Perinatal (fetal and neonatal) germ cell tumors

Background/Purpose

Germ cell tumors are relatively common in the fetus and neonate and are the leading neoplasms in some perinatal reviews. The purpose of this study is to focus on the fetus and neonate in an attempt to determine the various ways germ cell tumors differ clinically and morphologically from those occurring in the older child and adult and to show that certain types of tumors have a better prognosis than others.

Methods

The author conducted a retrospective review of perinatal teratomas and other germ cell tumors reported in the literature and of patients treated and followed up at Children’s Hospital San Diego and Children’s Hospital Los Angeles. Only fetuses and infants less than 2 months of age with adequate clinical and pathologic data were accepted for review.

Results

Five hundred thirty-four fetuses and neonates presented with teratomas diagnosed prenatally (n = 226) and at birth (n = 309). The most common initial finding was a mass, noted either by antenatal sonography or by physical examination during the neonatal period, with signs and symtoms referable to the site of origin. Overall polyhydramnios was next followed by respiratory distress and stillbirth. The number of mature and immature teratomas was approximately the same. The incidence of teratoma with yolk sac tumor either at presentation or at recurrence was 5.8%, and the survival rate was 39%. Sacroccoccygeal teratomas had the highest incidence of yolk sac tumor at 10%. Recurrent disease in the form of either teratoma or yolk sac tumor developed in 5% of patients. All individuals with teratomas who survived received surgical resection.

Conclusions

Some germ cell tumors of the fetus and neonate have a better prognosis than others. Neonates with gastric teratomas have the best survival rates, and those with intracranial germ cell tumors the worst. Fetuses with teratomas detected antenatally have 3 times the mortality rate compared with postnatally diagnosed neonates. Although perinatal teratomas have a relatively low recurrence rate of 5%, close follow-up with imaging studies and serum α-fetoprotein determinationsis is strongly recommended. Surgical resection alone may be adequate therapy for teratomas with nonmetastatic, microscopic foci of yolk sac tumor. In the nonteratoma group, patients with pure yolk sac tumor and gonadoblastoma have a much better outcome than those with choriocarcinoma, which has a very low survival of rate of 12%. Currently, the use of platinum-based combination chemotherapy has significantly improved the survival rate of infants with advanced malignant germ cell tumor disease.     

Evaluation of a new combined SpO2/PtcCO2 sensor in anaesthetized paediatric patients

BACKGROUND: The recently introduced TOSCA monitor (Linde Medical Sensors AG, Basel, Switzerland) combines pulse oximetry (SpO2) and transcutaneous PCO2 (PtcCO2) monitoring in a single ear sensor. The aim of the present study was to evaluate accuracy of the TOSCA monitor to estimate SaO2 and PaCO2 in anaesthetized children. METHODS: With approval of the hospital ethical committee and after obtaining informed parental consent, the TOSCA sensor was attached to one ear lobe of anaesthetized children in whom arterial access was established for cardiac catheterization or invasive blood pressure monitoring. SpO and PtcCO2 as well as SpO and PECO2 values from the anaesthesia monitoring (AS5; Datex-Ohmeda, Helsinki, Finland) were compared with SaO2 and PaCO2 values from arterial blood gas analysis. Corresponding data were compared using Bland Altman bias analysis. RESULTS: A total of 111 blood samples were taken from 60 children (median age: 4.41 years; 0.35-16.13 years). SaO2 values ranged from 63 to 100% (median: 98.7%), PaCO2 ranged from 3.8 to 7.3 kPa (median: 4.6 kPa). Mean difference (+/-2 sd) between PaCO2 and PtcCO2 was -0.035 kPa (+/-0.74 kPa), between PaCO2 and PECO2 0.002 kPa (0.73 kPa), respectively (1 kPa = 7.3 mmHg). Bias and precision between SaO2 and SpO was -0.63% (+/-2.77%) and 0.13% (+/-4.52%) between SaO2 and SpO. CONCLUSIONS: In anaesthetized children, the TOSCA ear sensor allows estimation of SaO2 and PaCO2, comparable in accuracy to endtidal capnometry and finger pulse oximetry. This makes the TOSCA monitor a helpful add-on to respiratory monitoring in anaesthetized children, in situations, in which endtidal capnometry is unreliable or difficult to establish.     

Combined photoplethysmographic monitoring of respiration rate and pulse: a comparison between different measurement sites in spontaneously breathing subjects

Background:  The non-invasive photoplethysmographic (PPG) signal reflects blood flow and volume in a tissue. The PPG signal shows variation synchronous with heartbeat (PPGc), as used in pulse oximetry, and variations synchronous with breathing (PPGr). PPGr has been used for non-invasive monitoring of respiration with promising results. Our aim was to investigate PPG signals recorded from different skin sites in order to find suitable locations for parallel monitoring of variations synchronous with heartbeat and breathing.
Methods:  PPG sensors were applied to the forearm, finger, forehead, wrist and shoulder on 48 awake healthy volunteers. From these sites, seven PPG signals were simultaneously recorded during normal spontaneous breathing over 10 min. Capnometry served as respiration and electrocardiogram (ECG) as pulse reference signals. PPG signals were compared with respect to power spectral content and squared coherence.
Results:  Forearm PPG measurement showed significantly higher power within the respiratory region of the power spectrum [median (quartile range) 42 (26)%], but significantly lower power within the cardiac region [9 (10)%] compared with the other skin sites. PPG finger measurement showed the opposite; in transmission mode, the power within the respiratory region was significantly lower [4 (10)%] and within the cardiac region significantly higher [45 (25)%] than the other sites. PPGc coherence values were generally high [>0.96 (0.08)], and PPGr coherence values lower [0.83 (0.35)–0.94 (0.17)].
Conclusion:  Combined PPG respiration and pulse monitoring is possible, but there are significant differences between the respiratory and cardiac components of the PPG signal at different sites.     

Forehead SpO2 monitoring compared to finger SpO2 recording in emergency transport

Continuous peripheral oxygen saturation monitoring using a finger pulse oximeter is standard in prehospital emergency medicine. Forehead peripheral oxygen saturation monitoring has been enhanced for better performance during movement and in cold ambient temperatures, both of which are common during emergency transport. We compared a new forehead monitor with standard finger pulse oximeter. The forehead technique had significantly fewer mean (SD) alarms per patient (3.0 (2.2)) than the finger pulse oximeter (7.8 (4.0)) and shorter durations of malfunction (76 (60) s compared to 333 (170) s) when using the finger pulse oximeter. We conclude that measuring peripheral oxygen saturation monitoring with a forehead sensor provides better monitoring quality in emergency care.     

Utilization of the Walking Oximetry Test to Allow Safe Ambulation After Pulmonary Resection

Supplemental oxygen therapy after pulmonary resection can generally be tapered according to arterial blood gases at rest or pulse oximetry (SpO₂). However, detecting exercise-induced oxygen desaturation can be difficult. We developed the walking oximetry test (WOT) so that thoracotomy patients could be rehabilitated without the risk of undetected ambulatory hypoxemia. The subjects were 58 patients who had undergone pulmonary resection and could walk at the bedside, with oxygen at 3 l/min via a nasal cannula. Patients with a value of more than 100 torr were allowed to walk with assistance for 6 min in the corridor. The oxygen flow rate was kept at 3 l/min and the walking pace was less than 50 m/min. SpO₂ was determined using a wristwatch pulse oximeter. The test was stopped if the SpO₂ fell below 90% or there was a score of 5 or more on the Borg scale (range 1–10). Oxygen desaturation occurred in six patients (10%) during the WOT. These patients underwent ambulatory training with sufficient oxygen supplementation and were then tested again. Patients whose SpO₂ values remained higher than 90% and who showed no more than 5% desaturation were permitted to walk in the corridor with oxygen at 3 l/min via a nasal cannula. All these patients had a Borg score of 4 or lower. The WOT is a reliable, nonvasive method for detecting exercise-induced oxygen desaturation during ambulation after pulmonary resection. Received: December 5, 2000 / Accepted: July 17, 2001     

Comparison of epidural methadone with epidural diamorphine for analgesia following caesarean section

Analgesia provided by either 5 mg diamorphine, or 5 mg methadone administered by the epidural route during elective caesarean section was compared in 40 women. The median time to further analgesia in the methadone group was 395 min, and 720 min in the diamorphine group, P = 0.0003. Linear analogue scores to assess pain were measured 2-hourly for 12 h, then again at 24 h postoperatively. Pain scores were significantly lower in the diamorphine group at 8 and 10 h. The median cumulative i.m. morphine dose administered during the first 24 h was 20 mg in the methadone group and 0 mg in the diamorphine group (P = 0.0005). Nausea and pruritis were common side effects in both groups. Continuous pulse oximetry data were available for 12 h post-operatively in 15 patients receiving methadone, and in 17 patients receiving diamorphine. One or more episodes of significant desaturation (<90% for 30 s), occurred in three patients receiving methadone, and in nine patients receiving diamorphine. Desaturation to 90–92% occurred in a further three patients given epidural diamorphine, and in one further patient given epidural methadone.     

Pilot study: Utility of long-wave infrared thermography as a correlate to transcutaneous oximetry for candidates of hyperbaric oxygen therapy

Hyperbaric oxygen (HBO₂) has been used as an adjunctive treatment for the care of advanced non-healing diabetic foot ulcers (DFUs). A patient's in-chamber transcutaneous oximetry measurement (TCOM) is currently the most effective predictor for response to HBO₂ therapy but still excludes close to one in four patients who would benefit out of treatment groups when used for patient selection. Improving selection tools and criteria could potentially help better demonstrate HBO₂ therapy's efficacy for such patients. We sought to identify if long-wave infrared thermography (LWIT) measurements held any correlation with a patient's TCOM measurements and if LWIT could be used in a response prediction role for adjunctive HBO₂ therapy. To investigate, 24 patients already receiving TCOM measurements were enrolled to simultaneously be imaged with LWIT. LWIT measurements were taken throughout each patient's therapeutic course whether they underwent only standard wound care or adjunctive HBO₂ treatments. A significant correlation was found between in-chamber TCOM and post-HBO₂ LWIT. There was also a significant difference in the post-HBO₂ LWIT measurement from 1st treatment to 6 weeks or the last treatment recorded. These initial findings are important as they indicate a possible clinical use for LWIT in the selection process for patients for HBO₂ therapy. Larger studies should be carried out to further articulate the clinical use of LWIT in this capacity.     

Effect of hyperventilation on brain tissue oxygen pressure, carbon dioxide pressure, pH value and intracranial pressure during intracranial hypertension in pigs

ＨＤｅｐａｒｔｍｅｎｔｏｆＮｅｕｒｏｓｕｒｇｅｒｙ ,ＣｈａｎｇｚｈｅｎｇＨｏｓｐｉｔａｌ,ＳｅｃｏｎｄＭｉｌｉｔａｒｙＭｅｄｉｃａｌＵｎｉｖｅｒｓｉｔｙ ,Ｓｈａｎｇｈａｉ 2 0 0 0 0 3,Ｃｈｉｎａ (ＢａｏＹＨ ,ＪｉａｎｇＪＹ ,ＺｈｕＣ ,ＬｕＹＣ ,ＣａｉＲＪａｎｄＭａＣＹ)ｙｐｅｒｖｅｎｔｉｌａｔｉｏｎ (ＨＶ )ｈａｓｂｅｅｎｗｉｄｅｌｙｕｓｅｄｔｏｄｅｃｒｅａｓｅｔｈｅｉｎｔｒａｃｒａｎｉａｌｐｒｅｓｓｕｒｅ (ＩＣＰ)ｉｎｔｈｅｐａｔｉｅｎｔｓｗｉｔｈｓｅｖｅｒｅｔｒａｕｍａｔｉｃｂｒａｉｎｉｎｊｕｒｙ…     

经食管监测主动脉血氧饱和度及其临床意义

目的探讨经食管监测主动脉血氧饱和度(SteO2)的敏感性与精确性。方法45例择期手术患者,全麻气管插管后放置自制SteO2装置入食管下段。SteO2和脉搏血氧饱和度(SpO2)停止机械通气和稳定后供氧,SteO2从100%降到90%后立即纯氧吸入,实时动脉血气监测,观察相同时点SteO2和SpO2的变化。结果(1)SteO2与动脉血氧饱和度(SaO2)有良好的相关性(r=0.9514);SteO2与SaO2比较,相对与绝对偏差分别是1.7%和1.2%。(2)SteO2下降变化早于SpO2,提前(109.8±19.3)s(P<0.01)。结论经食管连续监测SteO2具有可行性。在预警条件下,急性缺氧时SteO2较SpO2更早报警。SteO2可以作为无创连续SaO2另一监测手段。     

Development of a monitoring protocol for safe use of opioids in children

A monitoring protocol incorporating pulse oximetry was developed for children receiving patient-controlled analgesia (PCA) and was applied to 75 children undergoing major abdominal, urological or orthopaedic procedures. Patients used PCA for a mean of of 48.9 h (range 11–147 h). Eighty-three percent of hourly pain scores were 0 or 1, indicating no pain or mild pain, with only 1.7% of 3669 recorded pain scores indicating severe pain. The mean minimum oxyhaemoglobin saturation (Spo₂) value while breathing ambient air was 92% (range 84–99%). Eighty-four percent of Spo₂ recordings were in the range 95–100%. Only 1% of Spo₂ recordings were <90% and none of these was associated with a slow respiratory rate or oversedation. The mean minimum respiratory rate was 17 (range 10–26). The protocol proved to be easy to use in the general ward. It can be readily adapted for use in all children receiving opioids by whatever route and for children undergoing sedation for investigative procedures.     

Monitorização não invasiva da hemoglobina em ensaios clínicos: uma revisão sistemática e metanálise

Background and objectivesThe measurement of Hb by co‐oximetry is an innovative technique that offers efficiency and agility in the processing of information regarding the measurement of Hemoglobin concentration (Hb) obtained through continuous, non‐invasive and rapid monitoring. Because of this attribute, it avoids unnecessary exposures of the patient to invasive procedures by allowing a reduction in the number of blood samples for evaluation and other unnecessary therapies. It also helps to make decisions about the need for transfusion and how to handle it. The objective of this study is to compare the performance offered to obtain Hb values between the Masimo Corporation (Irvine, CA, USA) instrument and the standard gold tool (laboratory examination).ContentsThe study corresponds to a systematic review followed by meta‐analysis, which included fully registered full‐text clinical trials published from 1990 to 2018. PubMed, Cochrane, Medline, Embase and Web of Science databases were investigated. The mean overall difference found between the non‐invasive and invasive methods of hemoglobin monitoring was 0.23 (95% CI ‐0.16, 0.62), that is, it did not present statistical significance (p  =  0.250). The results of the analysis of heterogeneity within and between the studies indicated high levels of inconsistency (Q  =  461.63, p  <  0.0001, I²  =  98%), method for Hb values.ConclusionsAlthough the mean difference between noninvasive measurements of Hb and the gold standard method is small, the co‐oximeter can be used as a non‐invasive “trend” monitor in detecting unexpected responses at Hb levels.     

ULNAR NEUROPATHY AT THE ELBOW: CLINICAL AND ELECTROPHYSIOLOGICAL OUTCOME OF SURGICAL AND CONSERVATIVE TREATMENT

The objective was to evaluate and compare the clinical and electrophysiological outcome of treatment in patients with ulnar neuropathy at the elbow in 32 consecutive patients who were studied prospectively. Based on the electrophysiological findings 15 patients were treated by surgical decompression and 17 were treated conservatively. Sensory and motor nerve conduction studies across and below the elbow were done in all patients before treatment and again after one year. Postoperatively 10/15 patients (67%) improved clinically and 12 patients (80%) had improved nerve conduction results. There was clinical and electrophysiological agreement in eight patients in the surgically-treated group, all of whom improved both clinically and electrophysiologically. In the conservatively-treated group six patients (35%) showed clinical improvement, 10 patients had no improvement, and one patient was worse. The nerve conduction studies improved in six patients (35%), were unchanged in eight patients, and worse in three. There was clinical and electrophysiological agreement in 11 patients. We conclude that the electrophysiological examination was valuable in deciding which patients to operate on, and that most of the patients improved clinically or electrophysiologically postoperatively.     

体外循环控制氧分压与紫绀型心脏病的心肌保护

目的 探讨体外循环（CPB）控制动脉氧分压（PaO2）对紫绀型先天性心脏病心肌保护的影响。方法 3岁以下经皮血氧饱和度（SpO2〈0．85、行根治术的法洛四联症病儿40例，随机分为两组，每组20例：试验组（G1）以接近病儿术前水平的低氧分压启动CPB并控制血流复温前的PaO2≤130mmHg（1mmHg=0．133kPa），血流复温时使PaO2逐渐升至350～500mmHg；对照组（G2）始终保持CPB中Pa02在350．500mmHg。CPB前、主动脉开放（CCR）后取右心房组织测量超氧化物歧化酶（SOD）活性、丙二醛（佃A）含量；CPB前、CPB10min、CCR后10min、术后4h、24h抽取外周血检测心肌酶CK-MB、LDH活性及心肌钙蛋白（cTnI）浓度观察心肌组织自由基代谢和心肌生化改变；利用心脏B超测量术前及术后4～6d左心室射血分数（EF）、左心室短轴缩短速率（SF）观察左室功能；术后观察血管活性药物的使用、呼吸机辅助时间、重症监护室停留时间。结果 （1）自由基代谢：CPB前两组心肌组织SOD活性、MDA含量差异无统计学意义；CCR后，G1 SOD活性显著高于G2，MDA含量显著低于G2。（2）心肌生化改变：CPB前两组CK-MB、LDH及cTnI差异无统计学意义；CCR后10min、术后4hCK-MB、LDH活性及cTnI的浓度G1显著低于C2，术后24hcTnI的浓度G1也显著低于G2。（3）左室功能：两组间EF和SF术前、术后均差异无统计学意义；G2术后EF、SF显著低于术前，G1组内手术前、后差异无统计学意义。（4）多巴胺平均使用时间G1显著短于G2，ICU停留时问G1也显著短于G2。结论 对于紫绀型先心病，CPB控制PaO2能得到较好的心肌保护效果。     

Lifebox pulse oximeter implementation in Malawi: evaluation of educational outcomes and impact on oxygen desaturation episodes during anaesthesia

Pulse oximetry is an essential monitor for safe anaesthesia but is often not available in low‐income countries. The aim of this study was to determine whether the introduction of pulse oximetry with training was feasible and could reduce the incidence of oxygen desaturation during anaesthesia in a low‐income country. Pulse oximeters were donated, with training, to 83 non‐physician anaesthetists in Malawi. Knowledge was tested immediately before and after training and at follow‐up. Providers were asked to record the lowest peripheral oxygen saturation (SpO₂) for the first 100 cases anaesthetised after training. The primary clinical outcome was the proportion of cases with an oxygen desaturation event (SpO₂ < 90%). Seventy‐seven of 83 (93%) participants completed all pre‐ and post‐training tests. Pulse oximetry knowledge improved after training from a median (IQR [range]) score of 39 (37–42 [28–48]) to 44 (42–46 [35–50]) and this knowledge was maintained for 8 months (p < 0.001). Oxygen saturation data and provider responses were recorded for 4772 cases. The proportion of oxygen desaturation episodes decreased from 17.2% to 6.5%, representing a 36% reduction in the odds of an oxygen desaturation event in the second 50 cases compared with the first 50 (OR 0.64, 95%CI 0.50–0.82, p < 0.001). We conclude that donation of pulse oximeters, with training, in Malawi was feasible, improved knowledge and reduced the incidence of oxygen desaturation events.