The CT guided transoral approach: A biopsy technique for a poorly differentiated chordoma in a 5 year old

Mass lesions presenting at the craniocervical junction often present a unique challenge due to the complex anatomic arrangement limiting access for tissue diagnosis. The transoral approach has predominantly been used for percutaneous vertebroplasty of high cervical vertebrae with limited literature describing image guided biopsy for bony lesions in this region in the pediatric patient. We describe a technique of computed tomography guided transoral biopsy of a poorly differentiated chordoma located at the C1–C2 level in a 5-year-old child, and review this diagnosis.     

Less invasive transjugular approach with Fallopian bridge technique for facial nerve protection and hearing preservation in surgery of glomus jugulare tumors

For the past three decades, surgery of glomus jugulare tumors (GJTs) has been characterized by extensive combined head and neck, neuro-otologic, and neurosurgical approaches. In recent years, the authors have modified the operative technique to a less invasive approach for preservation of cranial nerves while achieving satisfactory tumor resection. We evaluated and compared the clinical outcomes of our current less invasive approach with our previous more extensive procedures. The clinical records of 39 cases of GJT surgically treated between 1992 and 2011 were retrospectively reviewed. The less invasive transjugular approach with Fallopian bridge technique (LI-TJ) was used for the most recent five cases. The combined transmastoid–transjugular and high cervical (TM-HC) approach was performed in 30 cases, while four cases were treated with a transmastoid–transsigmoid approach with facial nerve translocation. Operative technique, extent of tumor resection, operating time, hospital stay, and morbidity were examined through the operative records, and a comparison was made between the LI-TJ cases and the more invasive cases. No facial nerve palsy was seen in the LI-TJ group while the TM-HC group demonstrated six cases (17.6 %) of facial palsy (House–Brackmann facial nerve function grading scale grade II and III). The complication rate was 0 % in the LI-TJ group and 16.7 % in the more invasive group. The mean operative time and hospital stay were shorter in the LI-TJ group (6.4 h and 4.3 days, respectively) compared with the more invasive group (10.7 h and 8.0 days, respectively). The LI-TJ approach with Fallopian bridge technique provided adequate tumor resection with cranial preservation and definitive advantage over the more extensive approach.     

Relationship Between Neurological Injury and Patterns of Upright Mobility in Children With Spinal Cord Injury

Background:

The predictors and patterns of upright mobility in children with a spinal cord injury (SCI) are poorly understood.

Objective:

The objective of this study was to develop a classification system that measures children’s ability to integrate ambulation into activities of daily living (ADLs) and to examine upright mobility patterns as a function of their score and classification on the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) exam.

Methods:

This is a cross-sectional, multicenter study that used a convenience sample of subjects who were participating in a larger study on the reliability of the ISNCSCI. A total of 183 patients between 5 and 21 years old were included in this study. Patients were asked if they had participated in upright mobility in the last month and, if so, in what environment and with what type of bracing. Patients were then categorized into 4 groups: primary ambulators (PrimA), unplanned ambulators (UnPA), planned ambulators (PlanA), and nonambulators.

Results:

Multivariate analyses found that only lower extremity strength predicted being a PrimA, whereas being an UnPA was predicted by both lower extremity strength and lack of preservation of S45 pinprick sensation. PlanA was only associated with upper extremity strength.

Conclusions:

This study introduced a classification system based on the ability of children with SCI to integrate upright mobility into their ADLs. Similar to adults, lower extremity strength was a strong predictor of independent mobility (PrimA and UnPA). Lack of pinprick predicted unplanned ambulation, but not being a PrimA. Finally, upper extremity strength was a predictor for planned ambulation.Key words: ambulation, ISNCSCI, pediatrics, spinal cord injuryAfter a spinal cord injury (SCI), learning to walk often becomes the focus of rehabilitation for children and their families.^1,2 Although the majority of children with SCI do not return to full-time functional ambulation, those who accomplish some level of walking report positive outcomes such as feeling “normal” again, being eye-to-eye with peers, and having easier social interactions.³ Although not frequently reported by patients, there is some evidence of physiological benefits as well.^3–9 Regardless of age, upright mobility has been positively associated with community participation and life satisfaction.^10–12 For children, upright mobility allows them to explore their physical environment, which facilitates independence and learning as part of the typical developmental process.^13,14With the use of standers, walkers, and other assistive devices, as well as a variety of lower extremity orthoses, it is a reasonable expectation that some children with spinal injuries achieve upright stance and mobility.^7,9,13–21 However, there are 2 main challenges for clinicians and patients: understanding the factors that either encourage or discourage upright activities, and identifying how best to determine whether upright mobility is successful and meaningful. The literature on adults suggests that upright mobility is dependent on physiological and psychosocial factors. Physiological factors include the patient’s current age, neurological level, muscle strength, and comorbidities.^14,22–27 Psychosocial factors include satisfaction with the appearance of the gait pattern, cosmesis, social support for donning/doffing braces, and assistance with transfer and during ambulation.^{3,9,19,28–32}The identification of outcome measures that provide a meaningful indication of successful upright mobility has been difficult. The World Health Organization (WHO) describes 2 constructs for considering outcomes – capacity and performance.³³ Capacity refers to maximal capability in a laboratory setting. An example of a capacity measure is the Walking Index for Spinal Cord Injury (WISCI), which is an ordinal scale used to quantify walking capacity based on assistive device, type of orthosis, and amount of assistance required.^34,35 Other capacity measures include the Timed Up and Go test and the 6-minute walk test.^36,37 On the other hand, performance refers to actual activity during a patient’s daily activities in typical, real-life environments.³³ For example, the FIM is an observation scale that scores the patient’s typical daily performance.^36,38–40 The FIM is considered a burden of care measure that determines the amount of actual assistance provided to a patient during typical routines and environments, which may or may not reflect maximal ability or capacity. Performance measures provide an adequate clinical snap-shot of a patients’ daily function (evaluates what they do), whereas capacity measures are better research tools, as they are able to detect subtle changes in ambulation (evaluates what they can do).In children, no capacity outcome measures of ambulation have been tested for validity or reliability. Availability of reliable and valid performance measures is also lacking. The WeeFIM is a performance measure for children, but it is not SCI specific. It is scored on the child’s burden of care, that is, on the maximal assistance required rather than the child’s maximal independence or the highest capacity of performance during a typical day. For children, another commonly used scale is the Hoffer Scale, which relies on the physician’s or therapist’s subjective determination of the purpose of the upright mobility activities (for function or for exercise).^41,42 Because parents and school systems are encouraged to integrate “exercise” ambulation into daily activities, it may not be possible to distinguish between therapeutic and functional ambulation in the home, school, or community environments. In the schools, a teacher/therapist should incorporate upright mobility into the classroom setting by donning a child’s braces and then having her/him ambulate a short distance to stand at an easel in art class or to stand upright when talking to friends during recess. In this situation, walking serves the dual purpose of being functional and therapeutic.For this study, it was decided not to rely on a subjective determination of therapeutic versus functional ambulation as the main outcome measure. Instead, we were interested in the children and adolescents who have successfully integrated independent mobility into their daily activities, regardless of frequency, distance, or purpose. Recent literature in studies of children and adolescents suggests that spontaneity is important for participation in functional and social activities. For example, a survey of patients using functional electrical stimulation for hand function found a reduction in the dependence on others for donning splints, which facilitated independence with activities of daily living (ADLs) in adolescents.^43–45 In a more recent study, Mulcahey et al⁴⁶ found that a reduction of spontaneity in adolescents was a barrier for social activity; during cognitive interviews, children reported not participating in sleepovers due to planning their bowel/bladder programs.To date, there are no measures that integrate spontaneity of standing and/or upright mobility into the daily activities of children. Toward that aim, this study introduces a new scale that attempts to categorize children into 4 mutually exclusive groups: primary ambulators, unplanned ambulators, planned ambulators, and nonambulators. The purpose of this study was to examine ambulation patterns among children and adolescents with SCI as a function of neurological level, motor level, and injury severity, as defined by the motor, sensory, and anorectal examinations of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). A secondary aim of the study was to determine how performance on the ISNCSCI exam was associated with the ability of children to independently integrate ambulation into their daily routines.     

Spatial Characteristics of White Matter Abnormalities in Schizophrenia

There is considerable evidence implicating brain white matter (WM) abnormalities in the pathophysiology of schizophrenia; however, the spatial localization of WM abnormalities reported in the existing studies is heterogeneous. Thus, the goal of this study was to quantify the spatial characteristics of WM abnormalities in schizophrenia. One hundred and fourteen patients with schizophrenia and 138 matched controls participated in this multisite study involving the Universities of Iowa, Minnesota, and New Mexico, and the Massachusetts General Hospital. We measured fractional anisotropy (FA) in brain WM regions extracted using 3 different image-processing algorithms: regions of interest, tract-based spatial statistics, and the pothole approach. We found that FA was significantly lower in patients using each of the 3 image-processing algorithms. The region-of-interest approach showed multiple regions with lower FA in patients with schizophrenia, with overlap at all 4 sites in the corpus callosum and posterior thalamic radiation. The tract-based spatial statistic approach showed (1) global differences in 3 of the 4 cohorts and (2) lower frontal FA at the Iowa site. Finally, the pothole approach showed a significantly greater number of WM potholes in patients compared to controls at each of the 4 sites. In conclusion, the spatial characteristics of WM abnormalities in schizophrenia reflect a combination of a global low-level decrease in FA, suggesting a diffuse process, coupled with widely dispersed focal reductions in FA that vary spatially among individuals (ie, potholes).Key words: diffusion tensor imaging, fractional anisotropy, pothole, tract-based spatial statistics     

Contingency Management Versus Psychotherapy for Prenatal Smoking Cessation: A Meta-Analysis of Randomized Controlled Trials

Objectives

Prenatal smoking is the leading preventable cause of poor obstetric outcomes, yet treatment options are limited. Past reviews of prenatal smoking cessation have often grouped all counseling into a single category, which ignores the fact that psychotherapy is distinct from brief counseling. The objective of this study was to compare the effect sizes of two intensive interventions for prenatal smoking cessation: contingency management (i.e., financial incentives for abstinence) and psychotherapy.

Elimination of Laparoscopic Lens Fogging Using Directional Flow of CO2

Background and Objectives:

Surgeons constantly struggle with the formation of condensation on the lens of a laparoscope, which prolongs procedures and reduces visibility of the abdominal cavity. The goal of this project was to build a device that would direct a flow of carbon dioxide (CO₂) into an open chamber surrounding the lens of a laparoscope, acting to keep moisture away from the lens and eliminate condensation.

Methods:

The device isolates the lens of the laparoscope from the humid environment of the intraperitoneal cavity by creating a microenvironment of dry CO₂. This was accomplished by building a communicating sleeve that created an open chamber around the distal 2 to 3 cm of the scope. Into this cavity, dry cool CO₂ was pumped in from an insufflator so that the path of the gas would surround the lens of the scope and escape through a single outlet location through which the scope views the intraperitoneal cavity. This chamber is proposed to isolate the lens with a high percentage of dry CO₂ and low humidity. The device was tested in 7 different adverse conditions that were meant to challenge the ability of the device to maintain the viewing field with no perceptible obstruction.

Results:

In all of the conditions tested, 25 trials total, the device successfully prevented and/or eliminated laparoscopic lens fogging.

Conclusions:

The device designed for this project points to the potential of a simple and effective mechanical method for eliminating laparoscopic lens fogging.