Developmental delay in children: assessment with proton MR spectroscopy

BACKGROUND AND PURPOSE: The cause of developmental delay frequently is unknown, and clinicians and families can be frustrated by the lack of neuroimaging correlation especially when considering therapeutic options and long-term prognosis. We sought to determine if proton MR spectroscopy can depict abnormalities in patients with developmental delay who have structurally normal brain MR images. METHODS: Children with developmental delay who were older than 2 years (mean age, 5.0 years; range, 3.0-10.0 years) and those aged 2 years or younger (mean age, 1.5 years; range, 0.5-2.0 years) and age-matched control subjects for each patient group underwent brain MR imaging and proton MR spectroscopy. A point-resolved spectroscopy sequence (2000/144 [TR/TE]) was used. Voxels (8 cm(3)) were placed in the subcortical white matter of the frontal and parieto-occipital lobes bilaterally. N-acetylaspartate (NAA)/creatine (Cr) and choline (Cho)/Cr ratios were assessed. RESULTS: All patients had normal brain MR images. In children with developmental delay who were aged 2 years or younger, no statistically significant differences were detected in the NAA/Cr or Cho/Cr ratios compared with those of the control subjects. In children with developmental delay who were older than 2 years, decreases in the NAA/Cr ratio were observed in frontal (P <.001) and parieto-occipital (P <.017) subcortical white matter, and elevations in the Cho/Cr ratio were detected in the frontal (P <.24) and parieto-occipital (P <.002) subcortical white matter compared with age-matched control subjects. CONCLUSIONS: In children with developmental delay who are older than 2 years, proton MR spectroscopy depicted abnormalities in the NAA/Cr and Cho/Cr ratios. Proton MR spectroscopy should be performed as part of the neuroimaging evaluation of developmental delay. Further studies will be needed to determine if abnormalities detected with proton MR spectroscopy can be used as a diagnostic tool and neuroimaging marker to assess long-term functional outcome.     

Healthcare under sanctions in Iraq: an elective experience

As a consequence of the 1991 Gulf War and the ensuing UN sanctions, not only was the Iraqi government destroyed, but also the general infrastructure of the country was disrupted, with the civilian population and public services bearing much of the aftermath. Ten years after the war, the health system in Iraq is still in a perilous situation. The effects of sanctions have affected almost every aspect of medical care. There has been a mass exodus of health care professionals, many of whom were foreign nationals. Doctors' salaries fell rapidly to only $30 a month, barely enough to buy the necessities of daily living. Iraqi hospitals have no access to foreign journals, textbooks or the internet; leading to a generation of out-dated and under-skilled health professionals. Most worrying is the ever-present embargo on many essential medicines. Only one-third of the medicines are available for chemotherapy for the treatment of acute lymphoblastic leukaemia in children (UKALL 97 modified 99 protocol). At the Al-Mansour paediatric teaching hospital this shortfall has led to a substantial increase in childhood mortality, with disease-free survival rates falling to 25 per cent compared to 60 per cent in 1988.     

Is surgery necessary for asymptomatic tethered cord in anorectal malformation patients?

Background

Evidence supporting routine surgery for asymptomatic tethered cord in patients with anorectal malformation (ARM) is, at best, speculative. The authors therefore examined whether untethering is indicated for asymptomatic tethered cord in patients with ARM.

Methods

A retrospective analysis of all patients with ARM (n = 223) between 1992 and 2002 was conducted. During the same period, 435 patients had surgery for tethered cord.

Results

Tethered cord was detected radiologically in 22 (9.8%); 8 patients with a low conus, and 14 with a low conus with and thickened filum. Seven of 22 patients underwent untethering; 3 prophylatic (14%) and 4 for neuro/motor function deficits (18%). All 4 symptomatic patients had significant clinical improvement in their neuro/motor functions after surgery. However, bowel and urinary functions remained unchanged in all 7 patients with a mean follow-up of 6.4 years (range, 4 to 8 years). Fifteen patients with radiologically diagnosed tethered cord remain asymptomatic with a mean follow-up of 2.7 years (range, 8 months to 10 years).

Conclusions

Neuro/motor functions clearly improved with surgery in symptomatic patients. However, bowel and urinary functions remained unchanged after surgery. Only 4 ARM patients with tethered cord required surgery, whereas prophylactic surgery appears to have minimal benefit. Expectant conservative approach in the management of asymptomatic tethered cord patient appears to be safe.     

Gallstone abscess as a result of dropped gallstones during laparoscopic cholecystectomy

INTRODUCTIONWith the advent of laparoscopic cholecystectomy we have seen a “disease of medical progress” (DOMP). Herein we report a complication that developed 7 years after laparoscopic cholecystectomy.PRESENTATION OF CASEA 42 year old woman presented with worsening right-sided pain and tenderness. Seven years prior she underwent a laparoscopic cholecystectomy. Computed tomography demonstrated a subhepatic retroperitoneal inflammatory mass. On open exploration a 4 cm × 6 cm retroperitoneal mass was excised. The mass contained purulent material and gallstones.DISCUSSIONLaparoscopic cholecystectomy has become the “gold standard” for the treatment of symptomatic gallstones. Prior to laparoscopic cholecystectomy there was no body of literature about lost gallstones thus making this a DOMP. In contrast, it is reported that as many as 5.4–19% of laparoscopic cholecystectomies have stones spilled with variable rates of retrieval. Our case demonstrates an extreme example of a complication resulting seven years after a laparoscopic cholecystectomy with gallstones left behind.CONCLUSIONRecognizing that gallstones will be lost during some cases of laparoscopic cholecystectomy, we must remain vigilant and make a full attempt to retrieve all stones to prevent such rare but not insignificant potential complications.     

Peripheral nerve injuries following gunshot fracture of the humerus

Current best evidence supports observation for peripheral nerve palsies following a fracture of the humerus unless associated with an open fracture. However, the indications for nerve exploration with humerus gunshot fractures are unclear. All patients aged 18 to 89 years who were treated for a gunshot fracture of the humerus at an academic trauma center between 2004 and 2008 were retrospectively reviewed. Patient demographics, fracture characteristics, fracture healing, nerve injury, and intraoperative findings were examined. Twelve patients were identified, of which 6 had nerve palsies at presentation. Three patients had an isolated single nerve palsy, and all recovered spontaneously within 90 days with observation. The other 3 patients had a concomitant brachial artery laceration, and all required a secondary nerve procedure, including 1 primary nerve repair for a near complete transection and 2 re-explorations with neurolysis due to lack of spontaneous recovery by 90 days. Nerve palsies are common after gunshot fractures of the humerus, but nerve transections are uncommon. We observed 1 nerve transection in 12 cases. However, in all 3 cases with a brachial artery injury, a nerve injury required surgical intervention. Subsequently, we recommend continued observation of isolated nerve palsies associated with gunshot fractures of the humerus. However, consider early nerve exploration of palsies when associated with a concomitant vascular injury.     

Experience of fibrosing cholestatic hepatitis with hepatitis C virus in kidney transplant recipients

Background

Fibrosing cholestatic hepatitis C (FCH-C) is a rare entity that occurs among immune-compromised patients resulting from the direct hepatotoxicity of a high intracellular viral load along with an ineffective immune system ultimately leading to a fatal outcome. We have describes herein 4 renal transplant recipients who were diagnosed with FCH-C at our institution in the last 8 months.

Methods

Four renal transplant recipients presented with jaundice and deteriorating liver function tests. They were diagnosed to display FCH-C based on the presence of hepatitis C virus (HCV) RNA and characteristic liver biopsy findings; there was no evidence of any other cause of cholestasis or biliary obstruction.

Results

The patients were men of ages 40, 25, 20, and 27 years. The durations after transplantation were 1.5, 10, 1.5 and 2.0 years, respectively. In all cases pretransplantation screening was negative for HCV antibody, HCV RNA, and hepatitis B surface antigen (HBsAg). All 4 patients were infected with genotype 1, whereas case 2 had coinfection with type 3. Cases 1 and 2 who were treated with interferon and ribavirin, showed improvement in cholestasis but did not achieve a rapid virological response. Case 1 developed graft dysfunction secondary to acute cellular rejection at 4 months after initiation of interferon treatment, which was treated with pulse steroids. Interferon-based therapy was stopped prematurely in both cases due to pancytopenia. Case 3 developed florid pyelonephritis and died without receiving therapy for hepatitis C. Case 4 was managed conservatively by decreasing the immunosuppression with regular monitoring.

Conclusion

FCH-C is difficult to treat and shows high morbidity and mortality rates. Treatment is associated with a risk of graft rejection.     

Comparison of plain radiographs with CT scan to evaluate interbody fusion following the use of titanium interbody cages and transpedicular instrumentation

The availability of lumbar interbody cages has fuelled renewed interest in interbody fusion. Despite this, there is no consensus regarding the best non-invasive method for evaluation of interbody fusion, especially where cages have been used. The purpose of this study was to determine whether high-quality thin-slice (1- to 3-mm) computed tomography (CT) scans allow proper evaluation of interbody fusion through titanium cages. Patients undergoing lumbar interbody fusion were prospectively evaluated with CT scan and plain radiographs 6 months following surgery. These images were blindly and independently evaluated by a consultant radiologist and a spine research fellow, for bridging bony trabeculation both through and surrounding the cages as well as for changes at the cage endplate interface. Fifty-three patients (156 cages) undergoing posterior lumbar interbody fusion using titanium interbody cages were evaluated. Posterior elements were used to pack the cages and no graft was packed outside the cages. The outcome data were analysed using the Kappa co-efficient and chi-squared analysis. On CT scan, both observers noted bridging trabeculation in 95% of the cages (Kappa 0.85), while on radiographs this was present in only 4% (Kappa 0.74). Both observers also identified bridging trabeculation surrounding the cages on CT scan in 90% of cages (Kappa 0.82), while on the radiographs this was 8% (Kappa 0.86). Radiographs also failed to demonstrate all the loose cages. The results of the study show that high-quality CT scans show images suggesting bridging bony trabeculae following the use of titanium interbody cages. They also appear to show consistent bone outside the cages in spite of no bone graft having been used, and they appear to be better than plain radiographs in the early detection of cage loosening.     

Versatility of the distally based superficial sural flap for reconstruction of lower leg and foot in children

Twenty children are presented after undergoing a distally based superficial sural flap for coverage of defects at the lower leg and foot. The age of the patients was between 1 and 12 years. Fifteen patients had trauma to the lower leg, with eight of them having associated injuries. Three had postburn contracture and two had pressure sore. In 14 cases, the flap was used as a fasciocutaneous flap, whereas in six cases it was used as a fascial flap covered with a skin graft. The flaps were used to cover the defects from the dorsum of the foot distally up to the mid third of tibia proximally. The mean follow-up was for a period of 2 years. Even though free tissue transfer is reliable and safe for the reconstruction of major leg injuries in children, the distally based superficial sural flap has the advantage of being easy to perform, with short operating time, minimal donor side morbidity, and preservation of major arteries of the leg.     

The influence of rotator cuff disease on the results of shoulder arthroplasty for primary osteoarthritis: results of a multicenter study

BACKGROUND: Rotator cuff disease is uncommon in primary glenohumeral osteoarthritis. Consequently, the prognostic implications of rotator cuff disease in patients undergoing prosthetic replacement for the treatment of primary glenohumeral osteoarthritis are uncertain. The purpose of this study was to report the effects of the condition of the supraspinatus tendon and the rotator cuff musculature on the results of shoulder arthroplasty in the treatment of primary osteoarthritis. METHODS: Five hundred and fifty-five shoulders in 514 patients who had an arthroplasty for the treatment of primary glenohumeral osteoarthritis as part of a multicenter study were evaluated. Forty-one shoulders had a partial-thickness tear of the supraspinatus, and forty-two had a full-thickness tear. Ninety shoulders had moderate (stage-2) fatty degeneration of the infraspinatus, and nineteen had severe (stage-3 or 4) degeneration. Eighty-four shoulders had moderate fatty degeneration of the subscapularis, and fifteen had severe degeneration. The influence of the condition of the supraspinatus tendon and the infraspinatus and subscapularis musculature on the postoperative outcome was evaluated with respect to the scores according to the system of Constant and Murley, active mobility, subjective satisfaction, radiographic result, and rate of complications. RESULTS: The shoulders were evaluated at a mean of 43.1 months postoperatively. With the numbers available, supraspinatus tears were not found to influence the postoperative outcome with respect to the total Constant score, active mobility, subjective satisfaction, radiographic result, or rate of complications. Additionally, the treatment of these tears did not markedly influence the outcome parameters. Conversely, both shoulders with moderate fatty degeneration and those with severe degeneration of the infraspinatus were associated with poorer results than those with no degeneration with respect to the total Constant score (p < 0.0005), active external rotation (p < 0.0005), active forward flexion (p = 0.001), and subjective satisfaction (p = 0.031). Similar although less dramatic results were seen with fatty degeneration of the subscapularis. CONCLUSIONS: This study demonstrates that minimally retracted or nonretracted rotator cuff tears that are limited to the supraspinatus tendon do not appreciably affect most shoulder-specific outcome parameters in shoulder arthroplasty performed for the treatment of primary osteoarthritis. Conversely, fatty degeneration of the infraspinatus and, less importantly, subscapularis musculature adversely affects many of these parameters.