global Neurosurgery Initiative-Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.,2Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Abbas Rattani
- 1Global Neurosurgery Initiative-Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.,3Meharry Medical College School of Medicine, Nashville, Tennessee
| | - Graham Fieggen
- 4Department of Surgery, University of Cape Town, South Africa
| | - Miguel A Arraez
- 5Department of Neurosurgery, Carlos Haya University Hospital, Malaga, Spain
| | - Franco Servadei
- 6Department of Neurosurgery, Humanitas University and Research Institute, Milan, Italy
| | - Frederick A Boop
- 7Department of Neurological Surgery, University of Tennessee Health Sciences Center, LeBonheur Children's Hospital Neurosciences Institute, Semmes-Murphey Clinic, Memphis, Tennessee
| | - Walter D Johnson
- 8Emergency & Essential Surgical Care Programme Lead, World Health Organization, Geneva, Switzerland
| | - Benjamin C Warf
- 9Department of Neurological Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; and.,10CURE Children's Hospital of Uganda, Mbale, Uganda
| | - Kee B Park
- 1Global Neurosurgery Initiative-Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
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Dewan MC, Rattani A, Mekary R, Glancz LJ, Yunusa I, Baticulon RE, Fieggen G, Wellons JC, Park KB, Warf BC. Global hydrocephalus epidemiology and incidence: systematic review and meta-analysis. J Neurosurg 2018:1-15. [PMID: 29701543 DOI: 10.3171/2017.10.jns17439] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 10/18/2017] [Indexed: 01/08/2023]
Abstract
OBJECTIVEHydrocephalus is one of the most common brain disorders, yet a reliable assessment of the global burden of disease is lacking. The authors sought a reliable estimate of the prevalence and annual incidence of hydrocephalus worldwide.METHODSThe authors performed a systematic literature review and meta-analysis to estimate the incidence of congenital hydrocephalus by WHO region and World Bank income level using the MEDLINE/PubMed and Cochrane Database of Systematic Reviews databases. A global estimate of pediatric hydrocephalus was obtained by adding acquired forms of childhood hydrocephalus to the baseline congenital figures using neural tube defect (NTD) registry data and known proportions of posthemorrhagic and postinfectious cases. Adult forms of hydrocephalus were also examined qualitatively.RESULTSSeventy-eight articles were included from the systematic review, representative of all WHO regions and each income level. The pooled incidence of congenital hydrocephalus was highest in Africa and Latin America (145 and 316 per 100,000 births, respectively) and lowest in the United States/Canada (68 per 100,000 births) (p for interaction < 0.1). The incidence was higher in low- and middle-income countries (123 per 100,000 births; 95% CI 98-152 births) than in high-income countries (79 per 100,000 births; 95% CI 68-90 births) (p for interaction < 0.01). While likely representing an underestimate, this model predicts that each year, nearly 400,000 new cases of pediatric hydrocephalus will develop worldwide. The greatest burden of disease falls on the African, Latin American, and Southeast Asian regions, accounting for three-quarters of the total volume of new cases. The high crude birth rate, greater proportion of patients with postinfectious etiology, and higher incidence of NTDs all contribute to a case volume in low- and middle-income countries that outweighs that in high-income countries by more than 20-fold. Global estimates of adult and other forms of acquired hydrocephalus are lacking.CONCLUSIONSFor the first time in a global model, the annual incidence of pediatric hydrocephalus is estimated. Low- and middle-income countries incur the greatest burden of disease, particularly those within the African and Latin American regions. Reliable incidence and burden figures for adult forms of hydrocephalus are absent in the literature and warrant specific investigation. A global effort to address hydrocephalus in regions with the greatest demand is imperative to reduce disease incidence, morbidity, mortality, and disparities of access to treatment.
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Affiliation(s)
- Michael C Dewan
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.,2Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Abbas Rattani
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.,3Meharry Medical College, School of Medicine, Nashville, Tennessee
| | - Rania Mekary
- 4Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS University, Boston, Massachusetts.,5Department of Neurosurgery, Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurence J Glancz
- 6Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Ismaeel Yunusa
- 4Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS University, Boston, Massachusetts.,5Department of Neurosurgery, Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ronnie E Baticulon
- 7University of the Philippines College of Medicine-Philippine General Hospital, Manila, Philippines
| | - Graham Fieggen
- 8Departments of Surgery and Neurosurgery, University of Cape Town, South Africa
| | - John C Wellons
- 2Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kee B Park
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Benjamin C Warf
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.,9Department of Neurological Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; and.,10CURE Children's Hospital of Uganda, Mbale, Uganda
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Ranjeva SL, Warf BC, Schiff SJ. Economic burden of neonatal sepsis in sub-Saharan Africa. BMJ Glob Health 2018; 3:e000347. [PMID: 29564153 PMCID: PMC5859806 DOI: 10.1136/bmjgh-2017-000347] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 10/03/2017] [Accepted: 10/25/2017] [Indexed: 11/05/2022] Open
Abstract
Background and significance The third Sustainable Development Goal for child health, which aims to end preventable deaths of newborns and children less than 5 years of age by 2030, cannot be met without substantial reduction of infection-specific neonatal mortality in the developing world. Neonatal infections are estimated to account for 26% of annual neonatal deaths, with mortality rates highest in sub-Saharan Africa (SSA). Reliable and comprehensive estimates of the incidence and aetiology surrounding neonatal sepsis in SSA remain incompletely available. We estimate the economic burden of neonatal sepsis in SSA. Methods Data available through global health agencies and in the medical literature were used to determine population demographics in SSA, as well as to determine the incidence, disease burden, mortality and resulting disabilities associated with neonatal sepsis. The disability-adjusted life years (DALY) associated with successful treatment or prevention of neonatal sepsis in SSA for 1 year were calculated. The value of a statistical life (VSL) methodology was estimated to evaluate the economic burden of untreated neonatal sepsis in SSA. Results We conservatively estimate that 5.29–8.73 million DALYs are lost annually in SSA due to neonatal sepsis. Corresponding VSL estimates predict an annual economic burden ranging from $10 billion to $469 billion. Conclusions Our results highlight and quantify the scope of the public health and economic burden posed by neonatal sepsis in SSA. We quantify the substantial potential impact of more successful treatment and prevention strategies, and we highlight the need for greater investment in strategies to characterise, diagnose, prevent and manage neonatal sepsis and its long-term sequelae in SSA.
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Affiliation(s)
- Sylvia L Ranjeva
- Medical Scientist Training Program, Pritzker School of Medicine, and Department of Ecology & Evolution, University of Chicago, Chicago, Illinois, USA.,Department of Engineering Science and Mechanics, Center for Neural Engineering, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven J Schiff
- Department of Engineering Science and Mechanics, Center for Neural Engineering, The Pennsylvania State University, University Park, Pennsylvania, USA.,Departments of Neurosurgery and Physics, The Pennsylvania State University, University Park, Pennsylvania, USA
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Kulkarni AV, Schiff SJ, Mbabazi-Kabachelor E, Mugamba J, Ssenyonga P, Donnelly R, Levenbach J, Monga V, Peterson M, MacDonald M, Cherukuri V, Warf BC. Endoscopic Treatment versus Shunting for Infant Hydrocephalus in Uganda. N Engl J Med 2017; 377:2456-2464. [PMID: 29262276 PMCID: PMC5784827 DOI: 10.1056/nejmoa1707568] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Postinfectious hydrocephalus in infants is a major health problem in sub-Saharan Africa. The conventional treatment is ventriculoperitoneal shunting, but surgeons are usually not immediately available to revise shunts when they fail. Endoscopic third ventriculostomy with choroid plexus cauterization (ETV-CPC) is an alternative treatment that is less subject to late failure but is also less likely than shunting to result in a reduction in ventricular size that might facilitate better brain growth and cognitive outcomes. METHODS We conducted a randomized trial to evaluate cognitive outcomes after ETV-CPC versus ventriculoperitoneal shunting in Ugandan infants with postinfectious hydrocephalus. The primary outcome was the Bayley Scales of Infant Development, Third Edition (BSID-3), cognitive scaled score 12 months after surgery (scores range from 1 to 19, with higher scores indicating better performance). The secondary outcomes were BSID-3 motor and language scores, treatment failure (defined as treatment-related death or the need for repeat surgery), and brain volume measured on computed tomography. RESULTS A total of 100 infants were enrolled; 51 were randomly assigned to undergo ETV-CPC, and 49 were assigned to undergo ventriculoperitoneal shunting. The median BSID-3 cognitive scores at 12 months did not differ significantly between the treatment groups (a score of 4 for ETV-CPC and 2 for ventriculoperitoneal shunting; Hodges-Lehmann estimated difference, 0; 95% confidence interval [CI], -2 to 0; P=0.35). There was no significant difference between the ETV-CPC group and the ventriculoperitoneal-shunt group in BSID-3 motor or language scores, rates of treatment failure (35% and 24%, respectively; hazard ratio, 0.7; 95% CI, 0.3 to 1.5; P=0.24), or brain volume (z score, -2.4 and -2.1, respectively; estimated difference, 0.3; 95% CI, -0.3 to 1.0; P=0.12). CONCLUSIONS This single-center study involving Ugandan infants with postinfectious hydrocephalus showed no significant difference between endoscopic ETV-CPC and ventriculoperitoneal shunting with regard to cognitive outcomes at 12 months. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01936272 .).
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Affiliation(s)
- Abhaya V Kulkarni
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Steven J Schiff
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Edith Mbabazi-Kabachelor
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - John Mugamba
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Peter Ssenyonga
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Ruth Donnelly
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Jody Levenbach
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Vishal Monga
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Mallory Peterson
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Michael MacDonald
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Venkateswararao Cherukuri
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Benjamin C Warf
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
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Cherukuri V, Ssenyonga P, Warf BC, Kulkarni AV, Monga V, Schiff SJ. Learning Based Segmentation of CT Brain Images: Application to Postoperative Hydrocephalic Scans. IEEE Trans Biomed Eng 2017; 65:1871-1884. [PMID: 29989926 DOI: 10.1109/tbme.2017.2783305] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Hydrocephalus is a medical condition in which there is an abnormal accumulation of cerebrospinal fluid (CSF) in the brain. Segmentation of brain imagery into brain tissue and CSF [before and after surgery, i.e., preoperative (pre-op) versus postoperative (post-op)] plays a crucial role in evaluating surgical treatment. Segmentation of pre-op images is often a relatively straightforward problem and has been well researched. However, segmenting post-op computational tomographic (CT) scans becomes more challenging due to distorted anatomy and subdural hematoma collections pressing on the brain. Most intensity- and feature-based segmentation methods fail to separate subdurals from brain and CSF as subdural geometry varies greatly across different patients and their intensity varies with time. We combat this problem by a learning approach that treats segmentation as supervised classification at the pixel level, i.e., a training set of CT scans with labeled pixel identities is employed. METHODS Our contributions include: 1) a dictionary learning framework that learns class (segment) specific dictionaries that can efficiently represent test samples from the same class while poorly represent corresponding samples from other classes; 2) quantification of associated computation and memory footprint; and 3) a customized training and test procedure for segmenting post-op hydrocephalic CT images. RESULTS Experiments performed on infant CT brain images acquired from the CURE Children's Hospital of Uganda reveal the success of our method against the state-of-the-art alternatives. We also demonstrate that the proposed algorithm is computationally less burdensome and exhibits a graceful degradation against a number of training samples, enhancing its deployment potential.
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Sims-Williams HJ, Sims-Williams HP, Mbabazi Kabachelor E, Warf BC. Quality of life among children with spina bifida in Uganda. Arch Dis Child 2017; 102:1057-1061. [PMID: 28490461 DOI: 10.1136/archdischild-2016-312307] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [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: 11/07/2016] [Revised: 04/17/2017] [Accepted: 04/18/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Children surviving after spina bifida repair often have significant disability, the consequences of which may be more profound in low-income countries. The aim of this cross-sectional study was to measure quality of life (QOL) reported by children with spina bifida in Uganda, and to define factors associated with QOL. METHODS QOL was measured using both the Health Utilities Index (HUI3) Tool and a visual analogue scale (VAS) marked from 0 to 10. In keeping with the WHO definition of QOL, further analysis was conducted using subjective QOL scores (using the VAS). Multivariate regression was used to investigate the association between VAS scores and prespecified variables: age, sex, hydrocephalus, mobility, urinary continence, school attendance and family size. RESULTS Sixty two of 68 surviving children aged 10-14 were able to complete all aspects of the assessment. There was poor correlation between the VAS and HUI3 Tool (Pearson correlation 0.488). On multivariate regression, the following variables were associated with a significant change in the 10-point VAS (change in score; 95% CI): male sex (-1.45; -2.436 to -0.465), urinary continence (1.681; 0.190 to 3.172), large family size (-1.775; -2.773 to -0.777) and hydrocephalus (-1.382; -2.374 to -0.465). CONCLUSIONS Urinary continence and family size are potentially modifiable, the former by simple and inexpensive medical management. Enhanced investment in community-based rehabilitation and support is urgently needed. Delivery of family planning services is a national priority in Uganda, and should be discussed with families as part of holistic care.
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Affiliation(s)
- Helen J Sims-Williams
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Hugh P Sims-Williams
- Department of Neurosurgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Benjamin C Warf
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Furey CG, Choi J, Duran D, Timberlake AT, Zeng X, Nelson-Williams C, Khanna A, Iskandar B, Butler W, Heuer GG, Bayri Y, Sahin Y, Limbrick DD, Warf BC, Duncan CC, DiLuna ML, Gunel M, Lifton RP, Kahle KT. 102 Exome Sequencing Identifies Novel Molecular Determinants of Human Congenital Hydrocephalus. Neurosurgery 2017. [DOI: 10.1093/neuros/nyx417.102] [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: 11/12/2022] Open
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Warf BC. Growing Brains: How Adapting to Africa Advanced the Treatment of Infant Hydrocephalus. Neurosurgery 2017; 64:37-39. [DOI: 10.1093/neuros/nyx246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/15/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Benjamin C. Warf
- Department Neurosurgery, Harvard Med-ical School, Boston Children's Hospital, Boston, Massachusetts
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Kancherla V, Walani SR, Weakland AP, Bauwens L, Oakley GP, Warf BC. Scorecard for spina bifida research, prevention, and policy - A development process. Prev Med 2017; 99:13-20. [PMID: 28189808 DOI: 10.1016/j.ypmed.2017.01.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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] [Received: 11/06/2016] [Revised: 01/19/2017] [Accepted: 01/31/2017] [Indexed: 01/09/2023]
Abstract
Spina bifida is a serious and largely preventable neural tube birth defect and an important cause of mortality and lifelong disability. The People and Organizations United for Spina Bifida and Hydrocephalus (PUSH!) Global Alliance was formed in 2014 to provide a common platform for various organizations worldwide to raise the visibility of spina bifida and hydrocephalus. In its formative phase, the alliance recognized that in order to accelerate surveillance, prevention, and care for these conditions, there was a need to provide an evidence-based assessment of how nations are performing in specific areas. In this paper, we describe the impetus for, and the process of, developing country-level scorecards for spina bifida surveillance, prevention and care. The PUSH! Executive Committee formulated a comprehensive list of six actionable indicators measuring availability of published studies on population-based folate studies; surveillance of prevalence and mortality; prevention-based policies; access to care; and quality of life associated with spina bifida. Rubrics were developed to score each country on the aforementioned indicators. Country scores were pooled across each indicator and the composite scores ranged between zero and three if there was a need for improvement, four and five if they were in good standing, or six for an excellent status. The scorecard included country-specific recommendations assimilated from the literature and published guidelines to aid policy makers in accelerating surveillance and prevention, and improving the care and quality of life indicators. For comparison, country-level scorecards were grouped by WHO-regions. Score cards were made available publicly through the website "www.pu-sh.org".
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Affiliation(s)
- Vijaya Kancherla
- Center for Spina Bifida Prevention, Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA.
| | | | | | - Lieven Bauwens
- International Federation for Spina Bifida and Hydrocephalus, Brussels, Belgium
| | - Godfrey P Oakley
- Center for Spina Bifida Prevention, Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
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