Paediatric traumatic brain injury (pTBI) is a leading cause of death and disability in children globally. We reviewed pTBI data from a major UK healthcare centre, Alder Hey Children's Hospital, over a 12-month period to characterise clinical trends and predictors of emergency department (ED) re-attendance. 2707 children sustained a pTBI. Most were male (n = 1694, 62.6%), with an overall mean age of 4.96 years (SD 4.18). The dominant injury mechanism was a low energy fall from standing height (n = 1559, 57.6%). Short stay observation occurred in 7.7% (n = 209), and 1.7% (n = 45) required full hospital admission. Five patients (0.2%) underwent neurosurgical interventions, and one death was recorded (0.03%). Persistent post-concussion symptoms (PCS) drove unplanned re-attendance in 29 (1.1%) patients. Clinical signs at presentation were non-predictive of recovery trajectory, except for early emesis: frequent vomiting following injury was a clinical predictor of re-attendance with PCS (7.9% vs 0.6% for non-vomiting patient, p < 0.01). pTBI represents an immense healthcare volume, though most cases are mild and require minimal intervention. The cost of brief observation stays coupled with un-planned re-attendance highlights the need for objective stratification tools. Incorporating serum biochemical biomarkers represents a promising focus for future clinical risk-modelling.

This study investigated the effects of selective dorsal rhizotomy (SDR) on dystonia and dystonic posture in patients with cerebral palsy (CP) presenting with mixed spasticity and dystonia. A prospective, single-centre study was conducted at a UK supra-regional centre from May 2013 to September 2022. All children with spasticity, dystonia and/or dystonic posture undergoing SDR were included. The primary outcome measure was pre- and postoperative assessment of dystonic posture. Dystonia severity was measured using the Barry-Albright dystonia (BAD) scale. Two hundred and fifty-seven patients (aged 3–18 years) underwent SDR. Forty-three patients had dystonia and 52 exhibited dystonic posture without dystonia. At 3-month follow-up (n = 29), GMFCS levels tended to decrease, returning to baseline at 6 months (n = 25). Two patients required medication adjustments post-surgery. Dystonia levels remained unchanged in the dystonia group. In the dystonic posture group, 33 patients showed no change, while 21 improved. SDR may be beneficial for carefully selected patients with dystonia or dystonic posture, without worsening these conditions. Optimal patient selection, clear communication of surgical goals and multidisciplinary involvement are crucial.

Purpose Extremely premature neonates diagnosed with post-haemorrhagic hydrocephalus (PHH) are recognised to have particularly poor outcomes. This study assessed the impact of a number of variables on outcomes in this cohort, in particular the choice of shunt valve mechanism. Methods Electronic case notes were retrospectively reviewed of all premature neonates admitted to our centre for management of hydrocephalus between 2012 and 2021. Data included (i) gestational age, (ii) birth weight, (iii) hydrocephalus aetiology, (iv) surgical intervention, (v) shunt system, (vi) ‘surgical burden’ and (vii) wound failure and infection rate. Data was handled in Microsoft Excel and statistical analysis performed in SPSS v27.0 Results N = 53 premature hydrocephalic patients were identified ( n = 28 (52.8%) female). Median gestational age at birth was 27 weeks (range: 23–36 + 6 weeks), with n = 35 extremely preterm patients and median birth weight of 1.9 kg (range: 0.8–3.6 kg). Total n = 99 programmable valves were implanted ( n = 28 (28.3%) de novo, n = 71 (71.2%) revisions); n = 28 (28.3%) underwent n ≥ 1 pressure alterations, after which n = 21 (75%) patients had symptoms improve. In n = 8 patients exchanged from fixed to programmable valves, a mean reduction of 1.9 revisions per patient after exchange was observed (95%CI: 0.36–3.39, p = 0.02). Mean overall shunt survival was 39.5 weeks (95%CI: 30.6–48.5); 33.2 weeks (95%CI: 25.2–41.1) in programmable valves and 35.1 weeks (95%CI: 19.5–50.6) in fixed pressure ( p = 0.22) with 12-month survival rates of 25.7% and 24.7%, respectively ( p = 0.22). Shorter de novo shunt survival was associated with higher operation count overall (Pearson’s R : − 0.54, 95%CI: − 0.72 to − 0.29, p < 0.01). Wound failure, gestational age and birth weight were significantly associated with shorter de novo shunt survival in a Cox regression proportional hazards model; gestational age had the greatest impact on shunt survival (Exp(B): 0.71, 95%CI: 0.63–0.81, p < 0.01). Conclusion Hydrocephalus is especially challenging in extreme prematurity, with a shorter de novo shunt survival associated with higher number of future revisions. Programmable valves provide flexibility with regard to pressure setting, with the potential for fewer shunt revisions in this complex cohort.

Purpose Neuro-endoscopic lavage (NEL) is an increasingly popular intervention for intraventricular haemorrhage (IVH) and post-haemorrhagic hydrocephalus (PHH), with considerable variation in technique dependent on clinician and clinical circumstances. Whilst efforts to standardise the technique are ongoing, this work describes a tertiary centre experience utilising NEL, highlighting potential caveats to standardisation. Methods A retrospective review of electronic case notes for patients undergoing temporising surgical intervention for IVH between 2012 and 2021 at our centre was performed. Data collected included (i) gestational age, (ii) aetiology of hydrocephalus, (iii) age at time of intervention, (iv) intervention performed, (v) need for permanent CSF diversion, (vi) ‘surgical burden’, i.e. number of procedures following primary intervention, and (vii) wound failure and infection rate. Data was handled in Microsoft Excel and statistical analysis SPSS v27.0 Results 49 neonates ( n = 25 males) were included. Overall mean gestational age was 27 weeks and at intervention 35 + 3 weeks. IVH was the predominant cause of hydrocephalus (93.8%) and primary surgical interventions included insertion of a ventriculosubgaleal shunt (VSGS) in n = 41 (83.6%) patients, NEL in n = 6 (12.2%) patients and insertion of an EVD in n = 2 (4.1%). N = 9 (18.4%) patients underwent NEL at some point during the time interval reviewed; n = 4 (8.2%) received NEL monotherapy and n = 5 (10.2%) also received a VSGS. Rate of conversion to definitive CSF diversion between NEL ( n = 8, 88.9%) and VSGS cohorts ( n = 37, 92.5%) was not significantly different ( p = 0.57), nor between NEL alone ( n = 3, 75%) and NEL + VSGS ( n = 5, 100%) ( p = 0.44). None of the patients that underwent NEL monotherapy had any wound issues or CNS infection as a result of the initial intervention, compared to n = 3 (60%) of those that underwent NEL and implantation of VSGS ( p = 0.1). Conclusion Both NEL and VSGS are effective in temporising hydrocephalus in neonates, occasionally offering a definitive solution in and of themselves. The benefit of dual therapy however remains to be seen, with the addition of VSGS potentially increasing the risk of wound failure in an already vulnerable cohort.

Purpose Assess the effects of selective dorsal rhizotomy (SDR) on motor function and quality of life in children with a Gross Motor Function Classification System (GMFCS) level of IV or V (non-ambulatory). Methods This is a prospective, observational study in three tertiary neurosurgery units in England, UK, performing SDR on children aged 3–18 with spastic diplegic cerebral palsy, and a GMFCS level of IV or V, between 2012 and 2019. The primary outcome measure was the change in the 66-item Gross Motor Function Measure (GMFM-66) from baseline to 24 months after SDR, using a linear mixed effects model. Secondary outcomes included spasticity, bladder function, quality of life, and pain scores. Results Between 2012 and 2019, 144 children who satisfied these inclusion criteria underwent SDR. The mean age was 8.2 years. Fifty-two percent were female. Mean GMFM-66 score was available in 77 patients (53.5%) and in 39 patients (27.1%) at 24 months after SDR. The mean increase between baseline and 24 months post-SDR was 2.4 units (95% CI 1.7–3.1, p < 0.001, annual change 1.2 units). Of the 67 patients with a GMFM-66 measurement available, a documented increase in gross motor function was seen in 77.6% ( n = 52). Of 101 patients with spasticity data available, mean Ashworth scale decreased after surgery (2.74 to 0.30). Of patients’ pain scores, 60.7% ( n = 34) improved, and 96.4% ( n = 56) of patients’ pain scores remained the same or improved. Bladder function improved in 30.9% of patients. Conclusions SDR improved gross motor function and reduced pain in most patients at 24 months after surgery, although the improvement is less pronounced than in children with GMFCS levels II and III. SDR should be considered in non-ambulant patients.

Individuals recovering from surgery are at risk of nosocomial infections such as pneumonia. In this setting, the innate immune system faces competing inflammation in the injured skin and infected lung, raising the question of how the immune response prioritizes inflammatory sites. We hypothesized that the initiation of a lung infection would disrupt wound healing. Supporting this hypothesis, data from the ACS NSQIP database showed that the rate of laparotomy dehiscence in surgical patients with pneumonia was over double the rate of those without pneumonia. We next developed mouse models of post-operative pulmonary infection to assess cellular mechanisms. Using the tail skin excision and dorsal subcutaneous PVA sponge implantation wound healing models, we found that bacterial lung infection slowed the rate of wound closure and impaired wound neutrophil, monocyte, and cytokine/chemokine responses. Lung infection quickly suppressed wound fluid IL-1b and downstream chemokine concentrations within 6 hours of inoculation. IL-1 receptor antagonist (IL-1RA), an inhibitor of IL-1 signaling, was upregulated in the bronchoalveolar lavage fluid and plasma 6 hours after lung infection. Administration of IL-1RA to the wounds of uninfected mice phenocopied the effects of lung infection. Conversely, rIL-1b rescued wound inflammation when administered to the to the wounds of mice with lung infection, although this occurred at the expense of lung bacterial clearance. These results suggest that the infected lung induces IL-1RA systemically as a protective mechanism to tune inflammation at distal sites via IL-1b suppression, allowing the innate immune system to prioritize inflammatory insults. Supported by grants from Defense Advanced Research Projects Agency (DARPA), Brown University (Dean's Areas of Emerging New Science Award, Carney Institute Innovation Awards), and NIH (NIES T32-ES7272 Training in Environmental Pathology; NIGMS COBRE Award P20GM10935, NHLBI R01 126887),

Introduction: We present the largest series of paediatric intracranial empyemas occurring after COVID-19 infection to date, and discuss the potential implications of the pandemic on this neurosurgical pathology. Methods: Patients admitted to our centre between January 2016 and December 2021 with a confirmed radiological diagnosis of intracranial empyema were retrospectively reviewed, excluding non-otorhinological source cases. Patients were grouped according to onset before or after onset of the COVID-19 pandemic and COVID-19 status. A literature review of all post-COVID-19 intracranial empyemas was performed. SPSS v27 was used for statistical analysis. Results: Sixteen patients were diagnosed with intracranial empyema: n = 5 prior to 2020 and n = 11 after, resulting in an average annual incidence of 0.3% prior to onset of the pandemic and 1.2% thereafter. Of those diagnosed since the pandemic, 4 (25%) were confirmed to have COVID-19 on recent PCR test. Time from COVID-19 infection until empyema diagnosis ranged from 15 days to 8 weeks. Mean age for post-COVID-19 cases was 8.5 years (range: 7–10 years) compared to 11 years in non-COVID cases (range: 3–14 years). Streptococcus intermedius was grown in all cases of post-COVID-19 empyema, and 3 of 4 (75%) post-COVID-19 cases developed cerebral sinus thromboses, compared to 3 of 12 (25%) non-COVID-19 cases. All cases were discharged home with no residual deficit. Conclusion: Our post-COVID-19 intracranial empyema series demonstrates a greater proportion of cerebral sinus thromboses than non-COVID-19 cases, potentially reflecting the thrombogenic effects of COVID-19. Incidence of intracranial empyema at our centre has increased since the start of the pandemic, causes of which require further investigation and multicentre collaboration.

Amyotrophic lateral sclerosis is a rapidly progressive neurodegenerative disease that affects 1/350 individuals in the United Kingdom. The cause of amyotrophic lateral sclerosis is unknown in the majority of cases. Two-sample Mendelian randomization enables causal inference between an exposure, such as the serum concentration of a specific metabolite, and disease risk. We obtained genome-wide association study summary statistics for serum concentrations of 566 metabolites which were population matched with a genome-wide association study of amyotrophic lateral sclerosis. For each metabolite, we performed Mendelian randomization using an inverse variance weighted estimate for significance testing. After stringent Bonferroni multiple testing correction, our unbiased screen revealed three metabolites that were significantly linked to the risk of amyotrophic lateral sclerosis: Estrone-3-sulphate and bradykinin were protective, which is consistent with literature describing a male preponderance of amyotrophic lateral sclerosis and a preventive effect of angiotensin-converting enzyme inhibitors which inhibit the breakdown of bradykinin. Serum isoleucine was positively associated with amyotrophic lateral sclerosis risk. All three metabolites were supported by robust Mendelian randomization measures and sensitivity analyses; estrone-3-sulphate and isoleucine were confirmed in a validation amyotrophic lateral sclerosis genome-wide association study. Estrone-3-sulphate is metabolized to the more active estradiol by the enzyme 17β-hydroxysteroid dehydrogenase 1; further, Mendelian randomization demonstrated a protective effect of estradiol and rare variant analysis showed that missense variants within HSD17B1, the gene encoding 17β-hydroxysteroid dehydrogenase 1, modify risk for amyotrophic lateral sclerosis. Finally, in a zebrafish model of C9ORF72-amyotrophic lateral sclerosis, we present evidence that estradiol is neuroprotective. Isoleucine is metabolized via methylmalonyl-CoA mutase encoded by the gene MMUT in a reaction that consumes vitamin B12. Multivariable Mendelian randomization revealed that the toxic effect of isoleucine is dependent on the depletion of vitamin B12; consistent with this, rare variants which reduce the function of MMUT are protective against amyotrophic lateral sclerosis. We propose that amyotrophic lateral sclerosis patients and family members with high serum isoleucine levels should be offered supplementation with vitamin B12.

Individuals who are hospitalized with traumatic injuries are susceptible to pneumonia. The effect of lung infection on the course of wound healing is not well understood in this setting. To begin to understand this, we examined data from patients who had received laparotomies and found that those who developed pneumonia experienced higher rates wound dehiscence compared to those without pneumonia. Based on this finding and the known role for the innate immune system in responding to injuries and infections, we hypothesized that the immune system cannot meet the demands of competing inflammatory insults in the skin and lungs, leading to impairment of one or both responses. To test this, we established two murine models of post-injury lung infection in which mice are wounded by the dorsal subcutaneous implantation of polyvinyl alcohol (PVA) sponges or by tail skin excision, then infected intranasally with Klebsiella oxytoca. In these models, the presence of a wound did not alter the response to pulmonary infection. In contrast, pulmonary infection delayed the closure tail skin wounds. Pulmonary infection also led to rapid suppression of IL-1beta and chemokine levels, as well as decreased leukocyte accumulation, in PVA sponge wounds. The impaired wound healing observed in infected mice could be rescued by the addition of IL-1beta or the chemokines CCL2 and CXCL1 to the wound bed; however, these treatments caused a delay in bacterial clearance in the lungs. These data suggest that the immune response is not fully equipped to respond to disparate and competing inflammatory insults, which could have implications beyond the setting of post-injury pneumonia. Supported by grants from NIH (NIES T32-ES7272, NIGMS COBRE Award P20GM10935, and NHLBI R01HL126887), Defense Advanced Research Projects Agency (DARPA), and Brown University (Dean’s Areas of Emerging New Science Award and Carney Institute Innovation Awards)

BACKGROUND:The American College of Surgeons Resources for Optimal Care of the Injured Patient recommends using hypotension, defined as systolic blood pressure ≤90 mm Hg, as an indicator of a full team trauma activation. We hypothesized that an elevated shock index (SI) predicts significant traumatic injuries better than hypotension alone.METHODS:This is a retrospective cohort study analyzing full team trauma activations between February 2018 and January 2020, excluding transfers and those who had missing values for prehospital blood pressure or heart rate. We reviewed patients' demographics, prehospital and emergency department vitals, injury pattern, need for operation, and clinical outcomes. The primary outcome was rate of significant injury defined as identified injured liver, spleen, or kidney, pelvis fracture, long bone fracture, significant extremity soft tissue damage, hemothorax, or pneumothorax.RESULTS:Among 544 patients, 82 (15.1%) had prehospital hypotension and 492 had normal blood pressure. Of the patients with prehospital hypotension, 34 (41.5%) had a significant injury. There was no difference in age, gender, medical history, or injury pattern between the two groups. There was no difference between the two groups in rate of serious injury (41.5% vs. 46.1%, NS), need for emergent operation (31.7% vs. 28.1%, NS) or death (20.7% vs. 18.8%, NS). On the other hand, SI ≥1 was associated with increased rate of serious injury (54.6% vs. 43.4%, p=0.04). On a logistic regression analysis, prehospital hypotension was not associated with significant injury or need for emergent operation (OR 0.83, 95% CI 0.51 to 1.33 and OR 1.32, 95% CI 0.79 to 2.25, respectively). SI ≥1 was associated with both increased odds of significant injury and need for emergent operation (OR 1.57, 95% CI 1.01 to 2.44 and OR 1.64, 95% CI 1.01 to 2.66).DISCUSSION:SI was a better indicator and could replace hypotension to better categorize and triage patients in need of higher level of care.LEVEL OF EVIDENCE:Prognostic and epidemiologic, level III.

Purpose Achieving decompression without CSF over-drainage remains a challenge in hydrocephalus. Differential pressure valves are a popular treatment modality, with evidence suggesting that incorporation of gravitational units helps minimise over-drainage. This study seeks to describe the utility of the proGAV®2.0 programmable valve in a paediatric population. Methods Clinical records and imaging of all patients fitted with proGAV®2.0 valves and Miethke fixed-pressure valves between 2014 and 2019 at our tertiary centre were analysed. Patient demographics, indication for shunt and valve insertion/revision and time to shunt/valve revision were collected. Ventricular linear metrics (fronto-occipital horn ratio (FOHR) and fronto-occipital horn width ratio (FOHWR)) were collected pre- and post-valve insertion. Microsoft Excel and SPSS v24 were used for data collection and statistical analysis. Results Eighty-eight proGAV®2.0 valves were inserted in a population of 77 patients ( n = 45 males (58%), mean age 5.1 years (IQR: 0.4–11.0 years)). A total of 102 Miethke fixed-pressure valves were inserted over the same time period. Median follow-up was 17.5 months (1.0–47.3). One (1.1%) proGAV®2.0 was revised due to over-drainage, compared to 2 (1.9%) fixed-pressure valves ( p > 0.05). ProGAV®2.0 insertion resulted in a significant decrease in the mean number of revisions per patient per year (1.77 vs 0.25; p = 0.01). Overall shunt system survival with the proGAV®2.0 was 80.4% at 12 months, and mean time to revision was 37.1 months, compared to 31.0 months (95%CI: 25.7–36.3) and 58.3% in fixed-pressure valves ( p < 0.01). Significant decreases were seen following proGAV®2.0 insertion in both FOHR and FOHWR, by 0.014 (95%CI: 0.006–0.023, p = 0.002) and 0.037 (95%CI: 0.005–0.069, p = 0.024) respectively. Conclusion The proGAV®2.0 provides effective decompression of hydrocephalic patients, significantly reduces the number of valve revisions per patient and had a significantly greater mean time to revision than fixed-pressure valves.

Summary Studies of the immune response typically focus on single-insult systems, with little known about how multi-insult encounters are managed. Pneumonia in patients recovering from surgery is a clinical situation that exemplifies the need for the patient to mount two distinct immune responses. Examining this, we have determined that poor wound healing is an unreported complication of pneumonia in laparotomy patients. Using mouse models, we found that lung infection suppressed the trafficking of innate leukocytes to wounded skin, while pulmonary resistance to the bacterial infection was maintained. The dual insults caused distinct systemic and local changes to the inflammatory response, the most striking being a rapid and sustained decrease in chemokine levels at the wound site of mice with pneumonia. Remarkably, replenishing wound chemokine levels completely rescued the wound-healing rate in mice with a pulmonary infection. These findings have broad implications for understanding the mechanisms guiding the innate immune system to prioritize inflammatory sites. One Sentence Summary Chemokine-mediated signaling drives the prioritization of innate immune responses to bacterial pulmonary infection over cutaneous wound healing. Highlights Human laparotomy patients with pneumonia have an increased rate of incision dehiscence, and this observation can be recapitulated in mouse models of bacterial lung infections and skin wounds. Lung infection causes rapid and sustained suppression of skin wound chemokine and inflammatory cytokine production as well as leukocyte recruitment. Unique systemic shifts in the immune compartment occur with two inflammatory insults, including the cytokine/chemokine signature and the mobilization, recruitment, and phenotype of innate leukocytes. Restoration of chemokine signaling in the wounds of mice that have a lung infection results in increased neutrophil trafficking to the wound site and rescues the rate of healing. Graphical Abstract

None to declare. The data that support the findings of this study are available from the corresponding author upon reasonable request.

Background: Following the publication of the Management of Myelomeningocele study (MOMS), fetal repair of myelomeningocele (MMC) has become increasingly prevalent worldwide. However, limited case presentations exist illustrating the potential mechanical and embryological effects of fetal repair. We present a unique case report of a complex embryological cervicomedullary junction (CMJ) malformation and cerebellar hypoplasia following fetal repair of MMC. Case Description: A 1-day-old female was referred to the paediatric neurosurgical team after having successful surgical intrauterine closure of MMC abroad at 25 weeks gestation. The patient was born by emergency caesarean section at 33 weeks gestation and had a ventricular-peritoneal shunt inserted at 25 days old due to resulting hydrocephalus. Neonatal MRI scans revealed a complex number of malformations that included a split cord located at the CMJ, hypoplasia of the cerebellum and vermis, and a Chiari type II malformation. Conclusion: It is possible that the clefting of the upper cervical spinal cord was undetected at preoperative MRI; however, this is unlikely given the antenatal images. It is our hypothesis that the malformation may have exhibited mechanical change after the repair, as the preoperative MRI showed only a Chiari II malformation without any of the complex abnormalities being present and the split cord was already there but not obvious. There are no existing reports of such a complex malformation following antenatal surgery in the literature. This should be further explored as more cases and trials become available.

Hypoxia is a feature of neurodegenerative diseases, and can both directly and indirectly impact on neuronal function through modulation of glial function. Astrocytes play a key role in regulating homeostasis within the central nervous system, and mediate hypoxia-induced changes in response to reduced oxygen availability. The current study performed a detailed characterization of hypoxia-induced changes in the transcriptomic profile of astrocytes in vitro. Human astrocytes were cultured under normoxic (5% CO2, 95% air) or hypoxic conditions (1% O2, 5% CO2, 94% N2) for 24 h, and the gene expression profile assessed by microarray analysis. In response to hypoxia 4904 genes were significantly differentially expressed (1306 upregulated and 3598 downregulated, FC ≥ 2 and p ≤ 0.05). Analysis of the significant differentially expressed transcripts identified an increase in immune response pathways, and dysregulation of signalling pathways, including HIF-1 (p = 0.002), and metabolism, including glycolysis (p = 0.006). To assess whether the hypoxia-induced metabolic gene changes observed affected metabolism at a functional level, both the glycolytic and mitochondrial flux were measured using an XF bioanalyser. In support of the transcriptomic data, under physiological conditions hypoxia significantly reduced mitochondrial respiratory flux (p = 0.0001) but increased basal glycolytic flux (p = 0.0313). However, when metabolically stressed, hypoxia reduced mitochondrial spare respiratory capacity (p = 0.0485) and both glycolytic capacity (p = 0.0001) and glycolytic reserve (p < 0.0001). In summary, the current findings detail hypoxia-induced changes in the astrocyte transcriptome in vitro, identifying potential targets for modifying the astrocyte response to reduced oxygen availability in pathological conditions associated with ischaemia/hypoxia, including manipulation of mitochondrial function, metabolism, and the immune response.

Vein of Galen aneurysmal malformation (VGM) is a rare congenital abnormality of the embryonic choroid plexus, accounting for 1% of intracranial vascular malformations1. First described by Raybaud et al.1, the malformation develops during weeks 6–11 of fetal development, and the pathology consists of a direct communication between feeding arteries and the median prosencephalic vein of Markowski2. Whilst VGM may account for 30% of all pediatric vascular malformations1, it is very rare, with a prevalence of 1 in 25 000 singleton births and even fewer cases having been described in the setting of twins3-6 (Table 1). We report a case of VGM affecting one twin in a spontaneously conceived dichorionic diamniotic twin pregnancy. To the best of our knowledge, this is only the fourth reported case of its kind. An 18-year-old Caucasian woman with dichorionic diamniotic twin pregnancy was referred to the fetal-medicine unit at Liverpool Women's Hospital, Liverpool, UK, in February 2018 at 31 + 4 weeks' gestation due to suspected ventriculomegaly in Twin 2 (male). Twin 1 (female) was breech but otherwise had normal anatomy. In Twin 2, a cystic structure measuring 32 × 30 × 28 mm and demonstrating turbulent flow was identified in the posterior part of the brain, accompanied by numerous feeding vessels (Figure 1). Cerebellar compression secondary to the cystic structure was present, with evidence of associated bilateral ventriculomegaly with ventricular atrial width of 18 mm (Figure 2). Twin 2's heart appeared structurally normal but showed signs of cardiomegaly, likely secondary to a hyperdynamic circulation. The ultrasound findings strongly supported a diagnosis of VGM. Magnetic resonance imaging (MRI) confirmed the diagnosis. The report also suggested a thrombus in the VGM and its inferior extension, causing significant compression of the brain stem. Following multidisciplinary review of the MRI examinations by the neurosurgical and interventional neuroradiology teams, the parents were counseled about the very poor prognosis of the condition and the high likelihood that Twin 2 would not survive to delivery or beyond the neonatal period due to heart failure. The parents declined selective feticide and input from the palliative care team. The pregnancy was monitored twice weekly in our fetal medicine unit. The condition of Twin 2 remained stable, with no worsening of cardiac status. Both babies were born by elective Cesarean section at 37 + 2 weeks following administration of antenatal steroids. Twin 1 was well at birth and discharged as normal. Twin 2 made no spontaneous respiratory effort following delivery, requiring intubation and ventilation. High-output cardiac failure was identified, with dilated vessels and retrograde flow in the transverse and descending aorta secondary to the large VGM. On admission of Twin 2 to the neonatal intensive care unit (NICU), inotropic support was required to maintain adequate cardiac output and blood products to correct coagulopathy. Despite passing urine, renal function was deranged on serology. An interventional endovascular procedure was attempted but, due to the extent of tributary involvement, feeding vessels and fistulae, the intervention was deemed futile and abandoned. The patient returned to the NICU and, after further discussions with the parents, they decided to stop active interventions. Twin 2 died some hours later. The parents declined a postmortem examination.

Background: Cutimed ® Sorbact ® is a dressing marketed as having antimicrobial properties and easy application without the threat of antibiotic resistance and difficult accessibility. There is little evidence on the clinical outcomes of the use of Cutimed ® Sorbact ® in adults and currently no evidence of use of Cutimed ® Sorbact ® on superficial-partial thickness burn injuries in children. Objective: To summarise the clinical outcome of burn wounds in children with superficial-partial thickness burns in which Cutimed ® Sorbact ® was used. Method: An observational case series was conducted in Edendale Hospital, Pietermaritzburg, South Africa over the course of four weeks. Patients where included if they were aged < 10 years and had a ⩽ 15% superficial-partial burn. The primary outcome measure was time to 95% re-epithelialisation. Secondary outcome measures included wound complications, adverse healing and number of dressing changes. Results: Ten patients (five girls, five boys; age range = 11 months–8 years) were included in this case series. All participants had a type VI Fitzpatrick skin type and 80% of burns were hot water burns. Of all patients treated with Cutimed ® Sorbact ® , 50% healed within seven days, 70% within 14 days and 100% within 21 days. There was only one wound complication noted in this study and there was no adverse healing in any burn wounds. The mean number of dressing changes was 1.4 (range = 1–2) and length of hospital stay was in the range of 0–11 days (mean = 5.1 days). Conclusion: Cutimed ® Sorbact ® is a safe, useful and cost-effective dressing that should be used as an alternative for superficial-partial burns in children.

Background: Lymphocytes have become the target of cancer interventions through engineering or immune checkpoint antibodies. We previously found decreased lymphocyte counts to be a predictor of mortality and complications in trauma and cardiac surgery patients. We hypothesized lack of lymphocyte count recovery postoperatively would predict outcomes in esophagectomy patients. Methods: A retrospective review of all patients undergoing esophagectomy for adenocarcinoma performed over 13 y at our center by a single surgeon after institutional review board approval was performed. Patients were grouped by postoperative lymphocytes counts: never low, low with recovery, and low without recovery. Resolution of lymphopenia was assessed by day 4. Primary end points were overall and recurrence-free survival. Results: In total, 198 patients were included with a minimum 6-mo follow-up. Collectively the 5-y recurrence and overall survival rates were 36% and 50%, respectively. Recurrence was significantly higher at 5 y in patients with persistent lymphopenia (43%) compared with those who recovered (14% P = 0.0017) and those who never dropped (0% P = 0.0009). The persistent lymphopenia group had significantly lower survival (45%) compared with the two other groups (67% P = 0.0232). Conclusions: There is a significant decrease in the overalland recurrence-free survival in those patients whose lymphocyte count drops without recovery after their esophagectomy. These data imply differences in immune responses to the stress of surgery that can be measured with routine postoperative laboratory values and are indicative of overall outcomes. (C) 2019 Elsevier Inc. All rights reserved.

Abstract Aim Current standard of care for glioblastoma is maximum safe resection followed by radio chemotherapy with Temozolomide. Older patients are less likely to receive the full treatment. The aim was to determine treatment and outcomes in glioblastoma patients >65 years. Methods Single centre retrospective study from 2001–2016. Eligible patients had: (i) diagnosis of glioblastoma (ii) undergone biopsy or resection with radiotherapy ± adjuvant chemotherapy. Age at diagnosis, type of surgery, performance status, complications, adjuvant therapy and median survival (MS) were recorded. Patients were assigned to group A (age <65), B (age 65–69 years) or C (age >/= 70 years). Results 637 patients met the eligibility criteria and 403 had complete records for analysis. Age distribution of the cohort was 17.9 – 91.6 years. In the group A (n=259), those who had undergone resection had significantly longer MS compared to biopsy: 17.2 vs 13.2 months (P<0.05 CI: 444.043 – 561.957). 70 patients developed complications. In the group B (n=79), those who had undergone resection had significantly longer MS compared to biopsy: 12.3 vs 5.1 months (P<0.05 CI: 194.354 – 335.646). 17 patients developed complications. In the group C (n=64), analysis did not show statistically significant difference (P=0.066 CI: 220.476 – 321.524). Clinically, patients who had resection had longer MS (10.5 months vs 3.5 months). Furthermore, there was no significant difference in the rate of complications between resection and biopsy (Fisher’s exact test, P=0.755). Conclusion i) Patients >65 should be treated as per the Stupp protocol ii) In patients >70 surgical resection should be considered.: