OBJECTIVE Postoperative infections in pediatric spinal surgery commonly occur and necessitate reoperation(s). However, pediatric-specific infection prophylaxis guidelines are not available. This network meta-analysis compares perioperative prophylaxis methods including Betadine irrigation, saline irrigation, intrawound vancomycin powder, combination therapy (Betadine, vancomycin, gentamicin, and cefuroxime), Betadine irrigation plus vancomycin powder, and no intervention to determine the most efficacious prevention method. METHODS A systematic review was performed by searching the PubMed, EBSCO, Scopus, and Web of Science databases for peer-reviewed articles published prior to February 2022 comparing two or more infection prophylaxis methods in patients younger than 22 years of age. Data were extracted for treatment modalities, patient demographics, and patient outcomes such as total number of infections, surgical site infections, deep infections, intraoperative blood loss, operative time, follow-up time, and postoperative complications. Quality and risk of bias was assessed using National Institutes of Health tools. A network meta-analysis was performed with reduction of infections as the primary outcome. RESULTS Overall, 10 studies consisting of 5164 procedures were included. There was no significant difference between prophylactic treatment options in reduction of infection. However, three treatment options showed significant reduction in total infection compared with no prophylactic treatment: Betadine plus vancomycin (OR 0.22, 95% CI 0.09–0.54), vancomycin (OR 3.26, 95% CI 1.96–5.44), and a combination therapy (Betadine, vancomycin, gentamicin, and cefuroxime) (OR 0.24, 95% CI 0.07–0.75). P-Score hierarchical ranking estimated Betadine plus vancomycin to be the superior treatment to prevent total infections, deep infections, and surgical site infections (P-score 0.7876, 0.7175, and 0.7291, respectively). No prophylaxis treatment–related complications were reported. CONCLUSIONS The results of this network meta-analysis show the strongest support for Betadine plus vancomycin as a method to reduce infections following pediatric spinal surgery. There was heterogeneity among studies and inconsistent outcome reporting; however, three effective treatment options are identified.
Introduction Patient referrals to tertiary level of care neurological services are often potentially avoidable and result in inferior clinical outcomes. To decrease transfer burden, stakeholders should acquire a comprehensive perception of specialty referral process dynamics. We identified associations between patient sociodemographic data, disease category and hospital characteristics and avoidable transfers, and differentiated factors underscoring informed decision making as essential care management aspects. Materials and methods We completed a retrospective observational study. The inclusion criteria were pediatric and adult patients with neurological diagnosis referred to our tertiary care hospital. The primary outcome was potentially avoidable transfers, which included patients discharged after 24 hours from admission without requiring neurosurgery, neuro-intervention, or specialized diagnostic methodologies and consult in non-neurologic specialties during their hospital stay. Variables included demographics, disease category, health insurance and referring hospital characteristics. Results Patient referrals resulted in 1615 potentially avoidable transfers. A direct correlation between increasing referral trends and unwarranted transfers was observed for dementia, spondylosis and trauma conversely, migraine, neuro-ophthalmic disease and seizure disorders showed an increase in unwarranted transfers with decreasing referral trends. The age group over 90 years (OR, 3.71), seizure disorders (OR, 4.16), migraine (OR, 12.50) and neuro-ophthalmic disease (OR, 25.31) significantly associated with higher probability of avoidable transfers. Disparities between pediatric and adult transfer cases were identified for discrete diagnoses. Hospital teaching status but not hospital size showed significant associations with potentially avoidable transfers. Conclusions Neurological dysfunctions with overlapping clinical symptomatology in ageing patients have higher probability of unwarranted transfers. In pediatric patients, disease categories with complex symptomatology requiring sophisticated workup show greater likelihood of unwarranted transfers. Future transfer avoidance recommendations include implementation of measures that assist astute disorder assessment at the referring hospital such as specialized diagnostic modalities and teleconsultation. Additional moderators include after-hours specialty expertise provision and advanced directives education.
Purpose Prove the concept of high-resistance proximal catheters for valve-independent treatment of hydrocephalus. Methods A preliminary design process yielded optimal high-resistance proximal ventricular catheters with a "scaled" design and parallel-oriented, U-shaped inlets. Prototypes were manually constructed using carving tools to stamp through silicone tubings. A testing apparatus was developed to simulate cerebrospinal fluid flow through a catheter, and the prototypes were tested against a control catheter for exhibition of an "on/off" phenomenon whereby no flow occurs at low pressures, and flow begins beyond a pressure threshold. Flow distribution was visualized with India ink. Regression analysis was performed to determine linearity. ResultsThe new designs showed varying amounts of improved flow control with the "scaled" design showing the most practical flow rate control across various pressures, compared to the standard catheter; however, no true "on/off" phenomenon was observed. The "scaled" design showed various degrees of dynamism; its flow rate can be time dependent, and certain maneuvers such as flushing and bending increased flow rate temporarily. Variation in the number of inlets within each "scaled" prototype also affected flow rate. Contrastingly, the flow rate of standard catheters was found to be independent of the number of inlet holes. Ink flow showed even flow distribution in "scaled" prototypes. Conclusions This initial feasibility study showed that high-resistance ventricular catheters can be designed to mimic the current/valved system. The "scaled" design demonstrated the best flow control, and its unique features were characterized.
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