Percutaneous upsizing of a Blalock-Taussig shunt

Percutaneous upsizing of surgically placed Blalock-Taussig shunts is an uncommon practice. We report the case of an 8-month-old infant with single-ventricle physiology, who - due to comorbidities - was deemed unsuitable to proceed with Glenn operation. The 3.5-millimetre Blalock-Taussig shunt was stented successfully with a 5-millimetre pre-mounted stent, resulting in an increase in shunt diameter and oxygen saturation by nearly 30% and 10%, respectively.     

Conservative versus primary surgical treatment of acoustic neuromas: a comparison of rates of facial nerve and hearing preservation

Objectives: To determine whether patients with small to medium sized acoustic neuromas managed conservatively suffer reduced rates of facial nerve and hearing preservation when compared with patients undergoing primary surgery. Design: An intention‐to‐treat comparison between patients managed conservatively at first presentation and those managed with primary surgery. Setting: Tertiary referral neurotological centre in Birmingham, UK. Participants: Data were drawn from our database of 487 sporadic acoustic neuromas managed from 1997 to present day. Main outcome measures: Facial nerve status (assessed using the House‐Brackmann system) was collated for all conservatively managed patients (n = 167) and compared with that expected when calculated from primarily surgically managed tumours of equivalent size (n = 121). A chi‐square test was employed to test the statistical significance of any difference. Hearing preservation (maintenance of AAO‐HNS Class) in patients presenting with Class A or B hearing was compared between conservatively managed patients and those with primary surgical management. Results: Observed facial nerve preservation in conservatively managed patients was significantly better (P < 0.001) than expected when calculated from rates of facial nerve preservation in surgically managed patients. Hearing preservation was also significantly more successful in conservatively managed patients (Pearson chi‐square: P < 0.000). Conclusions: An initial period of conservative management is a safe and reasonable management policy in all acoustic neuromas up to 2 cm in size at the cerebello‐pontine angle. Given that there are no failsafe ways of deciding potential for growth in acoustic neuromas, initial conservative management of these tumours offers superior hearing and facial nerve preservation when compared with primary surgical treatment.     

A ten-year experience of thyroglossal duct cyst surgery in children

We discuss a 10-year experience of all the thyroglossal duct cysts (TGDC) removed at our institution, assessing whether management was appropriate and to compare our outcomes and success rate with current literature. We performed a retrospective review of TGDC surgery at our institution from 2000 to 2010. During the study period, 93 children were identified as having had a TGDC excision at an average age of 6.1 (1.1–15.3) years. Seventeen cases (18 %) were found to have not had their hyoid bone removed and of these 10 (59 %) were proven on histology to be non-TGDC. A total of 19 cases were confirmed TGDC on histology but received a non-Sistrunk’s procedure and 12 (63 %) of those recurred requiring a more definitive procedure (i.e. Sistrunks). Of the 76 (82 %) that did have their hyoid bone removed 13 (17 %) suffered complications of which 3 were recurrences (3.9 %), which is comparable to the literature (3–5 %). Of the complications that occurred 11 out of 13 (85 %) were infected cases at or around the time of procedure. Our experience, being the largest described in the United Kingdom supports the use of Sistrunk’s procedure with recurrence rates comparable to that within the literature.     

Effect of Diabetes Mellitus on the Clinical and Microbiological Features of Hospitalized Elderly Patients with Acute Pyelonephritis

OBJECTIVES: To study potential differences in the clinical and microbiological features of hospitalized elderly patients with acute pyelonephritis with and without diabetes mellitus.
DESIGN: Retrospective review of medical records.
SETTING: University hospital.
PARTICIPANTS: Eighty-eight patients aged 65 and older with diabetes mellitus (DM) (57 female; 64.8%) and 118 controls without DM (75 female; 63.6%), matched for age and sex, hospitalized with acute pyelonephritis between January 1997 and December 2005.
MEASUREMENTS: Medical records were reviewed for demographic, clinical, and microbiological characteristics.
RESULTS: The median age of both groups was 74 (range 65–95). Twenty-seven people with DM (30.7%) and 13 controls (11.0%) had bacteremia ( P =.001). People with DM had longer fever (median 4.5 vs 2.5 days; P <.001), longer hospitalization (median 10 vs 7 days; P <.001), and greater mortality (12.5% vs 2.5%; P <.01) than controls. Logistic regression analysis proved DM to be an independent predictor of bacteremia, long hospitalization, and mortality. Escherichia coli was the most common microorganism found in both groups, whereas Candida spp. were implicated more frequently in people with DM than controls (12.7% vs 1.7%; P <.01). Antimicrobial resistance did not increase over the study period.
CONCLUSION: Acute pyelonephritis in elderly people with DM is associated with risk of bacteremia, long hospitalization, and mortality.     

Replacement therapy for iron deficiency improves exercise capacity and quality of life in patients with cyanotic congenital heart disease and/or the Eisenmenger syndrome

Introduction

Iron deficiency is common in cyanotic congenital heart disease (CHD) and results in reduced exercise tolerance. Currently, iron replacement is advocated with limited evidence in cyanotic CHD. We investigated the safety and efficacy of iron replacement therapy in this population.

Methods

Twenty-five iron-deficient cyanotic CHD patients were prospectively studied between August 2008 and January 2009. Oral ferrous fumarate was titrated to a maximum dose of 200 mg thrice-daily. The CAMPHOR QoL questionnaire, 6 minute walk test (6MWT) and cardiopulmonary exercise testing were conducted at baseline and after 3 months of treatment.

Results

Mean age was 39.9 ± 10.9 years, 80% females. Fourteen had Eisenmenger syndrome, 6 complex cyanotic disease and 5 Fontan circulation. There were no adverse effects necessitating termination of treatment. After 3 months of treatment, hemoglobin (19.0 ± 2.9 g/dL to 20.4 ± 2.7 g/dL, p < 0.001), ferritin (13.3 ± 4.7 μg/L to 54.1 ± 24.2 μg/L, p < 0.001) and transferrin saturation (17.8 ± 9.6% to 34.8 ± 23.4%, p < 0.001) significantly increased. Significant improvements were also detected in the total CAMPHOR score (20.7 ± 10.9 to 16.2 ± 10.4, p = 0.001) and 6MWT distance (371.7 ± 84.7 m to 402.8.0 ± 74.9 m, p = 0.001). Peak VO₂ remained unchanged (40.7 ± 9.2% to 43.8 ± 12.4% of predicted, p = 0.15).

Conclusion

Three months of iron replacement therapy in iron-deficient cyanotic CHD patients was safe and resulted in significant improvement in exercise tolerance and quality of life. Identification of iron deficiency and appropriate replacement should be advocated in these patients.