Transition from child- to adult-orientated care for children with long-term health conditions: A process, not an event

This issue of CME contains the second of a two-part series of continuing medical education articles on various aspects of spina bifida, with the focus on some of the longer-term management issues such as hydrocephalus and limb deformity, as well as quality of life.

Surgical management of spasticity

The management of patients with cerebral palsy and other causes of spasticity is a challenge to an entire rehabilitation team and to caregivers.InSouth Africa, neurosurgeons have had limited involvement in this field owing to a perceived lack of options, leaving the care of these patientslargely in the hands of paediatric neurologists and orthopaedic surgeons. A committed team-based approach, where a neurosurgeon is partof the decision-making process, can however significantly improve functional outcomes in patients with spasticity. Key to the evaluationand therapeutic decision-making is the focus on function – not only the range of movement or the presence of spasticity. Some techniquescan completely remove spasticity and contractures, but these mostly leave a patient with more functional impairment than they had beforethe surgery. With the careful combination of botulinum toxin injections and oral baclofen, these patients, who may benefit from furtherorthopaedic and neurosurgical procedures, can be identified and helped in reducing the function-limiting spasticity. With the emphasison function as an individualising factor, significant improvements may follow minor interventions, e.g. performing a surgical procedure toallow reduced hip adductor spasticity, thereby allowing improved hygiene and less pain in a child in whom it was previously not possibleto abduct the hips enough to change a nappy. Functional improvement does not necessarily equate to walking. We describe the process ofevaluating patients with spasticity and outline the surgical decision-making process that helps towards an individualised therapeutic strategyin managing this challenging group of patients

Ventriculoperitoneal shunt insertion for hydrocephalus in human immunodeficiency virus-infected adults: a systematic review and meta-analysis protocol

Responses to peer reviewer comments. HIV VPS Protocol Reviewers Responses. (DOCX 126 kb

Ventriculoperitoneal shunt insertion in human immunodeficiency virus infected adults:a systematic review and meta-analysis

Abstract Background Hydrocephalus is a common, life threatening complication of human immunodeficiency virus (HIV)-related central nervous system opportunistic infection which can be treated by insertion of a ventriculoperitoneal shunt (VPS). In HIV-infected patients there is concern that VPS might be associated with unacceptably high mortality. To identify prognostic indicators, we aimed to compare survival and clinical outcome following VPS placement between all studied causes of hydrocephalus in HIV infected patients. Methods The following electronic databases were searched: The Cochrane Central Register of Controlled Trials, MEDLINE (PubMed), EMBASE, CINAHL Plus, LILACS, Research Registry, the metaRegister of Controlled Trials, ClinicalTrials.gov, African Journals Online, and the OpenGrey database. We included observational studies of HIV-infected patients treated with VPS which reported of survival or clinical outcome. Data was extracted using standardised proformas. Risk of bias was assessed using validated domain-based tools. Results Seven Hunderd twenty-three unique study records were screened. Nine observational studies were included. Three included a total of 75 patients with tuberculous meningitis (TBM) and six included a total of 49 patients with cryptococcal meningitis (CM). All of the CM and two of the TBM studies were of weak quality. One of the TBM studies was of moderate quality. One-month mortality ranged from 62.5–100% for CM and 33.3–61.9% for TBM. These pooled data were of low to very-low quality and was inadequate to support meta-analysis between aetiologies. Pooling of results from two studies with a total of 77 participants indicated that HIV-infected patients with TBM had higher risk of one-month mortality compared with HIV non-infected controls (odds ratio 3.03; 95% confidence-interval 1.13–8.12; p = 0.03). Conclusions The evidence base is currently inadequate to inform prognostication in VPS insertion in HIV-infected patients. A population-based prospective cohort study is required to address this, in the first instance

Surgical management of epilepsy

The fact that epilepsy can be cured or ameliorated with surgery is an often neglected and overlooked aspect of modern management.Epilepsy affects almost 50 million people worldwide. One-third of people who suffer from epilepsy are refractory to medication alone. Itis this group of patients who may benefit from epilepsy surgery, which can be divided into three main categories, i.e. resection procedures,disconnection procedures, and neuromodulation procedures. The goal of surgery in epilepsy is to remove the epileptogenic region from thebrain, or to disconnect it and thereby prevent spread to other parts of the brain. In cases where this is not possible owing to the location ofthe epileptic focus, certain neuromodulation techniques may benefit the patient. Successful outcomes of epilepsy surgery techniques varyfrom 50% to 80% in rendering patients free of their epilepsy; many more patients can expect improvement in the severity or frequency oftheir disabling seizures. The outcome depends on factors such as age, location of the epileptogenic zone, histology and cause of the seizures.Patients undergo a detailed and prolonged work-up to determine candidacy and to decide on the safest technique that will lead to the bestoutcomes. An experienced team should perform the surgery. This team should consist of multiple members who can attend to the medical,social, psychological and reintegration needs of the patient before and after surgery

Impressions of defensive medical practice and medical litigation among South African neurosurgeons

From a litigation perspective, neurosurgery is considered a ‘super high-risk’ field, and this has been associated with rapidly increasing malpractice cover costs. In 2013 the annual Medical Protection Society fee for cover was R250 900. We wished to determine whether high malpractice cover was influencing how neurosurgeons managed patients. A 40-question online survey asking questions on defensive medicine was distributed to determine perceptions around liability risk and whether these influenced how patients were managed. Eighty-four per cent of respondents agreed that a medicolegal crisis existed, and over half (53.8%) had been sued for malpractice during their career. Altering practice behaviour to minimise the risk of a lawsuit is common. The increasing number of legal claims against respondents in this survey has resulted in most neurosurgeons practising defensive medicine. Arguably this will result in increased healthcare costs, inferior patient care and decreased access to skilled surgeons.

Spina bifida: A multidisciplinary perspective on a many-faceted condition

Open spina bifida or myelomeningocele (SBM) is the most common birth defect involving the central nervous system, second only in incidence to congenital cardiac disease. Outcomes in this disorder were poor until the mid-20th century, when modern neurosurgical techniques (closing the lesion and treating hydrocephalus) and treatment for the neuropathic bladder addressed the major causes of mortality, although SBM may still be poorly treated in the developing world. Initial management – or mismanagement – has a profound impact on survival and long-term quality of life