A systematic review and meta-analysis of prophylactic medication of vestibular migraine

OBJECTIVE

Vestibular migraine is in the process of recognition as an individual clinical entity. At present, no guidelines exist for its management. This study aimed to conduct a systematic review and meta-analysis to determine the effectiveness of available prophylactic medication.

METHOD

A literature search was performed using PubMed, Ovid and Embase databases. Qualitative and quantitative analysis were performed as well as risk of bias analysis. Meta-analysis for the mean differences for pre- and post-treatment impact based on Dizziness Handicap Inventory and Vertigo Symptom Scale were performed. Proportionate transformation meta-analysis for the successful event rate based on complete symptoms control was explored.

RESULTS

Thirteen publications were identified: 3 were randomised, controlled trials and 10 were non-randomised, controlled trials. Propranolol and venlafaxine improved the Vertigo Symptom Scale score by -13.31 points and -4.16 points, respectively, and the Dizziness Handicap Inventory score by -32.24 and -21.24, respectively. Only propranolol achieved statistically significant impact with 60 per cent of patients achieving complete symptom control.

CONCLUSION

Propranolol should be offered as the first-line treatment for vestibular migraine followed by venlafaxine. Amitriptyline, flunarizine and cinnarizine showed a trend for symptom improvement, but this was not statistically significant.

[Clinical and economic impact of an ambulatory cataract surgery center without anesthesia in an area with poor ophthalmologic coverage]

INTRODUCTION

The Ambulatory Clinic for Cataract Surgery (CACC) is a public department of the Bourges Medical Center, with a fast-track protocol without perioperative anesthesia care launched in 2015. This study aimed to evaluate the benefits of the CACC in terms of access to cataract surgery.

METHODS

This retrospective study included all patients undergoing cataract surgery between 2012 and 2018. Data were collected from the French PMSI database. In order to evaluate the impact of the CACC, the surgical activity and change in indicators of patient flow and usage, as well as clinical and economic factors were analyzed.

RESULTS

Between 2012 and 2018, with the same number of ophthalmologists, surgical activity increased by 50.2% in the Cher (vs. a mean increase of 22.7% in France). The patient loss ratio decreased by 5.9 points, the attraction and self-sufficiency ratios increased by 2.3 and 8.6 points respectively. The standardized rate of healthcare utilization for cataract surgery increased by 4.3 points (from 11.6 to 15.9 surgeries per 1000 inhabitants). As a result, Cher became the second highest French Department in 2018 in terms of utilization rate despite its 96th place out of 109 Departments in terms of density of ophthalmologists.

CONCLUSION

The ambulatory cataract surgery center without anesthesia for selected patients might represent a solution in medical deserts to improve access to cataract surgery without increasing costs.

[Epidemiology of ocular emergencies in a non-university hospital: Clinical characteristics and severity grading according to the Base Score]

OBJECTIVE

This study aimed to analyse the epidemiological characteristics of ophthalmological emergencies at the Bourges Medical Center (CHB) and to identify factors associated with severity according to the Base Score in a region of France considered a healthcare desert.

METHODS

All consecutive charts of patients seen for an eye-related condition between January 1 and April 30, 2019 in the ocular emergency department of the CHB were studied retrospectively. Seven demographic and nine medical variables were collected, and ocular severity was defined according to the Base Score. Linear regressions were performed to identify the factors associated with higher severity.

RESULTS

1809 patients were included (mean age: 53.3±22.7 years, 51.4% women), of whom 1619 (89.5%) were self-referred. Ocular surface disease (12.5%) was the most frequent diagnosis. The severity of the eye-related condition was significantly associated with the following factors: male gender, distance from home to the emergency department, presentation soon after the onset of symptoms, and referral from a physician (ophthalmologist or not). The regression coefficient was greater than 1 only for the patient referral pattern.

CONCLUSION

The current study highlights that when patients with ocular emergencies can self-refer to an ocular emergency department within a French healthcare desert, 9 patients out of 10 self-refer. Referral from a physician is the main factor associated with ocular severity; thus, these cases should be considered severe until proven otherwise.

Predicting Ischemic Risk Using Blood Oxygen Level-Dependent MRI in Children with Moyamoya

BACKGROUND AND PURPOSE

Moyamoya is a progressive steno-occlusive arteriopathy. MR imaging assessment of cerebrovascular reactivity can be performed by measuring the blood oxygen level-dependent cerebrovascular reactivity response to vasoactive stimuli. Our objective was to determine whether negative blood oxygen level-dependent cerebrovascular reactivity status is predictive of ischemic events in childhood moyamoya.

MATERIALS AND METHODS

We conducted a retrospective study of a consecutive cohort of children with moyamoya who underwent assessment of blood oxygen level-dependent cerebrovascular reactivity. The charts of patients with written informed consent were reviewed for the occurrence of arterial ischemic stroke, transient ischemic attack, or silent infarcts. We used logistic regression to calculate the OR and 95% CI for ischemic events based on steal status. Hazard ratios for ischemic events based on age at blood oxygen level-dependent cerebrovascular reactivity imaging, sex, and moyamoya etiology were calculated using Cox hazards models.

RESULTS

Thirty-seven children (21 female; median age, 10.7 years; interquartile range, 7.5-14.7 years) were followed for a median of 28.8 months (interquartile range, 13.7-84.1 months). Eleven (30%) had ischemic events, 82% of which were TIA without infarcts. Steal was present in 15 of 16 (93.8%) hemispheres in which ischemic events occurred versus 25 of 58 (43.1%) ischemic-free hemispheres (OR = 19.8; 95% CI, 2.5-160; P = .005). Children with idiopathic moyamoya were at significantly greater risk of ischemic events (hazard ratio, 3.71; 95% CI, 1.1-12.8; P = .037).

CONCLUSIONS

Our study demonstrates that idiopathic moyamoya and the presence of steal are independently associated with ischemic events. The use of blood oxygen level-dependent cerebrovascular reactivity could potentially assist in the selection of patients for revascularization surgery and the direction of therapy in children with moyamoya.

Evaluation of plasma and erythrocyte fatty acids C15:0, t-C16:1n-7 and C17:0 as biomarkers of dairy fat consumption in adolescents

INTRODUCTION

Pentadecanoic (C15:0), heptadecanoic (C17:0) and trans-palmitoleic (t-C16:1n-7) fatty acids (FAs) are often used as biomarkers for dairy fat in adults. This study aimed to investigate the relationship between dairy product intake and these FAs in adolescents.

MATERIAL AND METHODS

Healthy adolescents were randomized to one of three groups (Group 1: control; Group 2: consume 3 dairy servings/day; and Group 3: consume ≥ 4 servings/d). C15:0, C17:0 and t-C16:1n-7 were quantified using gas chromatography. Dietary intakes were assessed by 24 h diet recalls.

RESULTS

No difference was observed in FAs at baseline or 6 months (mo), however, at 12 mo, erythrocyte C15:0 increased in group 3 (+0.37 µg/ml, p = 0.01). Dairy intake increased in both intervention groups (Group 2: +1.4 servings/d; Group 3: +2.4 servings/d, p < 0.0001) and positively correlated with erythrocyte C15:0 at 12 mo.

CONCLUSION

Erythrocyte FAs appear to be associated with increasing dairy intakes during adolescence.

Antineoplastic agents exacerbating Charcot Marie Tooth disease: red flags to avoid permanent disability

BACKGROUND

Charcot Marie Tooth (CMT) disease is the most common form of hereditary neuropathy. Due to the high prevalence of mild and undiagnosed forms, patients with CMT disease may be exposed to severe neurotoxicity following the administration of neurotoxic chemotherapies. The aim of this report is to alert oncologists to the potential to precipitate severe irreversible peripheral neuropathies when administering neurotoxic compounds to undiagnosed CMT patients.

MATERIAL AND METHODS

A retrospective research in the OncoNeuroTox database was performed (2010-2016), searching for patients with the diagnosis of chemotherapy-induced peripheral neuropathy (CIPN) and CMT disease. A comprehensive literature review for previously published cases was performed using the Pubmed and Cochrane databases (1972-2017).

RESULTS

Among 428 patients with CIPN, we identified eight patients with concomitant CMT disease. Seven patients out of the eight had no previous diagnosis of CMT disease, although accurate familial history disclosed mild signs of peripheral neuropathy in five cases. Patients themselves had minor stigmata of long-standing peripheral damage. Patients received chemotherapy regimens based on vinca alkaloids, taxanes or a combination of vinca alkaloids and platinum compounds. In two cases, cumulative doses were below or equal to the expected neurotoxic threshold. Following chemotherapy administration, patients developed severe length-dependent sensory-motor deficits. Despite early drug discontinuation, most patients remained severely disabled.

CONCLUSION

A brief checklist to disclose long-standing signs of peripheral neuropathy could be helpful to detect patients with undiagnosed hereditary neuropathies who could be at risk of developing severe irreversible neurotoxicity following the administration of neurotoxic agents.

Agomelatine for the treatment of patients with fibromyalgia and depressive symptomatology: an uncontrolled, 12-week, pilot study

INTRODUCTION

Agomelatine, a melatonin agonist and selective 5-HT2C antagonist, is a novel antidepressant with sleep-enhancing properties. The purpose of this study was to assess the efficacy and tolerability of agomelatine among patients with fibromyalgia and depression.

METHODS

23 patients with fibromyalgia and depressive symptomatology received 25-50 mg of agomelatine daily for 12 weeks. The primary outcome measure was the change of the Beck depression inventory score. Secondary outcome measures included the hospital anxiety and depression scale, Pittsburgh sleep quality index, Fibromyalgia Impact Questionnaire, short-form health survey, brief pain inventory and patient's global impression scale.

RESULTS

Agomelatine significantly improved depression, global fibromyalgia severity and pain intensity but effect sizes were small. No improvement was seen in sleep quality. Patients categorized as responders to treatment had milder disease severity than non-responders. Agomelatine therapy was well tolerated and patients only reported mild and transient side effects.

DISCUSSION

Agomelatine slightly improved depressive and fibromyalgia symptomatology but did not improve sleep quality. Our data do not support agomelatine as a first-line treatment option for the treatment of fibromyalgia and depression.

Validation of a Relative Head Injury Severity Scale for Pediatric Trauma

BACKGROUND

Brain injury is the most important independent predictor of mortality and morbidity in pediatric trauma. The Glasgow Coma Score (GCS) is the commonly used clinical instrument to assess brain injury. However, the GCS or one of its components is often not applicable in children under a certain age or cannot be computed reliably because of the patient's condition or the circumstances surrounding resuscitation efforts. This limits its usefulness in statistical models of trauma outcomes, which rely on complete data collection and entry into trauma registries. This study provides evidence validating use of a relative head injury severity scale (RHISS) derived from available International Classification of Diseases, 9th Revision (ICD-9) diagnosis codes to stratify degree of head injury.

METHODS

The patient population was derived from the National Pediatric Trauma Registry (NPTR;1994-2001). Survival Risk Ratios (SRRs) were computed for each head injury ICD-9 code. ICD-9 diagnosis codes related to head injury were then assigned to a RHISS category based on duration of loss of consciousness, location of skull fracture, or both: 0 = none; 1 = mild; 2 = moderate, or 3 = severe head injury. Analysis of variance compared mean SRRs across RHISS categories. Each patient was then assigned to a RHISS category based on their single worst ICD-9 head injury code. Logistic regression analysis was used to predict mortality based on New Injury Severity Score (NISS), whether the patient had been intubated, RHISS, and the Abbreviated Injury Score (AIS) for head and neck injuries.

RESULTS

GCS score was missing for 96% of nonsurvivors in the NPTR. Mean SRRs differed significantly (p < 0.001) among ICD-9 codes assigned to each RHISS category, as follows (Mean +/- SD): RHISS (0) = 0.93 +/- 0.16; RHISS (1) = 0.89 +/- 0.22; RHISS (2) = 0.85 +/- 0.26; RHISS (3) = 0.55 +/- 0.35. Logistic regression identified RHISS as an independent significant predictor (p < 0.01) of mortality.

CONCLUSION

RHISS is a valid index of degree of head injury in the pediatric trauma population. Unlike GCS, RHISS is more likely to be available in trauma registries, and can be computed from administrative data. RHISS provides a feasible and valid method for quantifying the degree of brain injury in statistical models of pediatric trauma outcome.

The safety of central line placement prior to treatment of pediatric acute lymphoblastic leukemia

BACKGROUND

Central venous lines are placed in children with acute lymphoblastic leukemia at diagnosis, despite significant cytopenias, to facilitate the administration of chemotherapy and blood sampling. The present study aimed to determine the safety of central line placement in these patients.

METHODS

We reviewed the charts of 115 consecutive patients treated during a 10-year period. Data abstracted comprised age, gender, presenting and preoperative blood counts, type of central line, blood products transfused preoperatively, duration of neutropenia (absolute neutrophil count [ANC], <500/microl), treatment, and central line-associated complications.

RESULTS

There were 66 male and 49 female patients with a median age of 4 years. Seventy-one patients were classified as standard-risk and 44 as high-risk. Respective median blood counts at diagnosis and prior to surgery were white cell count (microl), 4,200 and 5,550; hemoglobin (g/dl), 7.7 and 9.4; platelet count (microl), 63,000 and 72,000; and ANC (microl), 3,950 and 4,900. The median duration of neutropenia was 15 days in the standard-risk group and 18 days in the high-risk group. Thirty-eight patients were not transfused preoperatively. There were no episodes of bacteremia. Seven patients (7%) with life-ports experienced a complication: in four blood could not be aspirated, two ports needed realignment, and one a wound infection developed without dehiscence. Four patients (27%) with external lines had a complication: one each with line occlusion, accidental removal by patient, line rupture, and line leakage at insertion site. The complication rate between ports and external lines was different (P = 0.045).

CONCLUSIONS

Central line placement prior to anti-leukemia treatment is safe. Most complications are mechanical and not due to leukemia, chemotherapy, or cytopenias.

Intubation of Pediatric Trauma Patients in the Field: Predictor of Negative Outcome Despite Risk Stratification

BACKGROUND

Recently, evidence has shown that intubation in the field may not improve or may even adversely affect outcomes. Our objective was to analyze outcomes in pediatric intubated trauma patients using a large national pediatric trauma registry.

METHODS

The patient population was derived from the last phase of the National Pediatric Trauma Registry, comprising admissions from 1994 through 2002. Intubated patients were identified, as was their place of intubation: in the field, at a hospital that was not a trauma center, and at a trauma center. Risk stratification was performed for mortality using logistic regression models and variables available at presentation to the emergency room. Odds ratio and variable significance were calculated from the logistic regression model. The percentage of patients discharged to home and an abnormal Functional Independence Measure at hospital discharge examined functional outcome of survivors.

RESULTS

There were a total of 50,199 patients, 5460 (11.6%) of whom were intubated (1,930 in the field, 1,654 in the hospital, and 1,876 in a trauma center). Unadjusted mortality rates for intubated patients were as follows: field, 38.5%; hospital, 16.7%; and trauma center, 13.2% (all different, p < 0.05). The developed logistic regression model had an area under the receiver operating characteristic curve of 0.98. Compared with nonintubated patients, the odds ratio for field intubation, for non-trauma center, and for trauma center intubation was 14.4, 5.8, and 4.8, respectively (significantly different field vs. either hospital). The actual (observed) death rate was significantly higher than predicted in those intubated in the field. Stratification of injury by New Injury Severity Score or degree of head injury showed that this difference extended from mild to severe (e.g., odds ratio for New Injury Severity Score < 15 field vs. trauma center intubation, 12.3; odds ratio for none or moderate head injury, 5.1). Similar results were obtained for functional outcome in the survivors.

CONCLUSION

Field intubation is an independent strong negative predictor of survival or good functional outcome despite adjustment for severity of injury. Although not causal, the magnitude of these differences should lead to future controlled studies of pediatric trauma field intubations.

Knife wound to the posterior fossa in a child

BACKGROUND

Knife wounds to the posterior fossa are a rare occurrence, especially in children. We report an 8-year-old girl who sustained a penetrating knife injury through the occipital bone into the posterior fossa. On presentation, the large knife blade was firmly embedded in her head.

METHODS

Radiographic evaluation was limited to plain X-rays because of the large size and sharpness of the embedded blade. Innovative positioning was used during intubation and then the patient was positioned semi-prone on the operating room table. The blade was surgically removed and the dura was closed.

CONCLUSIONS

Atypical penetrating cranial injuries in children may require the treatment team to take a creative approach to the evaluation and repair of the lesion in order to maximize patient safety and minimize the risk of neurological injury.

Determination of national pediatric injury prevention priorities using the Injury Prevention Priority Score

PURPOSE

Previous studies have found that the Injury Prevention Priority Score (IPPS) provides a reliable and valid method to gauge the relative importance of different injury causal mechanisms at individual trauma centers. This study examines its applicability to prioritizing injury mechanisms on a national level and within defined pediatric age groups.

METHODS

A total of 47,158 patients (age <17) in the National Pediatric Trauma Registry were grouped into common injury mechanisms based on ICD-9 E-Codes. Patients also were stratified by age group. IPPS was calculated for each mechanism and within each age group.

RESULTS

Falls of all types account for the greatest number of injuries (n = 15,042; 32%), whereas child abuse results in the most severe injuries (mean Injury Severity Score, 13.3) However, the most significant mechanisms of injury, according to IPPS, were motor vehicle crashes followed by pedestrian struck by motor vehicles. Certain age groups had specific injury problems including child abuse in infants and assault and gun injuries in adolescents.

CONCLUSIONS

IPPS provides an objective, quantitative method for determining injury prevention priorities based on both frequency and severity at the national level. It also is sensitive to age-related changes in different mechanisms of injury.

Prediction of Mortality in Pediatric Trauma Patients: New Injury Severity Score Outperforms Injury Severity Score in the Severely Injured

BACKGROUND

The Injury Severity Score (ISS) is a widely accepted method of measuring severity of traumatic injury. A modification has been proposed--the New Injury Severity Score (NISS). This has been shown to predict mortality better in adult trauma patients, but it had no predictive benefit in pediatric patients. The aim of this study was to determine whether the NISS outperforms the ISS in a large pediatric trauma population.

METHODS

Admissions in the National Pediatric Trauma Registry between April 1996 and September 1999 were included. The ISS and NISS were calculated for each patient. The study endpoints were mortality at hospital discharge, functional outcome in three domains (expression, locomotion, and feeding), and discharge disposition for the survivors. Predictive ability of each score was assessed by area under the receiver operating characteristic curve.

RESULTS

The NISS and ISS performed equally well at predicting mortality in patients with lower injury severity (ISS < 25), but the NISS was significantly better at predicting mortality in the more severely injured patients. Both scores performed equally well at predicting expression and feeding ability. The NISS was superior to the ISS in predicting locomotion ability at discharge. Thirty-seven percent of patients had an NISS that was higher than their ISS. These patients had a significantly higher mortality and suffered worse functional outcomes.

CONCLUSION

The NISS performs as well as the ISS in pediatric patients with lower injury severity and outperforms the ISS in those with higher injury severity.

Diagnostic imaging in the follow-up of nonoperative management of splenic trauma in children

The spleen is the most frequently injured organ in blunt abdominal trauma (BAT). Contrast-enhanced computed tomography (CT) is approximately 95% sensitive and specific for detection of splenic injury. In children, nonoperative treatment is well-established. The basic tenet of such management is an obligatory period of rest to prevent recurrent bleeding and allow splenic healing. Splenic preservation prevents post-splenectomy sepsis. At our level I trauma center, pediatric patients (N=54) with BAT between 1993 and 1998 were retrospectively studied. Two (3.7%) died of associated injuries; 2 underwent splenectomy before transfer to our hospital. All had been diagnosed with splenic injury by CT. The mean age was 11.3 years. The mechanisms of injury were motor vehicle accidents (66%), bicycle accidents (26%), and falls (8%). All 50 remaining patients were followed by ultrasound (US) after the initial diagnosis by CT. The mean hospital stay was 6 days. One patient developed the rare complication of an arterio venous (AV) fistula within the damaged spleen; 47 (94%) had normal, homogeneous parenchymal echogenicity at healing (including the patient with the AV fistula). The remaining 3 demonstrated a visible echogenic scar. Imaging documentation of healing blunt splenic trauma should ideally minimize cost and relative risk. Our results add further evidence that US is well-suited to the task. No delayed complications with this approach were recorded in this series.

Development of a model for prediction of survival in pediatric trauma patients: comparison of artificial neural networks and logistic regression

BACKGROUND/PURPOSE

There is a paucity of outcome prediction models for injured children. Using the National Pediatric Trauma Registry (NPTR), the authors developed an artificial neural network (ANN) to predict pediatric trauma death and compared it with logistic regression (LR).

METHODS

Patients in the NPTR from 1996 through 1999 were included. Models were generated using LR and ANN. A data search engine was used to generate the ANN with the best fit for the data. Input variables included anatomic and physiologic characteristics. There was a single output variable: probability of death. Assessment of the models was for both discrimination (ROC area under the curve) and calibration (Lemeshow-Hosmer C-Statistic).

RESULTS

There were 35,385 patients. The average age was 8.1 +/- 5.1 years, and there were 1,047 deaths (3.0%). Both modeling systems gave excellent discrimination (ROC A(z): LR = 0.964, ANN = 0.961). However, LR had only fair calibration, whereas the ANN model had excellent calibration (L/H C stat: LR = 36, ANN = 10.5).

CONCLUSIONS

The authors were able to develop an ANN model for the prediction of pediatric trauma death, which yielded excellent discrimination and calibration exceeding that of logistic regression. This model can be used by trauma centers to benchmark their performance in treating the pediatric trauma population.

Lymphocyte-predominant Hodgkin disease in children

PURPOSE

To describe the clinicobiological features, treatment, treatment outcome, and sequelae of children with lymphocyte-predominant Hodgkin disease.

PATIENTS AND METHODS

The authors performed a retrospective chart review of 754 patients with Hodgkin disease diagnoses at New York Medical College and St. Jude Children's Research Hospital from 1962 to 2000 to identify those with lymphocyte-predominant histology. Hematopathologists at the treating institutions reviewed stored tissue specimens and reconfirmed the histopathology of each case.

RESULTS

Fifty-one children (44 boys, 7 girls) were identified. The median age was 10.5 years (range 3.2-18.5); five children were younger than age 60 months. The median duration of lymphadenopathy before diagnosis was 4 months (range 0.5-30). Thirty-six children had stage 1 disease, eight had stage 2 disease, four had stage 3 disease, and three had stage 4 disease. Fifteen children underwent staging laparotomy, and four of these were upstaged. Treatment comprised combined modality therapy (n = 27), radiation therapy alone (n = 17), and chemotherapy alone (n = 7). Four children had a Hodgkin disease recurrence. Forty-eight (94%) patients were alive and disease-free at a median follow-up of 8 years (range 0.4-32.6). Eleven patients had long-term, therapy-related adverse effects (cardiac, infertility, pulmonary, and second malignant neoplasms). Three patients died. Two died of complications of second malignant neoplasms and one died of infectious complications after Hodgkin disease recurrence.

CONCLUSIONS

Children with lymphocyte-predominant Hodgkin disease respond favorably to a variety of treatment modalities and are ideal candidates for less toxic therapy.

Prenatally diagnosed neuroblastoma

BACKGROUND

Prenatally diagnosed neuroblastomas have been reported in increasing numbers over the past several years, and there are now a few reviews based on up to 21 cases. The purpose of this article is to review the clinical and biologic features of prenatally diagnosed neuroblastoma based on a review of 55 cases.

METHODS

A review was conducted of 3 cases seen at the study institution and 52 other cases reported thus far in the literature.

RESULTS

Prenatal diagnosis was made usually after 32 weeks of gestation. Approximately 93% of the tumors were adrenal in origin, and 44% of these were cystic. Thirty-seven patients (67%) had Stage I disease, 12 (22%) had Stage IV-S disease, and only 3 (5%) had Stage IV disease. The DNA index was favorable (> 1) in 14 of 16 patients studied. None of these 16 patients studied had amplification of the N-myc oncogene. Catecholamines were elevated in only 33% of the patients. The liver was the most common site of dissemination, which was observed in 25% of patients; bone involvement was not observed in any patient. Ultrasonography failed to detect existing hepatic metastasis in three patients. Primary surgical resection was performed in 47 patients (85%). Chemotherapy was given to five patients and radiotherapy to three. Of the 50 patients for whom follow-up information was available, 45 (90%) were alive at a range of 2-120 months from diagnosis.

CONCLUSIONS

Prenatally diagnosed neuroblastomas are predominantly adrenal in origin and frequently cystic. The liver is the most common site of dissemination and bone involvement is notably absent. The vast majority of these infants have a favorable stage of disease (I, II, and IV-S) and favorable biologic features, and consequently have an excellent prognosis. Although surgery alone is curative for most patients, a period of observation may avoid surgery in some individuals who may achieve spontaneous regression.

Gastric ganglioneuroblastoma: a rare finding in an infant with multifocal ganglioneuroblastoma

PURPOSE

This report describes a female infant with stage 4 multifocal ganglioneuroblastoma with gastric involvement.

PATIENT

The patient had a right cervical tumor, a left posterior mediastinal tumor, bilateral adrenal tumors, and bony and bone marrow metastases. The tumor cells were diploid and lacked N-myc gene amplification. The gastric involvement, which did not produce clinical symptoms, was only detected by meticulous exploration during laparotomy.

RESULTS

Our patient achieved only a partial response to alternating cycles of cyclophosphamide, vincristine, and adriamycin; and etoposide and cisplatin. She currently has stable, unresectable disease with elevated catecholamines.

CONCLUSIONS

Multifocal ganglioneuroblastomas may arise from either neuroblastic rests or aberrant deposits of neuroblasts. The latter mechanism may have accounted for our patient's gastric tumor. Patients with multifocal ganglioneuroblastomas warrant meticulous radiographic and surgical evaluation to completely document the full extent of disease, and to ensure appropriate staging and therapy.

Solid variant of aneurysmal bone cyst in a patient with cyclic neutropenia

A 16-year-old female with cyclic neutropenia (CN) was incidentally found to have a thoracic vertebral mass during the preoperative work-up for maxillary sinus surgery. An exploratory thoracotomy revealed a very vascular tumor involving T-10 and T-11 vertebral bodies. Gross total resection of the tumor was achieved. Pathology revealed a solid variant of aneurysmal bone cyst. This is a rare benign neoplasm of bone more commonly seen in the mandible and facial bones as well as involving the small tubular bones of the hands and feet. Because of its rarity, location, and an unknown association with CN, we found this case worthwhile to publish.

Langerhans cell histiocytosis associated with partial DiGeorge syndrome in a newborn

PURPOSE

We report the unrecognized association of Langerhans cell histiocytosis (LCH) with partial DiGeorge syndrome.

PATIENT AND METHODS

A 7-week-old infant with endocrine and immunologic characteristics of DiGeorge syndrome displayed multisystem involvement of Letterer-Siwe disease at birth.

RESULTS

Despite vigorous medical support and chemotherapy, she died at 9 months of age with multisystem failure.

CONCLUSIONS

This case supports the role of the thymus n the pathogenesis of LCH.

Thrombosed Björk-Shiley standard disc mitral valve prosthesis

Between April 1980 and June 1986, 274 patients underwent mitral valve replacement (MVR) with the Björk-Shiley (BS) standard disc mitral valve prosthesis at the American University of Beirut Medical Center (AUBMC). Eleven patients (3.9%) presented 6-41 months after surgery with prosthetic valve dysfunction due to thrombosis. Inadequate control of anticoagulation was the major factor predisposing to thrombosis in all except one. All patients had documented rheumatic valvular disease. Nine patients were operated on an emergency basis and two died before any surgical intervention was possible. Thrombectomy was performed on six patients with four survivors and MVR in three with two survivors. Two patients died intraoperatively (22%). Three pregnant patients underwent mechanical declotting; pregnancy was terminated by abortion in 2 and by caesarean section and live birth in one. We conclude that implantation of the BS mitral valve prosthesis mandates emphasis on anticoagulation and the difficulty encountered with continuous anticoagulant therapy in pregnancy.

Combined occurrence of chyloperitoneum and chylothorax after surgery and chemotherapy for Wilms' tumor

Chyloperitoneum is an extremely rare complication of abdominal surgery in children and a combined occurrence of chylothorax and chyloperitoneum after abdominal surgery has never been reported in children. Chylous ascites usually occurs as a result of operative trauma to the thoracic duct, cisterna chyli, or its tributaries. About one third of all patients with chylous ascites after retroperitoneal lymph node dissection also develop secondary chylothorax. Diaphragmatic defects have been shown to be responsible for the occurrence of chylothorax secondary to chyloperitoneum. Congenital diaphragmatic weakness may result in evagination of the peritoneum causing diaphragmatic blebs, the rupture of which results in the movement of the peritoneal fluid into the pleural cavity. In the authors' patient, the rent in the diaphragm that occurred during surgery was probably responsible for the chylothorax. The role of chemotherapy, if any, in the pathophysiology of this complication is unknown. Total parenteral nutrition (TPN) is a simple and effective treatment for postoperative chylous effusions. Surgical treatments such as abdominal exploration for the repair of leaking lymphatics and peritoneovenous shunt should be reserved for patients who fail TPN.

Cardiac fibroma with tumor involvement of the mitral valve: diagnosis by cross-sectional echocardiography

The clinical, cross-sectional echocardiographic, haemodynamic, and angiographic features of a case of cardiac fibroma in a newborn with unexplained pulmonary hypertension, and direct tumor involvement of the posterior leaflet of the mitral valve, are presented. The role of echocardiography in the pre-operative evaluation of cardiac tumors is discussed.

Wandering intravascular missiles: report of five cases from the Lebanon war

From 1980 to 1986, during the Lebanon war, five patients with missile embolization were seen at the American University of Beirut Medical Center. Three had entry in the heart or thoracic aorta with peripheral embolization, and two had entry in the internal carotid artery and inferior vena cava with embolization to the middle cerebral artery and heart, respectively. Embolization was suspected when, in the absence of an exit, routine x-ray films showed the missile in a distant location. Angiography and echocardiography confirmed the diagnosis. Peripheral arterial emboli were extracted while cerebral and venous emboli were kept, as they caused transient symptoms and remained silent.

Neonatal appendicitis: case report and a revised review of the English literature

A case of perforated neonatal appendicitis in a surviving premature infant is presented. An up-dated review of the English literature on this subject is included. Of 111 cases with adequate documentation, 29 neonates had the inflamed appendix located within the inguinal hernial sac and survived after operation. In contrast only 24 (29%) of the remaining 82 patients with intra-abdominal acute appendicitis survived. The operative mortality rate in this review since 1901 with and without appendiceal perforation was 61% and 41% respectively. The diagnosis of acute appendicitis since 1976 was made at laparotomy in all patients except one, whereas it was made at necropsy in 57% of the cases of abdominal appendicitis that were reported previously.

Spinal cord compression in neuroblastoma

Twelve of 80 patients suffering from neuroblastoma who were treated during a 21-year period had intraspinal involvement. Mediastinal tumors have a greater tendency to extend to the spinal canal; however, distant spread of the tumor is rare in patients presenting with intraspinal extension. Patients with intraspinal extension also survive longer than those without. Other factors affecting survival are age, stage of disease, duration of neurological symptoms, degree of histologic differentiation, and mode of therapy. In the absence of osseous metastasis, total excision of the primary lesion and its intraspinal components is usually followed by a favorable outcome; residual neurological deficits among survivors, however, are relatively common.

Tetralogy of Fallot with pulmonary atresia in siblings

We present two sisters with tetralogy of Fallot and pulmonary valve atresia. Both had identical anatomical findings as seen at cardiac catheterization and angiography and verified operatively, with, in particular, identical bronchial circulation and pulmonary valve structure. The parents are first cousins and there is no history of other affected relatives. We suggest that this is a specific, recessively inherited type of tetralogy of Fallot.

Ehlers-Danlos syndrome type IV D: an autosomal recessive disorder

Two siblings born to consanguineous parents are reported with typical clinical features of the Ehlers-Danlos syndrome type IV. However, their cultured skin fibroblasts synthesize and secrete procollagen type III in normal amounts and proportions. This is probably a new form of the Ehlers-Danlos syndrome with autosomal recessive inheritance classified as Ehlers-Danlos syndrome type IV D.

Injuries to vessels of neck

A personal experience at the American University Medical Center with vascular neck injuries occurring between May and December 1976 is reported. Five unusual cases are presented and discussed, their ages ranging between 10 and 25 years. The causative agent was shrapnel in four and bullet in one. Four of the five cases had multiple associated injuries. The vessels involved were the carotid artery with internal jugular vein in two cases, the subclavian vein in one, the superior thyroid artery in one, and the carotid and vertebral arteries in one. The treatment consisted of a combined cervico-thoracic approach in two cases, a claviculectomy in one, suture-ligation and aneurysmectomy in four and venous graft to the artery in one. The complications consisted of postoperative bleeding in one case, partial facial nerve paresis in another, and superficial wound infection in a third. No deaths occurred among the five complicated cases presented.

Penetrating injuries of the heart and the great vessels

Twenty eight patients with penetrating injuries to the heart and/or the great vessels are presented. These constituted 9% of all penetrating chest injuries during the period between April 1975 and November 1976. The injuries were confined to the cardio-vascular system in 3 patients only. Twelve patients presented with signs of cardiac tamponade, of whom 2 succumbed intra-operatively due to ventricular fibrillation. Eight patients required respiratory support immediately after operation, of whom one died eventually due to extra-cardiac injuries. The mortality rate in this series was 11%. The remaining 25 survivors have resumed their regular life activities after discharge from the hospital. In none of the cases was the heart-lung machine used for repair.

One-lung ventilation of children during surgical excision of hydatid cysts of the lung

One-lung ventilation was used in 13 children, undergoing surgical excision of pulmonary hydatid cysts. Five had right-sided pulmonary cysts and eight had left cysts. An ordinary cuffed tracheal tube was introduced to the main bronchus of the healthy side. One-lung ventilation using 1-2% halothane in oxygen produced PaO2 values of 12.6-33.3 KPa and PaCO2 values of 4-6kPa. After operation there was a high frequency of right upper lobe collapse in cases of selective right bronchial intubation, but this cleared completely within 3-4 days. The technique proved to be a simple and effective method of isolating and ventilating the healthy lung.

Double zonal aganglionosis in long segment Hirschsprung's disease with a "skip area" in transverse colon

The case of an infant with Hirschsprung's disease involving the rectum, entire colon, cecum, appendix, terminal ileum and sparing the midtransverse colon is described. The purpose of the report is to submit an additional illustration of this rarely documented aspect of intestinal aganglionosis.