Neurological morbidity of surgical resection of pediatric cerebellar astrocytomas

Background

Review of children with low-grade cerebellar astrocytoma (LGCA) prior to 1992 showed a 98 % rate of gross total resection (GTR) but a concerning incidence of permanent neurological dysfunction. The purpose of this study was to determine the rate of GTR of LGCA since 1992 and frequency of neurologic injury.

Methods

Retrospective review of children with LGCA was performed. CT/MR scans were rereviewed to assess extent of resection. Primary outcomes included incidence of GTR and incidence of permanent new neurological deficits. Other outcomes included late effects severity score (LESS), Bloom score for functional status, and educational assessment.

Results

Of 50 LGCA, GTR was achieved in 38 (76 %) compared to 43 of 44 (98 %) prior to 1992 (p?<?0.004). Permanent new neurologic deficits from surgery occurred in 16 % compared to 18 % in the prior era (p?=?0.61). For 35 patients operated on by the 2 surgeons in the prior study, 74 % had GTR, with permanent neurological deficits in 8.6 %. At latest follow-up, all patients were alive, 16 % with residual tumor. LESS was two or less (mild or no deficit) in 94 %. Bloom score was one or two (no or mild disability) in 90 %. Eighty-six percent attended normal school.

Conclusions

Less aggressive resection of LGCA in children may reduce postoperative neurologic deficits in the hands of the same surgeons as in the prior study but not overall at our institution. The good long-term outcomes suggest that it may be appropriate to do incomplete resection rather than risk additional neurological deficit.     

ApoA-1 infusion reduces arterial cholesterol and myocardial lesions in a rat model of cardiac dysfunction and insulin resistance

ObjectiveLow plasma high-density lipoprotein cholesterol (HDL-C) concentration is associated with the metabolic syndrome (MetS) and increased prevalence of cardiovascular disease (CVD). Animal and human studies report infusion of apolipoprotein A-1 (apoA-1) can reduce endothelial dysfunction, and/or induce regression of atherosclerosis. However, the direct mechanisms underlying the vascular benefits of either apoA-1 or HDL-C remain unclear. In this study, we assessed the ability of reconstituted HDL (rHDL) to improve vascular complications of MetS, including left ventricular (LV)-hypertrophy, arterial cholesterol deposition and myocardial lesion development.Methods and resultsObese insulin resistant (IR) JCR:LA-cp rats were infused with rHDL (0.4 mg/kg) over 3 days before assessing cardiac function (Echocardiography) at days 7 and 50 post-infusion, as well as haematoxylin and eosin staining of myocardial lesions at day 50. Acute ex vivo arterial cholesterol deposition was assessed with acute infusion of rHDL ex-vivo. Infusion of rHDL partially corrected abnormal diastolic compliance (18%; *p < 0.05) and improved parameters of cardiac function in IR rats. Further, acute rHDL infusion in carotid vessels reduced remnant lipoprotein associated-cholesterol deposition (30–86%; **p < 0.01) ex vivo in IR and male Wistar rats and reduced (41%; *p < 0.05) the frequency of early-stage myocardial lesions in IR rats.ConclusionShort-term infusion of rHDL may beneficially reduce chronic vascular sequelae of MetS, including temporary improvement in LV-dysfunction, acute reduction of acute arterial cholesterol deposition and the development of early-stage myocardial lesions in the JCR:LA-cp rat.     

The prevalence and risk factors for atrioesophageal fistula after percutaneous radiofrequency catheter ablation for atrial fibrillation: the Canadian experience

Purpose

Atrioesophageal fistula (AEF) is an infrequent complication of radiofrequency (RF) ablation for atrial fibrillation (AF). The aim of this study was to determine the prevalence and operator-dependent factors associated with AEF using a nationwide survey of electrophysiologists (EP).

Methods

Thirty-eight EPs performing AF ablation between 2008 and 2012 were invited to complete a web-based questionnaire assessing the prevalence and factors associated with AEF.

Results

Responses were obtained from 25 EPs (68 %) accounting for 7,016 AF ablations. Five cases of proven AEF (0.07 %) were reported. Operators who reported AEF [AEF (+)] more often used general anesthesia (GA) [90 % AEF (+) vs. 44 % AEF (?), p?=?0.046]. AEF (+) operators were also more likely to be users of the non-brushing technique in the posterior wall of the LA [5 (100 %) AEF (+) vs. 5 (25 %) AEF (?), p?=?0.005]. The combined usage of GA and non-brushing technique during LA posterior wall ablation had a strong association with AEF (+) operators [4 (80 %) AEF (+) vs. 2 (10 %) AEF (?), p?=?0.002]. There was a trend towards higher maximal RF energy setting in the posterior wall [47.4 + 7.6 AEF (+) vs. 40.2 + 8 AEF (?), p?=?0.09]. Other procedure parameters were similar.

Conclusions

The reported prevalence of AEF among Canadian AF ablators is 0.07 %. AEF was associated with high mortality. The use of GA and non-brushing movements during posterior wall ablation were two factors associated with AEF.     

Postoperative radiographs following hip fracture surgery. Do they influence patient management?

There is still much debate on the appropriateness of taking postoperative radiographs following hip fracture surgery. In our unit, it is routine practice to request postoperative radiographs after hip hemiarthroplasty but not after internal fixation. An audit conducted in our unit highlighted the low acute implant-related complications. This prompted us to conduct a national audit on current UK practice regarding the use of check radiographs following hip fracture surgery. Retrospective case note review of all patients undergoing hip fracture surgery at our hospital, from 2002 to 2004, was performed. Patients undergoing revision surgery in the same admission were identified to determine whether check radiograph influenced the decision. Subsequently a postal performa was sent to 450 randomly chosen UK Orthopaedic Consultants. The performa was designed to determine practice relating to postoperative radiographs. It also attempted to determine whether postoperative radiographs (when requested) influenced the subsequent clinical management of the patient. A total of 1265 hip fractures treated surgically were reviewed locally. Average length of stay was 29.5 days. There were five acute implant-related complications. One revision was performed for a long hip screw which was obvious on the intra-operative image intensifier films. Only one decision to revise (because of incongruous reduction of a hip hemiarthroplasty) was based on a problem identified on a routine check radiograph. All patients undergoing revision were clinically symptomatic. We received 300 responses. Ninety-six per cent routinely took postoperative radiographs following hip hemiarthroplasty of which 83% allowed the patient to mobilise before checking the radiograph. Following dynamic hip screw (DHS)/dynamic condylar screw (DCS) fixation, 61% took check radiographs of which 75% allowed the patient to mobilise prior to reviewing the radiograph. Following cannulated screw (CS) fixation, 58% routinely performed check radiographs of which 67% allowed the patient to mobilise before reviewing the radiograph. The study highlights the lack of national consensus on the use of postoperative radiographs. We recommend that following DHS/DCS fixation and CS fixation, the use of postoperative radiographs should only be undertaken when clinically indicated. Postoperative radiographs following hip hemiarthroplasty should only be undertaken if there are operative concerns or postoperative complications.     

Outcome of cytomegalovirus retinitis in immunocompromised patients without Human Immunodeficiency Virus treated with intravitreal ganciclovir injection

Purpose

To study the outcomes of treatment with intravitreal ganciclovir injection for cytomegalovirus (CMV) retinitis in patients without Human Immunodeficiency Virus (HIV) infection.

Methods

In this retrospective cohort study, demographic and clinical characteristics of patients with CMV retinitis without HIV were noted. Patients received intravitreal ganciclovir injection (2 mg/0.1 ml) alone until quiescence. The outcome measures were time taken for the lesions to heal, number of injections, change in best-corrected visual acuity (BCVA), recurrence of retinitis, occurrence of immune recovery uveitis (IRU) or injection-related complications and retinal detachment (RD).

Results

18 eyes of ten patients (six males) with mean age of 33.7 years from June 2004 to March 2013 were included. Thirteen eyes with active lesions (mean BCVA of 0.51?±?0.41) received 5.54?±?3.36 intravitreal ganciclovir injections with complete healing within 1.81?±?1.25 months. The final BCVA was 0.43?±?0.52. IRU was observed in six eyes (33.33 %) and RD developed in one eye. One eye had recurrence 1 month after stopping ganciclovir injections. The rest of the patients had recurrence-free follow-up at 9.46?±?12.42 months.

Conclusions

Non-HIV patients with CMV retinitis can be successfully treated with intravitreal ganciclovir injection alone, avoiding the systemic side effects of systemic anti-CMV therapy.     

Characterization of VCC-1, a Novel Ambler Class A Carbapenemase from Vibrio cholerae Isolated from Imported Retail Shrimp Sold in Canada

One of the core goals of the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) is to monitor major meat commodities for antimicrobial resistance. Targeted studies with methodologies based on core surveillance protocols are used to examine other foods, e.g., seafood, for antimicrobial resistance to detect resistances of concern to public health. Here we report the discovery of a novel Ambler class A carbapenemase that was identified in a nontoxigenic strain of Vibrio cholerae (N14-02106) isolated from shrimp that was sold for human consumption in Canada. V. cholerae N14-02106 was resistant to penicillins, carbapenems, and monobactam antibiotics; however, PCR did not detect common β-lactamases. Bioinformatic analysis of the whole-genome sequence of V. cholerae N14-02106 revealed on the large chromosome a novel carbapenemase (referred to here as VCC-1, for Vibrio cholerae carbapenemase 1) with sequence similarity to class A enzymes. Two copies of bla_VCC-1 separated and flanked by ISVch9 (i.e., 3 copies of ISVch9) were found in an acquired 8.5-kb region inserted into a VrgG family protein gene. Cloned bla_VCC-1 conferred a β-lactam resistance profile similar to that in V. cholerae N14-02106 when it was transformed into a susceptible laboratory strain of Escherichia coli. Purified VCC-1 was found to hydrolyze penicillins, 1st-generation cephalosporins, aztreonam, and carbapenems, whereas 2nd- and 3rd-generation cephalosporins were poor substrates. Using nitrocefin as a reporter substrate, VCC-1 was moderately inhibited by clavulanic acid and tazobactam but not EDTA. In this report, we present the discovery of a novel class A carbapenemase from the food supply.     

Calcium hydroxyapatite fillers

Calcium hydroxyapatite fillers have unique advantages over other fillers in regards to duration of action and volume of product required for augmentation, especially in the midface and lower face. In this article, we describe our experience with calcium hydroxyapatite fillers and compare them with other available filler products.