Temporal Lobe Epilepsy in Children: Electroclinical Study of 77 Cases

Summary:  Purpose: Temporal lobe epilepsy (TLE) is probably more difficult to recognize in children than in adults. In fact, ictal symptoms in children are less stereotyped and less obvious, and the neuropathological substrate is more heterogeneous than in adults. The aim of this study is to examine the relationships between etiology, age at onset and electroclinical findings in 77 children with TLE, 32 of whom were surgically treated.
Methods: Electroclinical study including video-EEG recording of seizures in 77 children with TLE. The investigation focused on the first five initial ictal symptoms.
Results: Age at onset was less than 3 years in 39 cases, between 3 and 6 years in 17 cases and older than 6 years in 21 cases. Auras also occurred in younger children but were more common after the age of 6 years. A peculiar initial ictal semiology consisted in staring with arrest, lip cyanosis, and very slight oral automatisms. In some cases, EEG recordings documented seizures starting independently on both temporal lobes. Based on electroclinical and neuroradiological features, we recognized three subgroups: symptomatic TLE due to cortical malformations or nonevolutive tumors, TLE with mesial temporal sclerosis, and cryptogenic TLE.
Conclusions: A correct electroclinical and neuroradiological approach allows in several cases early recognition of TLE even when onset is earlier than the age of 6 years. A correct definition of the localization relies primarily on video-EEG recording of the seizures, possibly repeated during follow up in cases lacking obvious neuroradiological correlation.     

Comparison of the sleep pattern throughout a protocol of chronic sleep restriction induced by two methods of paradoxical sleep deprivation

The purpose of the present study was to evaluate the sleep homeostasis of rats submitted to a protocol of chronic sleep restriction by two methods and to evaluate the sleep characteristics during the recovery period. The sleep restriction protocol was accomplished by sleep depriving rats for 18 h everyday for 21 days, using the single platform method (SPM) or the modified multiple platform method (MMPM) of paradoxical sleep (PS) deprivation. Rats were allowed to sleep for 6 h (from 10:00 to 16:00; starting 3 h after lights on) in their individual home-cages, during which their sleep was recorded. At the end of the sleep restriction protocol, rats were recorded in their home-cages for 4 days, where they could sleep freely. Both methods used to induce chronic sleep restriction were effective, in sofar as they resulted in augmented sleep time during the 6h-sleep period, with very few bouts of wakening. Although comparison between the methods did not reveal differences, sleep restriction under MMPM produced a more consistent daily rebound, mainly of paradoxical sleep, with longer episodes. These results showed distinct sleep recovery patterns, suggesting a possible role of the waking experiences (i.e. immobilization stress, social interaction) acting on sleep consolidation.     

Is repetitive intraoperative splash basin use a source of bacterial contamination in total joint replacement?

Splash basins are used in arthroplasty cases to wash instruments. Several studies in the literature have shown these basins being a potential source of bacterial infection. This study assesses the risk of contamination of intraoperative splash basins used to wash and store instruments. A total of 46 random clean primary arthroplasty cases (32 hips, 13 knees, and 1 unicondylar knee) were studied by taking cultures of sterile splash basins as soon as they are opened (controls) and again at wound closure after instruments and debris have come into contact with the sterile water. All cultures were taken with sterile culture swabs and sent to the laboratory for aerobic, anaerobic, and fungal culture. Outcome measured was any positive culture. A total of 92 cultures from 46 cases were tested. Only 1 (2.17%) control culture, which grew Streptococcus viridans, was positive for bacterial growth. One of 46 samples (2.17%) taken at wound closure was positive for coagulase-negative Staphylococcus. Mean time between basin opening and wound closure was 180±45 minutes. For the 1 infected sample taken at the conclusion of the case, it was 240 minutes. Previous studies show contamination rates as high as 74% for splash basins used intraoperatively. Our study contradicts the belief that splash basins are a high source of infection, with only 2.17% of basins showing contamination. Splash basins can be a potential source of contamination, but the risk is not as high as previously cited in the orthopedic literature.     

Value of 18-Fluorodeoxyglucose Positron Emission Tomography in the Management of Patients With Cystic Tumors of the Pancreas

OBJECTIVE: To assess the reliability of 18-fluorodeoxyglucose positron emission tomography (18-FDG PET) in distinguishing benign from malignant cystic lesions of the pancreas. SUMMARY BACKGROUND DATA: The preoperative differential diagnosis of cystic lesions of the pancreas remains difficult: the most important point is to identify malignant or premalignant cysts that require resection. 18-FDG PET is a new imaging procedure based on the increased glucose metabolism by tumor cells and has been proposed for the diagnosis and staging of pancreatic cancer. METHODS: During a 4-year period, 56 patients with a suspected cystic tumor of the pancreas underwent 18-FDG PET in addition to computed tomography scanning, serum CA 19-9 assay, and in some instances magnetic resonance imaging or endoscopic retrograde cholangiopancreatography. The 18-FDG PET was analyzed visually and semiquantitatively using the standard uptake value. The accuracy of 18-FDG PET and computed tomography was determined for preoperative diagnosis of a malignant cyst. RESULTS: Seventeen patients had malignant tumors. Sixteen patients (94%) showed 18-FDG uptake with a standard uptake value of 2.6 to 12.0. Twelve patients (70%) were correctly identified as having malignancy by computed tomography, CA 19-9 assay, or both. Thirty-nine patients had benign tumors: only one mucinous cystadenoma showed increased 18-FDG uptake (standard uptake value 2.6). Five patients with benign cysts showed computed tomography findings of malignancy. Sensitivity, specificity, and positive and negative predictive values for 18-FDG PET and computed tomography scanning in detecting malignant tumors were 94%, 97%, 94%, and 97% and 65%, 87%, 69%, and 85%, respectively. CONCLUSIONS: 18-FDG PET is more accurate than computed tomography in identifying malignant pancreatic cystic lesions and should be used, in combination with computed tomography and tumor markers assay, in the preoperative evaluation of patients with pancreatic cystic lesions. A positive result on 18-FDG PET strongly suggests malignancy and, therefore, a need for resection; a negative result shows a benign tumor that may be treated with limited resection or, in selected high-risk patients, with biopsy, follow-up, or both.     

Ischemic mitral valve regurgitation: the new challenge for magnetic resonance imaging.

Ischemic mitral valve regurgitation (IMVR) refers to mitral regurgitation in patients with ischemic heart disease (IHD) in the presence of a structurally normal mitral valve. IMVR contributes significantly to morbidity and mortality in patients with IHD. The thresholds for clinical management, surgical intervention, and the choice of surgical procedure continue to evolve and independent determinants for surgical success in the pre- and post-operative evaluation of IMVR are still controversial. Although echocardiography has been valued as the gold standard in the evaluation of IMVR, new technologies such as magnetic resonance imaging (MRI) may be seen as applicable to the investigation of this complex pathology. MRI may allow for detection of parameters that could help clinicians and surgeons to better assess IMVR and eventually guide appropriate treatment whenever necessary. The present article discusses the main parameters that should be routinely investigated while adopting MRI technology to assess patients with IMVR. The review is the result of a multidisciplinary approach to this complex etiopathogenic entity and involves expertise spanning from radiology, cardiology, to cardiac surgery.     

Protruding left intercostal mass after left ventricular aneurysmectomy

In this report we summarize a case of myocardial infarction that developed an apical ventricular aneurysm, which was surgically removed to re-expand and reappear as a pulsating chest wall mass 16 years later.     

The management of obstructive jaundice in pancreatic cancer

Patients with pancreatic cancer often present with advanced disease; so, curative surgical resection is possible in a small number of patients. Palliation in these patients focuses particularly on relief of biliary obstruction. Palliative treatment modalities include both surgical and nonsurgical approaches. Biliary obstruction is initially treated with endoscopic biliary stenting, plastic or metallic stents. Both of these provide similar initial relief of biliary obstruction; however, plastic stents have a greater risk of occlusion and should be used in patients with short survival duration. Metallic stents have a greater initial cost, but provide an overall cost-saving in patients with expected survival more than 6 months. There is no evidence of benefit from routine stenting of jaundiced patients before resection. Surgical palliation for biliary obstruction should be primarily considered in patients who fail endoscopic or percutaneous biliary decompression or who develop gastroduodenal obstruction, It is also indicated for patients with good performance status and expected survival of over 6 months. Surgical decompression of biliary tree should be made with a choledochojejunostomy whenever feasible, associated to a gastroduodenal bypass.     

Surgical treatment of Basedow's disease: our experience with 424 operations

From February 2002 to December 2005, 424 operations for thyroid disease were performed in our institute. Twenty-two patients were suffering from Basedow's disease, 14 female and 8 male, mean age 36 years (range: 23 to 53 years). In each patient the diagnosis of Basedow's disease was made according to common clinical and laboratory criteria, by evaluation of the thyroid hormones, TSH and TRAB. Before operation all patients were rendered euthyroid with antithyroid drug treatment. Fourteen total thyroidectomies (64%) and 8 near-total thyroidectomies (36%) were performed. Postoperative thyroid function status was evaluated before, 3-4 weeks after the operation and then 3, 6,12 and 24 months postoperatively. The patients were classified as euthyroid (FT3-FT4 and TSH normal), hypothyroid (FT3 and/or FT4 reduced and TSH increased), or hyperthyroid (FT3-FT4 increased). In expert hands, surgical treatment appears to be capable of curing the hyperthyroidism of Basedow's disease effectively, with a very low and largely acceptable risk of complications. Among the different types of surgery, total thyroidectomy and near-total thyroidectomy are equally appropriate to ensure there is no risk of recurrence of hyperthyroidism.     

Presentation, treatment and prognosis of intraductal papillary mucinous neoplasm

Intraductal papillary mucinous neoplasms (IPMNs) are rare tumours rising from the pancreatic duct epithelium. They are characterized by intraductal papillary growth and thick mucin secretion; mucin fills the Wirsung and/or branch pancreatic ducts and may cause ductal dilatation. IPMNs are classified into three types, according to the site of involvement: main duct type, branch duct type, and combined type. Most branch type IPMNs are benign, while the other two types are frequently malignant. Recent advances in diagnostic imaging have led to an increased frequency of diagnosis of IPMNs, but the clinical features of them can range broadly from benign, borderline, and malignant non-invasive to invasive lesions, and their management has not yet been clearly defined. The most of patients are asymptomatic. The possibility of malignancy is increased in cases which large mural nodules are presented. Presence of a large branch type IPMN and marked dilatation of the main duct indicate the existence of adenoma. Not infrequently, synchronous or metachronous malignancies may be developed in various organs. Endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasonography (EUS), intraductal ultrasonography, and magnetic resonance cholangiopancreatography (MRCP) are the most valuable imaging techniques for diagnosis of these lesions. Prognosis is excellent after complete resection of benign and non-invasive malignant IPMNs. Total pancreatectomy should be reserved for patients with resectable but extensive IPMN involving the whole pancreas; its benefits must be balanced against perioperative risks.     

Real surgical morbidity and mortality after extrapleural pneumonectomy

As for other major thoracic operations the conventional 30-day morbidity and mortality marker may underestimate the actual surgical risk of extrapleural pneumonectomy. We retrospectively analysed the prolonged follow-up of 78 patients submitted to extrapleural pneumonectomy for pleural mesothelioma (55), lung cancer with associated carcinomatous (7) or purulent (8) pleuritis, empyema/destroyed lung (4), and mediastinal (2) and chest wall (2) tumours with pleuro-pulmonary involvement. Significant rates of surgery-related major complications (19%) and fatalities (6.6%) additionally occurred beyond 30 days and within 6 months of extrapleural pneumonectomy, making a 66% cumulative (early + late) morbidity rate and an 11.5% cumulative mortality rate, which are respectively 50% and 100% greater than the 30-day rate alone. The leading causes of late morbidity and mortality were respiratory/cardiac sequelae (50%) and broncho-pleural fistulas (30%). Strict preoperative functional selection and proper application of the technical learning curve can reduce the occurrence of the adverse events by anything up to 50% (early mortality: 2.3%). If the results of this novel study of long-term surgical outcomes of extrapleural pneumonectomy were to be confirmed, the preoperative risk/benefit balance of the procedure, mainly when performed for thoracic malignancies, should therefore include the entire spectrum of (early and late) potential surgery-related complications.