Neonatal Abstinence Syndrome Severity Index Predicts 18-Month Neurodevelopmental Outcome in Neonates Randomized to Morphine or Methadone

OBJECTIVE

To develop an index to determine which opioid-exposed neonates have the most severe neonatal abstinence syndrome (NAS).

STUDY DESIGN

Full-term neonates with NAS (n = 116) from mothers maintained on methadone or buprenorphine were enrolled from 8 sites into a randomized clinical trial of morphine vs methadone. Ninety-nine (85%) were evaluated at hospital discharge using the NICU Network Neurobehavioral Scale (NNNS). At 18 months, 83 of 99 (83.8%) were evaluated with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III), and 77 of 99 (77.7%) were evaluated with the Child Behavior Checklist (CBCL).

RESULTS

Cluster analysis was used to define high (n = 21) and low (n = 77) NAS severity. Compared with infants in the low NAS severity cluster, infants in the high NAS severity cluster had a longer length of stay (P < .001), longer length of stay due to NAS (P < .001), longer duration of treatment due to NAS (P < .001), and higher total dose of the study drug (P < .001) and were more likely to have received phenobarbital (P < .001), to have been treated with morphine (P = .020), and to have an atypical NNNS profile (P = .005). The 2 groups did not differ in terms of maximum Finnegan score. At 18 months, in unadjusted analyses, compared with the high-severity cluster, the low-severity cluster had higher scores on the Bayley-III Cognitive (P = .013), Language (P < .001), and Motor (P = .041) composites and less total behavior problems on the CBCL (P = .028). In adjusted analyses, the difference in the Bayley-III Language composite remained (P = .013).

CONCLUSIONS

Presumptive measures of NAS severity can be aggregated to develop an index that predicts developmental outcomes at age 18 months.

Prenatal Opioid Exposure: Neurodevelopmental Consequences and Future Research Priorities

Neonatal opioid withdrawal syndrome (NOWS) has risen in prevalence from 1.2 per 1000 births in 2000 to 5.8 per 1000 births in 2012. Symptoms in neonates may include high-pitched cry, tremors, feeding difficulty, hypertonia, watery stools, and breathing problems. However, little is known about the neurodevelopmental consequences of prenatal opioid exposure in infancy, early childhood, and middle childhood. Even less is known about the cognitive, behavioral, and academic outcomes of children who develop NOWS. We review the state of the literature on the neurodevelopmental consequences of prenatal opioid exposure with a particular focus on studies in which NOWS outcomes were examined. Aiming to reduce the incidence of prenatal opioid exposure in the near future, we highlight the need for large studies with prospectively recruited participants and longitudinal designs, taking into account confounding factors such as socioeconomic status, institutional variations in care, and maternal use of other substances, to independently assess the full impact of NOWS. As a more immediate solution, we provide an agenda for future research that leverages the National Institutes of Health Environmental Influences on Child Health Outcomes program to address many of the serious methodologic gaps in the literature, and we answer key questions regarding the short- and long-term neurodevelopmental health of children with prenatal opioid exposure.

Isolated conjugate gaze palsy after frontal lobe tumour surgery

Isolated conjugate gaze palsy following unilateral frontal lobe surgery is uncommon. When it does occur, usually it recovers within hours. We report a case of isolated conjugate gaze palsy which persisted for four weeks post-operatively before recovery commenced.

Comparative analysis of the post-lumpectomy target volume versus the use of pre-lumpectomy tumor volume for early stage breast cancer: implications for the future

Abstract #5134

Purpose: Accelerated partial breast irradiation (APBI) is increasingly being utilized for the treatment of early stage breast cancer. Planning target volume (PTV) generation with this approach is based on the post-lumpectomy cavity volume (post-LPC) and is often associated with treatment of large amounts of normal breast tissue which can result in patient ineligibility for external beam APBI (EB-APBI). In malignancies such as soft tissue sarcomas, neoadjuvant radiation therapy (RT) has been shown to be associated with smaller volumes of tissue irradiated compared to adjuvant RT. However, neoadjuvant RT has not been attempted in the setting of APBI. We hypothesized that a PTV generation based on an expansion of the pre-lumpectomy (pre-LP) intact tumor volume would result in a significant reduction in the volume of irradiated normal breast tissue compared to the current approach of using the post-LPC. We further hypothesize that the use of EB-APBI utilizing the pre-LP tumor will result in greater patient eligibility for APBI.&#x2028; Materials and Methods: 40 patients with 41 early stage breast cancers previously treated with breast conserving lumpectomy and RT were analyzed. Pre-operative imaging and pathology reports were used to determine a pre-LP tumor volume. A sphere, the diameter of which was the largest determined radiographic dimension, representing the pre-LP tumor volume was placed in the center of the previously contoured and treated lumpectomy cavity. PTVs were developed for the pre-LP tumor volume and the post-LPC volume as per the NSABP-B39 protocol guidelines. The pre-LP and post-LPC PTV volumes were compared. Suitability for APBI was analyzed using criteria set forth by NSABP-B39 guidelines.&#x2028; Results: For all patients, the pre-LP PTV was smaller than the post-LPC PTV. The median volume for the pre and post-LPC PTVs were 93 cc (range 24 – 570 cc) and 250 cc (range 45 – 879 cc), respectively. Paired t-test analysis demonstrated the pre-LP PTV to be significantly smaller than the post-LPC PTV, p &lt; 0.001. The average difference between pre-LP and post-LPC PTVs represented 173 cc (range 21 – 482 cc) or 18% (range 3 - 42%) of the whole breast volume. Based on our analysis, only 3 of 41 cases were ineligible for EB-APBI when using the pre-LP tumor volume, (2 based on pathologic criteria and 1 based on dose/volume constraints) while 13 of 41 cases were ineligible when using the post-LPC PTV (2 based on pathologic criteria and 11 based on dose/volume constraints).&#x2028; Conclusion: PTVs based on the pre-LP tumor expansion are likely to be associated with a significantly reduced amount of normal breast tissue irradiated compared to post-LPC PTVs potentially leading to improved breast cosmesis, decreased dose to critical structures and decreased toxicities. Additionally, eligibility for EB-APBI would potentially increase if administered in the pre-lumpectomy setting. The findings from this study support future investigation as to the implications and feasibility of neoadjuvant APBI.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5134.

Treatment of subtotally resected intracranial plasma cell granuloma with steroids: a case report

Primary intracranial plasma cell granuloma (PCG) is a rare form of inflammatory pseudotumour often characterized by non-neoplastic proliferation of plasma cells. The following case indicates a potential role for steroid therapy after subtotal resection.

Detection of cathepsin S cysteine protease in human brain tumour microdialysates in vivo

Microdialysis enables the chemistry of extracellular fluid in body tissues to be measured. Extracellular proteases such as the cysteine protease, cathepsin S (CatS), are thought to facilitate astrocytoma invasion. Microdialysates obtained from human brain tumours in vivo were subjected to cathepsin S activity and ELISA assays. Cathepsin S ELISA expression was detected in five out of 10 tumour microdialysates, while activity was detected in five out of 11 tumour microdialysates. Cathepsin S expression was also detected in microdialysate from the normal brain control although no activity was found in the same sample. While some refinements to the technique are necessary, the authors demonstrate the feasibility and safety of microdialysis in human astrocytomas in vivo. Characterisation of the extracellular environment of brain tumours in vivo using microdialysis may be a useful tool to identify the protease profile of brain tumours.

Delayed post-surgical development of dural arteriovenous fistula after cervical meningocele repair

A 34-year-old female patient presented with an intracranial subarachnoid hemorrhage and was found to have a dural arteriovenous fistula at the site of previous cervical meningocele repair. Subsequent occlusion was achieved with endovascular embolization. To our knowledge, the phenomenon of the development of a spinal dural fistula at the site of a meningocele repair has not been recorded before.

Dinosaurs, dragons, and dwarfs: the evolution of maximal body size

Among local faunas, the maximum body size and taxonomic affiliation of the top terrestrial vertebrate vary greatly. Does this variation reflect how food requirements differ between trophic levels (herbivores vs. carnivores) and with taxonomic affiliation (mammals and birds vs. reptiles)? We gathered data on the body size and food requirements of the top terrestrial herbivores and carnivores, over the past 65,000 years, from oceanic islands and continents. The body mass of the top species was found to increase with increasing land area, with a slope similar to that of the relation between body mass and home range area, suggesting that maximum body size is determined by the number of home ranges that can fit into a given land area. For a given land area, the body size of the top species decreased in the sequence: ectothermic herbivore > endothermic herbivore > ectothermic carnivore > endothermic carnivore. When we converted body mass to food requirements, the food consumption of a top herbivore was about 8 times that of a top carnivore, in accord with the factor expected from the trophic pyramid. Although top ectotherms were heavier than top endotherms at a given trophic level, lower metabolic rates per gram of body mass in ectotherms resulted in endotherms and ectotherms having the same food consumption. These patterns explain the size of the largest-ever extinct mammal, but the size of the largest dinosaurs exceeds that predicted from land areas and remains unexplained.

Cranioplasty: why throw the bone flap out?

Patients who undergo decompressive craniectomy for intracranial hypertension often require interval cranioplasty. Many cranioplasty agents are currently in use. The authors suggest that storage of the patient's own bone flap in the subcutaneous tissue of the abdominal wall, is a safe, efficacious and cost-effective alternative to use of synthetic cranioplasty materials.

Sildenafil (Viagra)-induced spontaneous intracerebral haemorrhage

Sildenafil (Viagra) has been developed as a drug to help male impotence. It has a direct effect on the vasculature of the corpus cavernosum. A case of spontaneous intracerebral haemorrhage (ICH) following the illicit use of Viagra is reported. A discussion of drug-induced ICH is included.

Modern management of head injuries

Management of the head-injured patient is designed to prevent secondary injury and to provide the neurosurgeon with a live patient who has some hope of recovery. This review sets out the background essentials for the non-neurosurgeon dealing with the initial care of a head-injured patient.

DNA hybridization, cladistics, and the phylogeny of phalangerid marsupials

Single-copy DNA/DNA hybridization experiments and numerical cladistic analyses of anatomical characters were used to investigate relationships among nine phalangerid (Marsupialia) species from four different genera. Both rate-dependent and rate-independent analyses of molecular data indicate that species of Trichosurus from one clade and that Strigocuscus, Phalanger, and Spilocuscus form a second. Within the latter group, Spilocuscus is excluded from a Strigocuscus-Phalanger clade, which, in turn, is not fully resolved on a jackknife strict consensus tree. Minimum-length Dollo, Wagner, and Camin-Sokal parisomy trees based on 35 anatomical characters, in contrast, suggest placement of Strigocuscus with Trichosurus rather than with Spilocuscus and Phalanger. However, there are two derived characters that support the alternative arrange of Strigocuscus with Spilocuscus and Phalanger and one character that further unites Strigocuscus and Phalanger. Thus, DNA hybridization results are not inconsistent with the distribution of derived character states among anatomical characters, only with minimum-length trees based on character data.

Notes on the distribution, abundance, diet and habitat of the New Guinea murid (Rodentia) Xenuromys barbatus (Milne-Edwards, 1900)

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Taxonomic and Phylogenetic Status of Living and Fossil Kangaroos and Wallabies of the Genus Macropus Shaw (Macropodidae: Marsupialia), with a New Subgeneric Name for the Larger Wallabies

Historical concepts of the generic status of the macropodines commonly known as kangaroos and wallabies are reviewed in this paper. A new diagnosis is provided for the genus Macropus, encompassing both living and fossil forms, and using cladistic principles to assess the phylogenetic value of diagnostic characters where possible. Cytological, biochemical and anatomical characters are used. Fourteen living and 11 extinct species of Macropus are recognized. Of these, 20 species have been classified into three subgenera, M.(Macropus), M.(Osphranter) and a new subgenus, M.(Notamacropus), as follows: M.(M.) giganteus, M.(M.) fuliginosus, M.(M.) mundjabus, M.(M.) pan, M.(M.) pearsoni and M.(M.) ferragus; M.(O.) antilopinus, M.(O.) bernardus, M.(O.) robustus, M.(O.) rufus and M.(O.) pavana; ,M.(N.) rufogriseus, M.(N.) eugenii, M.(N.) parryi, M.(N.) dorsalis, M.(N.) irma, M.(N.) agilis, M.(N.) greyi, M.(N.) parma, M.(N.) wombeyensis and M.(N) thor. Four poorly known extinct species, M. dryas, M. rama, M. woodsi and M. narada, have not yet been allocated to a subgenus. Prionotemnus palankarinnicus Stirton, 1957 is shown to belong outside Macropus. Because it is the type-species of Prionotemnus, that name is not available for a subgenus of Macropus. A current synonymy is presented for fossil species and the known stratigraphic range is given for each species. A phylogeny is presented expressing our view that M. (,Votamacropus) is the most plesiomorphic subgenus and M. (Macropus) is the most derived.

The taxonomy and distribution of Macropus (Fissuridon) pearsoni (Marsupialia: Macropodidae)

Macropus pearsoni, previously known only from the Pleistocene eastern Darling Downs, Queensland, is now recorded from the early Pleistocene Kanunka local fauna of the Katipiri Sands, South Australia. The presence of M. pearsoni as well as other species of macropodids in both the Darling Downs and Kanunka deposits may indicate a close temporal relationship between the faunas from these two localities. Fissuridon Bartholomai, 1973, appears to be a junior synonym of Macropus Shaw, 1790, but is retained as a subgeneric name and expanded to include Macropus (Fissuridon) pan DeVis, 1895.