Knowledge of patients with sarcoma about their illness-a cross-sectional questionnaire-based study (KNOWSARC)

Objective

To explore the knowledge of Indian patients with sarcoma about their illness in the sarcoma medical oncology clinic of a tertiary care centre.

Method

This prospective cross-sectional questionnaire-based study was done on patients attending the adult sarcoma clinic at the All India Institute of Medical Sciences, New Delhi. Patients aged between 18 and 60 years who gave consent and could understand Hindi or English were recruited for the study. A questionnaire (bilingual - English/Hindi) was given to the patients in the language they understood. The questionnaire captured the knowledge of patients about their illness (cancer/sarcoma), sub-type of sarcoma, the occurrence of the disease (common or rare), origin (bone or soft tissue), metastatic or non-metastatic and the understanding of the possibility of recurrence/progression.

Result

There were 102 patients in the study with a median age of 31.5 years. About 62% of patients had soft tissue sarcomas, and the rest had bone sarcomas. The most common sarcoma in the studied population was Ewing's sarcoma (23.5%). Metastatic disease was present in 48 (47.1%) of the total patients studied. About 87.2% of patients were aware that they had some form of cancer, and only 62 (69.9%) patients said that they had sarcoma. Only 55 of the 102 patients (56%) knew that the illness was rare. About 70.6% of patients knew about their disease's actual stage. More patients with metastatic disease understood the stage correctly (35 of 54 patients) as compared to patients with the non-metastatic disease (37 of 48 patients) (77% versus 64.8%, p = 0.001). About 77% of patients reported the site of origin of cancer correctly. The patients who had a higher level of education and belonged to a higher socioeconomic status had significantly better knowledge regarding the diagnosis, stage, rarity and prognosis of the disease.

Conclusion

Our patients have poor knowledge about different types of sarcomas, and very few patients know that sarcoma is a rare malignancy. The most crucial factor that influenced the knowledge was the level of education. Through this study, we could identify the sub-group wherein the knowledge gap was significant. Thus, active patient education programmes can help these patients to identify their illness and henceforth therapeutically manage it more wisely.

Effective One-Dimensional Coupling in the Highly Frustrated Square-Lattice Itinerant Magnet CaCo_{2-y}As_{2}

Inelastic neutron scattering measurements on the itinerant antiferromagnet CaCo_{2-y}As_{2} at a temperature of 8 K reveal two orthogonal planes of scattering perpendicular to the Co square lattice in reciprocal space, demonstrating the presence of effective one-dimensional spin interactions. These results are shown to arise from near-perfect bond frustration within the J_{1}-J_{2} Heisenberg model on a square lattice with ferromagnetic J_{1} and hence indicate that the extensive previous experimental and theoretical study of the J_{1}-J_{2} Heisenberg model on local-moment square spin lattices should be expanded to include itinerant spin systems.

Kondo lattice heavy fermion behavior in CeRh2Ga2

The physical properties of an intermetallic compound CeRh₂Ga₂ have been investigated by magnetic susceptibility [Formula: see text], isothermal magnetization M(H), heat capacity [Formula: see text], electrical resistivity [Formula: see text], thermal conductivity [Formula: see text] and thermopower S(T) measurements. CeRh₂Ga₂ is found to crystallize with CaBe₂Ge₂-type primitive tetragonal structure (space group P4/nmm). No evidence of long range magnetic order is seen down to 1.8 K. The [Formula: see text] data show paramagnetic behavior with an effective moment [Formula: see text]/Ce indicating Ce³⁺ valence state of Ce ions. The [Formula: see text] data exhibit Kondo lattice behavior with a metallic ground state. The low-T [Formula: see text] data yield an enhanced Sommerfeld coefficient [Formula: see text] mJ/mol K² characterizing CeRh₂Ga₂ as a moderate heavy fermion system. The high-T [Formula: see text] and [Formula: see text] show an anomaly near 255 K, reflecting a phase transition. The [Formula: see text] suggests phonon dominated thermal transport with considerably higher values of Lorenz number L(T) compared to the theoretical Sommerfeld value L ₀.

Investigations of the effect of nonmagnetic Ca substitution for magnetic Dy on spin-freezing in Dy₂Ti₂O₇

Physical properties of partially Ca substituted hole-doped Dy2Ti2O7 have been investigated by ac magnetic susceptibility χ(ac)(T), dc magnetic susceptibility χ(T), isothermal magnetization M(H) and heat capacity C(p)(T) measurements on Dy1.8Ca0.2Ti2O7. The spin-ice system Dy2Ti2O7 exhibits a spin-glass type freezing behavior near 16 K. Our frequency dependent χ(ac)(T) data of Dy1.8Ca0.2Ti2O7 show that the spin-freezing behavior is significantly influenced by Ca substitution. The effect of partial nonmagnetic Ca(2+) substitution for magnetic Dy(3+) is similar to the previous study on nonmagnetic isovalent Y(3+) substituted Dy(2-x)Y(x) Ti2O7 (for low levels of dilution), however the suppression of spin-freezing behavior is substantially stronger for Ca than Y. The Cole-Cole plot analysis reveals semicircular character and a single relaxation mode in Dy1.8Ca0.2Ti2O7 as for Dy2Ti2O7. No noticeable change in the insulating behavior of Dy2Ti2O7 results from the holes produced by 10% Ca(2+) substitution for Dy(3+) ions.

The magnetic structure of EuCu₂Sb₂

Antiferromagnetic ordering of EuCu2Sb2 which forms in the tetragonal CaBe2Ge2-type structure (space group P4/nmm #129) has been studied using neutron powder diffraction and (151)Eu Mössbauer spectroscopy. The room temperature (151)Eu isomer shift of -12.8(1) mm s(-1) shows the Eu to be divalent, while the (151)Eu hyperfine magnetic field (B(hf)) reaches 28.7(2) T at 2.1 K, indicating a full Eu(2+) magnetic moment. B(hf)(T) follows a smooth S = 7/2 Brillouin function and yields an ordering temperature of 5.1(1) K. Refinement of the neutron diffraction data reveals a collinear A-type antiferromagnetic arrangement with the Eu moments perpendicular to the tetragonal c-axis. The refined Eu magnetic moment at 0.4 K is 7.08(15) μ(B) which is the full free-ion moment expected for the Eu(2+) ion with S = 7/2 and a spectroscopic splitting factor of g = 2.

Muon spin relaxation study on itinerant ferromagnet CeCrGe₃ and the effect of Ti substitution on magnetism of CeCrGe₃

A Muon spin relaxation (µSR) study has been performed on the Kondo lattice heavy fermion itinerant ferromagnet CeCrGe3. Recent investigations of bulk properties have revealed a long-range ordering of Cr moments at Tc = 70 K in this compound. Our µSR investigation between 1.2 K and 125 K confirm the bulk magnetic order which is marked by a loss in initial asymmetry below 70 K accompanied with a sharp increase in the muon depolarization rate. Field dependent µSR spectra show that the internal field at the muon site is higher than 0.25 T apparently due to the ferromagnetic nature of ordering. The effect of Ti substitution on the magnetism in CeCrGe3 is presented. A systematic study has been made on polycrystalline CeCr(1-x)Ti(x)Ge3 (0 ⩽ x ⩽ 1) using magnetic susceptibility χ(T), isothermal magnetization M(H), specific heat C(T) and electrical resistivity ρ(T) measurements which clearly reveal that the substitution of Ti for Cr in CeCrGe3 strongly influences the exchange interaction and ferromagnetic ordering of Cr moments. The Cr moment ordering temperature is suppressed gradually with increasing Ti concentration up to x = 0.50 showing Tc = 7 K beyond which Ce moment ordering starts to dominate and a crossover between Cr and Ce moment ordering is observed with a Ce moment ordering Tc = 14 K for x = 1.0. The Kondo lattice behavior is evident from temperature dependence of ρ(T) in all CeCr(1-x)Ti(x)Ge3 samples.

Superconductivity and physical properties of CaPd2Ge2 single crystals

We present the superconducting and normal state properties of CaPd(2)Ge(2) single crystals investigated by magnetic susceptibility χ, isothermal magnetization M, heat capacity Cp, in-plane electrical resistivity ρ and London penetration depth λ versus temperature T and magnetic field H measurements. Bulk superconductivity is inferred from the ρ(T) and Cp(T) data. The ρ(T) data exhibit metallic behavior and a superconducting transition with T(c onset) = 1.98 K and zero resistivity at T(c 0) = 1.67 K. The χ(T) reveals the onset of superconductivity at 2.0 K. For T > 2.0 K, the χ(T) and M(H) are weakly anisotropic paramagnetic with χ(ab) > χ(c). The Cp(T) data confirm the bulk superconductivity below T(c) = 1.69(3) K. The superconducting state electronic heat capacity is analyzed within the framework of a single-band α-model of BCS superconductivity and various normal and superconducting state parameters are estimated. Within the α-model, the Cp(T) data and the ab plane λ(T) data consistently indicate a moderately anisotropic s-wave gap with Δ(0)/k(B)T(c) ≈ 1.6, somewhat smaller than the BCS value of 1.764. The relationship of the heat capacity jump at Tc and the penetration depth measurement to the anisotropy in the s-wave gap is discussed.

Investigations of the singlet ground state system: PrIrSi3

We report our comprehensive study of physical properties of a ternary intermetallic compound PrIrSi3 investigated by dc magnetic susceptibility χ(T), isothermal magnetization M(H), thermo-remnant magnetization M(t), ac magnetic susceptibility χac(T), specific heat Cp(T), electrical resistivity ρ(T), muon spin relaxation (µSR) and inelastic neutron scattering (INS) measurements. A magnetic phase transition is marked by a sharp anomaly at Ttr = 12.2 K in χ(T) measured at low applied fields which is also reflected in the Cp(T) data through a weak anomaly at 12 K. An irreversibility between the zero field cooled and field cooled χ(T) data below 12.2 K and a very large relaxation time of M(t) indicates the presence of ferromagnetic correlation. The magnetic part of specific heat shows a broad Schottky-type anomaly near 40 K due to the crystal electric field (CEF) effect. An extremely small value of magnetic entropy below 12 K suggests a CEF-split singlet ground state which is confirmed from our analysis of INS data. The INS spectra show two prominent inelastic excitations at 8.5 meV and 18.5 meV that could be well accounted by a CEF model. The CEF splitting energy between the ground state singlet and the first excited doublet is found to be 92 K. Our µSR data reveal a possible magnetic ordering below 30 K, which is much higher than that found from the specific heat and magnetic susceptibility measurements. This could be due to the presence of short range correlations well above the long range magnetic ordering or due to the electronic changes induced by muons. The induced moment magnetism in the singlet ground state system PrIrSi3 with such a large splitting energy of 92 K is quite surprising.

Physical properties of EuPd2As2 single crystals

The physical properties of self-flux grown EuPd2As2 single crystals have been investigated by means of magnetization M, magnetic susceptibility χ, specific heat Cp, and electrical resistivity ρ measurements versus temperature T and magnetic field H. The crystal structure was determined using powder x-ray diffraction measurements, which confirmed the ThCr2Si2-type body-centered tetragonal structure (space group I4/mmm) reported previously. The ρ(T) data indicate that EuPd2As2 is metallic. The χ(T) data indicate that the Eu(+2) moments have spin S = 7/2 with g = 2. Long-range antiferromagnetic (AFM) ordering is apparent from the χ(T), Cp(T), and ρ(T) measurements. For H∥c the χ(T) indicates two transitions at TN1 = 11.0 K and TN2 = 5.5 K, whereas for H⊥c only one transition is observed at TN1 = 11.0 K. Between TN1 and TN2 the anisotropic χ(T) data suggest a planar noncollinear AFM structure, whereas at T < TN2 the χ(T) and M(H, T) data suggest a spin reorientation transition in which equal numbers of spins cant in opposite directions out of the ab plane. We estimate the critical field at 2 K at which all Eu moments become aligned with the field to be about 22 T. An upturn in ρ at T < TN1 suggests superzone energy gap formation below TN1. This behavior of ρ(T < TN1) is not sensitive to applied magnetic fields up to H = 12 T.

Magnetic and transport properties of PrRhSi3

We have investigated the magnetic and transport properties of a noncentrosymmetric compound PrRhSi3 by dc magnetic susceptibility χ(T), isothermal magnetization M(H), thermoremanent magnetization M(t), specific heat Cp(T), electrical resistivity ρ(T,H) and muon spin relaxation (μSR) measurements. At low fields χ(T) shows two anomalies near 15 and 7 K with an irreversibility between ZFC and FC data below 15 K. In contrast, no anomaly is observed in Cp(T) or ρ(T) data. M(H) data at 2 K exhibit very sharp increase below 0.5 T and a weak hysteresis. M(t) exhibits very slow relaxation, typical for a spin-glass system. Even though the absence of any anomaly in Cp(T) is consistent with the spin-glass type behavior, there is no obvious origin of spin-glass behavior in this structurally well ordered compound. The crystal electric field (CEF) analysis of Cp(T) data indicates a CEF-split singlet ground state lying below a doublet at 81(1) K and a quasi-triplet at 152(2) K. The ρ(T) data indicate a metallic behavior, and ρ(H) exhibits a very high positive magnetoresistance, as high as ~300% in 9 T at 2 K. No long range magnetic order or spin-glass behavior was detected in a μSR experiment down to 1.2 K.

Complex magnetic order in Pr₂Pd₃Ge₅: a single crystal study

We have investigated the magnetic and electronic transport properties of single crystal Pr(2)Pd(3)Ge(5) grown by the Czochralski method. Complex magnetic behaviour (multiple magnetic transitions) is clearly seen in this compound from the magnetic susceptibility χ(T), isothermal magnetization M(H) and electrical resistivity ρ(T) data. For the magnetic field applied along the crystallographic c-axis (H ‖ [001]) the χ(T) data exhibit two sharp transitions at 6.9 and 6.3 K and a broad hump near 8 K. Four anomalies at 8.0, 7.3, 6.2 and 4.9 K are observed for the magnetic field along both a- and b-directions (H ‖ [100] and H ‖ [010]). Further, the ordered state χ(T) presents a large anisotropy with an easy axis along the c-axis. The presence of magnetocrystalline anisotropy is also inferred from the isothermal M(H) data. The M(H) data measured at 1.9 K for H ‖ [001] exhibit a step-like increase due to field-induced metamagnetic transitions at [Formula: see text] T and [Formula: see text] T. For H ‖ [100] and H ‖ [010] sharp step-like field-induced metamagnetic transitions occur at [Formula: see text] T and [Formula: see text] T which are accompanied by a weak S-shaped spin-flop metamagnetic transition at [Formula: see text] T. We have extracted the H-T phase diagram from the M(H) data collected at different temperatures in the magnetically ordered state which shows the existence of three magnetic phases below T(N) for H ‖ [100] and H ‖ [010], and two magnetic phases for H ‖ [001]. A sharp transition due to the onset of long range antiferromagnetic order is also seen in the ρ(T) data which also exhibit anisotropic behaviour. The observation of an upturn near T(N) in the ρ(T) data suggests the formation of a super-zone gap and hence the existence of incommensurate magnetic structure. Further, in the ordered state, the ρ(T) data present a gap in the excitation spectrum of magnons with a characteristic energy gap Δ ∼ 0.23 meV.

Ba(1-x)K(x)Mn2As2: an antiferromagnetic local-moment metal

The compound BaMn2As2 with the tetragonal ThCr2Si2 structure is a local-moment antiferromagnetic insulator with a Néel temperature T(N)=625 K and a large ordered moment μ=3.9μ(B)/Mn. We demonstrate that this compound can be driven metallic by partial substitution of Ba by K while retaining the same crystal and antiferromagnetic structures together with nearly the same high T(N) and large μ. Ba(1-x)K(x)Mn2As2 is thus the first metallic ThCr2Si2-type MAs-based system containing local 3d transition metal M magnetic moments, with consequences for the ongoing debate about the local-moment versus itinerant pictures of the FeAs-based superconductors and parent compounds. The Ba(1-x)K(x)Mn2As2 class of compounds also forms a bridge between the layered iron pnictides and cuprates and may be useful to test theories of high T(c) superconductivity.

Signatures of spin-glass behaviour in PrIr2B2 and heavy fermion behaviour in PrIr2B2C

The magnetic and transport properties of PrIr(2)B(2) and PrIr(2)B(2)C have been investigated by dc and ac magnetic susceptibility, specific heat, electrical resistivity and magnetoresistance measurements. PrIr(2)B(2) forms in CaRh(2)B(2)-type orthorhombic crystal structure (space group Fddd). At low fields the dc magnetic susceptibility of PrIr(2)B(2) exhibits a sharp anomaly near 46 K which is followed by an abrupt increase below 10 K with a peak at 6 K, and split-up in ZFC and FC data below 46 K. In contrast, the specific heat exhibits only a broad Schottky type hump near 9 K which indicates that there is no long range magnetic order in this compound. The thermo-remanent magnetization is found to decay very slowly with a mean relaxation time τ = 3917 s. An ac magnetic susceptibility measurement also observes two sharp anomalies; the peak positions strongly depend on the frequency and shift towards high temperature with an increase in frequency, obeying the Vogel-Fulcher law as expected for a canonical spin-glass system. The two spin-glass transitions occur at freezing temperatures T(f1) = 36 K and T(f2) = 3.5 K with shifts in the freezing temperatures per decade of frequency δT(f1) = 0.044 and δT(f2) = 0.09. An analysis of the frequency dependence of the transition temperature with critical slowing down, τ(max)/τ(0) = [(T(f)-T(SG))/T(SG)](-zν), gives τ(0) = 10(-7) s and exponent zν = 8, and the Vogel-Fulcher law gives an activation energy of 84 K for T(f1) and 27.5 K for T(f2). While zν = 8 is typical for spin-glass system, the characteristic relaxation time τ(0) = 10(-7) s is very large and comparable to that of superspin-glass systems. An addition of C in PrIr(2)B(2) leads to PrIr(2)B(2)C which forms in LuNi(2)B(2)C-type tetragonal structure (space group I4/mmm) and remains paramagnetic down to 2 K. The specific heat data show a broad Schottky type anomaly, which could be fairly reproduced with CEF analysis which suggests that the ground state is a CEF-split singlet and the first excited state singlet is situated 15 K above the ground state. The Sommerfeld coefficient γ∼300 mJ mol(-1) K(-2) of PrIr(2)B(2)C is very high and reflects a heavy fermion behaviour in this compound. We believe that the heavy fermion state in PrIr(2)B(2)C has its origin in low lying crystal field excitations as has been observed in PrRh(2)B(2)C.

Open-door maxillotomy approach for lesions of the clivus

The transpalatal route to the clival region has been used to approach both extradural and intradural lesions. Classic transpalatal surgery, however, entails a partial splitting of the soft palate or some form of palatal retraction, which leaves behind a bony palate that hinders surgical exposure. When necessary, operative exposure can be enhanced by an open-door maxillotomy approach that uses a combination of a Le Fort I osteotomy of the maxilla and a paramedian sagittal split of the hard palate. The nasal septum is translocated to create a wide contiguous oronasal aperture through which the clival region can be reached unobstructed. This technique was used in three patients. No significant complications were observed in any patient. Features of this extended transpalatal approach, including indications and adjunctive measures to minimize potential complications, are discussed.

Complex magnetic behavior in the novel Kondo lattice compound CeRhSn₃

We report the magnetic and transport properties of a new ternary intermetallic compound, CeRhSn₃, using magnetic susceptibility, magnetization, specific heat, electrical resistivity, muon-spin relaxation (μSR) and neutron diffraction investigations. The dc magnetic susceptibility data reveal two magnetic phase transitions at 0.9 and 4 K. The overall behavior of dc susceptibility and magnetization indicates a ferrimagnetic-type phase transition near 4 K. The specific heat data also exhibit sharp λ-type anomalies at 1 and 4 K. The behavior of the specific heat anomaly under the application of a magnetic field suggests that the 1 K transition is probably related to a transition from a ferri- to a ferromagnetic state. The low temperature specific heat exhibits an enhanced Sommerfeld coefficient γ (~100 mJ mol⁻¹ K⁻²) due to the formation of a moderate heavy fermion state. The resistivity of CeRhSn₃ demonstrates an interplay between the RKKY and Kondo interactions which is further modified by the presence of the crystal electric field. Interestingly, the resistivity of the nonmagnetic reference compound, LaRhSn₃, is found to increase with decreasing temperature. Further, the onset of long-range magnetic order below 1 K is confirmed from our μSR study on CeRhSn₃. However, the 4 K transition is not detected in the μSR and low temperature neutron diffraction data. Analysis of the dc magnetic susceptibility data within the framework of a two-sublattice model of ferrimagnetism supports the ferrimagnetic-type transition at 4 K in CeRhSn₃. We have observed an unusual frequency dependence of the peak near 4 K in the ac susceptibility, which shows that the transition temperature shifts toward the lower temperature side with increasing frequency.

Endoscopic management of a rare case of nasal glioma in Meckel's cave in an adult: case report

BACKGROUND

Nasal glioma or glial heterotopia is a rare embryologic anomaly that heralds its presence shortly after birth or in childhood. Nasal glioma in an adult is very rare, often asymptomatic and the occurrence of nasal glioma in Meckel's cave in an adult has not been previously reported.

CASE REPORT

The authors encountered a case of an incidentally diagnosed Meckel's cave nasal glioma in a 40-year-old male which was successfully excised by an endonasal endoscopic transmaxillary transpterygoid approach.

CONCLUSION

The occurrence of a nasal glioma in Meckel's cave an adult is very rare. Considering the deep skull base location, endonasal endoscopic surgery provides a minimal access technique to reach this location with excellent results.

(11)B and (195)Pt NMR study of heavy-fermion compound CePt(2)B(2)C

We report (11)B and (195)Pt NMR Knight shift K and spin-lattice relaxation rate 1/T(1) in CePt(2)B(2)C in the range 4-315 K. The quadrupolar coupling constant, ν(Q) for boron nuclei is 790 ± 10 kHz. The change of hyperfine field, H(hf), is observed below 30 K in the K versus susceptibility, χ, plot. The calculated value of H(hf) at the (11)B ((195)Pt) is 0.156 (6.86) kOe/μ(B) in the range 30-300 K and ∼0 (0.22) kOe/μ(B) below 30 K. The 1/T(1) versus T curve shows some exotic behavior. The Ce 4f spin contribution to the nuclear relaxation rate (1/T(1f)) in each case is obtained by subtracting the T(1K)(-1) estimated from its La analog, i.e. LaPt(2)B(2)C. In the case of (11)B resonance, in the temperature range of 300-100 K, (1/T(1f)) is independent of T, suggesting a Curie-Weiss behavior of the imaginary part of the dynamic susceptibility. It then shows a slow but continuous increment in the range 100-70 K, indicating a signature of the development of short-range magnetic correlation among the Ce 4f spins. Below 70 K, this enhancement of 1/T(1f) is completely suppressed and it decreases sharply, indicating a suppression of the effect of magnetic correlation, due to the dominance of the Kondo effect over the RKKY interaction. 1/T(1f), follows ∼T(α), with an exponent α∼0.7 in the range 4-30 K for (195)Pt and in the range 8-30 K for (11)B resonance. This is a characteristics of a non-Fermi-liquid like behavior. However, in the case of (11)B, there is again a clear change in the slope of the 1/T(1f) versus T curve below 8 K, with the value of α = 1.0, as if the behavior of the conduction electrons approaches towards a Fermi liquid, when probed near the (11)B site.

Three-dimensional neurostereoendoscopy: subjective and objective comparison to 2D

Neuroendoscopic procedures, particularly transnasal skull-base procedures, are currently performed with 2D endoscopes that lack stereoscopic vision and depth of field. In principal, 3D vision should be preferable to the operating surgeon, but the previously existing systems have not been adopted. We evaluated a novel 3D endoscope to compare with 2D endoscopy. 33 neurosurgeons and skull-base otolaryngologists were recruited, and randomized to complete two runs of a task-based simulator paradigm using 2D and/or 3D visualization. After the two trials, each subject completed a questionnaire assessing professional demographics and preferences for visualization. The task paradigm had objective endpoints that measured speed, efficiency, and error rates. 75% of respondents preferred 3D endoscopy, and 87.5% determined that 3D visualization either somewhat or greatly helped with the assigned tasks. In the second run, subjects using 3D demonstrated a significantly higher efficiency than subjects using 2D (p=0.04). Subjects' speed and efficiency improved significantly when moving from 2D to 3D, and speed and efficiency improved significantly from Run 1 to Run 2 for 3D visualization. Subjective and objective outcomes support the utility of 3D visualization for neuroendoscopic techniques. Visualization that provides real-time, high-resolution binocular depth perception has a role in endoscopic skull base surgery and other neuroendoscopic procedures.

Combined simultaneous endoscopic transsphenoidal and endoscopic transventricular resection of a giant pituitary macroadenoma

Intrasellar and sellar-suprasellar adenomas are generally removed through a transsphenoidal approach. Giant adenomas with significant suprasellar extension often require a craniotomy or combined "above and below" approach. The use of endoscopes has increased the visualization capacity of the transsphenoidal route and made these surgeries less invasive. In this report, we describe a novel combination of the endoscopic transsphenoidal approach with the endoscopic transventricular approach to remove a giant pituitary macroadenoma extending into the third and lateral ventricles. The tumor was initially removed via an endoscopic transnasal transsphenoidal, transtuberculum, transplanum approach. A second endoscope was then advanced into the lateral ventricle through a pre-coronal burr hole to assist in mobilizing the tumor and assure a complete resection. Multilayer closure and a ventriculo-peritoneal shunt were performed to insure a watertight seal of the skull base. Giant pituitary adenomas have traditionally been removed with staged or combined transsphenoidal and transcranial approaches. We describe the successful implementation of a minimal access endoscopic combined extended transsphenoidal and transventricular approach that avoids craniotomy and brain retraction.

Catch-up growth in children with late-diagnosed coeliac disease

Anthropometric parameters and catch-up growth were prospectively evaluated in fifty late-diagnosed children with coeliac disease aged 2.25-10 years after 1-4 years of adhering to a strict gluten-free diet (GFD). The anthropometric parameters were expressed as Z scores relative to National Centre for Health Statistics standards using Epi Info 2000 (weight-for-height Z score (WHZ) and height-for-age Z score (HAZ)). Catch-up growth was evaluated by repeated measures. ANOVA, overall significance by an F test and pair-wise comparisons for estimated marginal means using the least significant difference. At the time of enrolment, no significant difference was observed in WHZ and HAZ between children diagnosed before (group 1) or after (group 2) 4 years of age. On follow-up, HAZ was significantly higher in group 1 after the first and third years of the GFD (P=0.04 and 0.02, respectively), with a non-significant increase after completing 4 years of the GFD (P=0.22). Feeding the GFD resulted in an overall significant (F=3.99, P=0.011) increase in HAZ up to 4 years of follow-up. However, the catch-up in height was incomplete, with stunting in sixteen (55.4%) of twenty-nine children after 3 years and in seven (46.6%) of fifteen children after 4 years on the GFD. Pair-wise comparisons demonstrated a linear catch-up growth during the initial follow-up on GFD. Treatment with the GFD did not result in an overall significant increase in WHZ up to 4 years of follow-up (F=1.01, P=0.42). Our results suggest that, in children with late-diagnosed coeliac disease, treatment with a GFD leads to a normalisation of body mass and a significant but incomplete recovery in HAZ during 4 years of follow-up.

Disseminated infection with Cryptococcus neoformans var neoformans in an 8 years immunocompetent girl

Disseminated cryptococcosis is a rare and often fatal disease in children. The majority of cases usually occur in individuals with defective cell-mediated immunity, most commonly due to HIV infection. The authors here in report an 8-year-old girl from Nepal who presented with fever, cough, headache, lymphadenopathy, hepatosplenomegaly and cutaneous lesions. Lymph node biopsy revealed multiple granulomas composed of histiocytes and epitheliold cells along with numerous yeast forms of cryptococcus. Cultures of CSF, sputum and urine yielded cryptococcus neoformans. Surprisingly,the immune function in terms of T-cell number, CD4 : CD8 ratio, serum immunoglobulins and HIV serology was normal. After the diagnosis of disseminated cryptococcosis was established, the patient was treated with 5-fluorocytosine (100 mg/kg/day) for initial two weeks and amphotericin B (1 mg/kg/day) for 13 weeks. Patient responded well to the treatment with disappearance of presenting symptoms, cutaneous lesions, and lymphadenopathy, though she still had hepatosplenomegaly, which also decreased. Unfortunately, she developed loss of vision in 10th week of therapy. The patient was discharged on oral fluconazole (6 mg/kg/day) and no recurrence was found during the follow-up period of more than 9 months. This is the first case of disseminated cryptococcosis with no detectable immune deficit, from India.

Bjornstad syndrome

A 9-month-old boy presented with the complaints of loose motion, vomiting and difficulty in breathing. His scalp hairs were thin, brittle, and sparse and were of differing lengths with twisted appearance. Hair shaft microscopy revealed alternate light and dark segments and twisting of the hair shafts by 180 degrees along the axis. Serum copper levels were normal. The audiological testing revealed bilateral sensorineural hearing loss. Child was diagnosed as a case of Bjornstad Syndrome.

Henoch schonlein purpura with rheumatic carditis

Henoch Schonlein Purpura with acute rheumatic carditis is a rare entity and only few cases have been reported. An 8 year-old-girl presented with abdominal pain, arthralgia and rashes and was diagnosed as a case of Henoch Schonlein Purpura. She was managed conservatively and discharged. She was readmitted after 1 week with abdominal pain, fever and cough. She developed tachycardia with gallop rhythm on the third day of admission and pansystolic murmur of mitral regurgitation. Echocardiography showed features of myopericarditis, mild pericardial effusion and mitral regurgitation. She was diagnosed and managed as a case of acute rheumatic carditis.

Serum prolactin in celiac disease

Serum prolactin levels (SPL) were estimated in patients with celiac disease (CD), diagnosed as per ESPGAN criteria, on unrestricted gluten containing diet (group 1), as well as those consuming a gluten-free diet (GFD) (group 2). Forty-one children with CD, with 20 cases in group 1 (mean age 5.67 +/- 2.14, range 2.5-10.5 years) and 21 cases in group 2 (mean duration of follow-up 2 years, range 1-4 years), and 41 age- and sex-matched controls were studied. Hyperprolactinemia was defined as serum prolactin > 18 ng/ml in males and > 24 ng/ml in females. Upper gastrointestinal endoscopic biopsy was performed in both study groups for initial and follow-up evaluation. Hyperprolactinemia was detected in all the patients of group 1 and one patient of group 2 who had severe villous atrophy. The SPL in group 1 (mean 48.3 +/- 17.4; range 20-90 ng/ml) and group 2 (mean 18.3 +/- 6.9, range 10-39 ng/ml) was significantly higher compared with the controls (mean 9.3 +/- 4.5; range 2.4-20 ng/ml; p < 0.001). Among the patients with CD, mean SPL in group 1 was significantly higher than in group 2 (p < 0.001). In group 1, there was a positive correlation between SPL and duration of symptoms (p = 0.006, r = 0.768) and age of diagnosis (p < 0.001, r = 0.842). A positive correlation also existed in group 2 between SPL and degree of villous atrophy (p < 0.001, r = 0.71) and lamina propria infiltrate (p < 0.001, r = 0.568). Our results suggest that SPL has a significant correlation with activity of CD. Therefore serum prolactin estimation may provide an additional marker of disease activity in CD and may be a more viable option economically.

Progressive bulbur paralysis (Fazio-Londe disease)

Progressive bulbar paralysis of childhood is characterised by progressive paralysis of muscles innervated by cranial nerves. The authors report a case of progressive bulbar paralysis of childhood in a 12-year-old child. Child was admitted with the complaints of drooping of eyelids, difficulty in swallowing and hoarse voice. She had involvement of III, VII, IX, X, XI and XII cranial nerves and the corticospinal tracts. Electromyography revealed spontaneous activity in the form of fasciculations, giant motor unit potential and discrete recruitment of motor neurons suggestive of denervation pattern. Hearing assessment was normal. Muscle biopsy was also suggestive of neurogenic atrophy.

Iron supplementation in children with celiac disease

OBJECTIVE

To evaluate the effect of iron supplementation, in addition to gluten free diet (GFD), on hematological profile of children with Celiac Disease (CD).

METHODS

Children diagnosed as CD as per modified ESPGAN criteria were prospectively evaluated for their hematological profile at the time of their enrolment and after consuming GFD for at least one year. The results were compared with age and sex matched controls. Evaluation of hematological profile included hemoglobin estimation, complete blood counts, peripheral blood smear examination, serum iron, total iron binding capacity (TIBC), and serum ferritin estimation. All the enrolled cases were given iron supplementation in addition to exclusion of gluten from their diet. Repeat intestinal biopsy was performed in all the cases after completing 1 year on GFD.

RESULTS

Twenty one children (mean age 6.67 years, range 4-11 years) diagnosed as CD who completed at least one year of regular follow up on GFD (mean 1.5 years, range 1-2 years) were analysed for their hematological profile at the time of enrolment and after consuming GFD and iron supplementation. At the time of enrolment all the children had hemoglobin level <11 gm%, 78% had microcytic hypochromic anemia and 22% had dimorphic anemia, with lower mean MCV, MCH and serum ferritin levels, and a significantly higher mean TIBC as compared to controls (p<0.001). In the follow up evaluation of these cases on GFD, mean hemoglobin levels were comparable with controls but the cases continued to have lower mean MCV, MCH serum ferritin levels (p<0.05) and higher mean TIBC (p<0.05). Seven children had mild anemia. Serum ferritin levels showed a negative correlation with the grade of villous atrophy and lamina propria infiltrate.

CONCLUSION

Our results suggest that iron deficiency anemia (IDA) is commonly associated with CD and iron deficiency state continues for a longer time even after excluding gluten from the diet and iron supplementation. Apart from offering them GFD rich in iron, early detection and treatment of IDA and prophylactic iron folic acid supplementation will go a long way to optimize their mental and psychomotor functions.

Clinical and nutritional profile of children with celiac disease

This prospective study was aimed to evaluate the clinical and nutritional profile of children diagnosed as celiac disease (CD) as per the modified ESPGAN criteria, at the time of diagnosis and after institution of gluten free diet. Out of 65 enrolled cases of CD, 7 (10.8%) children did not follow a strict dietary compliance. Only 41 children with satisfactory dietary compliance on gluten free diet (GFD) who regularly attended the follow up for at least 6 months were evaluated for their nutritional and hematological status. Results were compared with age and sex matched controls. The mean age of diagnosis was 8.7 +/- 3.3 years. Diarrhea and failure to thrive were the most common presenting symptoms. At diagnosis, the nutritional and hematological indices were significantly lower in patients than in controls. Mean duration of follow up on GFD was 22 months (range 6-48 +/- 5.6 months). On follow up, height for age Z score was significantly lower, mean BMI was significantly higher, and weight for age Z score, weight for height Z score (%), mean triceps and biceps skin fold thickness, and mid arm circumference were comparable to controls. At diagnosis, 80% cases had microcytic hypochromic anemia and 20% had dimorphic anemia. On GFD for at least a period of more than 6 months, 19% had microcytic anemia and in 81% the hematological picture was normocytic normochromic. 60% cases had thrombocytosis at diagnosis in comparison to 2.3% after treatment. Institution of GFD leads to rapid improvement in clinical picture as well as most of the nutritional and hematological parameters.

Cladosporium bantianum meningitis in a neonate

Cladosporium bantianum meningitis has been reported mostly in adult farmers between 20 and 30 years of age. We report a 6-day-old male neonate who was admitted with fever, focal seizures and not accepting feeds. Initial investigations suggested a diagnosis of pyogenic meningitis but antibiotic therapy for 14 days did not result in any significant clinical improvement. Repeat CSF examination after 14 days suggested a diagnosis of C. bantianum meningitis which was supported by presence of multiple abscesses in the cerebral cortex on CT scan of the head and confirmed by CSF culture. Clinical response to antifungal therapy remained unsatisfactory.

Diagnostic modalities for gastroesophageal reflux

OBJECTIVE

To evaluate commonly utilized diagnostic modalities to detecting Gastroesophageal Reflux (GER).

METHODS

Sixty children aged 1-72 months (mean age 14.7 months) with symptoms suggestive of Gastroesosphageal Reflux (GER) were investigated and subjected to upper gastrointestinal endoscopy and esophageal biopsy (EB), gastroesophageal scintiscanning (GS) and 24 hour ambulatory pH monitoring.

RESULT

GER was detected in 28 (46.7%) cases by one or more diagnostic modalities. Ambulatory 24 hour pH monitoring was positive in higher proportion (43.3%) of cases in comparison to other modalities, followed by EB (38.3%) and GS (30%). Considering 24 hour pH monitoring as the gold standard, esophageal biopsy was positive in 22/26 cases (84.6%) detected by 24 hour pH monitoring with a specificity of 97.1% as compared to 17/26 cases (65.4%) by gastroesophageal scintiscanning with a specificity of 97.1%. When compared with EB results, amongst various parameters measured during 24 hour pH monitoring, Reflux index (RI) ranked highest (sensitivity 95.6 % and specificity 89.2 %) followed by duration of longest episode > 20 minutes and Euler Byrne score. Oscillatory index, calculated from tracings of pH monitoring, even though ranked lower because of its low sensitivity helped to pick up 2 cases missed by EB and RI.

CONCLUSION

Our results suggest that a combination of diagnostic modalities may be required to diagnose GER in young children. Ambulatory 24 hour pH monitoring appears to be the single best investigation and combining it with EB and/or GS can help to detect maximum number of cases.

Association of gastroesophageal reflux disease in young children with persistent respiratory symptoms

Forty children aged between 3 months and 3 years (median age 14 months) with persistent respiratory symptoms beyond 4 weeks or recurrence of respiratory symptoms were investigated for gastroesophageal reflux (GER). Diagnostic tests included upper gastrointestinal endoscopy, oesophageal biopsy, gastroesophageal scintiscan and 24 h ambulatory oesophageal pH monitoring. GER was detected in 14 (35 per cent) of these patients; which included 38 per cent of the enrolled cases of recurrent bronchopneumonia, 40 per cent cases of reactive airway disease, and 22 per cent cases of persistent cough. Amongst the cases detected to have GER, the age of onset of respiratory symptoms was less than 1 year in 86 per cent of cases (p < 0.01), nocturnal symptoms of cough and wheeze were reported in 78 per cent (p < 0.05), and 86 per cent cases did not present with typical gastrointestinal symptoms (p < 0.01). Family history of asthma was absent in all cases of GER-related reactive airway disease (p < 0.01). Cases detected to have GER were followed for 3-6 months after starting anti-reflux therapy. A significant (p < 0.01) decrease was noticed in the number of further episodes in children with GER-related recurrent bronchopneumonia and reactive airway disease after starting anti-reflux therapy. Improvement was also noticed in nocturnal symptoms and nutritional status after anti-reflux therapy was started. Our results suggest that GER may be one of the possible contributing factors in any child with recurrent and persistent respiratory complaints. Early diagnosis and anti-reflux therapy in cases with GER-related respiratory complaints can result in significant improvement in symptoms.

Evaluation of the utility and cost-effectiveness of obtaining histopathologic diagnosis on all routine tonsillectomy specimens

OBJECTIVES

To evaluate the use and necessity of obtaining histopathology on patients undergoing tonsillectomy, and to provide indications and guidelines for requesting histopathology on tonsillectomy patients.

STUDY DESIGN

At the University of Mississippi Medical Center, we have been routinely obtaining histopathologic diagnoses on every patient undergoing tonsillectomy or tonsillectomy and adenoidectomy. Specimens are separated into left and right tonsils and adenoids. This study was designed at our tertiary care academic center to evaluate the necessity for obtaining histopathologic diagnosis on each of these patients.

METHODS

A retrospective review of histopathologic reports on all patients in both pediatric and adult age groups undergoing tonsillectomy or tonsillectomy and adenoidectomy between January 1994 and December 1999 was performed.

RESULTS

A total of 2438 reports were reviewed. There were 2099 in the pediatric age group and 339 were adults. None of the children had an unusual histopathology finding other than lymphoid hyperplasia. Of the 339 adults, 34 had squamous cell carcinoma and 6 had lymphoma; however, these findings were suspected preoperatively by history and clinical manifestations.

CONCLUSIONS

The general practice guidelines mandate obtaining histopathologic diagnoses on most of the tissues received. Based on our review, histopathology of tonsillectomy and/or adenoidectomy may not be necessary, especially in children. In this era of cutting excess costs of health care dollars, waving histopathology in these cases may have major implications without compromising delivery of quality care.

Sinusitis complicated by meningitis: current management

OBJECTIVES

Meningitis is the most common intracranial complication of sinusitis. We review the incidence, current management, outcomes, and complications of this serious infection. Our study also examines the evolving roles of endoscopic sinus surgery and other new therapeutic and diagnostic modalities in our armamentarium.

STUDY DESIGN

A retrospective chart review was performed at a tertiary academic medical center of all patients diagnosed with sinusitis with complications between January 1985 and December 1999.

METHODS

The patients were divided into two main groups: intracranial versus orbital complications. Meningitis was the most common intracranial complication. Data on patients with sinusitis and meningitis were collected and analyzed.

RESULTS

Intracranial complications were present in 39 of 82 patients whereas orbital complications were noted in 43 patients. Twenty-one of the 39 intracranial complications were meningitis. The most common computed tomography finding in adults (54%) was sphenoid sinusitis. All patients with AIDS (6 of 21) had unique cryptococcus meningitis. In patients without AIDS, the most common organism was Streptococcus pneumoniae (10 of 21). The most common sequela was seizure disorder (4 of 21). Endoscopic sinus surgery was performed on 7 of 21 patients. One patient with AIDS who had sinusitis and meningitis died.

CONCLUSIONS

Meningitis as a complication of sinusitis may still pose a serious threat. Although outcomes are encouraging, sequelae such as seizure disorders and hearing loss are common complications. The introduction of high-resolution computed tomography scans and magnetic resonance imaging and the availability of wide-spectrum antibiotics have improved our management significantly.

Feeding problems in children with cerebral palsy

OBJECTIVE

To determine the magnitude and extent of feeding problems in children with cerebral palsy (CP) and to evaluate the effectiveness of nutritional interventions.

DESIGN

Prospective hospital based interventional study.

METHOD

Children with cerebral palsy of either sex were enrolled randomly and their parents were interviewed for their perception about feeding problems, nutritional status and for their views about the expected outcome of feeding problems. Each case was assessed for feeding problems based on Gisel and Patrick feeding skill score; for nutritional status by measurement of weight, skinfold thickness (at biceps, triceps, suprailiac and subscapular), mid arm circumference and caloric intake; neurologically for type and severity of cerebral palsy and for developmental age by Gasell s developmental scale. Equal number of age and sex matched controls were included for comparison of nutritional status and developmental quotient. Various rehabilitation procedures were applied and their response was observed in the followup ranging from 3-10 months.

RESULTS

One hundred children (76 boys and 24 girls) with cerebral palsy of mean age 2.5 years (range 1 to 9 years) and mean developmental age of 7.6 months (range 1 to 36 months) were included in the study. Oral motor dysfunction (OMD) was found in all cases and in each category. Spastic quadriplegic cerebral palsy (SQCP) and hypotonic patients had significantly poor feeding skill score (p < 0.001). Mean duration of feeding session was 31.5 minutes (range 10-60 minutes). Main food of children with cerebral palsy consisted of liquid and semisolid diet. Children with poor OMD were unable to take solid food. Cases with seizures had significantly more feeding problems than those without seizures (p < 0.001). Parental awareness about feeding problems of their children was significantly low and they overestimated the nutritional status of their children. Anthropometric indicators were significantly lower than controls (p < 0.001). Spastic quadreparesis, hypotonia and poor feeding skill score had negative effect on nutritional status. Thirty per cent parents of cerebral palsy patients were pessimistic about the possibility of any improvement in feeding problems. After nutritional rehabilitation, good improvement was seen in feeding problems, OMD and nutritional status.

CONCLUSION

Nutritional status of children with cerebral palsy is poor due to summation of several factors. Therefore, they should be thoroughly assessed for feeding problems and nutritional status in order to start timely nutritional rehabilitation which can significantly improve their nutritional status and quality of life.

Brush cytology: an adjunct to diagnostic upper GI endoscopy

Endoscopic brush cytology (EBC) was performed in antral and duodenal brushings of children subjected to upper GI endoscopy for the detection of H. pylori (Hp) and trophozoites of Giardia lamblia (Glt) in addition to routine endoscopic grasp biopsy (EGB). It was hospital based prospective study. EBC was performed in children subjected to upper GI endoscopy with a sheathed cytology brush. Mucosal brushings were collected from antrum, body of the stomach and second or third part of duodenum by gently rubbing the surface of the brush with the mucosal wall in all the directions, brush withdrawn and brushings performed on a glass slide. The smears were placed in 95% ethyl alcohol and later examined for Glt and Hp using Giemsa and Hematoxylin & Eosin stain. EGB was taken from antrum, body of the stomach and duodenum from sites other than those used for brushings. One hundred and seventy children between 1-13 years (median age = 5 years) were subjected to upper GI endoscopy for malabsorption (n = 94), recurrent abdominal pain (n = 49), failure to thrive (n = 16) and recurrent vomiting/regurgitation (n = 11) and EBC was performed in addition to routine EGB. Thirty five children (20.4%) were colonized by Hp, 14 (8.2%) were detected to have Glt and in 6 cases (3.5%) both Hp as well as Glt were detected. Out of 41 cases colonized by Hp, 24 cases (58.5%) were detected by EGB and 27 cases (65.8%) were detected by EBC. Out of 20 children in whom Glt were detected from their duodenum, the detection was by EBG in 12 cases (60%) and by EBC in as many as 19 cases (95%). Comparison of EGB and EBC suggested that detection rates with EBC were higher than EGB. Detection by EBC was significantly higher for Glt than Hp. There were no complications attributed to EBC and procedure time for endoscopy was not significantly prolonged. On the contrary, detection of Hp and particularly Glt in higher proportion of cases with the help of EBC was helpful in their appropriate management. Our results suggest that EBC is a safe and useful tool to enhance the value of diagnostic endoscopic procedure when used in combination with routine EGB.

Tracheobronchial extension of recurrent respiratory papillomatosis

Endobronchial and pulmonary dissemination reportedly occurs in 5% of patients with laryngeal papillomatosis. It is more frequently observed in the juvenile form, and carries significant implications for treatment. In this study, we review our experiences with pulmonary and endobronchial extension of laryngeal papillomatosis. The records of the 52 patients with laryngeal papillomas treated at our institution since 1980 were reviewed. Twenty-nine percent of the patients (N = 15) developed tracheobronchial extension; 7% (N = 4) demonstrated pulmonary involvement. The birth history, race, sex, age at onset of symptoms, presenting symptoms, site and type of papillomas, surgical procedures, other methods of treatment, complications, and mortality data were analyzed. Eighty percent of the patients with tracheobronchial involvement were born to mothers with a positive history of vaginal condylomas. Pulmonary changes in 4 patients were observed on either chest radiographs or computed tomography and were manifested as multiple parenchymal nodules in 3 of the 4 patients. Pneumatoceles, cavitary empyema, and multiple recurrent pneumonias were the predominant complications of pulmonary involvement. Of the 15 patients with tracheobronchial extension, 80% (N = 12) required tracheotomy before their presentation to us. The number of multiple surgical procedures performed to remove papillomas ranged from 7 procedures in 1 patient with a solitary tracheobronchial lesion to more than 100 procedures in 2 patients with diffuse bronchopulmonary papillomatosis. As our study shows, tracheobronchial involvement continues to complicate surgical treatment in this challenging disease process.

Effect of tympanic perforations on the detection of distortion-product otoacoustic emissions

The detection of distortion-product otoacoustic emissions (DPOAEs) depends on the viability of the ear's conduction apparatus. However, tympanic membrane perforations and other conductive disorders have not been fully investigated with regard to the examination of DPOAEs. Using the guinea pig model, we made perforations of different sizes and loci on the tympanic membrane and collected DPOAEs data for frequencies between 2,193 and 5,508 Hz for each condition. We found that small perforations, up to 25% of the area of the tympanic membrane, still allow us to detect emissions at the specified frequencies. However, perforations of 50% and larger, as well as those accompanied by traumatic perilymph fistulas and ossicular disarticulations, severely interfered with the detection of DPOAEs. We discuss the clinical relevance of these findings with respect to the potential uses of DPOAEs.

Value of radiologic imaging and computer assisted surgery in surgical decisions of the anterior skull base lesions

The role of radiologic imaging in surgical decision making of anterior skull base lesions has been found to be critical in the endoscopic surgical management of these lesions. The non-invasive radiologic imaging may include the use of CT scans, MRI scans, MRA scans and their subtraction technique. The imaging offers an understanding of the vascularity of the lesion, the relationship to the nearby neurovascular structures and the type of tissue density of these lesions. The addition of image guided applications offers one a sagittal reconstruction and a 3-D imaging capacity which has immensely improved the accuracy and precision in endoscopic surgical applications in these areas.

Yolk sac tumor of the temporal bone: report of a case

Yolk sac tumor (endodermal sinus tumor) is rarely encountered in the temporal bone. Facial nerve paralysis can be a primary manifestation of this condition. Histologically, the tumor can be difficult to diagnose, although elevated levels of alpha fetoprotein can facilitate its identification. In this report, we describe the case of an 18-month-old girl who developed peripheral VIIth nerve palsy and a polypoid mass in the left external ear canal 3 months following myringotomy. Computed tomography and magnetic resonance imaging revealed that the tumor involved the left external ear canal, middle ear space, and mastoid air cells. Biopsies were consistent with a yolk sac tumor. Special staining demonstrated that only a very few tumor cells were positive for alpha fetoprotein, despite the markedly elevated level of alpha fetoprotein in her serum. The patient was treated with chemotherapy, which included cisplatin, etoposide, and bleomycin. Within a period of weeks, she experienced a complete reversal of her left VIIth nerve palsy, a marked decrease in her serum alpha fetoprotein levels, and a dramatic resolution of the tumor as demonstrated radiographically. Such a successful chemotherapeutic response in this case argues against surgical intervention in other cases, particularly in view of the risk of serious complications with surgery.

Goldenhar syndrome with rare associations

Goldenhar syndrome is a malformation complex involving the structures arising from first and second branchial arches, the first pharyngeal pouch, first branchial cleft and primordia of the temporal bone. Though the syndrome itself is not very rare, the presence of polydactyly and hydrocephalus, which are rare associations, prompted us to report this case.

Hepatic dysfunction in childhood dengue infection

Hepatic functions of 61 children, diagnosed to have dengue infection (DI), aged 2 months to 12 years comprising 37 cases of dengue fever (DF), 16 with dengue hemorrhagic fever (DHF), and eight with dengue shock syndrome (DSS) were prospectively studied during the acute attack. Hepatomegaly (74 per cent), epistaxis (26 per cent), jaundice (25 per cent), and petechial rashes (18 per cent) were the common clinical manifestations of DI. On admission, levels of serum aspartate transaminase (AST), serum alanine transaminase (ALT) and serum alkaline phosphatase (AP) were raised in 80-87 per cent of children with hepatomegaly (group I) and 81 per cent of cases without hepatomegaly (group II). During the second week of hospitalization the proportion of cases with raised levels of AST, ALT, AP and serum bilirubin increased and the mean levels were significantly higher (p < 0.05) in both the groups. These levels gradually declined over the next 2-3 weeks. All the cases with DSS and DHF had raised AST, ALT and AP levels and the mean levels of these enzymes were significantly higher (p < 0.05) as compared to DF. Our results suggest a transient derangement of liver functions in childhood DI, more so in DSS and DHF, with or without hepatomegaly.

Study of diagnostic modalities and pathology of Helicobacter pylori infection in children

To evaluate various diagnostic tests for Helicobacter pylori (Hp) in children, and to study the spectrum of endoscopic and histological changes in the stomach and duodenum of children with gastroduodenal disorders, associated with Hp infection Children below 12 years of age with various gastroduodenal disorders requiring upper gastrointestinal endoscopy were studied. Endoscopic biopsy specimens were collected from duodenum and antrum. Apart from histopathological examination of biopsy material, rapid urease test (RUT) of the antral biopsy specimen and blood examination to estimate specific IgG antibodies to Hp by Indirect Solid Phase Enzyme Immunoassay was performed. Forty seven children were included. Nine (19.1%) of them were positive both by serology and RUT. Seven (14.9%) were positive by histology. A significant correlation of Hp was noticed with chronic antral gastritis (p = 0.002) and chronic duodenitis (p = 0.006). Age equal to or more than 10 years was found to be significant risk factor for acquiring Hp infection. Prevalence of Hp in children with gastroduodenal complaints was found to be 19%. Both RUT and serology were found to be reliable diagnostic tests for Hp as compared with histology. Antral gastritis and chronic duodenitis had a significant correlation with Hp colonization.

Magnetic resonance navigation for head and neck lesions

OBJECTIVE

Review applications of interventional magnetic resonance imaging and describe methods, procedures, and additional instrumentation for the magnetic resonance "operating theater." Describe advantages of magnetic resonance navigation for biopsies of head and neck tumors.

STUDY DESIGN

Patients with palpable and nonpalpable head and neck and cranial base tumors were recruited into the study. Patients underwent magnetic resonance-guided biopsy. Retrospective analysis of 21 patients was conducted.

METHODS

0.5 Tesla superconducting open magnetic resonance imaging was used for navigation of the biopsy needle. Patient records and magnetic resonance images were reviewed. The type, size, and location of the lesions were tabulated. Type of anesthesia and monitoring method were analyzed. The histopathologic correlation was conducted in patients who required further surgeries or open surgical biopsies.

RESULTS

Twenty-two biopsies were carried out in the magnetic resonance suite. One patient required general anesthesia and the other biopsies were conducted under intravenous sedation. There was only one case of nonconcurrence in a patient with Wegener's granulomatosis of the posterior orbit. Overall, a 92% concurrence rate between image-directed fine-needle aspiration, open biopsy, and surgical therapy was encountered. No complications occurred.

CONCLUSIONS

The use of interventional magnetic resonance imaging to assist with fine-needle aspiration core biopsy has made the biopsy procedure safer and more accurate. Potentially morbid and disfiguring surgeries have been avoided in some patients. Deeper lesions have been more easily approached, as the needle for biopsy is under constant magnetic resonance guidance. Improved visualization for critical structures allows safer performance of biopsies. The primary difficulties of open magnetic resonance imaging relate to the need for nonferromagnetic instrumentation and equipment and their high costs. An inverse relationship exists between the imaging quality and the "dead time" required to acquire images.

Electroneurography during facial nerve expansion

With the use of tissue-expansion techniques, it is possible to elongate the facial nerve without impairing its function. The rate of expansion is limited by ischemic events imposed by stretching of the nerve and by anatomic characteristics of the nerve segment. In this study, we used various electroneurography techniques to determine the first sign of facial dysfunction during expansion. The main objective of the study was to ascertain test-retest variability of electroneurography techniques. Facial nerves were expanded in 16 cats with the use of a tissue expander secured more deeply to the main trunk. We conducted electroneurography measurements with the use of surface electrodes, temporary needle electrodes, and permanently implanted electrodes. Technique-dependent variations encountered with the surface electrodes made this method unreliable. Using implanted electrodes, we noted gradual worsening of the compound-action potential amplitude with increasing expansion. During acute expansion, reduction in compound-action potential amplitude was correlated with clinically observed deterioration of facial-nerve function. In this study, electroneurography with implanted electrodes was found to be the most reliable predictor of the rate of successful facial nerve expansion.