Dystonia in children with acquired brain injury

AIM

To quantify the proportion of children who develop dystonia after acquired brain injury (ABI) admitted to a tertiary paediatric intensive care unit (PICU) and analyse the trajectory of dystonia over a 6 month period.

METHODS

Children's Health Ireland at Temple Street PICU electronic database was searched for key terms related to ABI from January 1, 2016 to March 14, 2021. Individuals meeting inclusion criteria were analysed, and clinical data pertinent to ABI, dystonia, treatment and outcomes were reviewed.

RESULTS

Six-hundred and forty-three PICU episodes (580 patients) met search criteria for ABI, with 379 included in the final analysis. Twelve patients developed dystonia following ABI, giving an incidence of 3.2%. The incidence was higher in the hypoxia/anoxia and TBI cohort at 8.3% and 6.2%, respectively. All patients developed dystonia within the first month following ABI (50% by a week). Patients who developed dystonia compared to non-dystonia cohort had a median lower GCS on admission (4.5 versus 7.0, p value 0.032), longer median length of PICU stay (14.0 versus 3.0 days, p value < 0.001) and were older (median age 9.08 versus 4.68 years, p value 0.06). Dystonia persisted in the majority at 6 months (10/11), requiring on-going medical therapies.

CONCLUSION

In our retrospective study, the estimated incidence of dystonia following ABI admitted to the PICU was 3.2%, highest in the hypoxia/anoxia (8.3%) and TBI (6.2%) cohorts. Dystonia emerged early and persisted at 6 months in the majority. This is the first review of dystonia, clinical trajectory and outcomes conducted post-PICU admission for ABI. Future prospective studies are required to determine the true prevalence and burden of disease in the PICU setting.

Requirements for Rehabilitation Services for Children after Severe Acquired Brain Injury

Aim Acquired brain injury (ABI) is a common cause of acquired disability in children. Rehabilitation services are known to be underdeveloped in Ireland. We aimed to estimate the incidence of severe ABI in young people in Ireland. Methods The National Quality Assurance and Information System (NQAIS) database was analysed to identify patients aged 1-16 years who had suffered a "probable severe acquired brain injury requiring rehabilitation" (PSABIR) from 2016 - 2019. PSABIR is defined as the co-occurrence of a medical condition likely to cause ABI with a length of hospital admission longer than 28 days. Results 187 young people in Ireland had PSABIRs from 2016-2019, accounting for 21.4% of all prolonged admissions (incidence 4.55 per 100,000 per year). Median length of stay was 46 days (IQR 35- 80 days). Two children (1%) were discharged directly to specialist rehabilitation; 132 (70.6%) were discharged directly home. Conclusion Severe ABI accounts for a significant proportion of prolonged paediatric admissions, with an average of 47 such events per year. Most young people spend the acute and subacute phases of recovery in a tertiary acute hospital, before being discharged directly home. Rehabilitation services need to be developed in all settings to address unmet need.

Older age and comorbidity are independent mortality predictors in a large cohort of 1305 COVID-19 patients in Michigan, United States

INTRODUCTION

Higher comorbidity and older age have been reported as correlates of poor outcomes in COVID-19 patients worldwide; however, US data are scarce. We evaluated mortality predictors of COVID-19 in a large cohort of hospitalized patients in the United States.

DESIGN

Retrospective, multicenter cohort of inpatients diagnosed with COVID-19 by RT-PCR from 1 March to 17 April 2020 was performed, and outcome data evaluated from 1 March to 17 April 2020. Measures included demographics, comorbidities, clinical presentation, laboratory values and imaging on admission. Primary outcome was mortality. Secondary outcomes included length of stay, time to death and development of acute kidney injury in the first 48-h.

RESULTS

The 1305 patients were hospitalized during the evaluation period. Mean age was 61.0 ± 16.3, 53.8% were male and 66.1% African American. Mean BMI was 33.2 ± 8.8 kg m^-2 . Median Charlson Comorbidity Index (CCI) was 2 (1-4), and 72.6% of patients had at least one comorbidity, with hypertension (56.2%) and diabetes mellitus (30.1%) being the most prevalent. ACE-I/ARB use and NSAIDs use were widely prevalent (43.3% and 35.7%, respectively). Mortality occurred in 200 (15.3%) of patients with median time of 10 (6-14) days. Age > 60 (aOR: 1.93, 95% CI: 1.26-2.94) and CCI > 3 (aOR: 2.71, 95% CI: 1.85-3.97) were independently associated with mortality by multivariate analyses. NSAIDs and ACE-I/ARB use had no significant effects on renal failure in the first 48 h.

CONCLUSION

Advanced age and an increasing number of comorbidities are independent predictors of in-hospital mortality for COVID-19 patients. NSAIDs and ACE-I/ARB use prior to admission is not associated with renal failure or increased mortality.

Robotic-assisted laparoscopic repair of rectovesical fistula after Hartmann's reversal procedure

The case is of a 59-year-old male with history of severe ischemic colitis following emergent intervention for a ruptured infrarenal aortic aneurysm who subsequently underwent left hemicolectomy, partial proctectomy, and Hartmann colostomy. The patient later underwent reversal of the Hartmann colostomy with diverting ileostomy. The surgery was complicated by a right ureteral and posterior bladder injury that resulted in a large rectovesical fistula involving the right hemitrigone and right ureteral orifice. An attempt to repair the rectovesical fistula at an outside facility was unsuccessful. Then, he underwent a robotic-assisted laparoscopic repair of rectovesical fistula, including simple prostatectomy, excision of rectovesical fistulous tract, rectal closure, peritoneal and omental flap interposition, bladder neck reconstruction, vesicourethral anastomosis and right ureteral reimplantation. There were no intraoperative or postoperative complications, and the patient was discharged at postoperative day 4; cystoscopy at 6-week follow-up demonstrated a successful closure of the fistula, at which time the ureteral stents were removed.

151 Associations of Testicular Size and Arterial Blood Flow with Sexual Development and Semen Characteristics in Dorper Rams Raised in a Subtropical Climate

Spectral Doppler (velocimetric) indices are important indicators of blood perfusion and physiological status of internal organs. Doppler ultrasound is used in andrology to assess the blood flow in the testicular arteries, aiding in the diagnosis of scrotal disorders and abnormal spermatogenesis. It was proposed that blood flow indices measured in the testicular artery, namely, blood flow resistance and pulsatility index, were significant predictors of semen quality in clinically healthy dogs. There is a paucity of studies on the associations of testicular morphology and blood flow dynamics with spermatogenesis in growing rams. Forty-five Dorper rams (24 rams aged 8 to 11 months and 21 rams aged 12 to 24 months) were examined using a portable ultrasound scanner connectecd to a linear-array 7.5-MHz transducer. Measurements of the testes were taken with built-in electronic calipers on images containing the largest cross-sectional area of each testicle in 3 planes (coronal, sagittal, and transverse). Colour and spectral Doppler scans were performed immediately after scrotal ultrasonography to detect the testicular arteries and record the following velocimetric indices: peak systolic velocity (PSV, cm/s), end-diastolic velocity (EDV, cm/s), resistive index (RI = [PSV – EDV)/PSV], and pulsatility index [PI = (SPV – EDV)/mean velocity] of the blood vessels. The length (9.7 ± 0.3 v. 9.0 ± 0.2 cm; mean ± SD) of the testes and scrotal circumference (33.3 ± 0.5 v. 31.8 ± 0.4 cm) were greater (P < 0.05) in sexually mature rams than in peri-pubertal rams. There were no differences (P > 0.05) between the 2 age groups of Dorper rams in mean values for blood flow indices measured in testicular arteries. Semen was collected by ejaculation into the artificial vagina from 38% (8/21) of post-pubertal rams and 21% (5/24) of peri-pubertal animals (Chi-squared test; P < 0.05). Semen volume was negatively correlated with PI of the testicular arteries (r = –0.57, P = 0.04). In summary, the attainment of sexual maturity in Dorper rams maintained in a subtropical climate was associated with significant elongation of testes but not with the changes in testicular volume and blood perfusion. Testicular artery PI was a significant predictor of semen volume in peri-pubertal and sexually mature rams. Based on this and several previous studies, B-mode ultrasonography combined with echotextural analyses of the epididymides and accessory sex glands and serum testosterone measurements provide more useful information on the progression of sexual maturation and present semen quality in rams than the ultrasonographic assessment of testicular dimensions and an array of blood flow indices.

[Interest using 3D ultrasound and MRI fusion biopsy for prostate cancer detection]

INTRODUCTION

The strategic therapy for prostate cancer depends on histo-pronostics data, which could be upgraded by obtaining targeted biopsies (TB) with MRI (magnetic resonance imagery) fusion 3D ultrasound.

OBJECTIVES

To compare diagnostic yield of image fusion guided prostate biopsy using image fusion of multi-parametric MRI (mpMRI) with 3D-TRUS.

MATERIALS AND METHODS

Between January 2010 and April 2013, 179 consecutive patients underwent outpatient TRUS biopsy using the real-time 3D TRUS tracking system (Urostation™). These patients underwent MRI-TRUS fusion targeted biopsies (TB) with 3D volume data of the MRI elastically fused with 3D TRUS at the time of biopsy.

RESULTS

A hundred and seventy-three patients had TBs with fusion. Mean biopsy core per patient were 11.1 (6-14) for SB and 2.4 (1-6) for TB. SBs were positive in 11% compared to 56% for TB (P<0.001). TB outperformed systematic biopsy(SB) in overall any cancer detection rate, detection of clinically significant cancer (58% vs. 36%), cancer core length (6.8mm vs. 2.8mm), and cancer rate per core (P<0.001). In multivariable logistic regression, with TB we have more chance to find a clinically significant cancer (OR:3.72 [2-6.95]). When both TRUS and MRI are positive, there is 2.73 more chance to find a clinically significant cancer.

CONCLUSION

MR/TRUS elastic fusion-guided biopsies outperform systematic random biopsies in diagnosing clinically significant cancer. Ability of interpretation of real-time TRUS is essential to perform the higher level of MR/US fusion and should be use for active surveillance.

LEVEL OF PROOF

4.

An oral lesion as the primary clinical manifestation of sarcoidosis

An oral lesion as the first clinical presentation of sarcoidosis is extremely rare. We present the case of a 39-year-old woman who was referred to the oral and maxillofacial surgery department with a persistent asymptomatic nodular lesion in the hard palate. This was located adjacent to a grossly carious upper first molar and a provisional diagnosis of chronic periapical granuloma was made. An incisional biopsy of the lesion was carried out, which unexpectedly revealed the presence of a non-caseating granulomatous inflammatory reaction. A referral was sent to the respiratory medicine team and a diagnosis was later confirmed of stage II sarcoidosis. This case report highlights the need for clinicians to be aware of all possible causes of oral lesions, including rare manifestations of underlying systemic disease.

Out of sight, out of mind? A national survey of paediatricians in Ireland regarding Fetal Alcohol Spectrum Disorders

Fetal Alcohol Spectrum Disorders (FASDs) are one of the major causes of preventable developmental delay. There is no register of children with FASDs in Ireland. Up to 81% of Irish women report drinking alcohol during the periconceptual period or pregnancy. We aimed to evaluate self-reported knowledge and practice of doctors working in paediatrics in Ireland with regards to FASDs and alcohol consumption during pregnancy. We circulated a survey to all paediatric doctors in Ireland, either enrolled in specialist training or registered as trainers. Fifty-six respondents (31.3%) were unaware of the existence of FASDs. Sixty-two (34.6%) believed most patients with FASDs have dysmorphic features. Seventy-three respondents (40.8%) routinely ask about maternal alcohol consumption during pregnancy in the context of developmental delay. Thirty-one respondents (17.3%) stated that mild alcohol intake in the third trimester of pregnancy is safe. Our survey suggests prenatal alcohol exposure may not be routinely considered in the evaluation of children with developmental delay by paediatric doctors in Ireland.

Neonatal referrals to the coroner service: a short survey on current practice

In Ireland, coroners are required by law to ascertain the details of potentially unexplained deaths. The Coroner's Acts (1962 and 2005) detail deaths which must be notified to the coroner. We surveyed current practice regarding the notification of the Coroner Service following neonatal deaths by telephone interview of senior clinical nurse managers of paediatric units with neonatal inpatients. Five of 21 units (23.8%) reported that all neonatal deaths would prompt contact with the Coroner Service, with four more units (19%) reporting that unexpected neonatal deaths would be referred. Nine units (42.9%) reported that referral was at the discretion of the consultant involved while three units (14.3%) do not refer neonatal deaths to the coroner.

A low energy paediatric clavicle fracture associated with acute brachial plexus injury and subclavian artery compression

Paediatric clavicle fractures are common injuries presenting to orthopaedic surgeons. The majority of these represent midshaft low energy fractures, which in the vast majority of cases are treated non-operatively and recover rapidly. The main indications to consider operative intervention include high energy of injury, >2cm shortening, open fractures and associated vascular or neurological injuries. Brachial plexus (BP) injuries are uncommon with variable outcomes. They often result from high energy motorcycle related accidents with potentially fatal associated injuries such as vascular disruption. Their management is complex, requiring expertise, and they are therefore usually managed in supraregional centres.

We present a unique case of a low energy midshaft clavicle fracture in a paediatric patient in whom there was an acute BP injury and subclavian artery compression that has not been described previously.

The relationship between vitamin D and chemotherapy-induced toxicity - a pilot study

BACKGROUND

There are anecdotal data that lower levels of vitamin D may be associated with increased levels of toxicity in individuals receiving chemotherapy; we therefore wished to investigate this further.

METHODS

From a cohort of over 11 000 individuals, we included those who had vitamin D levels (serum 1,25(OH)(2)D3) measured before and during chemotherapy. They were analysed for side effects correlating Chemotherapy Toxicity Criteria with vitamin D levels, normalising data for general markers of patient health including C-reactive protein and albumin.

RESULTS

A total of 241 (2% of the total cohort) individuals entered the toxicity analysis. We found no overall difference in toxicity effects experienced by patients depending on whether they were vitamin D depleted or had sufficient levels (P=0.78).

CONCLUSION

This pilot study suggests routine vitamin D measurement during treatment does not appear to be necessary in the management of chemotherapy-induced toxicity.

[A novel technique for distal ureterectomy and bladder cuff excision]

INTRODUCTION

We describe a novel endoscopic approach and provide a literature review for the "en bloc" dissection of the distal ureter and bladder cuff during laparoscopic radical nephroureterectomy using a transvesical single port approach under pneumovesicum.

MATERIALS AND METHODS

The procedure was performed in an 80-year old male with a history of gross hematuria due to left renal pelvic TCC and no history of prior bladder TCC. Laparoscopic radical nephroureterectomy was performed and the ureter was dissected down to the bladder and clipped. A single-port device was inserted transvesically and pneumovesicum established. A full thickness incision of the bladder around the ureter was performed with progressive intravesical mobilization of the distal ureter. Subsequently, a water-tight closure of the bladder defect was achieved. The distal ureter, together with the bladder cuff, was then delivered en bloc laparoscopically with the specimen.

RESULTS

The operating time (LESS radical nephroureterectomy, RPLND, and bladder cuff excision) was 6hours and 15minutes. The bladder cuff time was 45minutes. There were no intra or postoperative complications and the catheter was removed after 6 days. Histopathological analysis showed kidney-invasive papillary urothelial cancer, pT3 pN0 (0/7) G3.

CONCLUSION

The distal ureter and bladder cuff techniques have not yet been standardized. Management of the bladder cuff with a single port is feasible. Additional studies are needed to identify the best approach for management of the distal ureter at the time of laparoscopic nephroureterectomy.

Is peri-articular multimodal drug infiltration in knee arthroplasty safe when used in conjunction with autologous retransfusion drains?

INTRODUCTION

Adequate peri-operative analgesia following total knee arthroplasty (TKA) promotes earlier rehabilitation but remains problematic because of the drug side-effects. Peri-articular multimodal drug infiltration (PMDI) has been developed as an alternative strategy to avoid such complications. Autologous retransfusion drains reduce the need for peri-operative allogenic blood transfusions and the consequent risk. There is a theoretical risk of local anaesthesia toxicity when these systems are used concurrently. We performed a review of current practice to quantify this risk.

PATIENTS AND METHODS

A series of 10 patients undergoing TKA by the senior author (CAB) had drain fluid analysed for the concentration of ropivacaine. At the same time, the patients completed a questionnaire to establish the presence of ropivacaine-induced side-effects.

RESULTS

The ropivacaine level in the retransfusion blood was less than 10 mg in all patients. This concentration was a factor of 6 below the published safe level. Three patients had minor neurological disturbances which recovered spontaneously and quickly. There were no cases of significant cardiovascular compromise.

CONCLUSIONS

The theoretical risk of local anaesthesia toxicity when these systems are used together is negligible and we conclude that peri-articular multimodal drug infiltration is safe in conjunction with the use of autotransfusion drains.

Lyme disease: an unusual case of peripheral nerve palsy

Lyme disease is a vector-borne multisystem inflammatory disease caused by the spirochete Borrelia burgdorferi sensu lato. This disease is frequently seen in North America and to a lesser degree in Europe. However, its presence in England is uncommon and we present a case in which the patient developed a palsy of the common peroneal nerve.