The clinical use of longitudinal bio-electrical impedance vector analysis in assessing stabilization of children with severe acute malnutrition

BACKGROUND & AIMS

Severe Acute Malnutrition (SAM) in children is determined using anthropometry. However, bio-electrical impedance (BI) analysis could improve the estimation of altered body composition linked to edema and/or loss of lean body mass in children with SAM. We aimed to assess: 1) the changes in BI parameters during clinical stabilization and 2) whether BI parameters add prognostic value for clinical outcome beyond the use of anthropometry.

METHODS

This prospective observational study enrolled children, aged 6-60 months, that were admitted at Queen Elizabeth Central Hospital in Blantyre, Malawi, for complicated SAM (i.e., having either severe wasting or edematous SAM with a complicating illness). Height, weight, mid-upper arm circumference (MUAC), and BI were measured on admission and after clinical stabilization. BI measures were derived from height-adjusted indices of resistance (R/H), reactance (Xc/H), and phase angle (PA) and considered to reflect body fluids and soft tissue in BI vector analysis (BIVA).

RESULTS

We studied 183 children with SAM (55% edematous; age 23.0 ± 12.0 months; 54% male) and 42 community participants (age 20.1 ± 12.3 months; male 62%). Compared to community participants, the BIVA of children with edematous SAM were short with low PA and positioned low on the hydration axis which reflects severe fluid retention. In contrast, children with severe wasting had elongated vectors with a PA that was higher than children with edematous SAM but lower than community participants. Their BIVA position fell within the top right quadrant linked to leanness and dehydration. BIVA from severely wasted and edematous SAM patients differed between groups and from community children both at admission and after stabilization (p < 0.001). Vector position shifted during treatment only in children with edematous SAM (p < 0.001) and showed a upward translation suggestive of fluid loss. While PA was lower in children with SAM, PA did not contribute more than anthropometry alone towards explaining mortality, length of stay, or time-to-discharge or time-to-mortality. The variability and heterogeneity in BI measures was high and their overall added predictive value for prognosis of individual children was low.

CONCLUSIONS

BIVA did not add prognostic value over using anthropometry alone to predict clinical outcome. Several implementation challenges need to be optimized. Thus, in low-resource settings, the routine use of BI in the management of pediatric malnutrition is questionable without improved implementation.

A reduced-carbohydrate and lactose-free formulation for stabilization among hospitalized children with severe acute malnutrition: A double-blind, randomized controlled trial

BACKGROUND

Children with medically complicated severe acute malnutrition (SAM) have high risk of inpatient mortality. Diarrhea, carbohydrate malabsorption, and refeeding syndrome may contribute to early mortality and delayed recovery. We tested the hypothesis that a lactose-free, low-carbohydrate F75 milk would serve to limit these risks, thereby reducing the number of days in the stabilization phase.

METHODS AND FINDINGS

In a multicenter double-blind trial, hospitalized severely malnourished children were randomized to receive standard formula (F75) or isocaloric modified F75 (mF75) without lactose and with reduced carbohydrate. The primary endpoint was time to stabilization, as defined by the World Health Organization (WHO), with intention-to-treat analysis. Secondary outcomes included in-hospital mortality, diarrhea, and biochemical features of malabsorption and refeeding syndrome. The trial was registered at clinicaltrials.gov (NCT02246296). Four hundred eighteen and 425 severely malnourished children were randomized to F75 and mF75, respectively, with 516 (61%) enrolled in Kenya and 327 (39%) in Malawi. Children with a median age of 16 months were enrolled between 4 December 2014 and 24 December 2015. One hundred ninety-four (46%) children assigned to F75 and 188 (44%) to mF75 had diarrhea at admission. Median time to stabilization was 3 days (IQR 2-5 days), which was similar between randomized groups (0.23 [95% CI -0.13 to 0.60], P = 0.59). There was no evidence of effect modification by diarrhea at admission, age, edema, or HIV status. Thirty-six and 39 children died before stabilization in the F75 and in mF75 arm, respectively (P = 0.84). Cumulative days with diarrhea (P = 0.27), enteral (P = 0.42) or intravenous fluids (P = 0.19), other serious adverse events before stabilization, and serum and stool biochemistry at day 3 did not differ between groups. The main limitation was that the primary outcome of clinical stabilization was based on WHO guidelines, comprising clinical evidence of recovery from acute illness as well as metabolic stabilization evidenced by recovery of appetite.

CONCLUSIONS

Empirically treating hospitalized severely malnourished children during the stabilization phase with lactose-free, reduced-carbohydrate milk formula did not improve clinical outcomes. The biochemical analyses suggest that the lactose-free formulae may still exceed a carbohydrate load threshold for intestinal absorption, which may limit their usefulness in the context of complicated SAM.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02246296.

Pancreatic Enzyme Replacement Therapy in Children with Severe Acute Malnutrition: A Randomized Controlled Trial

OBJECTIVE

To assess the benefits of pancreatic enzyme replacement therapy (PERT) in children with complicated severe acute malnutrition.

STUDY DESIGN

We conducted a randomized, controlled trial in 90 children aged 6-60 months with complicated severe acute malnutrition at the Queen Elizabeth Central Hospital in Malawi. All children received standard care; the intervention group also received PERT for 28 days.

RESULTS

Children treated with PERT for 28 days did not gain more weight than controls (13.7 ± 9.0% in controls vs 15.3 ± 11.3% in PERT; P = .56). Exocrine pancreatic insufficiency was present in 83.1% of patients on admission and fecal elastase-1 levels increased during hospitalization mostly seen in children with nonedematous severe acute malnutrition (P <.01). Although the study was not powered to detect differences in mortality, mortality was significantly lower in the intervention group treated with pancreatic enzymes (18.6% vs 37.8%; P < .05). Children who died had low fecal fatty acid split ratios at admission. Exocrine pancreatic insufficiency was not improved by PERT, but children receiving PERT were more likely to be discharged with every passing day (P = .02) compared with controls.

CONCLUSIONS

PERT does not improve weight gain in severely malnourished children but does increase the rate of hospital discharge. Mortality was lower in patients on PERT, a finding that needs to be investigated in a larger cohort with stratification for edematous and nonedematous malnutrition. Mortality in severe acute malnutrition is associated with markers of poor digestive function.

TRIAL REGISTRATION

ISRCTN.com: 57423639.

Both Exocrine Pancreatic Insufficiency and Signs of Pancreatic Inflammation Are Prevalent in Children with Complicated Severe Acute Malnutrition: An Observational Study

OBJECTIVES

To assess whether pancreatic function is impaired in children with severe acute malnutrition, is different between edematous vs nonedematous malnutrition, and improves by nutritional rehabilitation.

STUDY DESIGN

We followed 89 children with severe acute malnutrition admitted to Queen Elizabeth Central Hospital in Blantyre, Malawi. Stool and blood samples were taken on admission and 3 days after initial stabilization to determine exocrine pancreatic function via fecal elastase-1 (FE-1) and serum trypsinogen and amylase levels.

RESULTS

A total of 33 children (37.1%) had nonedematous severe acute malnutrition, whereas 56 (62.9%) had edematous severe acute malnutrition. On admission, 92% of patients showed evidence of pancreatic insufficiency as measured by FE-1 <200 μg/g of stool. Patients with edematous severe acute malnutrition were more likely to have low FE-1 (98% vs 82.8%, P = .026). FE-1 levels remained low in these individuals throughout the assessment period. Serum trypsinogen was elevated (>57 ng/mL) in 28% and amylase in 21% (>110 U/L) of children, suggesting pancreatic inflammation.

CONCLUSION

Exocrine pancreatic insufficiency is prevalent in children with severe acute malnutrition and especially in children with edematous severe acute malnutrition. In addition, biochemical signs suggestive of pancreatitis are common in children with severe acute malnutrition. These results have implications for standard rehabilitation treatment of children with severe acute malnutrition who may benefit from pancreatic enzyme replacement therapy.

TRIAL REGISTRATION

ISRCTN.com: 13916953.

History of the surgical treatment of ulnar nerve compression at the elbow

OBJECTIVE

Surgery to achieve ulnar nerve decompression at the elbow has been performed for nearly 2 centuries. Several methods have been developed, some of which have been abandoned. Historical insight improves understanding of current techniques and provides the basis for the development of new methods. Which treatment method is best is the topic of ongoing debate.

METHODS

The literature was reviewed using the MEDLINE database. Standard textbooks and retrieved articles were checked for missing references. For older articles, the bibliographies of books and theses were consulted. When I was unsuccessful in finding information in standard biographies of authors of milestone publications, I contacted the hospitals or institutions in which these individuals worked or are currently working.

RESULTS

A systematic chronological overview of the surgical treatment of ulnar nerve compression at the elbow is presented, with special attention to people who described a treatment method for the first time.

CONCLUSION

This article is the first in the literature to provide information about and photographs of nearly all of the people who were important in the development of the surgical treatment of compression of the ulnar nerve at the elbow.

Height of cervical foramina after anterior discectomy and implantation of a carbon fiber cage

OBJECT

The authors evaluate the effects of implantation of a carbon fiber cage after anterior cervical discectomy (ACD) on the height of the foramen and the angulation between endplates of the disc space.

METHODS

Thirteen consecutive patients who were scheduled for standard microscopic ACD and interbody fusion underwent thin-slice (1.5 mm) spiral computerized tomography scanning 1 day preoperatively, 1 day postoperatively, and 1 year postoperatively. Oblique sagittal reconstructions were made through both foramina; the height of each foramen and the angle between the endplates were measured. Because 16 cages were implanted, 32 foramina were investigated. Preoperatively, the mean height of the foramina (+/- standard deviation) was 8.1 +/- 1.5 mm (range 5.7-12 mm), and at I day postoperatively it was 9.7 +/- 1.4 mm (range 7.5-12.8 mm). This difference reached statistical significance (p < 0.0005). The mean foraminal height after 1 year was 9.4 +/- 1.4 mm (range 6.9-12.7 mm). In terms of the preoperative value, the 1-year measurement still reached statistical difference (p < 0.005) but not with the direct postoperative mean foraminal height. Preoperatively the mean value of the angle between the two adjacent endplates was 1.3 +/- 2.4 degrees (range 0-8 degrees), and postoperatively it was 7.8 +/- 2.9 degrees (rauge 2-12 degrees), which was statistically significant (p < 0.0005).

CONCLUSIONS

The cervical carbon fiber cage effectively increased the height of the foramen even after 1 year, which contributed to decompression of the nerve root. The wedge shape of the device may contribute to restoration of lordosis.

Spinal arachnoiditis following subarachnoid haemorrhage: report of two cases and review of the literature

Two patients with spinal arachnoiditis following subarachnoid haemorrhage are described. A complete spinal block was seen at the mid thoracic level with characteristics of spinal arachnoiditis. Only one patient had severe symptoms. Both patients were treated conservatively. Signs and symptoms diminished in time. A review of the literature is given and the aetiology is discussed.

[Cavernous sinus syndrome]

A clear and concise description and clinical interpretation of the cavernous sinus syndrome are lacking. Pathological changes in or around the cavernous sinus may lead to failure of eye muscle nerves and of one or more branches of the trigeminal nerve. The clinical signs of the cavernous sinus syndrome are combinations of failure of these cranial nerves sometimes with exophthalmus. Because many nerves can be wholly or partially involved in the syndrome, there is no clinical uniformity and the cavernous sinus syndrome has never been well defined. A neurotopographical classification is proposed in order to simplify the multiple interpretations of the cavernous sinus syndrome. The classical cavernous sinus syndrome is divided into three syndromes: the syndrome of the superior orbital fissure, the syndrome of the lateral wall of the cavernous sinus and the central cavernous sinus syndrome.

Surgical approach and histoanatomical aspects of the oculomotor nerve in rats

The surgical approach and some histoanatomical characteristics of the intracavernous portion of the oculomotor nerve are described. Moreover, some perioperative precautions for intracranial surgical procedures in the rat are reported and the suitability of the rat as a model for studying intracranial nerve regeneration is discussed. With the data provided, this model of oculomotor nerve approach can be used to study various aspects of intracranial nerve regeneration.

End-to-end versus peripheral nerve graft repair of the oculomotor nerve in rats: A comparative histological and morphometric study

A comparative study was undertaken to evaluate end-to-end versus peripheral nerve graft repair in cranial nerve reconstruction. In 14 rats, the oculomotor nerve was sharply transected in the cavernous sinus and repaired either by end-to-end coaptation (n = 7) or by interposition of a peripheral nerve graft (n = 7). The results were evaluated 16 weeks after surgery by light and transmission electron microsurgery and by morphometric analysis. The degree of neuroma formation, fibrosis, and axonal disorganisation at the repair site was the same for both groups. Histologically, both end-to-end and graft repair groups revealed various degrees of axonal regeneration with myelinated nerve fibres in the distal nerve segments. In both groups, the number of nerve fibres distal to the repair site was increased compared to proximal to the repair (P < 0.001) but myelinated axon diameter was significantly less than that of control nerves (P < 0.001). No difference existed between the two repair groups in terms of mean myelinated axonal diameter. However, the number and density of myelinated axons was statistically greater in the graft group (P < 0.05). In conclusion, despite the disadvantage of two repair sites, peripheral nerve grafting results in equal or slightly superior axonal regeneration compared to an end-to-end repair in the rodent model of intracranial oculomotor nerve reconstruction. We speculate that this may be due to the structure of the peripheral nerve graft.

A new technique for the assessment of the draining area of a cerebral vein

BACKGROUND

At present, it is not exactly clear which vein is allocated for drainage of blood to a particular area of the human brain. Knowledge of these draining areas is very important for the understanding of occlusive venous diseases. A method was developed that offers the possibility to investigate the draining area of a cerebral vein, with the help of an animal model.

METHODS

Brains of sacrificed rabbits are removed and are anterogradely perfused with a coloring matter. Then a vein chosen at random is occluded and anterograde perfusion is restarted using another coloring substance. The working hypothesis is that the part of the brain that is solely dependent for its drainage of blood upon the occluded vein (the draining area of the vein) will show a deficit in staining after the second perfusion. RESULTS Using the abovementioned technique, no filling defect was seen if a vein was occluded near its entrance into the sinus (N = 8) or at a single point over the cortex (N = 7). If a longer trajectory (10-14 mm.) was obstructed, a clear staining defect was seen in 13 out of 16 hemispheres; the three remaining cases seemed to be technical failures.

CONCLUSION

A new method is described to investigate the draining area of a cerebral vein. Although the validity of the method is proven in an animal model, it seems a good technique for investigation of human brains postmortem. Application of this technique will contribute to the understanding of the pathophysiology of venous diseases and also elucidate the role of the venous anastomotic pathways.

Endoscope-assisted supraorbital craniotomy for lesions of the interpeduncular fossa

OBJECTIVE

The supraorbital approach is well accepted for lesions in the anterior fossa, the sellar region, and the anterior circle of Willis. However, the usefulness of this approach has not yet been elucidated for lesions in the interpeduncular fossa. The technique of an endoscope-assisted, ipsi- and contralateral supraorbital approach to lesions within the interpeduncular fossa is described, and the initial results are reported.

METHODS

A small supraorbital craniotomy, using an eyebrow incision, was performed in each of seven patients who were operated on for different types of lesions in the interpeduncular fossa, including a neuromuscular choristoma of the oculomotor nerve, a retrosellar epidermoid tumor, and five aneurysms (two of the basilar artery tip, two at the offspring of the superior cerebellar artery, and one fusiform arterial widening of the basilar artery apex). The surgical approach, its indications and limitations, and the additional value of an endoscope are outlined.

RESULTS

All lesions could be easily reached and well visualized through this approach by using an endoscope as an adjunct to the operating microscope. The saccular aneurysms all could be clipped successfully, the fusiform widening was wrapped, the epidermoid tumor was removed completely, and the choristoma was removed only partially because of brain stem invasion. The patient with the neuromuscular choristoma had persistent diabetes insipidus postoperatively, most probably caused by stretching the pituitary stalk with the endoscope. The patient with the epidermoid tumor showed a postoperative transient partial oculomotor nerve paresis at the side of the approach. The cosmetic results of the eyebrow incisions for this approach were excellent in all patients.

CONCLUSION

Lesions in the interpeduncular fossa can be effectively treated using a supraorbital approach, which can be ipsi- or contralateral to the side of the lesion, depending on the exact location of the lesion. The use of an endoscope is essential to visualize these lesions that lie in the shadow of the sellar and parasellar anatomic structures. The major advantage over other approaches are a nearly perpendicular surgical route (although the distance is longer, which is, on the other hand, not a disadvantage), a minimized amount of dissection and brain retraction by using an endoscope through anatomic gateways, and a small surgical incision with excellent cosmetic results.

Stabilization and accurate trimming of nerve ends: practical use of fibrin glue: technical note

OBJECTIVE

Peripheral nerve transection usually results in protrusion of the endoneurial contents ("mushrooming"). Trimming of the nerve ends before repair is often necessary to achieve cut nerve end planes. In this technical report, we describe a technique for stabilization and accurate trimming of nerve ends using fibrin glue.

SURGICAL TECHNIQUE

The nerve ends of divided peripheral nerves are coated with fibrin glue and subsequently trimmed using a razor blade before repair.

RESULTS

When fibrin glue is applied, a firm layer with a rubbery consistency is formed around the nerve. This layer stabilizes the nerve ends during trimming, and a clear-cut plane of the nerve can be achieved. Moreover, the fibrin glue stabilizes the nerve ends during manipulations caused by suturing of the nerve.

CONCLUSION

The technique results in easier handling of the nerve during trimming and manipulation, minimal tissue damage to the nerve, and a clear-cut plane of the nerve.

Surgical management of ulnar nerve compression at the elbow: an analysis of the literature

OBJECT

Surgical treatment for cubital ulnar nerve compression includes medial epicondylectomy, simple decompression, or anterior transposition (subcutaneous, intramuscular, or submuscular). There is a dearth of prospective randomized studies on which to base guidelines for choosing one operative treatment over another. The authors review the literature on this subject and present their findings.

METHODS

The authors reviewed the literature from January 1970 to July 1997. Two authors decided independently whether an article should be included for review based on previously formulated inclusion and exclusion criteria. In addition to demographic information, data concerning preoperative status and outcome were extracted. For statistical analyses chi-square and Kruskal-Wallis tests were performed. Irrespective of their preoperative status, patients with simple decompression had the best outcome, whereas those with anterior subcutaneous and submuscular transposition had the worst. If outcome was related to the patient's preoperative status, a significant difference was not found among the various groups for those patients with a preoperative McGowan Grade 2. However, for those with McGowan Grade 3 (severe) symptoms, patients with anterior intramuscular transposition had the best outcome followed by those with simple decompression and anterior submuscular transposition. Statistical analysis was not possible for patients with McGowan Grade 1 because of the small numbers of patients in several treatment modality groups.

CONCLUSIONS

Formulating a uniform guideline for operative treatment is not possible based on the results of this study. However, the authors believe that support is given to their policy, which is primarily to perform a simple decompression. Its surgical simplicity with preservation of the anatomy, especially the vascularization, and the possibility of rapid postoperative rehabilitation are also taken into consideration. If subluxation is found intraoperatively, anterior transposition is proposed.

Falcine sinus and occipital encephalocele: a magnetic resonance venography study

OBJECT

Occipital encephaloceles are relatively frequently encountered. Many investigators have addressed the embryogenesis of these formations, but the dural system has never before been studied. In this retrospective analysis the authors sought to gain a better understanding of the origins of these defects.

METHODS

The charts and radiological examinations, especially the magnetic resonance venography studies, were reviewed in seven patients. In six patients the straight sinus was absent. Drainage of the galenic system took place through a sinus within the falx, also known as a falcine sinus. The tentorium was not seen in five patients.

CONCLUSIONS

The combination of an absent straight sinus and dysplastic tentorium is no coincidence: both develop within the same mesenchyme in the mesencephalic flexure. Distortion of the mesenchyme by a neural tube defect, causing an occipital encephalocele, will lead not only to disorders of the tentorium but also of the straight sinus.

A giant cell tumor of the sacrum or a soft tissue giant cell tumor? A case report

STUDY DESIGN

A case report.

OBJECTIVE

Giant cell tumors are rare primary bone tumors. Generally, these tumors are expanding osteolytic lesions, but soft tissue giant cell tumors can occur. This is a case report of an unusual incidence of a giant cell tumor within the spinal sacral canal, in which there was no involvement of the surrounding bone or ligament structures and that was signaled by radicular pain. The pathologic course of the tumor is described.

SUMMARY OF BACKGROUND DATA

A 24-year-old woman had monoradicular pain in the right leg in the region of S2. Neuroradiologic examination showed a mass within the sacral spinal canal compromising the right S2 root, with no sign of bone involvement.

METHODS

A sacral laminectomy was performed. A tumor was located entirely intraspinally and extradurally and was removed completely. A giant cell tumor was identified in histologic examination.

RESULT

The patient recovered completely. No local regrowth or metastasis occurred during a 20-month follow-up.

CONCLUSION

The treatment of choice in giant cell tumors is complete surgical resection. Radiotherapy is recommended in cases of subtotal resection. Careful follow-up is warranted, because recurrence and metastasis are not uncommon.

Familial congenital hydrocephalus and aqueduct stenosis with probably autosomal dominant inheritance and variable expression

A kindred is reported on with suspected autosomal dominant congenital hydrocephalus and aqueduct stenosis. In contrast to patients with X-linked congenital hydrocephalus with stenosis of the aqueduct of Sylvius (HSAS) our patients were not mentally retarded and they did not show any pyramidal tract dysfunction or clasped thumbs; the pyramids were not affected either, as was confirmed by autopsy, CT or MRI. Molecular genetic studies in our patients have not revealed abnormalities of eight exons of the L1 neural adhesion molecule gene that is related to HSAS.

Occipitotranstentorial approach for lesions of the superior cerebellar hemisphere: technical report

OBJECTIVE

The occipitotranstentorial approach is well accepted for lesions of the pineal region, superior cerebellar vermis, or mesencephalon. Although evidently suitable, this approach has not, to our knowledge, been reported for lesions of the superior cerebellar hemisphere in adults. Experience with this approach is reported.

METHODS

Four patients underwent surgery between August 1995 and March 1997. The findings obtained are evaluated.

RESULTS

All lesions were situated in the quadrangular lobules (one extending into the vermis), and all were completely removed. Postoperative deficits, especially visual field deficits, did not occur.

CONCLUSION

Lesions of the superior cerebellar hemispheres are easily approached by an occipitotranstentorial route. The major advantages over a supracerebellar approach are that the surgical route is nearly perpendicular to the lesion and to the tentorium instead of parallel, and wide exposure is thereby possible.

Charles Labbé (1851-1889)

The vein of Labbé is a very important structure and every neurosurgeon is acquainted with its anatomy. Because of the recent increasing interest and experience in skull base surgery, the vein of Labbé has received a great deal of attention. Intraoperative damage to this vein should be avoided and several methods to prevent this have been described. Despite these developments, nothing is written in the neurosurgical literature about the man who described this vein for the first time: Charles Labbé. The authors therefore conducted an extensive search of the literature and uncovered several public records in France to learn more about Charles Labbé.

Intraoperative dislocation of the distal lens of a neuroendoscope: a very rare complication: technical case report

OBJECTIVE AND IMPORTANCE

A very unusual complication of neuroendoscopy that was caused by equipment failure is described.

CLINICAL PRESENTATION

Intraoperatively, the distal lens of a reusable rigid, lenscope-type neuroendoscope became dislodged. Fortunately, this did not have any adverse consequences for the patient.

DISCUSSION

The cause remains obscure but probably relates to the repeated use of the scope. Perhaps the use of a disposable neuroendoscope could have prevented this, but reusable lenscopes are designed to be used many times.

CONCLUSION

The risk of such equipment failure should be weighed against the distinct advantage of a much clearer image than is provided by fiberscopes.

Lumbar cerebrospinal fluid drainage for symptomatic sacral nerve root cysts: an adjuvant diagnostic procedure and/or alternative treatment? Technical case report

OBJECTIVE AND IMPORTANCE

The treatment of symptomatic sacral nerve root cysts is difficult and challenging. A major role has been ascribed to the hydrostatic and pulsatile forces of cerebrospinal fluid (CSF) for the symptomatology of sacral nerve root cysts. Theoretically, lowering those pressures should have a beneficial effect on the symptoms. Lowering the hydrostatic and pulsatile pressures may be achieved by lumbar CSF drainage. The effect of lumbar CSF drainage on the symptomatology of sacral nerve root cysts is described.

CLINICAL PRESENTATION

Three patients suffered from leg and/or low back pain as a result of sacral nerve root cysts.

INTERVENTION

First, CSF was drained through an external lumbar drain that was connected to a CSF bag. Mobilization was not restricted. All patients became free of symptoms. Eventually, a lumboperitoneal shunt was inserted in two patients. Those two patients remained free of complaints for 11 and 9 months, respectively.

CONCLUSION

To our knowledge, this is the first report that clearly establishes the role of CSF forces in the symptomatology of sacral nerve root cysts. Lumbar external CSF drainage is a diagnostic tool to investigate the clinical significance of sacral nerve root cyst(s). Lumboperitoneal CSF shunting is a promising alternative in the treatment of symptomatic sacral nerve root cysts.

Hemi-cauda equina syndrome from herniated lumbar disc: a neurosurgical emergency?

BACKGROUND

We report experience with patients presenting with a specific combination of symptoms: unilateral sciatica, unilateral sensibility loss in the dermatomes S1 to S5 (hemi-saddle) and subjective micturation problems secondary to ruptured lumbar disc. Because of its similarities with a cauda equina syndrome, this combination of symptoms was thought to be a unilateral cauda equina syndrome and it was called hemi-cauda equina syndrome. Consequently, it was treated as an emergency.

METHODS

Ten patients were evaluated. They compromised 2.3% of all patients undergoing lumbar discectomy.

RESULTS

Outcome is good with only 10% persisting minor neurologic deficit (sensibility loss in dermatomes S3 to S5). With the exception of urinary retention or incontinence, duration of symptoms and signs does not seem to influence outcome. Comparing signs, symptoms and radiographic findings with those of a cauda equina syndrome which were recently and thoroughly studied, they were found to be more severe in cases of cauda equina syndrome. Especially, the good outcome, (apparently unrelated to the duration of symptoms in cases of hemi-cauda equina syndrome) contrasted with the treatment results of cauda equina syndrome.

CONCLUSIONS

We defined the hemi-cauda equina syndrome from ruptured disc as a combination of unilateral leg pain, unilateral sensibility loss in dermatomes S1 to S5 and sphincter paralysis (proven urinary retention or incontinence). Motor deficit is not necessarily present. Emergency surgery is warranted. Patients presenting with micturation complaints other than urinary retention or incontinence do not suffer from a hemi-cauda equina syndrome.

Interhemispheric subdural hematoma in adults: case reports and a review of the literature

The interhemispheric subdural hematoma is a relatively uncommon type of subdural hematoma, especially seen in patients with blood clotting disturbances. When its mass becomes sufficiently large, specific neurological abnormalities such as hemiparesis and signs of the falx syndrome are seen. Treatment can consist of conservative observation or craniotomy and is dictated by the clinical course. Conservative management is the treatment of choice for patients without disturbances of consciousness and for patients with stable clinical conditions. Surgical treatment is necessary in patients with progressive deterioration. Three case reports are presented, as well as a review of 64 cases described in the literature. The salient aspects of this clinical entity are discussed.

Intramedullary spinal cord abscess. A case report

STUDY DESIGN

A case of an intramedullary spinal cord abscess is presented. The literature on this subject is carefully reviewed.

OBJECTIVES

To give an overview of clinical presentation, radiographic examination, pathogenesis, treatment, and outcome of intramedullary spinal cord abscesses. Cases presented in the literature are arranged and the findings summarized.

SUMMARY OF BACKGROUND DATA

Intramedullary spinal cord abscesses are rare. Most frequently, single cases were reported, followed by a short discussion. All previously reported cases were reviewed.

METHODS

After an extensive literature search, all cases of an intramedullary spinal cord abscess (totaling 93 patients), including ours, were reviewed. Incidence, clinical presentation, neuroradiologic investigations, treatment, and pathogenesis are discussed.

RESULTS

Intramedullary spinal cord abscesses are rare. The presentation can be very confusing, mimicking thoracic or abdominal diseases. Magnetic resonance imaging is the best diagnostic technique, although the findings are not pathognomonic. Appropriate antibiotic therapy after surgical drainage is warranted. If left untreated, the outcome is bleak. Whereas most cultures remain sterile (38.7%), Staphylococcus or Streptococcus species are involved frequently (23.7% and 17.2%).

CONCLUSIONS

Although intramedullary spinal cord abscess is a rare disease, every spine surgeon should have knowledge of its existence because misjudgment and deferring adequate treatment may lead to an unfavorable outcome.

Abnormal venous system in occipital meningoencephalocele: MR angiography

In the literature, the combination of an abnormal cerebral venous system at conventional cerebral angiography with meningoencephalocele has been described. To our knowledge an abnormal venous system in patients with a meningoencephalocele disclosed by magnetic resonance angiography (MRA) has never been reported. A case is presented and the value of MRA, especially in the pediatric population, is stressed.

Transcranial Doppler ultrasonography: influence on scheduling of angiography and delayed surgery for ruptured intracranial aneurysms

The role of transcranial Doppler ultrasound (TCD) was studied retrospectively in relation to the management of 73 patients with a subarachnoid hemorrhage due to a ruptured intracranial aneurysms. TCD velocity measurements provided very valuable data to assist scheduling of angiography and delayed surgery. Angiography and surgery were planned significantly sooner in the TCD examined group of patients with TCD velocities indicative for the absence of vasospasm than in the group of patients who did not have TCD examinations. The cerebral circulatory resistance index (R), calculated as: (maximum systolic velocity--end diastolic velocity)/maximum systolic velocity, and changes in R did not predict a change in clinical grade or outcome.

Acute pancreatitis due to sulfamethoxazole-trimethoprim

We have reported a case of sulfonamide-induced acute pancreatitis. A review of the literature showed only eight previously reported cases. Adverse reactions to sulfonamides are well known, but acute pancreatitis is a very serious complication. If evidence of pancreatic involvement occurs during sulfonamide therapy, the medication should be discontinued immediately and, if necessary, be replaced by an alternative. Other causes of pancreatitis must be excluded.

Spinal subdural abscess

✓ Only 44 cases of spinal subdural abscess have been reported to date. The authors present another case and review the relevant literature. The findings of intraspinal gassification on computerized tomography scans and Escherichia coli as the causative organism have not previously been described in relation to spinal subdural abscess. Most frequently, Staphylococcus aureus is the responsible organism. Hematogenous spread of infection from a distant source often takes place. In a surprising number of incidences, iatrogenic causes are the primary foci of spinal subdural abscess.

Spinal subdural abscess is an unpredictable disease, with an unfavorable outcome if left untreated. If there is suspicion of a spinal subdural abscess, urgent radiological examination followed by immediate surgical drainage and appropriate antibiotic therapy is warranted.

Symptomatic vertebral hemangiomas

Symptomatic vertebral hemangiomas are rare. Several therapeutic modalities for vertebral hemangiomas with neurologic deficit have been described. Personal experience with laminectomy followed by radiation therapy in four patients and radiation therapy in one patient is reported. Considering our results, literature and theoretical aspects a proposal for treatment of symptomatic vertebral hemangiomas is made.

Selection of regression models for health care data

We discuss several linear and nonlinear regression models and their appropriateness in modeling a set of data from a cohort study of the use of medical services in a prepaid medical plan. Although computational considerations once forced researchers to use linear models almost exclusively, modern computer hardware and efficient algorithms have made it possible to use nonlinear models almost as easily as linear ones. Thus, in choosing a regression model, a researcher should give strong consideration to how well the model reflects (presumed) intrinsic properties of the phenomena under study, even if the consideration leads to the choice of a nonlinear model. Modern computer programs for nonlinear minimization should be employed to fit the model. The model should be judged on how well it describes the data and how reasonably it predicts the future.