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The microscopic transciliary SupraOrbital keyhole (mtSO) approach has been used for a wide variety of anterior and middle fossa pathologies, including aneurysms, meningiomas, craniopharyngiomas, and other skull-base tumors. Several clinical series have proven its efficacy and safety, but detailed anatomical demarcations of the anterior and middle cranial base exposure are lacking. Our aim was to define the surgical limitations of the mtSO approach to the ipsilateral and contralateral anterior and middle skull base.Five cadaveric specimens (10 sides) were studied with image guidance to illustrate the limits of the surgical exposure. In addition, 30 dry skulls were used to measure the working distances between the craniotomy and key bony landmarks of the mtSO approach.Surgical exposure at the anterior skull base covered the area between the medial half of the contra- and the medial two-thirds of the ipsilateral sphenoid wing including both optic nerves and interoptic space. The anterior limit at the midline was the sphenoethmoidal suture. Ipsilateral anterior clinoidectomy permitted exposure of the superior orbital fissure, which defined the anteromedial limit at the middle fossa, whereas the anterolateral limit was defined by the ophthalmic branch of the trigeminal nerve. Moreover, the posteromedial and posterolateral limits were the posterior clinoid process and the petrous ridge, respectively.Our findings define the surgical limitations of the mtSO approach for the treatment of anterior and middle cranial base pathologies. These limits can be reliably identified on imaging studies allowing assessment of exposure to guide preoperative case selection.

A number of studies have demonstrated that patients with autoimmune disease have lower levels of vitamin D prompting speculation that vitamin D might suppress inflammation and immune responses in children with juvenile idiopathic arthritis (JIA). The objective of this study was to compare vitamin D levels in children with JIA at disease onset with healthy children. We hypothesized that children and adolescents with JIA have lower vitamin D levels than healthy children and adolescents. Data from a Canadian cohort of children with new-onset JIA (n= 164, data collection 2007-2012) were compared to Canadian Health Measures Survey (CHMS) data (n=4027, data collection 2007-2011). We compared 25-hydroxy vitamin D (25(OH)D) concentrations with measures of inflammation, vitamin D supplement use, milk intake, and season of birth. Mean 25(OH)D level was significantly higher in patients with JIA (79 ± 3.1 nmol/L) than in healthy controls (68 ± 1.8 nmol/L P.05). Patients with JIA more often used vitamin D containing supplements (50% vs. 7%; P.05). The prevalence of 25(OH)D deficiency (30 nmol/L) was 6% for both groups. Children with JIA with 25(OH)D deficiency or insufficiency (50 nmol/L) had higher C-reactive protein levels. Children with JIA were more often born in the fall and winter compared to healthy children. In contrast to earlier studies, we found vitamin D levels in Canadian children with JIA were higher compared to healthy children and associated with more frequent use of vitamin D supplements. Among children with JIA, low vitamin D levels were associated with indicators of greater inflammation.

Musculoskeletal (MSK) complaints in children and adolescents are common. The differential diagnosis is broad and based predominantly on clinical assessment. The skills both for eliciting history and for examination require understanding of the child/young person's specific emotional and cognitive developmental stage; interpretation of the findings requires knowledge of normal (and abnormal) motor and musculoskeletal growth and development. We specifically describe the different approach, unique skills and knowledge required by all clinicians who assess children and adolescents with MSK complaints; children and adolescents are not 'just little adults'. We emphasize the importance of clinical competence in ensuring that patients with juvenile idiopathic arthritis are diagnosed early and referral to specialist centres is not delayed with consequential suboptimal management and outcome. There is evidence that physician clinical skills in MSK assessment are inadequate, probably as a result of systemic deficiencies in the education process. Current and proposed solutions are discussed.

We performed serial CT scans at the time of admission and discharge, and again after 6 to 18 months, in children older than 2 months of age with bacterial meningitis. During the 2-year study period, 60 patients with bacterial meningitis were admitted to British Columbia's Children's Hospital. Forty-one were included in the study, two of whom died soon after admission. The infecting organism was Haemophilus influenzae in 29, Neisseria meningitidis in six, and Streptococcus pneumoniae in six. Abnormalities on the first two CT scans included subdural effusion in eight patients, focal infarction in five, and pus in the basal cisterns in one. All patients with focal infarction or cisternal pus had hemiparesis. Marked cerebral edema was seen in the two patients who died. Transient mild dilation of the subarachnoid space was a common finding; the size of the ventricles or subarachnoid space was increased on the second scan in 29 of 36 patients, and decreased to normal on the third scan in 30 of 33 patients. Clinical management was not influenced by the CT findings, which failed to reveal any clinically significant abnormalities that were not suspected on neurologic examination.