The safety of spinal pedicle screws in children ages 1 to 12

Background contextPedicle screws have shown to be a safe and effective method of spinal fixation, offering superior multiplanar correction compared with hooks or sublaminar wires in selected situations. Though only food and drug administration (FDA) approved in the adolescent population, they are commonly used in an off-label manner in the preadolescent population.PurposeTo determine if the complication rate of the off-label use of pedicle screws for spinal fixation in the preadolescent 0- to 12-year-old population is comparable with the complication rate in the FDA-approved 13- to 18-year-old population.Study design/settingRetrospective medical record and radiograph review.Patient sampleA total of 726 pediatric patients who underwent a spinal fusion procedure at a single tertiary institution between January 2003 and December 2008 were reviewed.Outcome measuresIncidence of instrumentation failure, infection, neurological complication, and total complications.MethodsThe study population was divided into two groups based on age: the younger group included 0- to 12-year olds and the older group included 13- to 18-year olds at the time of surgery. Groups were further subdivided based on diagnosis: “A,” neuromuscular scoliosis; “B,” idiopathic scoliosis, and “C,” other spinal deformities. Rates of neurovascular complications, infections, and instrumentation complications were compared statistically between the younger and the older groups. Only patients with greater than or equal to 1-year follow-up and greater than or equal to 2-year follow-up were included in the calculations for infection and instrumentation complication rates, respectively.ResultsThere were 206 patients (33% males, 67% females) in the younger group (0 to 12 years) and 520 (41% males, 59% females) in the older group (13 to 18 years). Overall, younger group had a 13.6% complication rate compared with 16.9% in the older group. Younger subjects showed a 13.4% complication rate because of instrumentation-related complications, 0.5% for neurovascular complications, and an infection rate of 9.2%. The older group showed a 15.4% complication rate because of instrumentation-related complications, 1.92% for neurovascular complications, and an infection rate of 11.0%. Complication rates were statistically insignificant between the two groups. Other complications in the younger group included one patient with aspiration pneumonia, two with ileus, and one with pulmonary and other complications in the older group included one patient with aspiration pneumonia, two with ileus, three with superior mesenteric artery syndrome, and three with wound dehiscence.ConclusionsThe complication rates in the young pediatric population associated with the off-label use of pedicle screws for spinal fusions are not statistically different from the complication rates associated with the FDA-approved adolescent population.     

Hypoxia and its therapeutic possibilities in paediatric cancers

In tumours, hypoxia—a condition in which the demand for oxygen is higher than its availability—is well known to be associated with reduced sensitivity to radiotherapy and chemotherapy, and with immunosuppression. The consequences of hypoxia on tumour biology and patient outcomes have therefore led to the investigation of strategies that can alleviate hypoxia in cancer cells, with the aim of sensitising cells to treatments. An alternative therapeutic approach involves the design of prodrugs that are activated by hypoxic cells. Increasing evidence indicates that hypoxia is not just clinically significant in adult cancers but also in paediatric cancers. We evaluate relevant methods to assess the levels and extent of hypoxia in childhood cancers, including novel imaging strategies such as oxygen-enhanced magnetic resonance imaging (MRI). Preclinical and clinical evidence largely supports the use of hypoxia-targeting drugs in children, and we describe the critical need to identify robust predictive biomarkers for the use of such drugs in future paediatric clinical trials. Ultimately, a more personalised approach to treatment that includes targeting hypoxic tumour cells might improve outcomes in subgroups of paediatric cancer patients.Subject terms: Tumour biomarkers, Paediatric cancer, Cancer microenvironment, Cancer therapy     

Step UP! To Stamp Out Stigma: adapting and testing a bystander intervention to reduce HIV-related stigma

Aim

HIV-related stigma is a traumatizing experience operating across socioecological levels. Few interventions have combined multiple methods of stigma reduction into a comprehensive approach. This study adapted bystander training to the context of HIV-related stigma and pilot tested the model.

Subjects and methods

The study drew upon the team’s prior research to create an adapted bystander intervention. Thirty-nine participants met in three separate workshop sessions, which consisted of didactic training, group discussions, and contact between people living with HIV (PLHIV) and their friends/family members, and healthcare workers. Participants completed pre-/post-intervention questionnaires that included demographic characteristics and standardized measures of stigma and empowerment. A person living openly with HIV served as the moderator. The study’s principal investigator led a discussion to evaluate the workshop model.

Results

The workshops were associated with decreased feelings of powerlessness but did not show any immediate effects on feelings of stigmatization. Subjects unanimously recommended requiring the training for all healthcare providers.

Conclusion

The study showed the feasibility of adapting a bystander approach to HIV-related stigma. Interactive participation across different stakeholder groups allows for addressing various types of stigma and incorporating multiple evidence-based approaches to stigma reduction. Future research will incorporate further adaptations and test the approach using a large-scale randomized controlled trial.

     

Does training learners on simulators benefit real patients?

Despite limited data on patient outcomes, simulation training has already been adopted and embraced by a large number of medical schools. Yet widespread acceptance of simulation should not relieve us of the duty to demonstrate if, and under which circumstances, training learners on simulation benefits real patients. Here we review the data on performance of healthcare providers or trainees following simulation training, and discuss ways of enhancing transfer of learning from simulated to real patients. While there is tremendous potential for simulation in medical education and healthcare, further studies are needed to identify if and when simulation training improves the quality of care delivered to patients, and to compare the cost-effectiveness of simulated learning experiences to lower fidelity and less expensive interventions.