The changing face of paediatric hydrocephalus: a decade's experience.

All 253 children receiving neurosurgical intervention for hydrocephalus (HCP) at a single British Neurosurgical Unit over a decade were investigated by retrospective case note review. Referral rates and mean age at presentation remained stable throughout, as did proportions of children presenting due to myelomeningocoele or meningitis. Comparing the first and second halves of the decade, the predominant aetiologies (intraventricular haemorrhage [IVH] at <1 year and brain tumour at 1-16 years) reduced from comprising half (70/129) of all cases to just over one-third (43/124). Other significant changes included a 45% reduction in neonatal IVH and a 179% increase in rare miscellaneous disorders. Outcome after 4 years of follow-up for all patients showed 44.4% without deficit, 11.9% with non-cognitive neurological deficits only, 11.5% with cognitive impairment only, 13.5% with both cognitive and neurological impairments, and 15.5% mortality.     

Treatment of severe acute lung allograft rejection with OKT3 and temporary extracorporeal membrane oxygenation bridging.

OBJECTIVES: The use of OKT3 for treatment of advanced high-grade acute rejection episodes eventually can result in cytokine release and consecutive pulmonary edema. Temporary extracorporeal membrane oxygenation (ECMO) bridging can be used to overcome this crucial period before the beneficial effects of OKT3 can be observed. METHODS: We summarize our experience with three patients, who underwent lung transplantation and presented with severe acute rejection episodes. OKT3 had to be initiated due to insufficient response to standard rejection therapy with corticosteroids. Upon initiation of OKT3 treatment, a massive life-threatening deterioration of lung function in spite of heavily invasive respirator treatment was seen and temporary ECMO support was imperative to support graft function. Results of this treatment were retrospectively reviewed. RESULTS: In all cases femoro-femoral veno-arterial ECMO was used for support of the impaired graft and after a period of 4-5 days led to a massive improvement of graft function. In the further course two patients could be discharged from hospital and are still alive 30 and 36 months, respectively, after the described incident. One patient died 4 months later due to liver failure. CONCLUSIONS: We conclude that the use of ECMO support in patients experiencing significant side effects from OKT3 therapy is a useful and effective therapeutic tool to overcome the initial critical period until the lung has sufficiently recovered.     

In-office laryngeal surgery with the 585nm pulsed dye laser (PDL).

OBJECTIVES: The 585nm pulsed dye laser (PDL) is a promising tool for in-office laryngeal surgery. Data with respect to the safety and efficacy of the PDL for office laryngeal use is sparse. The purpose of this study is to review our experience with unsedated office PDL surgery. METHODS: Records of individuals undergoing in-office PDL between September 1, 2004, and September 1, 2006 were abstracted from a clinical database. RESULTS: Forty-seven patients underwent 117 treatments. The most common indications were recurrent respiratory papillomatosis (RRP), Reinke's edema, and vocal fold polyps. One hundred and four of 117 procedures were felt to be a success ablating all disease. Thirteen treatments required early termination. The most common factor responsible for termination was an inability to achieve a comfortable level of anesthesia. One patient with Reinke's edema developed postprocedure stridor that required a 3-day hospital admission for observation and corticosteroids. There was no incidence of any vocal fold scarring, web formation, or other complications. CONCLUSIONS: The 585nm PDL is a promising tool for in-office treatment of various laryngeal disorders. Complications are rare.     

Surveillance von postoperativen Wundinfektionen

Identification and assessment (surveillance) of wound infections represents the basis for hygienic interventions aiming at the reduction of incidence of postoperative wound infection. Surveillance should be carried out prospectively by qualified personnel using generally accepted case criteria. Wound infection rates have to be stratified in regard to the individual patient’s risk. Data from national reference institutions allow for the calculation of standardized wound infection rates that can be used for the hospital’s own assessment as part of a quality management system. Postdischarge surveillance represents a major problem, but allows for identification of a considerable number of wound infections.     

A quantitative analysis of valgus torque on the ACL: a human cadaveric study.

The loads needed to elicit a positive pivot shift test in a knee with an anterior cruciate ligament (ACL) rupture have not been quantified. The coupled anterior tibial translation (ATT), coupled internal tibial rotation (ITR), and the in situ force in the ACL in response to a valgus torque, an inherent component of the pivot shift test, were measured in 10 human cadaveric knee specimens. Using a robotic/universal force-moment sensor testing system, valgus torques ranging from 0.0 to 10.0 Nm were applied in nine increments on the intact and ACL-deficient knee in flexion ranging from 0 degrees to 90 degrees. At 15 degrees of knee flexion, the coupled ATT and ITR were significantly increased in the ACL-deficient knee when compared to the intact knee. Coupled ATT increased a maximum of 291% (6.7 mm, p<0.05), while coupled ITR increased a maximum of 85% (5.1 degrees, p<0.05). At 30 degrees, the increases in coupled ATT and ITR were significant at valgus loads of 3.3 Nm and greater with a maximum increase in coupled ATT of 137% (6.3 mm, p<0.05) and a maximum increase in coupled ITR of 38% (3.6 degrees, p<0.05). At 45 degrees, coupled ATT increased significantly (maximum of 69%, 4.4 mm, p<0.05), but only at torques > or =6.7 Nm. The in situ force in the ACL was less than 20 N for all flexion angles when a torque between 3.3 and 5.0 Nm was applied. Low valgus torque elicited tibial subluxation in the ACL-deficient knee with low in situ ACL forces, similar to a positive pivot shift test. Thus, application of a valgus torque may be suitable to evaluate ACL-deficient and ACL-reconstructed knees, since subluxation can be achieved with minimal harm to the ACL graft. This work is important in understanding one load component needed for the pivot shift examination; further studies quantifying other load components are essential for better comprehension of the in vivo pivot shift examination.     

Newer aspects of antiarrhythmic drug development: Introduction

Although cardiac arrhythmias remain a serious clinical problem in many patients with heart disease, the exact role of antiarrhythmic drug therapy is currently under intense evaluation. Within the last several years it has become clear that there are significant risks as well as potential benefits associated with existing agents. Ongoing studies in large patient populations should help determine the benefit/risk ratio of traditional therapy. Regardless of the outcome of these trials, current electrophysiological dogma will have to be re-evaluated and newer concepts evolve for drug development to make further progress. The goal of this symposium is to exchange information among basic and clinical investigators so as to facilitate the emergence of novel electrophysiological concepts that will form the basis for future generations of antiarrhythmic drugs.