Differential effects of right hemisphere injection during the wada procedure on the primary and secondary languages in a bilingual speaker

Abstract

A Wada procedure was performed on a bilingual seizure surgery candidate. Immediately after the injection of barbiturate into the right internal carotid artery the patient spontaneously switched from counting in English (the language he indicated that he used most often) to Spanish (the language he learned first). He named in Spanish spontaneously as well. After injection of the left ICA the patient exhibited a global aphasia, with no evidence for differential recovery of language as the aphasia cleared. These observations are discussed in relation to the hypothesis that a language learned later in life may be more likely to be bilaterally represented than the first language learned.     

Abiotrophia Endocarditis in Children with No Underlying Heart Disease: A Rare but a Virulent Organism

Infective endocarditis is extremely rare in children with structurally normal hearts. The most common etiological agents are staphylococcal and streptococcal species. Nutritionally variant streptococci also classified as Abiotrophia species are a group of fastidious organisms that account for only 5% to 6% of all cases of culture‐negative infective endocarditis. Only seven cases of Abiotrophia infective endocarditis have been previously reported in children with no underlying structural heart disease. We report two cases of Abiotrophia infective endocarditis in children without any predisposing factors. Both patients presented with nonspecific symptoms leading to delay in diagnosis. While bacteriological clearance was achieved in both cases, both had a complicated course including development of brain mycotic aneurysms, splenic infarction, renal failure, and irreversible damage to the mitral valve. Both patients required surgical removal of the native mitral valve and replacement. We also present review of seven cases with similar diagnosis published previously in literature and highlight important differences. Our cases highlight special challenges in management of Abiotrophia endocarditis in pediatric patients. As the organism may not be isolated in routine culture media, may present with atypical clinical symptoms and may have a complicated course even without antibiotic failure, a high index of suspicion should be maintained in children with subacute symptoms even with no underlying structural cardiac disease.     

Endometrioid adenocarcinoma treated by hysteroscopic endomyometrial resection

A 53-year-old multiparous woman, with no identifiable risk factor for endometrial cancer, presented with menorrhagia. She had been treated with oral contraceptives for 3 years. Office endometrial biopsy indicated well-differentiated villoglandular adenocarcinoma of the endometrium. The patient refused hysterectomy and would consent only to hysteroscopic resection. She remains alive and well, with no clinical evidence of recurrence 5 years after resection. We propose that skillful resectoscopic surgery, under specific circumstance, may be an appropriate alternative treatment to hysterectomy for some early uterine malignancies.     

Resectoscopic surgery may be an alternative to hysterectomy in high-risk women with atypical endometrial hyperplasia

STUDY OBJECTIVE: Endometrial hyperplasia is found in 2% to 10% of women with abnormal uterine bleeding (AUB). Up to 43% of patients with cytologic atypia harbor coexisting adenocarcinoma, and approximately 20% to 52% of atypical hyperplasias, if untreated, progress to cancer. The objective of this study was to estimate the incidence of atypical endometrial hyperplasia encountered during routine resectoscopic surgery in women with AUB and to evaluate the role of resectoscopic surgery in the management of women with AUB and atypical endometrial hyperplasia who refused and/or were at high risk for hysterectomy. DESIGN: Prospective cohort study (Canadian Task Force classification II-3). SETTING: University-affiliated teaching hospital. PATIENTS: From January 1990 through December 2005, the senior author (GAV) performed primary resectoscopic surgery in 3401 women with AUB. Among these, there were 22 women with atypical (17 complex, 5 simple) endometrial hyperplasia. INTERVENTIONS: All women underwent hysteroscopic evaluation and partial (n = 3) or complete (n = 19) endometrial electrocoagulation and/or resection. Subsequently, 6 women had hysterectomy and bilateral salpingo-oophorectomy (BSO). MEASUREMENTS AND MAIN RESULTS: The median (range) for age, parity, and body mass index were 55 years (24-78 years), 2 (0-4), and 30.1 kg/m2 (22.5-52.2 kg/m2), respectively. Among the 3401 women, there were 22 cases of atypical endometrial hyperplasia, 12 of which were incidentally diagnosed at the time of hysteroscopy (complex 10, simple 2, incidence 0.35%). After hysteroscopic diagnosis or confirmation of diagnosis, 6 women underwent hysterectomy and BSO. Of the remaining 16 women, followed for a median of 5 years (range 1.5-12 years), 1 was lost to follow-up, 1 had only a biopsy to preserve fertility, 1 died from lung cancer after 4 years, and 1 died from colon cancer after 5 years. One patient developed endometrial cancer after 10.5 years with postmenopausal bleeding. She remains alive and well 3.5 years after hysterectomy and BSO. The remaining 11 patients are amenorrheic at a median follow-up of 6 years (range 1.5-12 years). CONCLUSIONS: Resectoscopic surgery in 3391 women with AUB detected 12 incidental cases of atypical endometrial hyperplasia (incidence 0.35%). Skillful resectoscopic surgery may be an alternative to hysterectomy in women with AUB and atypical endometrial hyperplasia, who refuse or are at high-risk for hysterectomy and who are compliant with regular and long-term follow-up.     

Disseminated cat scratch disease with vertebral osteomyelitis and epidural abscess

A 5-year-old boy with cat scratch disease presented with fever of unknown origin and osteomyelitis of the thoracic spine and epidural abscess. He did not have localizing signs or symptoms. Computed tomography of the abdomen, which was initially negative, showed hepatosplenic disease. Cat scratch disease has variable systemic presentations and should be included in the differential diagnosis of fever of unknown origin if an epidemiologic risk factor is present.     

Human herpesvirus 6 (HHV6) infection

Human herpes virus-6 was first reported in 1986 and is the sixth member of the herpes virus family. HHV-6 consists of two closely related variants HHV-6A and HHV-6B. The majority of infections occur in healthy infants with most infections caused by HHV-6B. The virus preferentially infects CD4+T-lymphocytes and the surface marker CD46 acts as a co-receptor. Infection is followed by persistence and latency in different cells and organs including monocytes/macrophages, salivary glands, the brain and the kidneys. In this article we will discuss the clinical manifestations of HHV-6 infection in healthy children and the syndromes associated with HHV-6 reactivation in immunocompromised patients. Evidence of association between HHV-6 infection and different clinical entities such as multiple sclerosis, malignancy, infectious momononucleosis, drug hypersensitivity syndromes and skin eruptions is discussed. Published data on the use and efficacy of antiviral agents in complicated infections and infections in immunocompromised patients is presented.     

Mycoplasma hominis scalp abscess in the newborn

Scalp abscess in the newborn is usually a complication of fetal scalp monitoring and is typically polymicrobial, reflecting maternal vaginal flora. We present a newborn with no apparent scalp trauma who developed scalp abscess that yielded pure growth of Mycoplasma hominis. The clue to diagnosis was the growth of pinpoint translucent colonies on blood agar that were Gram stain-negative. Abscess drainage and systemic clindamycin were curative.     

Outcome for West Syndrome Following Surgical Treatment

We report the case of an 18-month-old child with infantile spasms and a hypsarrhythmic electroencephalogram (EEG) pattern associated with a porencephalic cyst. Surgical removal of the cyst and its surrounding tissue was performed following failure of medical therapy. Postoperatively, the patient has been free of infantile spasms for 12 months and the EEG has normalized. He has been maintained on the same preoperative antiepileptic medications. This case suggests that surgical treatment is helpful in selected patients with infantile spasms and focal CNS lesions.     

Three simple steps during closed laparoscopic entry may minimize major injuries

Objectives  To describe three steps: (1) the initial Veress pressure (VIP-Pressure), (2) transient high-pressure pneumoperitoneum (HIP-Entry) prior to trocar/cannula insertion, and (3) visual entry with a trocarless cannula during closed laparoscopic entry, which may reduce major injuries. Design  Prospective observational cohort study (Canadian Task Force Classification II-2). Setting  University-affiliated teaching hospital. Interventions  VIP-Pressure. During laparoscopic entry, the initial VIP pressure was measured and correlated against the body habitus and parity of 365 consecutive women. HIP-Entry was performed in 2,498 consecutive cases. In 100 women, the CO₂ volume, heart rate, blood pressure, oxygen saturation, and pulmonary compliance were recorded at pressures of 10, 15, 20, 25, and 30 mmHg. Visual entry with a trocarless blunt cannula was performed in 776 women. The cannula, housing a 0° laparoscope, was rotated clockwise applying minimal downward force. Measurements and results  VIP-Pressure. Pneumoperitoneum was established after one, two or three Veress needle attempts at the umbilicus in 82.4%, 10.9%, and 4.0% of women, respectively. In seven (2.2%), pneumoperitoneum was established at the left upper quadrant (LUQ) during the fourth attempt, and in two (0.6%) entry was abandoned. Median initial Veress pressure was 4 mmHg (range 2–10 mmHg). The VIP pressure correlated positively with women’s weight (r = 0.518, p < 0.001) and body mass index (BMI) (r = 0.545, p < 0.001), and negatively with parity (r = −0.179, p < 0.001). HIP-Entry. The abdomen was insufflated to 25−30 mmHg prior to primary trocar/cannula insertion. There were no changes in cardiovascular parameters between 15 and 30 mmHg. A 21% decrease in pulmonary compliance from 15 to 30 mmHg was of no clinical significance. No injury has been experienced with the visual cannula in 776 cases. Conclusions  (1) A VIP-Pressure (<10 mmHg) indicates intraperitoneal placement of the Veress needle. (2) The use of transient HIP-Entry does not adversely affect cardiopulmonary function in healthy women. (3) Visual cannula offers an additional step towards safer entry.