Dumbbell trigeminal schwannoma in a child: complete removal by a one-stage pterional surgical approach

Objective The objective was to describe a rare case of a trigeminal schwannoma in a child and the surgical procedure performed for therapy.Patient and methods A 6-year-old girl presented with tiredness, dysarthric speech and cerebellar symptoms. Imaging studies revealed a unilateral dumbbell-shaped tumour, extending into both the middle and posterior fossa, centred over Meckels cave. One-stage surgery was performed by pterional craniotomy. The tumour was first debulked in the middle fossa, then peeled from the wall of the cavernous sinus, followed by extirpation of the tumour from the posterior fossa. The tumour extended to the caudal cranial nerves and was completely removed. Trigeminal fascicles were distributed throughout the tumour. Histopathological examination revealed a schwannoma.Conclusion Trigeminal schwannoma is a tumour that occurs rarely in childhood. Although several, often multistaged surgical strategies have been reported in the literature, this tumour was eradicated by a one-stage pterional approach.     

Consecutive cervical pregnancies

OBJECTIVE: Report of a rare case of consecutive spontaneous cervical pregnancies. DESIGN: Case study. SETTING: Teaching hospital. PATIENT(S): One healthy nulliparous woman in the early years of her fourth decade. INTERVENTION(S): The first of two cervical pregnancies was treated with two doses of methotrexate and subsequent uterine artery embolization. The second was treated with methotrexate, intracervical Foley catheter placement, hysteroscopic ablation of the bleeding cervical bed, and replacement of the Foley catheter with gradual deflation of balloon. MAIN OUTCOME MEASURE(S): Recognition and successful treatment of cervical ectopic pregnancy. RESULT(S): Each of the two cervical pregnancies was successfully treated. The patient subsequently carried a spontaneous intrauterine pregnancy to term. CONCLUSION(S): A comprehensive MEDLINE search revealed that this appears to be the first reported case of recurrent spontaneous cervical pregnancies, and only the second known case of recurrent cervical pregnancy. Cervical pregnancies have generally been treated with hysterectomy because of the potential for massive hemorrhage. However, current treatment options permit effective conservative management in women who desire continued fertility. This case illustrates various treatment options, under different circumstances, in the same individual.     

A report card on outcomes for surgically treated gastrointestinal cancers: are we improving?

INTRODUCTION: Longitudinal analyses of cancer registries provide an opportunity for population-based explanations of epidemiology and survival-related outcomes. This study used two population-based data sets to report on nine surgery-related cancers over the past three decades. MATERIALS AND METHODS: Using the SEER cancer database (1973-1999), all patients (>18 years old) with adenocarcinoma of esophagus, gastric, biliary system, pancreas, small bowel, colon, rectum; esophageal squamous cell carcinoma (ESC), or hepatocellular (HCC) carcinoma (n = 379,640) were analyzed. Changes in incidence rates, stage at diagnosis, and 5-year cancer and stage-specific survivals were determined. A separate database, the California inpatient database (1990-2000), was concurrently used to evaluate inpatient mortality after surgical resection (n = 34,057). RESULTS: Incidence rates increased for three cancers (esophageal, HCC, small bowel); decreased for three (rectal, gastric, ESC); and stayed constant for three (biliary, pancreatic, colon). More patients presented with local/regional disease in the 1990s versus 1970s for eight tumors (except small bowel, P < 0.05). Five-year overall survival improved for all but small bowel (P < 0.05); and local stage survival was improved for all except small bowel and biliary (P < 0.05). Finally, inpatient mortality rates improved significantly for liver, esophageal, pancreatic, and gastric resections (P < 0.05) over the past decade. CONCLUSIONS: For these nine surgically treated cancers, we are detecting disease at earlier and therefore more treatable stages, and surgical care and outcomes also appear to have improved. Continued reexamination of longitudinal trends of surgically relevant outcomes is important for future improvement of surgical care.     

Treatment of a proximal accessory nerve injury with nerve transfer

OBJECTIVE AND HYPOTHESIS: This study presents a case report of a patient who sustained an iatrogenic proximal accessory nerve injury that was treated with a medial pectoral to accessory nerve transfer. STUDY DESIGN: Case study. MATERIALS AND METHODS: Chart of one patient who was treated with a medial pectoral to accessory nerve transfer was reviewed. RESULTS: Five months after excision of a branchial cyst that resulted in a very proximal injury to the accessory nerve, this patient underwent a medial pectoral to accessory nerve transfer. At final follow-up, 3 years after surgery, the patient had full abduction overhead with some residual shoulder/scapular discomfort and mild scapular winging. CONCLUSION: The medial pectoral to accessory nerve transfer provides a viable surgical option with good reinnervation of the trapezius muscle in patients with a proximal accessory nerve injury where standard nerve repair or graft techniques are not feasible.     

Arnold-Chiari malformation with syrinx presenting as carpal tunnel syndrome: a case report

A 26-year-old administrative assistant presented with 3 years of left-hand dysesthesia involving primarily the first 3 digits. Her symptoms increased at night and with keyboard use. Through 12 visits to primary and specialty care physicians over 3 years, she experienced minimal improvement with splints and moderate improvement with gabapentin. On presentation, careful questioning revealed an abrupt onset of symptoms 3 years previously, related to a 2-week episode of gastritis associated with recurrent emesis. Examination revealed a negative Tinel sign over the median nerve at the wrist, decreased left biceps reflex, positive Spurling test, and decreased sensation over the palmar and dorsal surfaces of the left hand in the C5-6 distribution. The atypical onset of symptoms, poor response to therapy, and physical findings suggested the possibility of a radicular or central neurologic etiology for the patient's hand numbness. Magnetic resonance imaging demonstrated a Chiari I malformation with a syrinx extending from C2 to T10, with the greatest diameter at C4. Neurosurgical decompression led to a decrease in symptoms. A meticulous history and physical examination should be performed on patients with presumed carpal tunnel syndrome with an atypical onset of symptoms or response to therapy.     

Fibrocartilaginous embolism--an uncommon cause of spinal cord infarction: a case report and review of the literature

Fibrocartilaginous embolism is a rare cause of spinal cord infarction. It is postulated that an acute vertical disk herniation of the nucleus pulposus material can lead to spinal cord infarction by a retrograde embolization to the central artery. An increased intradiskal pressure resulting from axial loading of the vertebral column with a concomitant Valsalva maneuver is thought to be the initiating event for the embolus. We present a previously healthy 16-year-old boy with sudden onset of back pain and progressive paraparesis within 36 hours after lifting exercises in a squat position. His clinical presentation and neuroimaging studies were consistent with spinal cord infarction resulting from a central artery embolus at the T8 spinal cord level. Laboratory investigation showed no evidence of infectious, autoimmune, inflammatory, or neoplastic causes. Although no histologic confirmation was obtained, lack of evidence for other plausible diagnoses in the setting of his clinical presentation and in the magnetic resonance imaging findings made fibrocartilaginous embolism myelopathy the most likely diagnosis. We postulated that some cases of transverse myelitis might actually be fibrocartilaginous embolism, making it a more prevalent cause of an acute myelopathy than commonly recognized. Relevant literature and current theories regarding the pathogenesis of fibrocartilaginous embolism myelopathy are reviewed.     

Quality specification in haematology: the automated blood cell count

BACKGROUND: Quality specifications for automated blood cell counts include topics that go beyond the traditional analytic stage (imprecision, inaccuracy, quality control) and extend to pre- and post-analytic phases. METHODS: In this review pre-analytic aspects concerning the choice of anticoagulants, maximum conservation times and differences between storage at room temperature or at 4 degrees C are considered. For the analytic phase, goals for imprecision and bias obtained with various approaches (ratio to biologic variation, state of the art, specific clinical situations) are evaluated. For the post-analytic phase, medical review criteria (algorithm, decision limit and delta check) and the structure of the report (general part and comments), which constitutes the formal act through which a laboratory communicates with clinicians, are considered. RESULTS: K2EDTA is considered the anticoagulant of choice for automated cell counts. Regarding storage, specimens should be analyzed as soon as possible. Storage at 4 degrees C may stabilize specimens from 24 to 72 h when complete blood count (CBC) and differential leucocyte count (DLC) is performed. For precision, analytical goals based on the state of the art are acceptable while for bias this is satisfactory only for some parameters. CONCLUSIONS: In haematology quality specifications for pre- and analytical phases are important, but the review criteria and the quality of the report play a central role in assuring a definite clinical value.     

Is there value in routinely obtaining a report from the general practitioner as part of pre-entry health screening of students for nursing studies?

BACKGROUND: Reports from general practitioners (GPs) are requested on applicants for nurse training, but there is no published evidence of the merit of this practice. AIMS: To assess the benefit of GP report in health assessments of student nurse applicants. METHODS: An audit was made of information obtained by health declaration form (HDF), nurse's assessment, GP report and, when performed, a physician's assessment for each applicant. Agreement between the health questionnaire and GP report was analysed by kappa statistics. RESULTS: Of 254 applicants, 246 (97%) were declared 'fit to work', four (1.6%) were deemed 'fit with restrictions' and four (1.6%) were considered 'unfit to work'. The most common problems declared were psychiatric and skin problems. The agreement between health declaration and the information provided by GPs was classed as almost perfect for diabetes and only fair to moderate for all other measures. The reports provided additional information on problems not declared by applicants, but all of these were passive problems. The four unfit candidates all had psychiatric illness, but in all cases the occupational health assessment was sufficient to make this decision or to request further information. In the 'fit with restrictions' category, three of the four GP reports (75%) helped in correctly assigning the applicants to this category. In one of these eight cases a passive problem had not been declared. CONCLUSIONS: The additional information in GP reports does not affect the conclusion regarding fitness for training in most cases and does not provide sufficient information to merit it being sought routinely.