Search

OBJECTIVEPerioperative hypothermia (PH) is a preventable, pathological, and iatrogenic state that has been shown to result in increased surgical blood loss, increased surgical site infections, increased hospital length of stay, and patient discomfort. Maintenance of normothermia is recommended by multiple surgical quality organizations; however, no group yet provides an ergonomic, evidence-based protocol to reduce PH for pediatric neurosurgery patients. The authors’ aim was to evaluate the efficacy of a PH prevention protocol in the pediatric neurosurgery population.METHODSA prospective, nonrandomized study of 120 pediatric neurosurgery patients was performed. Thirty-eight patients received targeted warming interventions throughout their perioperative phases of care (warming group—WG). The remaining 82 patients received no extra warming care during their perioperative period (control group—CG). Patients were well matched for age, sex, and preparation time intraoperatively. Hypothermia was defined as < 36°C. The primary outcome of the study was maintenance of normothermia preoperatively, intraoperatively, and postoperatively.RESULTSWG patients were significantly warmer on arrival to the operating room (OR) and were 60% less likely to develop PH (p < 0.001). Preoperative forced air warmer use both reduced the risk of PH at time 0 intraoperatively and significantly reduced the risk of any PH intraoperatively (p < 0.001). All patients, regardless of group, experienced a drop in core temperature until a nadir occurred at 30 minutes intraoperatively for the WG and 45 minutes for the CG. At every time interval, from preoperatively to 120 minutes intraoperatively, CG patients were between 2 and 3 times more likely to experience PH (p < 0.001). All patients were warm on arrival to the postanesthesia care unit regardless of patient group.CONCLUSIONSPreoperative forced air warmer use significantly increases the average intraoperative time 0 temperature, helping to prevent a fall into PH at the intraoperative nadir. Intraoperatively, a strictly and consistently applied warming protocol made intraoperative hypothermia significantly less likely as well as less severe when it did occur. Implementation of a warming protocol necessitated only limited resources and an OR culture change, and was well tolerated by OR staff.

Single-junction flat-plate terrestrial solar cells are fundamentally limited to about 30% solar-to-electricity conversion efficiency, but multiple junctions and concentrated light make much higher efficiencies practically achievable. Until now, four-junction III–V concentrator solar cells have demonstrated the highest solar conversion efficiencies. Here, we demonstrate 47.1% solar conversion efficiency using a monolithic, series-connected, six-junction inverted metamorphic structure operated under the direct spectrum at 143 Suns concentration. When tuned to the global spectrum, a variation of this structure achieves a 1-Sun global efficiency of 39.2%. Nearly optimal bandgaps for six junctions were fabricated using alloys of III–V semiconductors. To develop these junctions, it was necessary to minimize threading dislocations in lattice-mismatched III–V alloys, prevent phase segregation in metastable quaternary III–V alloys and understand dopant diffusion in complex structures. Further reduction of the series resistance within this structure could realistically enable efficiencies over 50%. Stacking multiple junctions with different bandgaps and operating under concentrated light allows solar cells to reach efficiencies beyond the limits of standard devices. Geisz et al. present a six-junction solar cell based on III–V materials with a 47.1% efficiency—the highest reported to date.

This study examines an 11-year-old boy with a known history of a large previously asymptomatic arachnoid cyst (AC) presenting with acute onset of right facial droop, hemiplegia, and expressive aphasia. Shortly after arrival to the emergency department, the patient exhibited complete resolution of right-sided hemiplegia but developed headache and had persistent word-finding difficulties. Prior to symptom onset while in class at school, there was an absence of reported jerking movements, headache, photophobia, fever, or trauma. At the time of neurology consultation, the physical exam showed mildly delayed cognitive processing but was otherwise unremarkable. The patient underwent MRI scanning of the brain, which revealed left convexity subdural hematohygroma and perirolandic cortex edema resulting from ruptured left frontoparietal AC. He was evaluated by neurosurgery and managed expectantly. He recovered uneventfully and was discharged two days after presentation remaining asymptomatic on subsequent outpatient visits. The family express concerns regarding increased anxiety and mild memory loss since hospitalization.

OBJECT Distraction osteogenesis (DO) may allow for maximal volumetric expansion in the posterior vault (PV) by overcoming viscoelastic forces of overlying soft tissues. Little evidence exists regarding surgical planning and anticipated 3D volumetric changes pre- and post-operatively. We aim to study the volumetric changes occurring in PV distraction in lambdoid craniosynostosis. METHODS From 2007 to 2019, a single institution retrospective review revealed 232 craniosynostosis patients. Fourteen demonstrated lambdoid synostosis (6%), and of those, 11 patients were included in the study due to treatment with PVDO or representative sample. Six patients had unilateral synostosis and 5 had bilateral synostosis. Imaging protocol for PVDO patients included preoperative head CT within 1 month of surgery and 8 weeks following distraction cessation with weekly skull plain films. 3D volumetric analyses were performed on pre and postoperative head CT using 3D Slicer software. RESULTS Posterior fossa volume (PFV) increased by 38.7% and foramen magnum area increased by 26.9% postoperatively. Unilateral lambdoid craniosynostosis patients had greater increases in PFV versus bilateral lambdoid craniosynostosis patients (63.5% versus 8.9%, P = 0.007). Osteotomy to the asterion was more effective in increasing PFV versus osteotomy to foramen magnum (P = 0.050). Placement of distractor in the inferior third of the lambdoid suture is more effective in increasing PFV versus placement in the middle or top third of the suture (P = 0.041). CONCLUSIONS Highest volumetric increases are seen in unilateral lambdoid synostosis. Extending osteotomy beyond the asterion is not necessary for maximal PV volumetric gain. Placement of distractor in the inferior third of the suture leads to maximal PV volumetric gains.

Accurate measurements of six-junction inverted metamorphic concentrator solar cells under AM1.5 direct spectrum are obtained by adjusting the spectrum of a tunable high-intensity solar simulator with custom mirrors. Isotype reference cells and broadband InGaAs QE calibration cells were developed for accurate measurements. Modeling and varying the illumination show that an unavoidable 15% - 17% overillumination on the sixth junction does not result in significant error of these 6J IMM devices. Spectrally adjusted flash measurements are independently confirmed by NREL's Cell and Module Performance team. Concentration measurements of a 6J IMM solar cell resulted in 47.1 ± 3.2% (absolute) efficiency at 143 suns.

Abusive head trauma (AHT) is the leading cause of death from trauma in infants and young children. An AHT animal model was developed on 12-day-old mice subjected to 90° head extension-flexion sagittal shaking repeated 30, 60, 80 and 100 times. The mortality and time until return of consciousness were dependent on the number of repeats and severity of the injury. Following 60 episodes of repeated head shakings, the pups demonstrated apnea and/or bradycardia immediately after injury. Acute oxygen desaturation was observed by pulse oximetry during respiratory and cardiac suppression. The cerebral blood perfusion was assessed by laser speckle contrast analysis (LASCA) using a PeriCam PSI system. There was a severe reduction in cerebral blood perfusion immediately after the trauma that did not significantly improve within 24 h. The injured mice began to experience reversible sensorimotor function at 9 days postinjury (dpi), which had completely recovered at 28 dpi. However, cognitive deficits and anxiety-like behavior remained. Subdural/subarachnoid hemorrhage, damage to the brain-blood barrier and parenchymal edema were found in all pups subjected to 60 insults. Proinflammatory response and reactive gliosis were upregulated at 3 dpi. Degenerated neurons were found in the cerebral cortex and olfactory tubercles at 30 dpi. This mouse model of repetitive brain injury by rotational head acceleration-deceleration partially mimics the major pathophysiological and behavioral events that occur in children with AHT. The resultant hypoxia/ischemia suggests a potential mechanism underlying the secondary rotational acceleration-deceleration-induced brain injury in developing mice., Summary: A neonatal mouse model that mimics abused head trauma in children offers a novel and reliable tool for finding mechanisms underlying the trauma and assessing treatments.

The purpose of this paper is to provide a better conceptualization of insurgent strategies. Specifically, I shall examine Che Guevara's ‘Foco’ theory of insurgency, as it is one of the most theoretically popular and most pervasive strategies of insurgency currently practiced throughout the world. After briefly examining the origins, objectives, and theoretical strengths of the Foco theory (also known as the Vanguard Theory), I will argue that Guevara's theory suffers from an internal tension that I term the ‘Vanguard's Dilemma’. The significance of this dilemma creates a tension within the Vanguard Theory that can be fatal for insurgents if properly exploited by counterinsurgent operations. This paper will examine in detail this dilemma and show how it can be exploited. Given that several insurgent groups within Iraq and Afghanistan currently adhere to the Vanguard Theory of insurgency, a proper understanding of this insurgent strategy is an essential first step in the long road towards confronting and wi...

Ventriculomegaly in infants with congenital myotonic dystrophy (CDM) is common, and the neurosurgical determination of shunting is complex. The natural history of CDM-associated ventriculomegaly from prenatal to natal to postnatal stages is poorly known. The relationship between macrocephaly and ventriculomegaly, incidence of shunt necessity, and early mortality outcomes lack pooled data analysis. This study aims to review clinical features and pathophysiology of CDM, with emphasis on ventriculomegaly progression, ventriculomegaly association with macrocephaly, and incidence of shunting. This is a literature review with pooled data analysis and case report. One hundred four CDM patients were reviewed in 13 articles that mentioned CDM with ventriculomegaly and/or head circumference. Data was very limited: only 7 patients had data on the presence or absence of prenatal ventriculomegaly, 97 on ventriculomegaly at birth, and 32 on whether or not the ventricles enlarged post-natally. Three patients of 7 (43 %) had pre-natally diagnosed ventriculomegaly, 43 of 97 (44 %) had ventriculomegaly at birth, and only 5 of 32 (16 %) had progressive enlargement of ventricles post-natally. Only 5 of 104 patients had a documented shunt placement: 1 for obstructive, 1 for a post-hemorrhagic communicating, 2 for a communicating hydrocephalus without hemorrhage, and 1 with unknown indication. Of 13 macrocephalic patients with data about ventricular size, 12 had ventriculomegaly. Ventriculomegaly occurs regularly with CDM but most often does not require CSF diversion. Decisions regarding neurosurgical intervention will necessarily be based on limited information, but shunting should only occur once dynamic data confirms hydrocephalus.

Rationale and Objectives To review magnetic resonance safety protocols and supplement them for interventional applications. Materials and Methods The American College of Radiology White Papers on MR Safety are summarized. Elements relevant to interventional MR procedures are emphasized. Additional policies and procedures specifically for interventional MR applications covering safety, training, and MR compatibility are proposed. Results A comprehensive operational policy for an interventional MR department is proposed. The policies and procedures helped our department perform over 400 surgeries and maintain a perfect safety record for 5 years. Conclusion Interventional MR departments can operate safely but require policies and procedures beyond those required for diagnostic MR departments.

International audience; This chapter proposes a method for estimating risk to honey bees (Apis mellifera) and non-Apis bees from pesticides that are applied through sprays (acting on contact) and through seed or soil treatments and tree trunk injections (acting systemically). It describes the risk assessment process for honey bees and non-Apis bees. Problem formulation articulates the intent of the risk assessment and is predicated on particular protection goals for which the regulatory authority is responsible. The chapter illustrates the proposed risk assessment process identified by the participants of the 2011 SETAC Workshop on Pesticide Risk Assessment for Pollinators. The potential risk to adult honey bees from spray applications is assessed through calculation of an HQ. The screening-level and refined risk assessment processes for soil or seed treatment-applied pesticides incorporate different degrees of ecological realism. Screening-level assessments are typically based on conservative assumptions regarding both exposure and effects.

Study Objective To describe how pediatric and adolescent patients present to the gynecologist when they have tethered cord syndrome (TCS). Design We conducted a retrospective chart review on all patients suspected by the gynecologist of having TCS. Setting Single pediatric and adolescent gynecology clinic in a mid-sized city in the midwest. Participants Thirty-two patients, first seen between 2005 and 2012, suspected of having TCS and for whom follow-up information was available. Interventions and Main Outcome Measures Patient characteristics, including patient history, gynecologic clinical indicators, clinical outcomes, indications for surgery, and postoperative resolution of symptoms, were reviewed. Results The initial review of systems indicated stress urinary incontinence, back pain, and constipation as common markers in the 32 patients who were suspected of having TCS. All 32 patients underwent lumbar magnetic resonance imaging without contrast and evaluation by neurosurgery. Of the 32 patients with suspected TCS, 18 were later confirmed and 14 were shown to not have TCS. Of the 18 patients with sufficient information to justify a detethering procedure, 14 patients were followed and 93% (13 patients) had complete resolution of symptoms. Final diagnosis in the non-TCS group varied, including vulvovaginitis, enuresis, chronic constipation, and lichen sclerosis. Symptoms improved with the treatment of each primary condition. Conclusions TCS symptoms overlap with gynecologic conditions; therefore, patients with TCS may present initially to the gynecologist. In pediatric/adolescent patients, TCS should be considered when stress urinary incontinence, back pain, and constipation are discovered in the review of systems. Because possible irreversible ischemic and neurologic changes are believed to be involved, early diagnosis and surgery are crucial for resolution. Providers should be aware of TCS in these pediatric and adolescent settings, because quick assessment may result in complete resolution of a chronic progressive disease.

Social and technical trends in medicine are continuously driving the development of safer and less invasive neurosurgical procedures. Our success as anatomists, in conjunction with the high-quality and noninvasive diagnostic modalities of CT and MRI, has better defined surgical targets and avenues. Effective neuroimaging contributes to the arrival of patients with subtle – or even no – symptoms to our OR, increasing the stakes of neurosurgical intervention dramatically. Patient and/or parental expectations, education, and access to understandable medical information on the internet have increased dramatically, effectively raising the bar for what should be accomplished by attending physicians. In turn, the need for procedural refinement drives surgical innovation, several aspects of which were reviewed in the pediatric neurosurgical context in a recent article. In this chapter we will focus on the use of intraoperative magnetic resonance imaging (ioMRI) in the pediatric neurosurgical context, beginning with a history of its development with a review of current configurations and their results in the pediatric neurosurgical realm. We then share some key points about our experience using this real-time, high-resolution modality in the care of young patients.

Molding helmet therapy is a widely accepted treatment for positional plagiocephaly that is generally considered to be low risk. Multiple large outcome studies have shown good results, but adverse events are rarely reported. The literature on helmet therapy was reviewed to clarify the clinical experience with associated complications. Although significant complications were extremely rare, there was a large degree of variability in detection of lesser problems such as minor skin irritation. Patients with a primarily brachycephalic morphology may be at higher risk for poorly fitting orthoses. Most reported complications are minor and self-limited. Maintenance of good helmet hygiene appears to be the most effective strategy for reducing or eliminating complications.

Pituitary gland duplication is a rare malformation of unknown cause that is often associated with a nasopharyngeal teratoma, among other secondary malformations. This clinical report describes a case of pituitary gland duplication with a nasopharyngeal teratoma, cleft palate, and hypothalamic hamartoma, as well as the surgical management of this patient. This case also raises the question of whether the nasopharyngeal teratoma is the cause of the pituitary duplication above and the cleft palate below or whether it is a result of the primary duplication of the notochordal process. Various theories are presented in an attempt to answer this question, but the exact cause of these malformations remains equivocal. Future research in this topic may elucidate the answer to this question.

Langerhans cell histiocytosis (LCH) is a clonal proliferation of Langerhans cells of unknown etiology that results in a range of clinical manifestations. LCH has been known to be associated with a variety of malignant diseases. A 7-year-old boy was treated for standard-risk acute lymphoblastic leukemia (ALL) at age 2 years, on a Children's Cancer Group chemotherapy protocol for 3 years and developed LCH 2 years after completion of chemotherapy. The case and a review of literature on the association of LCH and ALL are presented.

Intraoperative and interventional MR have opened a new chapter in neurosurgery bringing both new therapeutic opportunities and creating unique safety challenges for the MR operating room. The presence of a large magnetic field in the otherwise familiar environment of the operating room necessitates site-specific comprehensive policies for safety, staff training, infection control, and MR compatibility. Intraoperative MRI also creates unique MR image interpretation challenges that are of paramount significance for patient safety. These safety concerns are reviewed with particular reference to the nine years experience of the authors.

Neurosurgical procedures demand precision, and efforts to create accurate neurosurgical navigation have been central to the profession through its history. Magnetic resonance image (MRI)-guided navigation offers the possibility of real-time, image-based stereotactic information for the neurosurgeon, which makes possible a number of diagnostic and therapeutic procedures. This article will review both current options for intraoperative MRI operative suite arrangements and the current therapeutic/diagnostic uses of intraoperative MRI.

In this paper, we present an automatic statistical approach for extracting 3D blood vessels from time-of-flight (TOF) magnetic resonance angiography (MRA) data. The voxels of the dataset are classified as either blood vessels or background noise. The observed volume data is modeled by two stochastic processes. The low level process characterizes the intensity distribution of the data, while the high level process characterizes their statistical dependence among neighboring voxels. The low level process of the background signal is modeled by a finite mixture of one Rayleigh and two normal distributions, while the blood vessels are modeled by one normal distribution. The parameters of the low level process are estimated using the expectation maximization (EM) algorithm. Since the convergence of the EM is sensitive to the initial estimate of the model parameters, an automatic method for parameter initialization, based on histogram analysis, is provided. To improve the quality of segmentation achieved by the proposed low level model especially in the regions of significantly vascular signal loss, the high level process is modeled as a Markov random field (MRF). Since MRF is sensitive to edges and the intracranial vessels represent roughly 5% of the intracranial volume, 2D MRF will destroy most of the small and medium sized vessels. Therefore, to reduce this limitation, we employed 3D MRF, whose parameters are estimated using the maximum pseudo likelihood estimator (MPLE), which converges to the true likelihood under large lattice. Our proposed model exhibits a good fit to the clinical data and is extensively tested on different synthetic vessel phantoms and several 2D/3D TOF datasets acquired from two different MRI scanners. Experimental results showed that the proposed model provides good quality of segmentation and is capable of delineating vessels down to 3 voxel diameters.

In this paper, we present a novel algorithm for adaptive fuzzy segmentation of MRI data and estimation of intensity inhomogeneities using fuzzy logic. MRI intensity inhomogeneities can be attributed to imperfections in the RF coils or some problems associated with the acquisition sequences. The result is a slowly-varying shading artifact over the image that can produce errors with conventional intensity-based classification. Our algorithm is formulated by modifying the objective function of the standard fuzzy c-means (FCM) algorithm to compensate for such inhomogeneities and to allow the labeling of a pixel (voxel) to be influenced by the labels in its immediate neighborhood. The neighborhood effect acts as a regularizer and biases the solution towards piecewise-homogeneous labelings. Such a regularization is useful in segmenting scans corrupted by salt and pepper noise. Experimental results on both synthetic images and MR data are given to demonstrate the effectiveness and efficiency of the proposed algorithm.

The emergence of intraoperative MRI has opened new doors for the surgical treatment of pediatric disorders. This technology will hopefully not only improve the surgeon’s ability to obtain complete tumor resections with minimal damage to surrounding structures, but also allows surgeons to perform various procedures via less invasive measures.

In this paper, we present a novel algorithm for fuzzy segmentation of magnetic resonance imaging (MRI) data and estimation of intensity inhomogeneities using fuzzy logic. MRI intensity inhomogeneities can be attributed to imperfections in the radio-frequency coils or to problems associated with the acquisition sequences. The result is a slowly varying shading artifact over the image that can produce errors with conventional intensity-based classification. Our algorithm is formulated by modifying the objective function of the standard fuzzy c-means (FCM) algorithm to compensate for such inhomogeneities and to allow the labeling of a pixel (voxel) to be influenced by the labels in its immediate neighborhood. The neighborhood effect acts as a regularizer and biases the solution toward piecewise-homogeneous labelings. Such a regularization is useful in segmenting scans corrupted by salt and pepper noise. Experimental results on both synthetic images and MR data are given to demonstrate the effectiveness and efficiency of the proposed algorithm.

We present a new method for 3-D volume segmentation of the human cerebrovascular structures from Magnetic Resonance Angiograms (MRA) and Magnetic Resonance Ventriculargrams (MRV). A slice through the volume containing large vein or artery structures is chosen, which becomes the seed location for the segmentation process. A modified 3-D computer graphics based region-filling algorithm is used to sweep the vascular tree from seed locations in order to track and label the vascular structure. The labelled-segmented images are extracted and a 3-D model is created using VTK toolkit. The 3-D model can then be viewed on a stereo graphics capable workstation or in a Virtual Reality environment. We also present a new maximum intensity projection (MIP) based technique for validating the results. We implemented MIP and used it to project both the segmented and original volume at different angles. Hence, the resultant images from both volumes can be compared side by side, which facilitates validation process.

Introduction: Intracavitary treatment of solitary cystic craniopharyngiomas with 32P is an emerging treatment option, especially for pediatric patients. We have treated two patients with solitary cystic craniopharyngiomas using intraoperative MRI (iMRI)-guided catheter placement. Methods: The optical tracking system of the General Electric Signa SP iMRI system was utilized for preoperative planning and intraoperative catheter tracking during insertion. Intraoperative volumetric imaging was then used to confirm final catheter position. Patients were brought back to the iMRI suite approximately 8 weeks later and diluted gadolinium was injected with further MRI to confirm the absence of communication between the cyst lumen and surrounding CSF spaces and for volumetric analysis. Results: Intraoperative imaging illustrated deformation and changes in the cyst wall during catheter placement and cyst aspiration and confirmed final catheter placement. Images acquired 8 weeks following catheter placement prior to the instillation of 32P showed decreases in cyst volume of 40 and 85%. Conclusion: iMRI-guided catheter placement for cystic craniopharyngiomas helps to assure successful catheter placement. Significant decreases in cyst volume occur in the interval between catheter placement and 32P administration and must be accounted for to prevent overdosing of the radioisotope.

Children with spastic diplegia from cerebral palsy (CP) experience measurable improvement in their spasticity and motor function following selective dorsal rhizotomy (SDR). The role of this operation in the treatment of other spasticity causes is less well defined. A literature review was undertaken to survey outcomes from SDRs performed outside the CP population. Multiple sclerosis was the most common diagnosis found, accounting for 74 of 145 patients described. Selective dorsal rhizotomies have also been reported in patients with traumatic brain and spinal cord injuries, ischemic and hemorrhagic stroke, neurodegenerative disease, hypoxic encephalopathy, and other causes of spasticity. Outcomes from surgery are generally described as favorable, although postoperative assessments and follow-up times are not standardized across reports. Long-term outcomes are sparsely reported. Larger numbers of patients and more detailed outcomes data have the potential to form a basis for expanding the inclusion criteria for SDR.

OBJECTIVE To assess the application accuracy of intraoperative magnetic resonance imaging for frameless stereotactic surgery, and to evaluate the performance of intraoperative magnetic resonance imaging for the brain biopsy, a standard stereotactic procedure. METHODS A series of spatial coordinate and phantom experiments were performed to analyze the application accuracy of the system. A prospective analysis of 68 consecutive patients undergoing stereotactic brain biopsy was then performed. RESULTS The spatial coordinate experiments revealed a mean overall error in acquisition of 0.2 mm. The phantom experiments demonstrated a 1:1 correlation between the magnetic resonance image of a stereotactically guided probe and its relationship to a target and the actual relationship of the probe and target. Sixty-eight brain biopsies were successfully performed in all intracranial compartments except the sella. The radiographic abnormality was localized successfully in all patients (100%). Sixty-six (97.1%) of the biopsies yielded diagnostic tissue. Two biopsies (2.9%) were complicated by intraparenchymal hemorrhage. One expanding temporal lobe hemorrhage was evacuated by immediate craniotomy in the magnet with no postoperative sequelae. A deep hemorrhage from a lymphoma was managed conservatively with interval resolution of symptoms. There were no infections. There was no perioperative mortality. CONCLUSION Intraoperative magnetic resonance imaging allows excellent target localization, provides true real-time imaging to account for anatomic changes during surgery, and permits intraoperative confirmation that the biopsy needle has reached the targeted lesion. Immediate postoperative imaging in the operating room allows assessment of adverse events and the potential for immediate management of hemorrhagic complications.

e21000 Background: We describe two Caucasian boys with rare presentations of non-metastatic Ewings sarcoma (ES) with atypical primary sites. One was extradural but FISH negative for 22q11.2. Another was intradural but extramedullary, and FISH positive. Literature search showed few publications which describe such cases, and there is currently no standard of care. Methods: MG, an 11 year old male, presented with a frontal skull mass, with an intracranial epidural extension of about 5 mm. Biopsy confirmed ES. MG was treated with Vincristine, Doxorubicin, and Cyclophosphamide, alternating with Ifosfamide and Etoposide every 2 weeks, for 6 weeks. He underwent tumor excision for local control with good response. Chemotherapy continued, completing 14 cycles total. He is in remission 15 months after completion. AH, a 13 year old male, presented with lower back pain and paraesthesias of feet. MRI revealed an intradural, extra-medullary L1-L3 mass. Intra-operatively, all visible tumor peeled off readily, except for the L2 nerve root. The tumor was FISH positive for EWSR1. He was treated with the same regimen as MG for 6 cycles. Local control was done with radiation. He then continued chemotherapy, completing a total of 14 cycles. MRI scans 3 months later revealed enhancing intradural lesions along the spinal cord (involving C5, T5 and T8) and two lesions along the cerebellum. He was started on cyclophosphamide and topotecan and has completed 8 cycles without disease progression. Results: MG was diagnosed based solely on histo-pathological diagnosis. While MG’s lesion was extra-osseus in nature, more unusual presentations demonstrate the importance of molecular diagnostic techniques. AH was diagnosed based on chromosomal analysis. Progression is presumably from microscopic residual disease in intradural space that invaded CSF. He is presently on salvage chemotherapy. Nine months after relapse, disease is stable, with plans to minimize disease and consolidate. Conclusions: Intradural tumors tend to progress rapidly, maybe more so than extradural tumors. Future suggestions include developing a standard approach that will improve both treatment of Ewing’s sarcoma and prognostic outcomes for rare initial presentations.

Introduction Infection continues to be a common problem in CSF diversion procedures in children with substantial morbidity. There is evidence that adherence to strict sterile technique in the OR can impact the rate of infection, but the impact may be short-lived (Hawthorne effect). We sought to change our infection rate by adhering to a strict set of rules for pre-, intra-, and postoperative management of CSF diversion procedures. Methods After 2004, a rigid protocol for ventricular shunt surgery was established at the Kosair Children's Hospital with OR staff, medical staff (neurosurgery and anesthesiology), and hospital administration enabled to enforce compliance. Preop (antibiotics, OR suite, room set-up), intraop (standardized extensive prep, double-gloving, frequent glove changes, tissue and shunt handling, room traffic, “two-foot rule”), and postop factors (wound care, leak surveillance) were considered. The data were collected prospectively by infection control personnel using pre-established defin...

An experiment was conducted to determine the importance of stigma in the experience of deviance. Male college students participated in an opinion exchange on important political and social issues. Each subject was made to feel that he was, on most issues, in the minority but in agreement with one other group member. Two variables were manipulated during the exchange: stigma (the minority was either derogated by the majority, or there was no reaction to the opinion differences) and public versus secret minority status of subject (either the subject announced his opinions to the group or merely listened to the opinions of others.) The variables were manipulated orthogonally. After the opinion exchange, the subject rated the attractiveness of the others in the group and then took part in a disguised test of social influence. Results suggest that only when minority members are stigmatized do they feel and act like social deviants. This was reflected in more frequent reports of a desire to change during the exchange, actual changes of opinion during the exchange, ambivalence toward fellow minority members, and greater susceptibility to social influence from a fellow minority member in the public-stigma condition. The reactions of subjects in the absence of stigma suggest that minority status alone is not sufficient to produce feelings of deviance or the behavior usually attributed to social deviants. Deviance, as a social category, includes diverse types of individuals and groups. A contemporary listing (Goffman, 1963) includes "prostitutes, drug addicts, delinquents, criminals, jazz musicians, bohemians, gypsies, carnival workers, hobos, winos, show people, full-time gamblers, beach dwellers, homosexuals, and the urban unrepentant poor [pp. 143-144]." More general lists (e.g., Clinard, 1963) have included the mentally ill and members of racial and ethnic minorities. Although it is agreed that there are special consequences for those included in this category, the necessary and sufficient conditions for placement are subject to debate. Becker 1 This article is based on a dissertation submitted