G207, a mutant herpes simplex virus (HSV) type 1, is safe when inoculated into recurrent malignant glioma. We conducted a phase 1 trial of G207 to demonstrate the safety of stereotactic intratumoral administration when given 24 hours prior to a single 5 Gy radiation dose in patients with recurrent malignant glioma. Nine patients with progressive, recurrent malignant glioma despite standard therapy were included. Patients received one dose of G207 stereotactically inoculated into the multiple sites of the enhancing tumor margin and were then treated focally with 5 Gy radiation. Treatment was well tolerated, and no patient developed HSV encephalitis. The median interval between initial diagnosis and G207 inoculation was 18 months (mean: 23 months; range: 11-51 months). Six of the nine patients had stable disease or partial response for at least one time point. Three instances of marked radiographic response to treatment occurred. The median survival time from G207 inoculation until death was 7.5 months (95% confidence interval: 3.0-12.7). In conclusion, this study showed the safety and the potential for clinical response of single-dose oncolytic HSV therapy augmented with radiation in the treatment of malignant glioma patients. Additional studies with oncolytic HSV such as G207 in the treatment of human glioma are recommended.

Objectives To address disparities in adverse birth outcomes, communities are challenged to improve the quality of health services and foster systems integration. The purpose of this study was to explore the perspectives of Medicaid-insured women about their experiences of perinatal care (PNC) across a continuum of clinical and community-based services. Methods Three focus groups (N = 21) were conducted and thematic analysis methods were used to identify basic and global themes about experiences of care. Women were recruited through a  local Federal Healthy Start (HS) program in Michigan  that targets services to African American women. Results Four basic themes were identified: (1) Pursuit of PNC; (2) Experiences of traditional PNC; (3) Enhanced prenatal and postnatal care; and (4) Women's health: A missed opportunity. Two global themes were also identified: (1) Communication with providers, and (2) Perceived socio-economic and racial bias. Many women experienced difficulties engaging in early care, getting more help, and understanding and communicating with their providers, with some reporting socio-economic and racial bias in care. Delays in PNC limited early access to HS and enhanced prenatal care (EPC) programs with little evidence of supportive transitions to primary care. Notably, women's narratives revealed few connections among clinical and community-based services. Conclusions The process of participating in PNC and community-based programs is challenging for women, especially for those with multiple health problems and living in difficult life circumstances. PNC, HS and other EPC programs could partner to streamline processes, improve the content and process of care, and enhance engagement in services.

OBJECT Pediatric sports-related concussions are a growing public health concern. The factors that determine injury severity and time to recovery following these concussions are poorly understood. Previous studies suggest that initial symptom severity and diagnosis of attention deficit hyperactivity disorder (ADHD) are predictors of prolonged recovery (> 28 days) after pediatric sports-related concussions. Further analysis of baseline patient characteristics may allow for a more accurate prediction of which patients are at risk for delayed recovery after a sports-related concussion. METHODS The authors performed a single-center retrospective case-control study involving patients cared for at the multidisciplinary Concussion Clinic at Children's of Alabama between August 2011 and January 2013. Patient demographic data, medical history, sport concussion assessment tool 2 (SCAT2) and symptom severity scores, injury characteristics, and patient balance assessments were analyzed for each outcome group. The control group consisted of patients whose symptoms resolved within 28 days. The case group included patients whose symptoms persisted for more than 28 days. The presence or absence of the SCAT2 assessment had a modifying effect on the risk for delayed recovery; therefore, stratum-specific analyses were conducted for patients with recorded SCAT2 scores and for patients without SCAT2 scores. Unadjusted ORs and adjusted ORs (aORs) for an association of delayed recovery outcome with specific risk factors were calculated with logistic regression analysis. RESULTS A total of 294 patients met the inclusion criteria of the study. The case and control groups did not statistically significantly differ in age (p = 0.7). For the patients who had received SCAT2 assessments, a previous history of concussion (aOR 3.67, 95% CI 1.51–8.95), presenting SCAT2 score < 80 (aOR 5.58, 95% CI 2.61–11.93), and female sex (aOR 3.48, 95% CI 1.43–8.49) were all associated with a higher risk for postconcussive symptoms lasting more than 28 days. For patients without SCAT2 scores, female sex and reporting a history of ADHD significantly increased the odds of prolonged recovery (aOR 4.41, 95% CI 1.93–10.07 and aOR 3.87, 95% CI 1.13–13.24, respectively). Concussions resulting from playing a nonhelmet sport were also associated with a higher risk for prolonged symptoms in patients with and without SCAT2 scores (OR 2.59, 95% CI 1.28–5.26 and OR 2.17, 95% CI 0.99–7.73, respectively). Amnesia, balance abnormalities, and a history of migraines were not associated with symptoms lasting longer than 28 days. CONCLUSIONS This case-control study suggests candidate risk factors for predicting prolonged recovery following sports-related concussion. Large prospective cohort studies of youth athletes examined and treated with standardized protocols will be needed to definitively establish these associations and confirm which children are at highest risk for delayed recovery.

We have demonstrated that the Koos classification system for vestibular schwannoma is a reliable method for tumor classification. This study lends further support to the results of current literature using Koos grading system. Further studies are required to evaluate its validity and utility in counseling patients with regard to outcomes.

Object Postresection hydrocephalus is observed in approximately 30% of pediatric patients with posterior fossa tumors. However, which patients will develop postresection hydrocephalus is not known. The Canadian Preoperative Prediction Rule for Hydrocephalus (CPPRH) was developed in an attempt to identify this subset of patients, allowing for the optimization of their care. The authors sought to validate and critically appraise the CPPRH. Methods The authors conducted a retrospective chart review of 99 consecutive pediatric patients who presented between 2002 and 2010 with posterior fossa tumors and who subsequently underwent resection. The data were then analyzed using bivariate and multivariate analyses, and a modified CPPRH (mCPPRH) was applied. Results Seventy-six patients were evaluated. Four variables were found to be significant in predicting postresection hydrocephalus: age younger than 2 years, moderate/severe hydrocephalus, preoperative tumor diagnosis, and transependymal edema. The mCPPRH produced observed likelihood ratios of 0.737 (95% CI 0.526–1.032) and 4.688 (95% CI 1.421–15.463) for low- and high-risk groups, respectively. Conclusions The mCPPRH utilizes readily obtainable and reliable preoperative variables that together stratify children with posterior fossa tumors into high- and low-risk categories for the development of postresection hydrocephalus. This new predictive model will aid patient counseling and tailor the intensity of postoperative clinical and radiographic monitoring for hydrocephalus, as well as provide evidence-based guidance for the use of prophylactic CSF diversion.

OBJECTIVEIn children, the repair of skull defects arising from decompressive craniectomy presents a unique set of challenges. Single-center studies have identified different risk factors for the common complications of cranioplasty resorption and infection. The goal of the present study was to determine the risk factors for bone resorption and infection after pediatric cranioplasty.METHODSThe authors conducted a multicenter retrospective case study that included all patients who underwent cranioplasty to correct a skull defect arising from a decompressive craniectomy at 13 centers between 2000 and 2011 and were less than 19 years old at the time of cranioplasty. Prior systematic review of the literature along with expert opinion guided the selection of variables to be collected. These included: indication for craniectomy; history of abusive head trauma; method of bone storage; method of bone fixation; use of drains; size of bone graft; presence of other implants, including ventriculoperitoneal (VP) shunt; presence of fluid collections; age at craniectomy; and time between craniectomy and cranioplasty.RESULTSA total of 359 patients met the inclusion criteria. The patients’ mean age was 8.4 years, and 51.5% were female. Thirty-eight cases (10.5%) were complicated by infection. In multivariate analysis, presence of a cranial implant (primarily VP shunt) (OR 2.41, 95% CI 1.17–4.98), presence of gastrostomy (OR 2.44, 95% CI 1.03–5.79), and ventilator dependence (OR 8.45, 95% CI 1.10–65.08) were significant risk factors for cranioplasty infection. No other variable was associated with infection.Of the 240 patients who underwent a cranioplasty with bone graft, 21.7% showed bone resorption significant enough to warrant repeat surgical intervention. The most important predictor of cranioplasty bone resorption was age at the time of cranioplasty. For every month of increased age the risk of bone flap resorption decreased by 1% (OR 0.99, 95% CI 0.98–0.99, p < 0.001). Other risk factors for resorption in multivariate models were the use of external ventricular drains and lumbar shunts.CONCLUSIONSThis is the largest study of pediatric cranioplasty outcomes performed to date. Analysis included variables found to be significant in previous retrospective reports. Presence of a cranial implant such as VP shunt is the most significant risk factor for cranioplasty infection, whereas younger age at cranioplasty is the dominant risk factor for bone resorption.

OBJECTIVEDysphagia and vocal cord palsy (VCP) are common complications after anterior cervical discectomy and fusion (ACDF). The reported incidence rates for dysphagia and VCP are variable. When videolaryngostroboscopy (VLS) is performed to assess vocal cord function after ACDF procedures, the incidence of VCP is reported to be as high as 22%. The incidence of dysphagia ranges widely, with estimates up to 71%. However, to the authors’ knowledge, there are no prospective studies that demonstrate the rates of VCP and dysphagia for reoperative ACDF. This study aimed to investigate the incidence of voice and swallowing disturbances before and after reoperative ACDF using a 2-team operative approach with comprehensive pre- and postoperative assessment of swallowing, direct vocal cord visualization, and clinical neurosurgical outcomes.METHODSA convenience sample of sequential patients who were identified as requiring reoperative ACDF by the senior spinal neurosurgeon at the University of Alabama at Birmingham were enrolled in a prospective, nonrandomized study during the period from May 2010 until July 2014. Sixty-seven patients undergoing revision ACDF were enrolled using a 2-team approach with neurosurgery and otolaryngology. Dysphagia was assessed both preoperatively and postoperatively using the MD Anderson Dysphagia Inventory (MDADI) and fiberoptic endoscopic evaluation of swallowing (FEES), whereas VCP was assessed using direct visualization with VLS.RESULTSFive patients (7.5%) developed a new postoperative temporary VCP after reoperative ACDF. All of these cases resolved by 2 months postoperatively. There were no new instances of permanent VCP. Twenty-five patients had a new swallowing disturbance detected on FEES compared with their baseline assessment, with most being mild and requiring no intervention. Nearly 60% of patients showed a decrease in their postoperative MDADI scores, particularly within the physical subset.CONCLUSIONSA 2-team approach to reoperative ACDF was safe and effective, with no new cases of VCP on postoperative VLS. Dysphagia rates as assessed through the MDADI scale and FEES were consistent with other published reports.

OBJECTIVEThere are many classification systems for injuries of the thoracolumbar spine. The recent Thoracolumbar Injury Classification and Severity Score (TLICS) has been shown to be a reliable tool for adult patients. The aim of this study was to assess the reliability of the TLICS system in pediatric patients. The validity of the TLICS system is assessed in a companion paper.METHODSThe medical records of pediatric patients with acute, traumatic thoracolumbar fractures at a single Level 1 trauma center were retrospectively reviewed. A TLICS was calculated for each patient using CT and MRI, along with the neurological examination recorded in the patient’s medical record. TLICSs were compared with the type of treatment received. Five raters scored all patients separately to assess interrater reliability.RESULTSTLICS calculations were completed for 81 patients. The mean patient age was 10.9 years. Girls represented 51.8% of the study population, and 80% of the study patients were white. The most common mechanisms of injury were motor vehicle accidents (60.5%), falls (17.3%), and all-terrain vehicle accidents (8.6%). The mean TLICS was 3.7 ± 2.8. Surgery was the treatment of choice for 33.3% of patients. The agreement between the TLICS-suggested treatment and the actual treatment received was statistically significant (p < 0.0001). The interrater reliability of the TLICS system ranged from moderate to very good, with a Fleiss’ generalized kappa (κ) value of 0.69 for the TLICS treatment suggestion among all patients; however, interrater reliability decreased when MRI was used to contribute to the TLICS. The κ value decreased from 0.73 to 0.57 for patients with CT only vs patients with CT/MRI or MRI only, respectively (p < 0.0001). Furthermore, the agreement between suggested treatment and actual treatment was worse when MRI was used as part of injury assessment.CONCLUSIONSThe TLICS system demonstrates good interrater reliability among physicians assessing thoracolumbar fracture treatment in pediatric patients. Physicians should be cautious when using MRI to aid in the surgical decision-making process.