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Hector E. James

OBJECTIVE

The author describes the creation, structuring, and development of a pediatric neurosurgery telemedicine clinic (TMC) to provide telehealth across geographical, time, social, and cultural barriers.

METHODS

In July 2009 the University of Florida (UF) Division of Pediatric Neurosurgery received a request from the Southeast Georgia Health District (Area 9–2) to provide a TMC to meet regional needs. The Children's Medical Services (CMS) of the State of Georgia installed telemedicine equipment and site-to-site connectivity. Audiovisual connectivity was performed in the UF Pediatric Neurosurgery office, maintaining privacy and HIPAA (Health Insurance Portability and Accountability Act) requirements. Administrative steps were taken with documentation of onsite training of the secretarial and nursing personnel of the CMS clinic. Patient preregistration and documentation were performed as required by the UF College of Medicine–Jacksonville. Monthly clinics are held with the CMS nursing personnel presenting the pertinent clinical history and findings to the pediatric neurosurgeon in the presence of the patient/parents. Physical findings and diagnostic studies are discussed, and management decisions are made.

RESULTS

The first TMC was held in August 2011. A total of 40 TMC sessions have been held through January 2016, with a total of 43 patients seen: 13 patients once; 13 patients twice; 8 patients for 3 visits; 2 for 4 visits; 2 for 6 visits; 2 for 5 visits; 2 for 7 visits; and 1 patient has been seen 8 times.

CONCLUSIONS

Pediatric patients in areas of the continental US and its territories with limited access to pediatric neurosurgery services could benefit from this model, if other pediatric neurosurgery centers provide telehealth services.

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Hector E. James and Graham Lubinsky

Object

The authors describe the cases of eight patients with terminal myelocystoceles and report on their initial diagnoses, neuroimaging findings, surgical procedures, and clinical follow-up examinations.

Methods

There were seven girls and one boy. The initial age at diagnosis ranged from prenatal age (determined by imaging) to 14 years. Operative correction was performed from 6 weeks to 14 years of age. One patient presented with a large prevertebral (intraabdominal) meningocele. Four patients have associated abdominal wall defects and are significantly handicapped. Two are wheelchair bound and the other two ambulate with prosthetic devices; all are incontinent. The four patients without abdominal wall defects are fully ambulatory; one wears an ankle—foot orthosis. One patient has normal bowel and bladder functions, and the other three require intermittent clean catheterization. No patient to date has had clinical evidence of retethering, although a low-set conus medullaris and residual lipoma were visible on postoperative neuroimaging. No patient in this series had hydrocephalus or Chiari malformation.

Conclusions

It is concluded that patients with myelocystoceles without abdominal wall defects have a favorable neurological outcome when compared with those having ventral wall defects.

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Hector E. James and Richard Postlethwait

Object

The authors describe a series of attempts to treat with minimally invasive surgery cerebrospinal fluid (CSF) fistulas that develop following operations of the spine for congenital anomalies.

Methods

Sixteen patients in whom CSF fistulas developed following repair of congenital spinal disorders (nine lipomeningoceles, one arachnoid cyst, two myelocystoceles, three tethered cords after myelomeningocele repair, and one scoliosis surgery) underwent placement of a temporary subcutaneous peritoneal shunt. The CSF fistulas resolved in all instances. Two patients required revision of the shunts prior to resolution of the fistula and subsequent shunt removal. Three patients suffered a lumbar wound or shunt infection, which necessitated shunt removal. Subsequent to the removal, the infection resolved and there was no recurrence of the CSF leak. Fourteen patients had their shunts completely removed within 1 year of placement. Two patients did not have their shunts removed because parental consent for the additional surgery was not given.

Conclusions

Postoperative subcutaneous CSF fistulas of the spine can be successfully treated using temporary subcutaneous peritoneal shunts. This procedure reduces hospital stay and obviates the need for more extensive or multiple surgical interventions.

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Hector E. James

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Hector E. James

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Hector E. James and John S. Bradley

Object

The authors present their experience with a protocol for the treatment of patients with complicated shunt infections.

Methods

Complicated shunt infections are defined for the purpose of this protocol as multiple compartment hydrocephalus, multiple organism shunt infection, severe peritonitis, or infections in other sites of the body. The initial treatment protocol for these patients was 3 weeks of intravenous antibiotic therapy and 2 weeks of twice daily intraventricular/intrashunt antibiotic therapy. Cerebrospinal fluid (CSF) cultures were monitored during therapy and obtained again 48 hours after completion. The shunt was completely replaced. Additionally, follow-up cultures were obtained in all patients 3–6 months after therapy was completed.

Results

A cure of the infection was achieved in all patients as defined by negative cultures obtained at completion of antibiotic therapy and in follow-up studies. The follow-up period was 2–11 years (mean 4.4 ± 2.5 years). The treatment protocol was modified in the patients treated after 1991, and 18 patients were treated with this modified treatment regime. In these patients, intraventricular antibiotics were administered only once daily for 14 days, and the CSF was cultured 24 hours after antibiotic therapy had been stopped instead of after 48 hours. The results were similar to those obtained with the initial protocol.

Conclusions

Based on their prospective nonrandomized series, the authors believe that patients with complicated shunt infections can be successfully treated with 2 weeks of intraventricular antibiotic therapy administered once daily, concurrent with 3 weeks of intravenous antibiotic therapy. This protocol reduces length of treatment and hospital stay, and avoids recurrence of infection.

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Hector E. James, Richard A. Postlethwait and E. Dayan Sandler

The authors describe 3 children who presented with progressively enlarging skin-covered solid masses over the shunt catheter in the neck/clavicular region. The authors reviewed the clinical, laboratory, pathological, radiographic, and follow-up data for all 3 patients and reviewed the literature on the subject. The patients had no clinical evidence of an infectious process. Surgical exploration revealed that masses were surrounding and encasing the shunt tubing to which they were strongly attached. Pathological studies of the tissues demonstrated varying degrees of exuberant chronically inflamed granulation tissues, interstitial fibrosis, and dystrophic calcification. One patient had associated thinning of the skin overlying the mass and subsequently developed ulceration. No infectious organisms were observed. The cerebrospinal fluid aspirates from the shunts did not yield any organisms. There has been no recurrence of the masses. The presence of a growing mass over the shunt tube in the neck or the chest region without clinical evidence of infection does not indicate that the mass should be treated with antibiotics and complete shunt removal. Rather, the mass can be cured by extirpation and with “bypass” new shunt tubing locally.

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Philipp R. Aldana, Hector E. James and Richard A. Postlethwait

Object

The authors report a clinical protocol for the application of ventriculogallbladder (VGB) shunts in children who may be unable to maintain or receive ventriculoperitoneal (VP) shunts.

Methods

Eighteen patients underwent placement of VGB shunts as an alternative to VP shunt therapy for the following reasons: malfunction of the VP shunt due to suspected failure of the peritoneum to absorb cerebrospinal fluid (17 cases) and multiple intraabdominal general surgical procedures (1 case). The patients ranged in age from 4 months to 17 years (mean 6.5 ± 6.1 years [standard deviation {SD}]). All patients underwent preoperative imaging of the gall-bladder either by ultrasonography or computed tomography scanning. A team consisting of a pediatric neurological surgeon and a pediatric general surgeon performed all operative procedures. The procedures were conducted by open laparotomy to precisely place the appropriate length of distal catheter and to anchor it to the gallbladder wall.

Results

There were 2 early shunt malfunctions, both obstructions due to “sludge” (1 in the biliary duct and 1 in the common bile duct). A late-onset (5-year) malfunction occurred secondary to gallbladder stones. In all 3 cases of malfunction, the devices were successfully converted to VP shunts. In 1 patient a conversion to a VP shunt was chosen following a general surgical intervention. There were 2 shunt infections (Staphylococcus epidermidis and Haemophilus influenzae). These were successfully treated. Two patients underwent conversion to a VGB shunt on 2 occasions. Thirteen patients had functional VGB shunts at the time of their last follow-up assessment. The follow-up for these 13 patients ranged from 1 to 8 years (mean 2.1 ± 2.0 years [SD]).

Conclusions

Ventriculogallbladder shunts may be considered for the treatment of hydrocephalus in children when the peritoneal cavity cannot be used as a distal terminus.

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Hector E. James, Luis Schut and Patrick P. Pasquariello

✓ A 3-year-old child who had had respiratory and feeding difficulties at birth was admitted because of respiratory distress and stridor. Radiological evaluation with Pantopaque and air myelography revealed an Arnold-Chiari malformation associated with extensive hydromyelia and communication between the fourth ventricle and the hydromyelic cavity.