Abdominal binders

Journal ArticleSklar and colleagues2 describe their experience managing "over-shunting headaches" with an abdominal binder. Seventy children with over-shunting headaches complied with application of a binder for about 1 month. In 61 patients (87%), the headaches "greatly improved or went away." This headache relief persisted even after use of the binder was discontinued. Among the 61 patients with relief, 36 (59%) eventually had recurrent headaches, but the recurrence was delayed (mean 1.5 years). Twenty-nine of these tried the binder again and among the 19 with follow-up, the binder was again effective in 15. These are interesting results. Children with chronic headaches and small ventricles can be very difficult to treat, often undergo repeated surgical interventions, and may have a poor quality of life. Anything that might help them is welcome, especially a simple noninvasive intervention

Tertiary delivery modes and construction industry sector habits, do they match yet?

Collaboration has become a buzzword, whether describing tertiary educational delivery modes or themes in industry related conferences, or touted by leaders in the construction industry sector. Educational organisations would not thrive without collaboration, and hence the term collegiality. Over the last two or so years Unitec has been developing and facilitating delivery modes involving blended learning, and project based learning for the undergraduate construction management and construction economics students. Teamwork and real-world learning is the norm. The question is, “How real is integrated collaboration in our construction industry as yet and does it yet match the focus of the Integrated design and construction management undergraduate course run at our institute?”. How the course is delivered and assessed is compared with the findings and trends from the industry assignment, and presented in this paper. The findings suggest that whilst the majority of projects are still being run on the Design-Bid-Build basis of design then construct in that order, that there appears to be a slow but obvious shift toward several companies working collaboratively with clients, stakeholders, designers and contractors from the earliest stages of the project

It's randomized and double blinded... what more do we want?

Journal ArticleThis issue of Journal of Neurosurgery: Pediatrics presents a randomized trial in which investigators have evaluated antimicrobial suture (AMS) in the prevention of shunt infection. The authors randomized 84 shunt procedures in 61 patients over 21 months. The surgeons and patients were blinded to treatment group. The groups appeared to be balanced with respect to shunt infection risk factors. Infection within 6 months of surgery occurred in 2 (4.3%) of 46 AMS procedures and in 8 (21%) of 38 control procedures. This study is a good first step. The authors should be applauded for conducting a double-blinded randomized trial, but the results need to be considered preliminary, and as they stand are not sufficient for a change in practice. As the authors state, they need further evaluation in a larger randomized trial

Tracking resident work hours: available software is not yet ideal, but it's helpful

Journal ArticleAn ideal system would be completely passive and would allow more detailed tracking of activity inside the hospital. A new reality began July 1. We are all now responsible for tracking our residents' work hours and ensuring compliance with the new regulations mandated by the Accreditation Council for Graduate Medical Education (ACGME). In order to do this in the Department of Neurosurgery at the University of Utah, a number of options involving commercial time-tracking software were considered

Ventriculoperitoneal shunts in children: indications, equipment and techniques

Journal ArticleThe decision to implant a ventriculoperitoneal shunt in a child with ventriculomegaly should not be taken lightly. Once a shunt has been implanted, it is very difficult to determine that it is no longer necessary, and therefore the initial decision is very important. Sometimes the need is obvious, such as a baby who presents with irritability, vomiting, a full fontanelle, splayed sutures, and increasing head circumference. Similarly, older children with headaches, vomiting, and papilledema clearly require intervention. At the other end of the spectrum are children with moderately enlarged ventricles, normal development, and no progression in head size or ventricle size on imaging. Although the ventricles may be bigger than average in these children, a shunt should not be implanted unless their symptoms progress

Comparison between magnetic resonance imaging and computed tomography for stereotactic coordinate determination

Journal ArticleThe spatial accuracy of magnetic resonance imaging (MRI) has not been established for stereotactic surgery. Magnetic susceptibility artifacts may lead to anatomical distortion and inaccurate stereotactic MRI coordinates, especially when targets are in regions of the brain out of the center of the magnetic field. MRI-guided stereotactic localization, however, provides better multiplanar target resolution than is available with computed tomographic (CT) scanning. Therefore, we compared the accuracy of stereotactic coordinates determined by MRI and CT studies in 41 patients (53 targets). Coordinates were measured in each plane and as vector distances between the target and the center of the stereotactic frame on axial or coronal MRI studies. Absolute axial plane MRI and CT distances varied an average of 2.13 ± 1.59 mm. The mean difference in measurements in the X (left-right) dimension was 1.19 mm and 1.55 mm in the Y (anteriorposterior) dimension. Central targets (located less than 2 cm from the frame center) had a mean MRI-CT difference of 2.09 ± 1.79 mm; peripheral targets (greater than 2 cm from the frame center) differed by 2.17 ± 1.3 mm. The voxel volumes were calculated for all compared images. Although differences between the physical properties of data acquisition with each imaging modality could explain the observed CT-MRI discrepancies, a 1-pixel difference in target selection could account totally for all the variance observed. MRI field strength (0.5 vs. 1.5 T) did not correlate with coordinate determination accuracy. We conclude that MRI-guided stereotactic localization can be used with confidence for most diagnostic, functional, and therapeutic stereotactic procedures

Deterministic and Probabilistic Risk Management Approaches in Construction Projects: A Systematic Literature Review and Comparative Analysis

Risks and uncertainties are inevitable in construction projects and can drastically change the expected outcome, negatively impacting the project’s success. However, risk management (RM) is still conducted in a manual, largely ineffective, and experience-based fashion, hindering automation and knowledge transfer in projects. The construction industry is benefitting from the recent Industry 4.0 revolution and the advancements in data science branches, such as artificial intelligence (AI), for the digitalization and optimization of processes. Data-driven methods, e.g., AI and machine learning algorithms, Bayesian inference, and fuzzy logic, are being widely explored as possible solutions to RM domain shortcomings. These methods use deterministic or probabilistic risk reasoning approaches, the first of which proposes a fixed predicted value, and the latter embraces the notion of uncertainty, causal dependencies, and inferences between variables affecting projects’ risk in the predicted value. This research used a systematic literature review method with the objective of investigating and comparatively analyzing the main deterministic and probabilistic methods applied to construction RM in respect of scope, primary applications, advantages, disadvantages, limitations, and proven accuracy. The findings established recommendations for optimum AI-based frameworks for different management levels—enterprise, project, and operational—for large or small data sets

Natural history of cerebral cavernous malformations

Journal ArticleTo determine the natural history of brain cavernous malformations, the authors entered patients referred to their center into a prospective registry between 1987 and 1993. All patients underwent magnetic resonance imaging, which showed the typical appearance of this lesion, and conservative management was recommended in all. Patients or their referring physicians were contacted for follow-up data. The purpose of the study was to define the rate of symptomatic hemorrhage and to determine the outcome in those patients who had suffered seizures. Follow-up data were available for 122 patients with a mean age at entry of 37 years (range 4-82 years). The malformation was located in the brainstem in 43 cases (35%), the basal ganglia/thalamus in 20 (17%), and a hemispheric area in 59 (48%). Fifty percent of patients had never had a symptomatic hemorrhage, 41% had one bleed, 7% had two, and 2% had three. Seizures were reported in 23% of patients and headaches in 15%. Lesions were solitary in 80% of patients and multiple in 20%. The retrospective annual hemorrhage rate (61 bleeds/4550.6 patient-years of life) was 1.3%. The mean prospective follow-up period was 34 months. There were nine bleeds during this time, six with new neurological deficits. In patients without a prior bleed, the prospective annual rate of hemorrhage was 0.6%. In contrast, patients with prior hemorrhage had an annual bleed rate of 4.5% (p = 0.028). Patient sex (p = 0.97) or the presence of seizures (p = 0.11), headaches (p = 0.06), or solitary versus multiple lesions (p = 0.15) were not significant predictors of later hemorrhage. There was no difference in the rate of bleeds between brain locations. Four patients with seizures became seizure-free and four patients without seizures later developed seizures; only one patient developed intractable seizures. Fourteen patients (11%) underwent surgery (two after hemorrhage, five with seizures, and seven with progressive deficits), and five had radiosurgery. No patient died in the follow-up period. This study indicates that conservative versus operative management strategies may need to be redefined, especially in patients who present with hemorrhage and who appear to have a significantly increased risk of subsequent rehemorrhage

Value of postoperative surveillance imaging in the management of children with some common brain tumors

Journal ArticleThe rationale for obtaining surveillance computerized tomography (CT) scans or magnetic resonance (MR) images in pediatric patients with brain tumors is that early detection of recurrence may result in timely treatment and better outcome. The purpose of this study was to investigate the value of surveillance cranial images in a variety of common pediatric brain tumors managed at a tertiary care pediatric hospital. A retrospective chart review was performed of children with astrocytoma of the cerebral hemisphere, cerebellum, optic chiasm/hypothalamus, or thalamus; cerebellar or supratentorial high-grade glioma; supratentorial ganglioglioma; posterior fossa or supratentorial primitive neuroectodermal tumor (PNET); and posterior fossa ependymoma. Data were analyzed to determine the frequency with which recurrences were identified on a surveillance image and how the type of image at which recurrence was identified related to outcome. In 159 children, 17 of 44 recurrences were diagnosed by surveillance imaging. The percentage of recurrences identified by surveillance imaging was 64% for ependymoma, 50% for supratentorial PNET, 43% for optic/hypothalamic astrocytoma, and less than 30% for other tumors. The rate of diagnosis of recurrence per surveillance image varied from 0% to 11.8% for different tumor types. Only for ependymomas did there appear to be an improved outcome when recurrence was identified prior to symptoms. Our results indicate that, using the protocols outlined in this study, surveillance imaging was not valuable in identifying recurrence of cerebellar astrocytoma or supratentorial ganglioglioma during the study period, but was probably worthwhile in identifying recurrence of posterior fossa ependymoma and optic/hypothalamic astrocytoma and, possibly, medulloblastoma. Surveillance protocols could be made more effective by individualizing them for each type of tumor, based on current data on the patterns of recurrence