Image-defined risk factors in localized thoracic neuroblastoma and ganglioneuroma

Background

The pretreatment International Neuroblastoma Risk Group Staging System (INRGSS) discriminates localized tumors L1/L2 depending on the absence/presence of image-defined risk factors (IDRFs) at diagnosis. Referring to this new staging system, we assessed initial imaging of localized thoracic neuroblastoma (NB) and ganglioneuroma (GN) and the extent of initial tumor resection.

Methods

Patients with localized thoracic NB/GN from the German clinical trials NB97 and NB2004 were included. Imaging at diagnosis and operative reports were reviewed retrospectively. IDRFs were assessed centrally and correlated to International Neuroblastoma Staging System (INSS) stage and extent of tumor resection. Additionally, we analyzed data on surgery-related complications.

Results

Imaging series of 88 patients were available for central review. In 18 children, no IDRF was present, 28 exhibited one IDRF, 42 two or more IDRFs, resulting in 70 patients with L2 disease. The most frequently observed IDRF was encasement of any vessel (n = 38). Initial surgical resection was aimed for in 45 patients (L1: n = 11; L2: n = 34). Complete and gross total resection rates were higher children with L2 NB (n = 8/25 L1, n = 17/25 L2 vs. n = 2/15 L1, n = 13/15 L2, respectively). The proportion of surgical complications was very similar between INRGSS L1 and L2 (n = 4/11 vs. n = 17/34). All complications were manageable, and no surgery-related deaths were observed.

Conclusion

In this retrospective cohort, the extent of resection and the rate of surgical complications did not differ substantially between patients classified as L1/L2, indicating that INRGSS L2 does not equate unresectability. It appeared that individual IDRFs differ in value. Larger studies are needed to assess the significance and therapeutic/prognostic impact of such findings.     

Albumin and artificial colloids in fluid management: where does the clinical evidence of their utility stand?

Key questions remain unresolved regarding the advantages and limitations of colloids for fluid resuscitation despite extensive investigation. Elucidation of these questions has been slowed, in part, by uncertainty as to the optimal endpoints that should be monitored in assessing patient response to administered fluid. Colloids and crystalloids do not appear to differ notably in their effects on preload recruitable stroke volume or oxygen delivery. Limited evidence nevertheless suggests that colloids might promote greater oxygen consumption than crystalloids. It remains unclear, in any case, to what extent such physiological parameters might be related to clinically relevant outcomes such as morbidity and mortality. Recent randomized controlled trial results indicate that, at least in certain forms of fluid imbalance, albumin is effective in significantly reducing morbidity and mortality. Much further investigation is needed, however, to determine the effects of colloid administration on clinically relevant outcomes in a broad range of critically ill patients. The ability of administered colloids to increase colloid osmotic pressure (COP) constitutes one mechanism by which colloids might reduce interstitial oedema and promote favourable patient outcomes. However, the applicability of this mechanism may be limited, due to the operation of compensatory mechanisms such as increased lymphatic drainage. Attempts to increase COP might also be less useful in states of increased vascular permeability such as acute respiratory distress syndrome, although this issue has by no means been settled by empirical data. Colloids are clearly more efficient than crystalloids in attaining resuscitation endpoints as judged by the need for administration of far smaller fluid volumes. Among the colloids, albumin offers several advantages compared with artificial colloids, including less restrictive dose limitations, lower risk of impaired haemostasis, absence of tissue deposition leading to severe prolonged pruritus, reduced incidence of anaphylactoid reactions, and ease of monitoring to prevent fluid overload. The cost of albumin, nevertheless, limits its usage. Crystalloids currently serve as the first-line fluids in hypovolaemic patients. Colloids can be considered in patients with severe or acute shock or hypovolaemia resulting from sudden plasma loss. Colloids may be combined with crystalloids to obviate administration of large crystalloid volumes. Further clinical trials are needed to define the optimal role for colloids in critically ill patients.     

Fast Track and the Pediatric Emergency Department: Resource Utilization and Patient Outcomes

OBJECTIVE: To examine differences in the evaluation, management, and outcomes for patients seen in an on-site "fast track" (FT) vs the main ED. METHODS: Over a three-month period, patients presenting to an urban pediatric ED were prospectively assessed. Patients included were: triaged as "nonurgent"; aged 2 months to 10 years; not chronically ill; and had fever, or complaint of vomiting, diarrhea, or decreased oral intake. Evening and weekend care was provided in the FT; at all other times these low-acuity patients were seen in the ED. Seven days after the visit, families were interviewed by telephone. RESULTS: Four hundred seventy-nine and 557 patients were seen in the FT and ED, respectively. The patients in the two settings did not differ in age, clinical condition, race, or commercial insurance status. Patient mean test charges were $27 and $52 for the FT and ED, respectively (p < 0.01). Twenty-four percent of the FT patients vs 41% of the ED patients had tests performed (p < 0.01). Average length of stay was 28 minutes shorter in the FT (95% CI = 19 to 36, p < 0.01). Follow-up was completed for 480 of 755 families with telephones (64%). The FT and ED patients did not differ at follow-up: 90% vs 88% had improved conditions (p = 0.53), 18% vs 15% had received unscheduled follow-up care (p = 0.44), and 94% of the families in both groups were satisfied with the visit (p = 0.98). CONCLUSIONS: Compared with those in the main ED, the study patients seen in the FT had fewer tests ordered and had briefer lengths of stay. These findings were not explained by differences in patient ages, vital signs, or demographic characteristics. No difference in final outcomes or satisfaction was detected among the families contacted for follow-up.     

Children with First-time Simple Febrile Seizures Are at Low Risk of Serious Bacterial Illness

OBJECTIVE: To describe the rates of serious bacterial illness (SBI) in children presenting to emergency departments (EDs) with first-time uncomplicated febrile seizures. METHODS: The ED visits from seven Chicago metropolitan area hospitals (two tertiary pediatric EDs, five community general EDs) for all pediatric patients seen between July 1995 and December 1997 with a discharge diagnosis including the term "seizure" were retrospectively identified. Records of patients who met criteria for simple, first-time febrile seizure were reviewed (age 6-60 months; temperature > or =38.0 degrees C; single, generalized, tonic-clonic seizure <20 minutes; absence of known central nervous system disease). Rates of bacteremia, urinary tract infection, bacterial meningitis, and pneumonia were determined. RESULTS: Four hundred fifty-five children were identified who had first-time simple febrile seizures. The study participants had a mean age of 21 months and a mean temperature of 39.6 degrees C, and 64% were male. Seventy-three percent were seen in a community hospital setting. Blood cultures were obtained for 315 children (69%). Four children (1.3% [95% CI = 0.1% to 2.5%]) were bacteremic, all with Streptococcus pneumoniae; the rate of bacteremia did not differ in the subset at highest risk for bacteremia (6-36 months, temperature >39 degrees C). No demographic or laboratory data distinguished the bacteremic children from those with negative blood cultures. One hundred seventy-one children (38%) had urine cultures obtained; 5.9% [95% CI = 2.4% to 9.4%] of the cultures grew >100,000 colony-forming units/mL of a single pathogenic organism. One hundred thirty-five children (30%) had cerebrospinal fluid cultures performed. None of these cultures grew a bacterial pathogen [95% CI = 0% to 2.2%]. Two hundred eight children (45.7%) had chest x-rays performed; 12.5% [95% CI = 10.2% to 14.8%] (n = 26) of the x-rays were read as consistent with pneumonia by the radiologist at the treating institution. None of the blood cultures performed on children with abnormal radiographs were positive (cultures drawn on 23 of 26 patients, 88%). Stool cultures were performed on 14 children (3.1%); two cultures (14.3% [95% CI = 0% to 32.6%]) grew a bacterial pathogen, both Shigella. CONCLUSIONS: Rates of SBI in this multi-institution population of children with first-time simple febrile seizures were low and are consistent with those published in the literature for febrile children without seizures.     

Internationalizing the Broselow Tape: How Reliable Is Weight Estimation in Indian Children

Objectives:  The Broselow pediatric emergency weight estimation tape is an accurate method of estimating children's weights based on height–weight correlations and determining standardized medication dosages and equipment sizes using color-coded zones. The study objective was to determine the accuracy of the Broselow tape in the Indian pediatric population.
Methods:  The authors conducted a 6-week prospective cross-sectional study of 548 children at a government pediatric hospital in Chennai, India, in three weight-based groups: <10 kg ( n =  175), 10–18 kg ( n =  197), and >18 kg ( n =  176). Measured weight was compared to Broselow-predicted weight, and the percentage difference was calculated. Accuracy was defined as agreement on Broselow color-coded zones, as well as agreement within 10% between the measured and Broselow-predicted weights. A cross-validated correction factor was also derived.
Results:  The mean percentage differences were −2.4, −11.3, and −12.9% for each weight-based group. The Broselow color-coded zone agreement was 70.8% in children weighing less than 10 kg, but only 56.3% in the 10- to 18-kg group and 37.5% in the >18-kg group. Agreement within 10% was 52.6% for the <10-kg group, but only 44.7% for the 10- to 18-kg group and 33.5% for the >18-kg group. Application of a 10% weight-correction factor improved the percentages to 77.1% for the 10- to 18-kg group and 63.0% for the >18-kg group.
Conclusions:  The Broselow tape overestimates weight by more than 10% in Indian children >10 kg. Weight overestimation increases the risk of medical errors due to incorrect dosing or equipment selection. Applying a 10% weight-correction factor may be advisable.     

Tolerability and efficacy of nabumetone and naproxen in the treatment of rheumatoid arthritis

OBJECTIVE: The purpose of this study was to compare the tolerability and efficacy of nabumetone and naproxen in the treatment of patients with rheumatoid arthritis (RA). The occurrence of gastrointestinal (GI) adverse events was compared. BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) have similar efficacy at equipotent doses, but the therapeutic response to various NSAIDs often differs in individual patients. METHODS: This was a 3-month, randomized, double-blind, multicenter, parallel-group study conducted in adult patients with RA. The study had 2 phases: a 3- to 14-day washout period and a 12-week treatment period. During the treatment phase, the tolerability and efficacy of nabumetone 2000 mg/d were compared with those of naproxen 1000 mg/d. The change from baseline in efficacy variables, including global assessments, number of tender or swollen joints, and pain, was evaluated. The study was sized to provide an 80% power to detect a 15% difference in the percentage improvement on the physician's global assessment (alpha = 0.05). GI safety was assessed by monitoring the occurrence of clinically important adverse GI events. RESULTS: A total of 346 RA patients at 31 US rheumatology centers were randomly assigned to treatment (173 patients per group). The study population was predominantly white (87.0%) and female (70.5%), with a mean age of 54 years. Both treatments improved the signs and symptoms of RA, with no statistically significant differences between groups for any efficacy variables. No serious GI adverse events occurred with either NSAID. The most frequent treatment-related adverse events in both groups were predominantly GI in origin, as were those that resulted in withdrawal from the study. Diarrhea with lower abdominal pain was the most common adverse event in the nabumetone group; upper abdominal pain was the most common adverse event in the naproxen group. The only significant difference between the 2 groups was a higher incidence of diarrhea (P < 0.01) in patients receiving nabumetone. CONCLUSIONS: Nabumetone 2000 mg/d was as effective as naproxen 1000 mg/d in relieving the signs and symptoms of RA. In this study, no serious GI adverse events were observed with either NSAID, but nabumetone was associated with a higher incidence of diarrhea.