Infection rate correlated with time to repair of open neural tube defects (myelomeningoceles): an institutional and national study

Background

The optimal time to closure of a newborn with an open neural tube defect (NTD–myelomeningocele) has been the subject of a number of investigations. One aspect of timing that has received attention is its relationship to repair site and central nervous system (CNS) infection that can lead to irreversible deficits and prolonged hospital stays. No studies have evaluated infection as a function of surgical timing at a national level. We hypothesized an increase in wound infection in those patients with delays in myelomeningocele repair when evaluated in both a single-center and national database.

Methods

Treatment outcomes following documented times to transfer and closure were evaluated at Children’s Hospital of Los Angeles (CHLA) for the years 2004 to 2014. Data of newborns with a myelomeningocele with varying time to repair were also obtained from non-overlapping abstracts of the 2000–2010 Kids’ Inpatient Database (KID) and Nationwide Inpatient Sample (NIS). Poisson multivariable regression analyses were used to assess the effect of time to repair on infection and time to discharge.

Results

At CHLA, 95 neonates who underwent myelomeningocele repair were identified, with a median time from birth to treatment of 1 day. Six (6 %) patients were noted to have postrepair complications. CHLA data was not sufficiently powered to detect a difference in infection following delay in closure. In the NIS, we identified 3775 neonates with repaired myelomeningocele of whom infection was reported in 681 (18 %) patients. There was no significant difference in rates of infection between same-day and 1-day wait times (p = 0.22). Wait times of two (RR = 1.65 [1.23, 2.22], p < 0.01) or more days (RR = 1.88 [1.39, 2.54], p < 0.01), respectively, experienced a 65 % and 88 increase in rates of infection compared to same-day procedures. Prolonged wait time was 32 % less likely at facilities with increased myelomeningocele repair volume (RR = 0.68 [0.56 0.83], p < 0.01). The presence of infection was associated with a 54 % (RR = 1.54 [1.36, 1.74], p < 0.01) increase in the length of stay when compared to neonates without infection.

Conclusion

Myelomeningocele closure, when delayed more than 1 day after birth, is associated with an increased rate of infection and length of stay in the national cohort. High-volume centers are associated with fewer delays to repair. Though constrained by limitations of a national coded database, these results suggest that early myelomeningocele repair decreases the rate of infection.

     

Large‐scale expansion of pre‐isolated bone marrow mesenchymal stromal cells in serum‐free conditions

The regenerative potential of mesenchymal stromal or stem cells (MSCs) has generated tremendous interest for treating various degenerative diseases. Regulatory preference is to use a culture medium that is devoid of bovine components for stem cell expansion intended for therapeutic applications. However, a clear choice an alternative to fetal bovine serum (FBS) has not yet emerged. We have screened five different commercially available serum‐free media (SFM) for their ability to support the growth and expansion of pre‐isolated undifferentiated bone marrow‐derived MSCs (BM‐MSCs) and compared the results with cells grown in standard FBS‐containing medium as control. In addition, based on initial screening results, BD Mosaic? Mesenchymal Stem Cell Serum‐free (BD‐SFM) medium was evaluated in large‐scale cultures for the performance and culture characteristics of BM‐MSCs. Of the five different serum‐free media, BD‐SFM enhanced BM‐MSCs growth and expansion in Cell STACK (CS), but the cell yield per CS‐10 was less when compared to the control medium. The characteristics of MSCs were measured in terms of population doubling time (PDT), cell yield and expression of MSC‐specific markers. Significant differences were observed between BD‐SFM and control medium in terms of population doublings (PDs), cell yield, CFU‐F and morphological features, whereas surface phenotype and differentiation potentials were comparable. The BD‐SFM‐cultured MSCs were also found to retain the differentiation potential, immune‐privileged status and immunosuppressive properties inherent to MSCs. Our results suggest that BD‐SFM supports large‐scale expansion of BM‐MSCs for therapeutic use. Copyright © 2014 John Wiley & Sons, Ltd.     

Long-term outcomes of blebs repaired with scleral patch graft and conjunctival advancement in late-onset leak post-trabeculectomy

Purpose:To report long-term outcomes in eyes that developed late-onset bleb leak post trabeculectomy, with or without hypotony and/or maculopathy, due to a scleral melt/fistula and who required a scleral patch graft and conjunctival advancement for repair.Methods:Retrospective, non-comparative, interventional case series over a decade (2010–2019), presenting with late bleb leak post-filtration-surgery. All cases required a scleral patch graft and conjunctival advancement for management via a standard technique, performed by an experienced glaucoma surgeon.Results:A total of 18 eyes were included. Mean age was 51.5 ± 10.2 years (95% CI [46.4–56.7]) and were followed up after repair for 52.4 ± 26.9 months, 95%CI [39.1–65.8]. 66.7% eyes (n = 12) had IOP ≦6 mmHg and also had hypotony maculopathy. None of the eyes presented with blebitis. 44.5% (n = 8) eyes underwent phacoemulsification as significant cataract was present. LogMAR best-corrected visual acuity (BCVA) was 0.8 ± 0.7 (95% CI [0.4–1.1]) prior to intervention and improved to 0.4 ± 0.6 (95% CI[0.1–0.6], P = 0.004). 22.3% (n = 4) eyes had persistent choroidal folds but BCVA was improved. Mean pre-intervention intraocular pressure (IOP) was 6.3 ± 3.8 mmHg (95% CI 4.4–8.2]) which increased to 12.1 ± 2.9 mmHg (95%CI[10.6–13.5], (P < 0.001). 27.8% (n = 5) eyes needed laser suture lysis post repair to control IOP; two needed further surgical intervention. Number of anti-glaucoma medications at last follow-up was 0.4 ± 0.9 (95% CI [−0.1–0.8], P = 0.09). No serious complications were encountered.Conclusion:Scleral patch graft and conjunctival advancement is a useful technique for repair of a scleral fistula post-filtering surgery, and this is recommended not only for the restoration of anatomy for prevention of infection and control of IOP, but also for visual rehabilitation.     

Optic nerve head melanocytoma: Optical coherence tomography/angiography features

Purpose:The objective of this study was to identify the diagnostic features of optic nerve head melanocytoma (ONH-MCT) on spectral domain optical coherence tomography (SD OCT) and OCT angiography (OCT-A).Methods:Retrospective study of 11 patients for their demographic, clinical features and imaging including SD OCT (tumour location, extent and interface) and OCT-A (surface and intrinsic vascularity) were reviewed. Flow rate percentage (FR %) was calculated over the lesion and compared to fellow eye and similar pigmented lesions.Results:The average age was 52.8 ± 10.9 years. ONH-MCT tumors occupied 3-tissue spaces- optic disc (n = 2), retinal layer (n = 5) and retina-choroidal layers (n = 4). SD OCT (11 eyes) showed elevated hyper reflective disorganized retinal layers with posterior shadowing (9 eyes) and hyper reflective dots within the tumor (all eyes). Microvascular features on OCT-A (8 eyes) in radial peripapillary capillary slab showed surface vascularization (7 eyes) and intrinsic vascularity in choroidal slab (8 eyes) with surrounding hypo reflective boundary. The mean FR % was higher at 65.1 ± 3.77% (CI: 61.9-68.2) compared to mean FR at 60.4 ± 1.06% (CI: 59.5-61.2) in the fellow eye (p = 0.01). Comparison with nevus and melanoma SD OCT showed a high reflective choroidal layer with normal or irregular outer retinal layers respectively; OCT-A showed hypo reflective area at the center with hyper reflective boundary and iso reflective area at center with hyper reflective boundary respectively.Conclusion:SD OCT and OCT-A features may help to differentiate ONH-MCT from clinically similar looking pigmented lesions like nevus and melanoma.