Magnetic resonance imaging-guided stereotactic laser ablation therapy for the treatment of pediatric epilepsy: a retrospective multiinstitutional study

OBJECTIVE

The authors of this study evaluated the safety and efficacy of stereotactic laser ablation (SLA) for the treatment of drug-resistant epilepsy (DRE) in children.

METHODS

Seventeen North American centers were enrolled in the study. Data for pediatric patients with DRE who had been treated with SLA between 2008 and 2018 were retrospectively reviewed.

RESULTS

A total of 225 patients, mean age 12.8 ± 5.8 years, were identified. Target-of-interest (TOI) locations included extratemporal (44.4%), temporal neocortical (8.4%), mesiotemporal (23.1%), hypothalamic (14.2%), and callosal (9.8%). Visualase and NeuroBlate SLA systems were used in 199 and 26 cases, respectively. Procedure goals included ablation (149 cases), disconnection (63), or both (13). The mean follow-up was 27 ± 20.4 months. Improvement in targeted seizure type (TST) was seen in 179 (84.0%) patients. Engel classification was reported for 167 (74.2%) patients; excluding the palliative cases, 74 (49.7%), 35 (23.5%), 10 (6.7%), and 30 (20.1%) patients had Engel class I, II, III, and IV outcomes, respectively. For patients with a follow-up ≥ 12 months, 25 (51.0%), 18 (36.7%), 3 (6.1%), and 3 (6.1%) had Engel class I, II, III, and IV outcomes, respectively. Patients with a history of pre-SLA surgery related to the TOI, a pathology of malformation of cortical development, and 2+ trajectories per TOI were more likely to experience no improvement in seizure frequency and/or to have an unfavorable outcome. A greater number of smaller thermal lesions was associated with greater improvement in TST. Thirty (13.3%) patients experienced 51 short-term complications including malpositioned catheter (3 cases), intracranial hemorrhage (2), transient neurological deficit (19), permanent neurological deficit (3), symptomatic perilesional edema (6), hydrocephalus (1), CSF leakage (1), wound infection (2), unplanned ICU stay (5), and unplanned 30-day readmission (9). The relative incidence of complications was higher in the hypothalamic target location. Target volume, number of laser trajectories, number or size of thermal lesions, or use of perioperative steroids did not have a significant effect on short-term complications.

CONCLUSIONS

SLA appears to be an effective and well-tolerated treatment option for children with DRE. Large-volume prospective studies are needed to better understand the indications for treatment and demonstrate the long-term efficacy of SLA in this population.

Early implementation of stereoelectroencephalography in children: a multiinstitutional case series

OBJECTIVE

Pediatric stereoelectroencephalography (SEEG) has been increasingly performed in the United States, with published literature being limited primarily to large single-center case series. The purpose of this study was to evaluate the experience of pediatric epilepsy centers, where the technique has been adopted in the last several years, via a multicenter case series studying patient demographics, outcomes, and complications.

METHODS

A retrospective cohort methodology was used based on the STROBE criteria. ANOVA was used to evaluate for significant differences between the means of continuous variables among centers. Dichotomous outcomes were assessed between centers using a univariate and multivariate logistic regression.

RESULTS

A total of 170 SEEG insertion procedures were included in the study from 6 different level 4 pediatric epilepsy centers. The mean patient age at time of SEEG insertion was 12.3 ± 4.7 years. There was no significant difference between the mean age at the time of SEEG insertion between centers (p = 0.3). The mean number of SEEG trajectories per patient was 11.3 ± 3.6, with significant variation between centers (p < 0.001). Epileptogenic loci were identified in 84.7% of cases (144/170). Patients in 140 cases (140/170, 82.4%) underwent a follow-up surgical intervention, with 47.1% (66/140) being seizure free at a mean follow-up of 30.6 months. An overall postoperative hemorrhage rate of 5.3% (9/170) was noted, with patients in 4 of these cases (4/170, 2.4%) experiencing a symptomatic hemorrhage and patients in 3 of these cases (3/170, 1.8%) requiring operative evacuation of the hemorrhage. There were no mortalities or long-term complications.

CONCLUSIONS

As the first multicenter case series in pediatric SEEG, this study has aided in establishing normative practice patterns in the application of a novel surgical technique, provided a framework for anticipated outcomes that is generalizable and useful for patient selection, and allowed for discussion of what is an acceptable complication rate relative to the experiences of multiple institutions.

Queer Students, International Service-Learning, and Inclusivity: Insights into Identity, Activism, and Learning

This qualitative study examines the experiences of LGBTQ students involved in international service-learning, exploring the possibilities, positive impacts, and complexities of navigating LGBTQ identities while participating in international service-learning. Analysis of their experiences yielded three themes that played an important role shaping their experiences: balancing their stance as learners and as activists, viewing their LGBTQ identities as assets as well as objects of structural barriers, and navigating language to make sense of their context and make themselves understood. These findings have implications for how universities and community partners prepare, train, and support students before, during and after their experiences abroad.

Magnetic resonance-guided stereotactic laser ablation therapy for the treatment of pediatric brain tumors: a multiinstitutional retrospective study

OBJECTIVE

This study aimed to assess the safety and efficacy of MR-guided stereotactic laser ablation (SLA) therapy in the treatment of pediatric brain tumors.

METHODS

Data from 17 North American centers were retrospectively reviewed. Clinical, technical, and radiographic data for pediatric patients treated with SLA for a diagnosis of brain tumor from 2008 to 2016 were collected and analyzed.

RESULTS

A total of 86 patients (mean age 12.2 ± 4.5 years) with 76 low-grade (I or II) and 10 high-grade (III or IV) tumors were included. Tumor location included lobar (38.4%), deep (45.3%), and cerebellar (16.3%) compartments. The mean follow-up time was 24 months (median 18 months, range 3-72 months). At the last follow-up, the volume of SLA-treated tumors had decreased in 80.6% of patients with follow-up data. Patients with high-grade tumors were more likely to have an unchanged or larger tumor size after SLA treatment than those with low-grade tumors (OR 7.49, p = 0.0364). Subsequent surgery and adjuvant treatment were not required after SLA treatment in 90.4% and 86.7% of patients, respectively. Patients with high-grade tumors were more likely to receive subsequent surgery (OR 2.25, p = 0.4957) and adjuvant treatment (OR 3.77, p = 0.1711) after SLA therapy, without reaching significance. A total of 29 acute complications in 23 patients were reported and included malpositioned catheters (n = 3), intracranial hemorrhages (n = 2), transient neurological deficits (n = 11), permanent neurological deficits (n = 5), symptomatic perilesional edema (n = 2), hydrocephalus (n = 4), and death (n = 2). On long-term follow-up, 3 patients were reported to have worsened neuropsychological test results. Pre-SLA tumor volume, tumor location, number of laser trajectories, and number of lesions created did not result in a significantly increased risk of complications; however, the odds of complications increased by 14% (OR 1.14, p = 0.0159) with every 1-cm3 increase in the volume of the lesion created.

CONCLUSIONS

SLA is an effective, minimally invasive treatment option for pediatric brain tumors, although it is not without risks. Limiting the volume of the generated thermal lesion may help decrease the incidence of complications.

Palliative functional hemispherectomy for treatment of refractory status epilepticus associated with Alpers' disease

PURPOSE

Palliative epilepsy surgery is considered for patients that would benefit from surgical therapy for intractable epilepsy but are not candidates for curative procedures. In many cases, the goals of therapy focus on improved quality of life more than seizure freedom. We discuss the use of epilepsy surgery for refractory status epilepticus, as well as the rationale and ethical considerations for employing a palliative procedure in otherwise fatal diseases.

METHODS

We present a child with Alpers' disease presenting with refractory status epilepticus which was treated with functional hemispherectomy after failure of multiple typical therapies. Hemispherectomy allowed for the child to be extubated and ultimately discharged to home with her family. Unfortunately, the child died several months later after developing new-onset liver failure in the setting of a viral illness.

CONCLUSION

Functional hemispherectomy was effective for the treatment of refractory status epilepticus in Alpers' disease. We believe that the procedure resulted in improved quality of life which was the primary outcome goal. Palliative procedures should be considered in diseases with ultimate fatal outcome when the short-term benefits outweigh the risks. The ethical aspects of treatment must be carefully considered to insure treatment is provided in the best interest of the patient.

Preservation of a subcutaneous pocket for vagus nerve stimulation pulse generator during magnetoencephalography. Technical note

Patients with epilepsy and an implanted vagus nerve stimulation (VNS) device who are referred for consideration of definitive epilepsy surgery (removal of the epileptogenic cortex) may require magnetoencephalography (MEG), a study requiring explantation of the pulse generator, as part of their evaluation. Nonetheless, these patients may not wish to abandon palliative VNS therapy should definitive surgery prove unsuccessful or impossible. To avoid obliteration of the pocket by scar tissue after the pulse generator is explanted, the authors have preserved the dead space in several patients with insertion of a similarly sized silicone block. This block is easily replaced with the pulse generator if continued VNS therapy is appropriate, and is left in place in patients who appear to no longer require VNS therapy. Upon completion of MEG, if pulse generator replacement proves desirable, atraumatic retrieval of the electrode connector pin and body is easy. Silicone block implantation during what may prove to be temporary device explantation facilitates reuse of the original pulse generator implantation site and atraumatic distal electrode wire retrieval.

Nativity and older women's health: constructed reliance in the health and retirement study

Gender and nativity are known risk factors for physical and economic dependency. Immigrant women are particularly disadvantaged because of their greater lack of social and economic resources. In this study, we investigate how women immigrants coordinate and utilize various support systems as they approach retirement age, as well as how choices and constraints affect their physical wellbeing. Experiences throughout the life course play a role in the maintenance of health, but the pre-retirement years are particularly crucial to the establishment of patterns of reliance to be used in later life. We examine the effects of economic resources, social support, and family ties (as well as several exogenous variables) on women's physical health using data from the Health and Retirement Survey. For the women in this study, demographic characteristics, such as Hispanic ethnicity and low education are strong risk factors for poor health. Findings also indicate that reliance patterns across resource domains do not differ significantly by nativity and that both economic and familial resource access significantly lessens the risk of poor health for both native and foreign born women.

Differences in ambulatory teaching and learning by gender match of preceptors and students

BACKGROUND AND OBJECTIVES

Important differences exist in traditional medical education by gender of the teachers and learners. Much less is known about how gender influences educational experiences in community-based ambulatory settings. In this study, we explored how community-based teaching and learning varies by gender of the students and preceptors.

METHODS

This prospective study used both paper- and computer-based documentation systems to collect information on student-patient-preceptor encounters. A consecutive sample of third-year medical students contributed data on one full clinical day each week as they rotated through a required 8-week family medicine clerkship. The main measures of interest included patient age and gender, health care visit type (acute, acute exacerbation of chronic, chronic, and health maintenance), method of learning in history taking and physical examinations (observing preceptor, being observed by preceptor, performing unobserved, or working jointly with preceptor), content of physical examinations, amount of preceptor feedback, preceptor teaching content, and gender of the students and their preceptors.

RESULTS

Ninety-three students contributed data on 5,017 patient encounters. The distribution of encounters by student-preceptor dyad included: 1,926 (38%) female students with male preceptors. 1,716 (34%) male students with male preceptors, 841 (17%) female students with female preceptors, and 534 (11%) male students with female preceptors. We found that female preceptors conduct more complete physical exams with students than do male preceptors (28% versus 23%). Female students with male preceptors devoted more encounters to observation only than any other dyad (20% versus 12%), and female preceptors are more likely than male preceptors to allow students to perform unobserved (70% versus 59%). Patient gender played little if any role in how students and their preceptors worked together.

CONCLUSIONS

Differences of potential importance were found in teaching and learning by gender of the student-preceptor dyad. This factor can and should be considered when determining how students can best meet educational objectives in community-based ambulatory settings.

Impact of a preceptor education board and computer network to engage community faculty at Dartmouth Medical School

In 1994, as part of the Generalist Physician Initiative of The Robert Wood Johnson Foundation, Dartmouth Medical School established two programs to support and engage community-based teaching. The Preceptor Education Board and Community Computer Network were established to support a network of community-based preceptors and to facilitate communication between course directors at the school and community-based teachers. The board's mission is to organize, develop, and support a network of community-based primary care faculty, and to create and review community-based curricula. Through the board, community faculty members have made substantial contributions to curriculum, evaluation, faculty development, governance, and financing in community-based teaching. The Community Computer Network provides hardware, software, network systems, and support. Course directors and students have reported improved community-based educational experiences as a direct result of the Network. These two initiatives are dynamic and effective ways to improve the quality of community-based education and preceptors' morale. These efforts have strengthened the community faculty and their connection to the academic medical center.

Significance of short-segment Barrett's esophagus

Barrett's esophagus can progress to dysplasia and adenocarcinoma. Although the incidence of adenocarcinoma of the gastroesophageal junction has increased suddenly in the United States and Europe, we do not know how much of this increase is related to Barrett's esophagus. Interest in mucosal cell abnormalities at the gastroesophageal junction has led researchers to re-examine short-segment Barrett's esophagus. In this recently described condition, specialized columnar epithelium is found in the distal 2 to 3 cm of the esophagus, yet it is not clear how it relates to conventional long-segment Barrett's esophagus, in which the metaplastic epithelium extends higher than 2 to 3 cm above the squamocolumnar junction. The reported prevalence of short-segment Barrett's esophagus found on diagnostic endoscopy varies from 8% to 32%. This wide variation would be lessened by standardized location of biopsy specimens and of endoscopic and histologic staining techniques. Based on the information available, it is apparent that the age range and sex ratios are similar. Although reflux symptoms may be more common in short-segment Barrett's esophagus, disturbances in esophageal motility are less severe and there is less reflux as measured by continuous pH monitoring. Furthermore, recognized complications of Barrett's esophagus, such as ulceration, stricture, high-grade dysplasia, and adenocarcinoma, appear to be uncommon in short-segment Barrett's esophagus.

Regional differences in gastric acidity and antacid distribution: is a single pH electrode sufficient?

Accurate measurement of intragastric acidity has both clinical and investigational importance in studying gastric pathophysiology.

OBJECTIVES

The aims of this study were fourfold: (1) to investigate whether regional differences in intragastric acidity exist; (2) to determine intragastric acidity after a standard antacid was administered in both the fasting and fed states; (3) to monitor gastric emptying of and anatomic distribution of radiolabeled antacid during fasting and postprandial periods; and (4) to determine whether the regional effects of ingested antacid correlated with the anatomic distribution of the antacid.

METHODS

Eight normal male volunteers were studied after fluoroscopically guided nasogastric placement of a tube assembly containing four pH electrodes, with one electrode in each quartile of the stomach. Simultaneous pH readings were made from the four electrodes while fasting, after administration of fasting antacid (30 ml, 79 mEq buffering capacity), postprandially, and after postprandial antacid ingestion. All subjects repeated the protocol on a separate day, five of them using radiolabeled antacid. Gastric emptying and gastric distribution over time of radiolabeled antacid were determined for comparison to regional intragastric acidity.

RESULTS

Intragastric acidity varied regionally over time in response to meals and to fasting and postprandial antacid. In the fasting state, intragastric acidity returned to baseline after antacid ingestion in a proximal to distal (cardia to antrum) sequence, while postprandial antacid resulted in a return to baseline acidity in a distal to proximal (antrum to cardia) sequence. Radiolabeled antacid distribution paralleled intragastric pH and hydrogen ion concentration in the fasting state, with 82% of the antacid localizing in the distal half of the stomach within the first minute after antacid ingestion. Postprandially, the greatest initial and most prolonged antacid buffering effect occurred proximally, correlating with the presence of radiolabeled antacid. Postprandial antacid remained in the stomach for a longer time (T1/2 = 93.1 +/- 23.4 min) compared with fasting antacid (T1/2 = 23.6 +/- 11.1 min).

CONCLUSIONS

Measurement of acidity in the four quartiles of the stomach demonstrated regional variation in response to both food and a standard antacid. A single pH electrode does not detect regional intragastric pH differences.

A single intragastric pH electrode does not accurately measure intragastric acidity

OBJECTIVES

Recent studies have raised concerns about the validity of using a single intragastric pH electrode to measure gastric acidity accurately and reproducibly. The aim of this study was to compare simultaneous intragastric pH measurements obtained from an indwelling glass pH electrode to those determined by aspirations from the gastric pool and from ex vivo measurement.

METHODS

Twenty two normal volunteers were studied after fluoroscopically guided placement of a combined nasogastric tube-pH probe assembly. Simultaneous intragastric pH electrode and aspirate pH determinations were made basally for 120 min after administration of 15 ml of antacid (40 mEq buffering capacity) and for another 120 min an hour postprandially after administration of a second 15-ml dose of antacid. Gastric acid concentration (pH) measurements were recorded every 15 min during the following study protocols: 1) fasting baseline (30 min); 2) fasting antacid (120 min); 3) test meal (60 min); and 4) postprandial antacid (120 min).

RESULTS

Intragastric pH was consistently and significantly lower as measured by intragastric pH electrode than by aspiration. Baseline hydrogen ion concentration ([H+]) was 4.3 times higher by direct electrode measurement than by aspirate. Antacid-administered fasting decreased [H+] maximally at 15 min to 48% and 82% of baseline by electrode and aspiration, respectively. The minimal residual intragastric [H+] after fasting antacid was 12.4 times higher by electrode than by aspiration. Postprandial antacid maximally reduced [H+] by 46% at 15 min when recorded using an electrode compared with 60% at 30 min by aspiration. Correlation coefficients for intragastric electrode [H+] versus aspiration [H+] were 0.26 (p = 0.253), 0.61 (p < 0.001), 0.56 (p < 0.01), and 0.31 (p < 0.001), for baseline, fasting antacid, meal, and postprandial antacid, respectively.

CONCLUSIONS

Quantitative evaluations of intragastric acidity (pH) using an intragastric pH electrode and aspiration of gastric juice may yield remarkably different results. Studies that rely on a single intragastric electrode to quantitate intragastric acidity may be highly inaccurate.

High prevalence of serological markers of autoimmunity in patients with chronic hepatitis C

The advent of specific antiviral therapy for chronic hepatitis C has increased the importance of establishing the correct etiology of chronic hepatitis in patients, especially because interferon alfa (IFN-alpha) has been reported to exacerbate autoimmune hepatitis (AIH), whereas corticosteroids increase viral replication in chronic hepatitis C. In our medical center, we have treated many patients with apparent chronic hepatitis C and serological or clinical evidence of autoimmunity. Our aim was to estimate the prevalence of this association and to learn whether demographic or clinical features distinguished between patients with or without autoimmune markers. We performed a retrospective review of the records of 244 unselected patients seen at the Clinics and Hospital of the University of Massachusetts between May 1991 and November 1993, who had elevated serum aminotransferases. One hundred seventeen patients had chronic hepatitis C defined by elevations of serum alanine transaminase (ALT) for at least 6 months, positive serum antibodies to hepatitis C virus (HCV; second-generation enzyme immunoassay [EIA2] or recombinant immunoblot assay [RIBA]), and absence of hepatitis B surface antigen in the serum. Records were reviewed for results of autoimmune markers in sera, including anti-nuclear antibodies (ANAs), anti-smooth muscle antibodies (SMAs), rheumatoid factor (RF), antimitochondrial antibodies (AMAs), anti-liver and kidney microsomal (LKM) antibodies, and cryoglobulins. We found a high prevalence of positivity, particularly for anti-SMAs (66%) and RF (76%) in both men and women. Forty of 41 patients tested negative for anti-LKM antibodies.(ABSTRACT TRUNCATED AT 250 WORDS)

Maternal-fetal physical assessment in the home setting: role of the advanced practice nurse

Maternal-fetal physical assessment in the home setting reflects a review of the literature, AWHONN's practice guidelines, and the authors' clinical experience. The goals of prenatal home care and the role of the advanced practice nurse are described. Emphasis is placed on the maternal-fetal physical assessments that allow the advanced practice nurse to provide additive or substitutive prenatal care visits in the home. Delivering prenatal care in the home by the advanced practice nurse is an alternative type of health-care delivery for pregnant women.

Acute care visits and rehospitalization in women and infants after cesarean birth

This study, conducted as a randomized clinical trial, focuses on acute care visits and rehospitalizations of mothers whose infants were delivered by cesarean section (n = 122) and infants (n = 123) for 8 weeks after hospital discharge. There were three maternal rehospitalizations. Maternal acute care visits were for wound infections or complications (27 of 34); 21 occurred in the first 4 weeks. Seventy-five percent of infant rehospitalizations were for infection or possible infection; 22 of 31 infant acute care visits occurred in first 4 weeks for bilirubin checks and infant care problems, and 21 of 25 visits in weeks 5 to 8 were for infections. Discharge teaching and home care in first 4 weeks after discharge and issues related to infant infections in the second 4-week period may reduce the need for rehospitalizations and acute care visits in both mothers who had cesarean section and their infants.