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BACKGROUND Minimally-invasive endoscopic strip-craniectomy (or suturectomy) for the repair of craniosynostosis combined with postoperative cranial orthotic molding has been widely adopted in the past 2 decades, proving itself as a safe and effective procedure. Over time the authors transitioned from performing an endoscopic strip-craniectomy, to performing the same surgery without the endoscope. The authors here describe our technique and compare its results to those published in the literature for endoscopic suturectomies. METHODS A retrospective chart review was performed for patients with nonsyndromic craniosynostosis who underwent minimally-invasive nonendoscopic suturectomy between 2019 and 2020 at our institution. RESULTS Thirteen patients (11 males; 2 females) were operated including 5 Metopic, 5 Sagittal, 2 coronal, and 1 lambdoid craniosynostosis. The average age at surgery was 4.35 months. The average length of surgery was 71 minutes. Averaged intraoperative estimated blood loss was 31.54 mL. Eleven patients received a blood transfusion (most before performing the skin incision) with a mean amount of 94.62 mL of blood transfused during surgery. The mean hemoglobin at discharge was 10.38 mg/dL. There was only 1 intraoperative mild complication. The mean intrahospital length of stay was 1.77 days with no postoperative complications noted. All patients initiated remodeling orthotic treatment following surgery. Long-term follow-up scans were available for 8 patients (5 metopic, 2 sagittal, and 1 lambdoid) with an average follow-up of 9 months. In all cases, there was a significant improvement in the skull width at the synostosis location as well as in the skull proportions and symmetry. The above outcomes are similar to those published in the literature for endoscope-assisted strip-craniectomies. CONCLUSIONS Suturectomies assisted with cranial orthosis remodeling for the treatment of all types of nonsyndromic craniosynostosis can be performed without an endoscope while maintaining minimal-invasiveness, good surgical results, and low complication rates.

Background Primary breast cancer in the pediatric population is rare. To our knowledge, no cases of intracystic papillary carcinoma have been reported in patients younger than 21 years. Case A 16-year-old patient presented with a retroareolar mass and bloody nipple discharge in her left breast. A biopsy established papillary intracystic carcinoma. The patient was treated surgically and a risk reduction strategy developed in a multidisciplinary session was implemented.

Cranioplasty is commonly performed to treat craniosynostosis. A rare postsurgical complication is massive brain swelling with elevated intracranial pressure. This commonly presents with mydriasis, coma, and seizures; radiologic findings include cerebral edema, parenchymal hemorrhages, and ischemic changes.The authors describe a 9-year-old boy who developed massive brain swelling following reduction cranioplasty for secondary turricephaly. His history included surgical repair of metopic-craniosynostosis at age 5.5 months, by means of an anterior cranial-vault reconstruction with fronto-orbital advancement. After presenting to our clinic with a significant turricephalic skull deformity, he underwent cranial reduction cranioplasty. On postoperative day 1, mild neurological signs associated to increased intracranial pressure were noticed. As they worsened and massive brain swelling was identified, he was treated pharmacologically. On postoperative day 13, the patient was operated for decompression.A literature review yielded 4 articles related to massive brain swelling for post-traumatic craniectomies. None described elevated intracranial pressure or massive brain swelling following cranial reduction for secondary craniosynostosis. The main dilemma regarding our patient was the necessity and timing of a second operation.The literature did not reveal relevant recommendations regarding treatment timing nor preventative measures.The authors recommend presurgical neuro-ophthalmological and imaging evaluation, for comparisons and management during the immediate and short-term follow-ups. The authors suggest that for a patient presenting with signs and symptoms of cerebral edema or high intracranial pressure following reduction-cranioplasty, pharmacological treatment should be initiated promptly, and careful drainage and eventual surgical-treatment should be considered if no improvement is shown in the subsequent days.

High grade gliomas (HGG) in children carry a dismal prognosis. Standard therapy includes resection when possible, radiotherapy and sometimes the addition of temozolomide. There is no standard treatment for progression or relapse. Since November 2018 we have offered upfront molecular testing to all children with HGG who had biopsy/ resection. Testing was mainly done by next generation sequencing panel, and some had research based methylation profiling and RNA seq. We aimed to see whether families chose to receive additional investigational treatment as a result of the molecular testing results and whether the treatment involved participation in a clinical study, or whether treatment was compassionate. A total of 22 patients aged 2.8-16.8 years with HGG had a biopsy/resection over this three year period. Thirteen had diffuse midline glioma (DMG) of which 11 had the H3K27 mutation, and 9 were cortical. Six children had underlying predisposition syndromes: mismatch repair deficiency (n=3 proven + 1 highly suspected), neurofibromatosis1 (n=1), Li-Fraumeni (n=1). All the cortical gliomas had potential treatment options based on their molecular testing. 10/22 (45%) children received investigational therapy of which only three participated in a clinical study while the rest received compassionate therapy. Compassionate treatments included BRAF/MEK inhibitors (n=4), Larotrectinib (n=1), and immune checkpoint inhibitors (n=2). Of the 12 who did not receive investigational therapy, four, all cortical, have potential therapy options but are currently in remission. Of the remaining eight, two had very rapid clinical deterioration and died, and six (all DMG) did not wish/ were unable to travel abroad and no relevant clinical study was available locally. We conclude that the families of children with HGG are highly motivated to receive investigational therapy. Upfront molecular testing of these tumors, especially for cortical HGG, is imperative and there is a growing need for accessible clinical studies.

OBJECTIVE Pediatric idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure despite normal cerebrospinal fluid and neuroimaging findings. Initial management is typically medical; however, nearly 10% of children will eventually require surgery for persistent headache and/or vision loss. External lumbar drainage, which is a considerably safer treatment option, has not been adequately analyzed in children with medically refractory IIH. METHODS The authors conducted a single-institution retrospective analysis of children with medically refractory IIH who had undergone external lumbar drain (ELD) placement because of worsening papilledema, reflected as increased retinal nerve fiber layer (RNFL) thickness on optical coherence tomography (OCT) testing. The main outcome measures were effects of external lumbar drainage on papilledema resolution, symptoms, and vision. RESULTS The authors analyzed the medical records of 13 children with IIH (11 girls, mean age 15.0 ± 2.3 years) whose mean CSF opening pressure was 45.5 ± 6.8 cm H2O. In all children, the average global RNFL thickness in both eyes significantly increased at ELD placement (right eye 371.8 ± 150.2 μm, left eye 400.3 ± 96.9 μm) compared with presentation thickness (right eye 301.6 ± 110.40 μm, left eye 350.2 ± 107.7 μm) despite acetazolamide medical therapy (20–30 mg/kg/day), leading to ELD placement after 9.5 ± 6.9 days (range 3–29 days). After ELD insertion, there was headache resolution, gradual and continuous improvement in optic disc thickness, and preservation of good vision. CONCLUSIONS ELD placement in children with medically refractory IIH who demonstrated worsening papilledema with increased RNFL thickening on OCT testing typically results in symptom relief and disc edema resolution with good visual outcome, often preventing the need for additional definitive surgeries that carry greater failure and morbidity risks.

The multicenter randomized controlled trial Management of Myelomeningocele Study demonstrated that prenatal repair of open spina bifida by hysterotomy, compared with postnatal repair, decreases the need for ventriculoperitoneal shunting and increases the chances of independent ambulation. However, the hysterotomy approach is associated with risks that are inherent to the uterine incision. Fetal surgeons from around the world embarked on fetoscopic open spina bifida repair aiming to reduce maternal and fetal/neonatal risks while preserving the neurologic benefits of in utero surgery to the child.This study aimed to report the main obstetrical, perinatal, and neurosurgical outcomes in the first 12 months of life of children undergoing prenatal fetoscopic repair of open spina bifida included in an international registry and to compare these with the results reported in the Management of Myelomeningocele Study and in a subsequent large cohort of patients who received an open fetal surgery repair.All known centers performing fetoscopic spina bifida repair were contacted and invited to participate in a Fetoscopic Myelomeningocele Repair Consortium and enroll their patients in a registry. Patient data entered into this fetoscopic registry were analyzed for this report. Fisher exact test was performed for comparison of categorical variables in the registry with both the Management of Myelomeningocele Study and a post-Management of Myelomeningocele Study cohort. Binary logistic regression analyses were used to assess the registry data for predictors of preterm birth at30 weeks' gestation, preterm premature rupture of membranes, and need for postnatal cerebrospinal fluid diversion in the fetoscopic registry.There were 300 patients in the fetoscopic registry, 78 in the Management of Myelomeningocele Study, and 100 in the post-Management of Myelomeningocele Study cohort. The 3 data sets showed similar anatomic levels of the spinal lesion, mean gestational age at delivery, distribution of motor function compared with upper anatomic level of the lesion in the neonates, and perinatal death. In the Management of Myelomeningocele Study (26.16±1.6 weeks) and post-Management of Myelomeningocele Study cohort (23.3 [20.2-25.6] weeks), compared with the fetoscopic registry group (23.6±1.4 weeks), the gestational age at surgery was lower (comparing fetoscopic repair group with the Management of Myelomeningocele Study; P.01). After open fetal surgery, all patients were delivered by cesarean delivery, whereas in the fetoscopic registry approximately one-third were delivered vaginally (P.01). At cesarean delivery, areas of dehiscence or thinning in the scar were observed in 34% of cases in the Management of Myelomeningocele Study, in 49% in the post-Management of Myelomeningocele Study cohort, and in 0% in the fetoscopic registry (P.01 for both comparisons). At 12 months of age, there was no significant difference in the number of patients requiring treatment for hydrocephalus between those in the fetoscopic registry and the Management of Myelomeningocele Study.Prenatal and postnatal outcomes up to 12 months of age after prenatal fetoscopic and open fetal surgery repair of open spina bifida are similar. Fetoscopic repair allows for having a vaginal delivery and eliminates the risk of uterine scar dehiscence, therefore protecting subsequent pregnancies of unnecessary maternal and fetal risks.

Falafel and Shwarma are two iconic national Israeli dishes that are widely recognized and loved in Mexico. They are also the most mentioned by the participants. Kosher stores selling Israeli snack like Bamba, Bisli and Shkedei Marak (soup almonds) have a long-standing tradition in Mexico. However, restaurants serving Israeli food are far less common. In fact, for most of the 1980s and 1990s there were only three establishments, until recently when a new gourmet Israeli cuisine restaurant opened up. So, why is Strauss Israel’s largest food company bothering to invest in Mexico? Why are they marketing a line of Israeli popular items there? In addition to answering these questions. other queries to be explored include: How is Israeli food perceived in Mexico by the Jewish community? How did it go from a simple snack/street food to a gourmet affair? How are they framed and marketed? The main objective is to compare three different groups: Jewish Mexicans in Israel, Israelis in Mexico and Jewish Mexicans who remained in Mexico and how they perceive Israeli food in Mexico and in Israel. In addition to this, how marketing of Israeli food in Mexico has evolved. Twenty interviews will be conducted in Israel in total. Ten will be conducted with Mexican Jews living in Israel and ten will with Israelis who lived in Mexico and who have returned to Israel. To date, eight interviews have been conducted. They will be carried out in various cities in Israel. So far the median age is 45. It seems that for the Israelis eating their national food in Mexico represented an attempt at trying to connect to a symbolic sense of home. For Jewish Mexicans, eating Israeli food was either a way to connect to their future home (those that later immigrated to Israel) or a means to show their solidarity with Israel. Israeli companies investing in Mexico have a vested interest in selling and marketing their authentic wares in Mexico as they seek to gain a foothold in this emerging market.