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Child s Nervous System 07/2012; 28(8):1127-8. · 1.54 Impact Factor
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ABSTRACT: Radiotherapy remains a widely accepted postoperative treatment modality for unresectable or recurrent low-grade glioma (LGG). However, there is increasing evidence to suggest that chemotherapy can delay and may obviate the need for radiotherapy in progressive/recurrent LGG. The majority of the published experience is in children with hypothalamic/optic chiasmatic lesions and little information is available regarding its use in LGG of the brainstem.
We describe clinical characteristics and course of children with LGG of the brainstem who received carboplatin-based chemotherapy in two institutions over 10 years (1996-2006). This was a retrospective review of consecutively treated children with LGG of the brainstem (midbrain, pons, medulla, and upper cervical cord). Vincristine and carboplatin were first-line chemotherapy regimen used in all patients.
In this series, there were 16 children (9 males) with median age at diagnosis of 4.2 years (range 0.5-8). Eight children were treated at diagnosis while the remaining eight received chemotherapy after either radiological progression or clinical deterioration. After a median follow-up of 57 months (range 20-136) from initiation of chemotherapy all children are alive and 11 remain progression free (1 complete response, 8 with partial response + minor response, and 2 stable diseases).
The efficacy of this chemotherapy regimen in this series supports its role in children with progressive unresectable LGG of brainstem.
Pediatric Blood & Cancer 09/2010; 55(3):471-7. · 1.89 Impact Factor
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ABSTRACT: Despite lower failure and infection rates compared with shunt placement, it has not been known whether endoscopic third ventriculostomy/choroid plexus cauterization (ETV/CPC) might be inferior in regard to neurocognitive development. This study is the first to describe neurocognitive outcome and ventricle volume in infants with hydrocephalus due to myelomeningocele that was treated primarily by ETV/CPC.
The modified Bayley Scales of Infant Development (BSID-III) test was administered to 93 children with spina bifida who were 5-52 months of age. Fifty-five of these children had been treated by ETV/CPC, 19 received ventriculoperitoneal (VP) shunts, and 19 had required no treatment for hydrocephalus. Raw scores were converted to scaled scores for comparison with age-corrected norms. Ventricular volume was assessed by frontal/occipital horn ratio (FOR) calculated from late postoperative CT scans. The mean values between and among groups of patients were compared using independent samples t-test and ANOVA. The comparison of mean values to population normal means was performed using the single-sample t-test. Linear regression analyses were performed using BSID scores as the dependent variables, with treatment group and ventricular size (FOR) as the independent variables. Probability values < 0.05 were considered significant.
There was no significant difference in mean age at assessment among groups (p = 0.8). The mean scale scores for untreated patients were no different from normal (all p > 0.27) in all portions of the BSID (excluding gross motor), and were generally significantly better than those for both VP shunt-treated and ETV/CPC groups. The ETV/ CPC-treated patients had nonsignificantly better mean scores than patients treated with VP shunts in all portions of the BSID (all p > 0.06), except receptive communication, which was significantly better for the ETV/CPC group (p = 0.02). The mean FOR was similar among groups, with no significant difference between the untreated group and either the VP shunt or ETV/CPC groups. The FOR did not correlate with performance.
The ETV/CPC and VP shunt groups had similar neurocognitive outcomes. Neurocognitive outcomes for infants not requiring treatment for hydrocephalus were normal and significantly better than in those requiring treatment. The mean ventricular volume was similar among all 3 groups, and significantly larger than normal. There was no association between FOR and performance. Stable mild-to-moderate ventriculomegaly alone should not trigger intervention in asymptomatic infants with spina bifida.
Journal of Neurosurgery Pediatrics 12/2009; 4(6):564-70. · 1.53 Impact Factor
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ABSTRACT: Questionnaire survey.
To elicit orthopedic surgeons' attitudes toward chiropractic.
Orthopedic surgeons and chiropractors often attend to similar patient populations, but little is known about the attitudes of orthopedic surgeons toward chiropractic.
We administered a 43-item cross-sectional survey to 1000 Canadian and American orthopedic surgeons that inquired about demographic variables and their knowledge and use of chiropractic. Imbedded in our survey was a 20-item chiropractic attitude questionnaire (CAQ).
487 surgeons completed the survey (response rate, 49%). North American orthopedic surgeons' attitudes toward chiropractic were diverse, with 44.5% endorsing a negative impression, 29.4% holding favorable views, and 26.1% being neutral. Approximately half of respondents referred patients for chiropractic care each year, mainly due to patient request.The majority of surgeons believed that chiropractors provide effective therapy for some musculoskeletal complaints (81.8%), and disagreed that chiropractors could provide effective relief for nonmusculoskeletal conditions (89.5%). The majority endorsed that chiropractors provide unnecessary treatment (72.7%), engage in overly-aggressive marketing (63.1%) and breed dependency in patients on short-term symptomatic relief (52.3%). In our adjusted generalized linear model, older age (-2.62 points on the CAQ for each 10 year increment; 95% confidence interval [CI] = -3.74 to -1.50), clinical interest in foot and ankle (-2.77; 95% CI = -5.43 to -0.10), and endorsement of the research literature (-4.20; 95% CI = -6.29 to -2.11), the media (-3.05; 95% CI = -5.92 to -0.19), medical school (-7.42; 95% CI = -10.60 to -4.25), or 'other' (-4.99; 95% CI = -8.81 to -1.17) as a source of information regarding chiropractic were associated with more negative attitudes; endorsing a relationship with a specific chiropractor (5.05; 95% CI = 3.00 to 7.10) or residency (3.79;95% CI = 0.17 to 7.41) as sources of information regarding chiropractic were associated with more positive attitudes.
North American orthopedic surgeons' attitudes toward chiropractic range from very positive to extremely negative. Improved interprofessional relations may be important to ensure optimal care of shared patients.
Spine 11/2009; 34(25):2818-25. · 2.08 Impact Factor
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ABSTRACT: In the current literature, there are essentially no comparisons of quality of life (QOL) outcome after endoscopic third ventriculostomy (ETV) and shunt in childhood hydrocephalus. Our objective was to compare QOL in children with obstructive hydrocephalus, treated with either ETV or shunt.
A cross-sectional survey was conducted at SickKids, Toronto of children between ages five and 18 years, with obstructive hydrocephalus due to aqueductal obstruction and no other brain abnormalities. Measures of QOL were the Hydrocephalus Outcome Questionnaire and the Health Utilities Index Mark 3. A subset of patients was given the Wechsler Intelligence Scales for Children (WISC-IV).
A total of 47 of 59 (80%) eligible patients participated (24 had ETV as primary treatment, 23 had shunt as primary treatment), with a mean age of 12.1 years (standard deviation 3.9) at assessment. The ETV group was older at initial surgery (p < 0.001) and had larger ventricle size at last follow-up (p = 0.047). In all QOL measures, there were no significant differences between the ETV group and shunt group (all p > or = 0.09). Treatment failure, hydrocephalus complications, and the presence of a functioning ETV at assessment were not associated with QOL differences. Among the 11 children (six ETV, five shunt) who were given the WISC-IV, there were no significant differences between the scores of the ETV group and shunt group (all p > or = 0.11).
This is the first study to provide a meaningful comparison of QOL after ETV and shunt in children. These preliminary results suggest that there is no obvious difference in QOL after ETV and shunt.
Child s Nervous System 09/2009; 26(1):75-9. · 1.54 Impact Factor
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ABSTRACT: Uncertainty persists on the best treatment for patients with obstructive hydrocephalus: endoscopic third ventriculostomy (ETV) or shunt, particularly in the younger age groups. We performed decision analysis for quality of life (QOL) outcomes comparing these two procedures.
Frequency of outcome events for ETV was obtained from the Canadian Pediatric Neurosurgery Study Group (368 patients) and for shunts from two prospective randomized trials, the Shunt Design Trial and the Endoscopic Shunt Insertion Trial (647 patients combined). Quality-adjusted life year (QALY) estimates for various outcomes were obtained from the literature. Decision analysis was performed at 1 year of follow-up for specific age groups, e.g., <1 month, 1-6 months, etc.
Failure from cerebrospinal fluid (CSF) diversion from either procedure was a function of age with higher failures rates in younger patients. Expected QALY at 1 year were marginally higher for ETV for all age groups, but the outcomes were similar enough to be regarded as equivalent. The results, however, were highly sensitive to the assigned health utility value estimates for patients who are well with a functioning ETV or shunt and the severe complication rate from ETV.
Age is a major determinant of outcome from CSF diversion with worse outcomes in young patients. QALY estimates for either ETV or shunt are similar at 1 year.
Child s Nervous System 01/2009; 25(4):467-72. · 1.54 Impact Factor
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ABSTRACT: Osteogenesis imperfecta (OI) is a rare genetic disorder characterized by disruption of normal collagen formation resulting in varying degrees of skeletal vulnerability, ligamentous laxity, and scleral discoloration. Children with OI may suffer from complex neurosurgical problems affecting the brain and spine. The authors sought to determine the neurosurgical implications of OI in a cohort of patients treated at a quaternary care center for pediatrics. The authors reviewed the case histories of 10 children with OI treated by the neurosurgical service at the Hospital for Sick Children in Toronto between January 1988 and March 2007. The cases of 4 of these children are highlighted in the article. The most common neurosurgical conditions encountered in this cohort included macrocephaly in 5 patients, subdural hematoma in 3 patients, epidural hematoma in 2 patients, and hydrocephalus in 3 patients. Basilar invagination and spinal fractures were observed in 20% of the cohort. Although some patients could be treated nonoperatively, several required craniotomy for clot evacuation, decompression, and spinal fixation for fracture or basilar invagination, and cerebrospinal fluid shunt insertion. Neurosurgical conditions affecting patients with OI include macrocephaly, the development of an acute intracranial hematoma after often minimal trauma, the development of chronic subdural fluid collections that may require drainage, hydrocephalus (both communicating and noncommunicating), basilar invagination, and subaxial spinal fractures. Surgery may be complicated in some children because of the underlying bone fragility and bleeding diathesis commonly observed in patients with OI.
Journal of Neurosurgery Pediatrics 04/2008; 1(3):229-36. · 1.53 Impact Factor
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ABSTRACT: Abstract
Background
The frequent use of chiropractic, naturopathic, and physical and occupational therapy by patients with fibromyalgia has been emphasized repeatedly, but little is known about the attitudes of these therapists towards this challenging condition.
Methods
We administered a cross-sectional survey to 385 senior Canadian chiropractic, naturopathic, physical and occupational therapy students in their final year of studies, that inquired about attitudes towards the diagnosis and management of fibromyalgia.
Results
336 students completed the survey (response rate 87%). While they disagreed about the etiology (primarily psychological 28%, physiological 23%, psychological and physiological 15%, unsure 34%), the majority (58%) reported that fibromyalgia was difficult to manage. Respondants were also conflicted in whether treatment should prioritize symptom relief (65%) or functional gains (85%), with the majority (58%) wanting to do both. The majority of respondents (57%) agreed that there was effective treatment for fibromyalgia and that they possessed the required clinical skills to manage patients (55%).
Chiropractic students were most skeptical in regards to fibromyalgia as a useful diagnostic entity, and most likely to endorse a psychological etiology. In our regression model, only training in naturopathic medicine (unstandardized regression coefficient = 0.33; 95% confidence interval = 0.11 to 0.56) and the belief that effective therapies existed (unstandardized regression coefficient = 0.42; 95% confidence interval = 0.30 to 0.54) were associated with greater confidence in managing patients with fibromyalgia.
Conclusion
The majority of senior Canadian chiropractic, naturopathic, physical and occupational therapy students, and in particular those with naturopathic training, believe that effective treatment for fibromyalgia exists and that they possess the clinical skillset to effectively manage this disorder. The majority place high priority on both symptom relief and functional gains when treating fibromyalgia.
BMC Complementary and Alternative Medicine. 01/2008;
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Cerebrospinal Fluid Research. 01/2006;
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Abhaya Kulkarni
Cerebrospinal Fluid Research. 01/2005;
