Rupture of a flow aneurysm secondary to spontaneous extracranial to intracranial revascularisation in the posterior fossa following radiation-induced vasculopathy for cerebellar tumour

Paediatric patients receiving cranial irradiation therapy for brain tumours are at increased risk of cerebrovascular complications. Radiation-induced moyamoya syndrome (MMS) is a well-recognised complication of this. We present a case of an 8-year-old boy with a history of medulloblastoma, who underwent surgical excision followed by post-operative adjuvant oncological treatment. Six years later, he developed cerebellar/intraventricular haemorrhage. He underwent an emergency external ventricular drain (EVD) insertion followed by posterior fossa suboccipital craniotomy. On dural opening, an abnormal vessel was visualised on the surface of the right cerebellar hemisphere, which was not disturbed. No obvious abnormalities were identified intra-operatively. Cerebral catheter angiography confirmed the presence of a right-sided occipital artery (OA) to posterior inferior cerebellar artery (PICA) extracranial to intracranial (EC-IC) bypass with a zone of the distal PICA territory supplied by this EC-IC bypass. A presumed flow aneurysm originated from the bypass in the distal PICA, identified as cause for the haemorrhage. We highlight a rare cause for intracranial haemorrhage in this cohort of patients. Children who have undergone radiotherapy may have exquisitely sensitive cerebral vasculature and need careful vigilance and evaluation for vasculopathic complications following spontaneous haemorrhage.

Experimental platform to facilitate novel back brace development for the improvement of spine stability

The spine or 'back' has many functions including supporting our body frame whilst facilitating movement, protecting the spinal cord and nerves and acting as a shock absorber. In certain instances, individuals may develop conditions that not only cause back pain but also may require additional support for the spine. Common movements such as twisting, standing and bending motions could exacerbate these conditions and intensify this pain. Back braces can be used in certain instances to constrain such motion as part of an individual's therapy and have existed as both medical and retail products for a number of decades. Arguably, back brace designs have lacked the innovation expected in this time. Existing designs are often found to be heavy, overly rigid, indiscrete and largely uncomfortable. In order to facilitate the development of new designs of back braces capable of being optimised to constrain particular motions for specific therapies, a numerical and experimental design strategy has been devised, tested and proven for the first time. The strategy makes use of an experimental test rig in conjunction with finite element analysis simulations to investigate and quantify the effects of back braces on flexion, extension, lateral bending and torsional motions as experienced by the human trunk. This paper describes this strategy and demonstrates its effectiveness through the proposal and comparison of two novel back brace designs.

Determinants of Radiation Dose in Selective Ophthalmic Artery Chemosurgery for Retinoblastoma

BACKGROUND AND PURPOSE

Retinoblastoma is the most common pediatric ocular neoplasm. Multimodality treatment approaches are commonplace, and selective ophthalmic artery chemosurgery has emerged as a safe and effective treatment in selected patients. Minimizing radiation dose in this highly radiosensitive patient cohort is critical. We explore which procedural factors affect the radiation dose in a single-center cohort of children managed in the UK National Retinoblastoma Service.

MATERIALS AND METHODS

A retrospective review was performed of 177 selective ophthalmic artery chemosurgery procedures in 48 patients with retinoblastoma (2013-2017). Medical records, angiographic imaging, and radiation dosimetry data (including total fluoroscopic screening time, skin dose, and dose-area product) were reviewed.

RESULTS

The mean fluoroscopic time was 13.5 ± 13 minutes, the mean dose-area product was 11.7 ± 9.7 Gy.cm², and the mean total skin dose was 260.9 ± 211.6 mGy. One hundred sixty-three of 177 procedures (92.1%) were technically successful. In 14 (7.9%), the initial attempt was unsuccessful (successful in 13/14 re-attempts). Screening time and radiation dose were associated with drug-delivery microcatheter location and patient age; screening time was associated with treatment cycle.

CONCLUSIONS

In selective ophthalmic artery chemosurgery, a microcatheter tip position in the proximal or ostial ophthalmic artery and patient age 2 years or younger were associated with reduced fluoroscopic screening time and radiation dose; treatment beyond the first cycle was associated with reduced fluoroscopic screening time.

TP1-2 Treatment of dural and direct caroticocavernous fistulas via the transorbital approach

Objectives

To analyse the outcome of this novel approach in patients with Caroticocavernous fistulas (CCFs) and to compare it with the commonly used transvenous pathway.

Design

Retrospective analysis of patients with CCFs treated using the transorbital approach.

Subjects

10 patients were identified following review of inpatient databases and collection of information for those treated offsite.

Methods

Analysis of Angiography findings and follow up imaging alongwith review of outcomes from patient records (Using TO approach, coils were used over liquid embolic due to risk of reflux of liquid from perforators).

Results

No failure to puncture No orbital hematoma requiring drainage/canthotomy Occlusion rate 100% Commonest symptoms of eye pain and proptosis (all subjects) with chemosis, opthalmoplegia and reduced visual acuity (fairly common) in the patients studied improved significantly post the TO procedure with transient 3rd and 4th Nerve palsy being the only complication.

Conclusions

Transorbital approcah (TO) is a safer, acceptable alternative to the catheter transveous approaches for CCFs (dural and direct) With greater numbers and experience, TO could be considered as a 1 st line approach.

Patient-reported quality of life outcomes following treatment for oral cancer

Patient-reported quality of life (QoL) outcomes have the potential to assist clinicians in providing individually tailored treatment decisions. QoL assessments were collected prospectively for 168 consecutive patients treated for oral cancer between 1 January 2010 and 31 December 2014 using the University of Washington Quality of Life Questionnaire. Patients were followed up for 18 months post-treatment. Sub-group analyses were performed using paired t-tests and analysis of variance (ANOVA) to compare the effects of adjunctive chemoradiotherapy, type of bone resection, and methods of soft and hard tissue flap reconstruction. The greatest statistically significant reduction in QoL for all oral cavity sub-sites was found following the treatment of floor of mouth tumours (-18.9%, P=0.018). Laser excision for matched patient cohorts resulted in improved resultant QoL compared to other excision techniques (P=0.0002). No significant difference in QoL was found when radial forearm and anterolateral thigh flaps were matched, or when fibula and scapula flaps were matched. These findings support the use of laser excision and the avoidance of postoperative radiotherapy if curative intent and survival outcomes are maintained.

A pilot study to assess the role of the Internet to provide structured training in obstetrics and gynaecology

Recent recommendations in the Calman Report on medical training address perceived deficiencies in the current system in the UK. These recommendations include shorter and more structured training for junior doctors. Structured training will require the provision of specific educational and assessment materials. The current expansion of the Internet may provide a timely opportunity to help with these educational challenges. Our pilot study will investigate the potential role of the Internet in the delivery of structured training materials. We will also be evaluating a number of educational strategies supported by the Internet, particularly computer based simulation, for teaching the management of two sample obstetric emergencies: post partum haemorrhage and pre-eclampsia.

Health-related quality of life after maxillectomy: obturator rehabilitation compared with flap reconstruction

Health-related quality of life (QoL) reported by patients has the potential to improve care after ablative surgery of the midface, as existing treatment algorithms still generally revolve around outcomes assessed traditionally only by clinicians. Decisions in particular relate to reconstruction with a flap compared with rehabilitation with an obturator, the need for adjuvant treatment, and morbidity related to the size of the defect. We prospectively collected health-related QoL assessments for 39 consecutive patients treated by maxillectomy between 01 January 2010 and 31 December 2014 using the University of Washington Quality of Life Questionnaire, and who had a mean (SD) duration of follow-up of 14 (4). We made sub-group analyses using paired t tests and analysis of variance (ANOVA) to compare reconstruction with a flap with rehabilitation with obturators, size of the vertical defect, and whether adjuvant treatment with radiotherapy or chemoradiotherapy adversely affected it. Overall there was a significant decrease in health-related QoL after treatment compared with before (p<0.001), but there was no significant difference in the effects of any of the paired reconstructive and rehabilitation treatments on it. Obturators remain an important option for rehabilitation in selected patients in addition to reconstruction with a flap. We found that neither increasing the size of the vertical defect (in an attempt to ensure clear margins) nor the use of postoperative radiotherapy seemed to have any adverse effect on QoL. More patients are required before we can conclude that the potential survival benefits of such measures may outweigh any adverse effects.

Kabuki syndrome: a case report

This article reports the case of an 8-year-old female with Kabuki syndrome and the oral/dental implications of this syndrome, namely hypodontia with interdental spacing, abnormal tooth morphology, malocclusion and a defect in the anterior midline of the palate. The oral findings will aid the clinician in diagnosing this syndrome, which was once thought to be seen exclusively in the Japanese population.

Maternal serum proteome changes between the first and third trimester of pregnancy in rural southern Nepal

Characterization of normal changes in the serum proteome during pregnancy may enhance understanding of maternal physiology and lead to the development of new gestational biomarkers. In 23 Nepalese pregnant women who delivered at term, two-dimensional difference in-gel electrophoresis (DIGE) was used to assess changes in relative protein abundance between paired serum samples collected in the first and third trimesters. One-hundred and forty-five of over 700 protein spots in DIGE gels (pI 4.2-6.8) exhibited nominally significant (p < 0.05) differences in abundance across trimesters. Additional filtering using a Bonferroni correction reduced the number of significant (p < 0.00019) spots to 61. Mass spectrometric analysis detected 38 proteins associated with gestational age, cytoskeletal remodeling, blood pressure regulation, lipid and nutrient transport, and inflammation. One new protein, pregnancy-specific β-glycoprotein 4 was detected. A follow-up isotope tagging for relative and absolute quantitation (iTRAQ) experiment of six mothers from the DIGE study revealed 111 proteins, of which 11 exhibited significant (p < 0.05) differences between trimesters. Four of these proteins: gelsolin, complement C1r subcomponent, α-1-acid glycoprotein, and α-1B-glycoprotein also changed in the DIGE analysis. Although not previously associated with normal pregnancy, gelsolin decreased in abundance by the third trimester (p < 0.01) in DIGE, iTRAQ and Western analyses. Changes in abundance of proteins in serum that are associated with syncytiotrophoblasts (gelsolin, pregnancy-specific β-1 glycoprotein 1 and β-2-glycoprotein I) probably reflect dynamics of a placental proteome shed into maternal circulation during pregnancy. Measurement of changes in the maternal serum proteome, when linked with birth outcomes, may yield biomarkers for tracking reproductive health in resource poor settings in future studies.

Blunt traumatic vertebral artery injury: a clinical review

Blunt traumatic vertebral injury (TVAI) is frequently associated with head and neck injury and is being detected with increasing frequency due to improved imaging of the trauma patient. In a few cases, it can lead to potentially fatal posterior circulation ischaemia There is debate in the literature regarding whether TVAI should be actively screened for and, if so, how. Management of TVAI may be conservative, medical (antiplatelet agents or anticoagulation), endovascular or open surgery. We review the literature concerning the mechanisms and presentation of TVAI following blunt injury and the current screening recommendations. Management strategies proposed are based on the radiological grade and clinical severity of TVAI, where high-grade symptomatic injuries and high-grade injuries in patients where anticoagulation is contraindicated are treated endovascularly and asymptomatic or low-grade injuries are managed with anticoagulation where it is not contraindicated. Follow-up is via CT angiography to assess for resolution of the injury.

Investigation of global developmental delay

The investigation of global developmental delay in preschool children varies between centres and between paediatricians. Following a literature search and review of the evidence base, guidelines were developed to assist in the assessment and management of such children presenting to secondary level services. Evidence supporting the use of genetic and biochemical investigations on a screening basis was found, but there was no evidence to support the use of metabolic investigations or neuroimaging in the absence of other positive findings on history or examination. Detailed history and examination are paramount in the assessment of children with global developmental delay. Investigations can be a useful adjunct in determining aetiology. Evidence based guidelines have been developed to assist doctors in the selection of appropriate investigations for this group of children.

Cutaneous manifestations of fucosidosis

Angiokeratoma corporis diffusum (ACD) is still often thought to be synonymous with Anderson-Fabry disease, a deficiency of alpha-galactosidase. It is important, however, to consider other possible enzyme deficiencies in patients with ACD. We report an 8-year-old boy with neurodevelopmental delay who was diagnosed as having fucosidosis following recognition of ACD in the dermatology department. Other cutaneous features in this patient included distal transverse purple nail bands, acrocyanosis and a naevus anaemicus. Histology and electron microscopy of skin papules was consistent with angiokeratoma. Skeletal survey demonstrated dysostosis multiplex. The diagnosis was confirmed by leucocyte oligosaccharide enzyme analysis. There are only three previous reports of fucosidosis in the U.K.

Specular reflection of neutrons at phospholipid monolayers. Changes of monolayer structure and headgroup hydration at the transition from the expanded to the condensed phase state

The specular neutron reflection technique has been applied for the first time to study the structure and head group hydration of a phospholipid monolayer (dimyristoylphosphatidylcholine containing negatively charged phospholipids) in the condensed and expanded state. By variation of the contrast of the subphase to that of the air it is shown that at the transition from the condensed to the expanded state the carboxyl bonds of the glycerol backbone are hydrated leading to a strong structural change of the headgroup. The total monolayer thickness in the condensed state is 22.5 +/- 1 A (tilt angle 32 +/- 6 degrees) and decreases to 19.5 +/- 1 A in the expanded state. The mean molecular volume increases from 1190 +/- 50 A3 to 1250 +/- 50 A3.