Late effects of treatment on the intelligence of children with posterior fossa tumors

This retrospective pilot study was undertaken to evaluate the late effects of treatment on intelligence in a population of children with posterior fossa tumors. Ten children with posterior fossa tumors treated with radiation and chemotherapy received intellectual evaluations at least one year following diagnosis. Six children had medulloblastomas, one child had a fourth ventricular ependymoma, two children had brainstem gliomas, and one child had a recurrent cerebellar astrocytoma. Children with supratentorial tumors were specifically excluded from the study in order to eliminate the possible influence of the tumor on intellectual functioning. Four children had had intelligence testing in school prior to treatment of their tumor. In each case results following treatment revealed a deterioration of full scale IQ of at least 25 points. Six children did not have prior testing; of these, two had IQ's less than 20. Overall, 50% of the patients had IQ's of less than 80 and 20% had IQ's of greater than 100. Furthermore, four children with normal intelligence (IQ greater than 80) have learning problems requiring special classes. Thus, of the ten children evaluated, all have either dementia, learning disabilities, or evidence of intellectual retardation. This study suggests that aggressive treatment of children with brain tumors may improve survivals but may be associated with significant long-term disabilities.

Visual-evoked responses in children with optic gliomas, with and without neurofibromatosis

Gliomas of the optic pathway are considered to be slowly growing, potentially benign neoplasms. Association of this tumor with neurofibromatosis has been well established. We have recently evaluated 7 children with putative evidence of optic glioma, 6 of whom had additional evidence of neurofibromatosis. All children had CT scans and visual-evoked responses. CT scan allows anatomic assessment of the optic nerve mass while evoked responses offer the possibility of identifying functional abnormalities in the optic pathway. It is felt that both these modalities will add in the early diagnosis of optic gliomas and help to further establish the true natural history of this tumor.

An improved high-pressure liquid chromatographic assay for secobarbital in serum

A high-pressure liquid chromatographic method for the analysis of secobarbital in serum was developed. Secobarbital was extracted from buffered serum (pH 5.5) with a solvent mix of hexane-ether-n-propanol. 5-(4-Methylphenyl)-5-phenylhydantoin was added as an internal standard. Separation of secobarbital and internal standard from serum constituents and other drugs was achieved on a 5-mum C-18 reversed-phase column using an acetonitrile-phosphate buffer (pH 4.4) mobile phase. The eluent was monitored at 195 nm. The sensitivity limit of the assay was approximately 0.02 microgram/ml with 0.5 ml of serum sample. The application of this method to pharmacokinetic studies in pediatric patients was demonstrated.

Referral patterns of childhood brain tumors in the state of Connecticut

Data from the Connecticut Tumor Registry (1968-1979) were analyzed to determined whether referral patterns influenced survival rates in children with brain tumors. Two-hundred-seventy-eight children with brain tumors were identified. Less that one-third of the children received all their treatment at university cancer centers. An actuarial analysis of survival rates revealed that children with medulloblastomas treated solely at university cancer centers had projected five-year survival rates of 7.4%. Children with medulloblastomas treated solely at community hospitals had projected five-year survival rates of 29%. Children with brainstem gliomas treated at university cancer centers had projected five-year survival rates of 40% whereas of those children treated at community hospitals only one patient was alive at 13 months. No major differences in survival were identified among children with other tumor types. These data suggest that children with certain types of brain tumors may fare better when treated at university cancer centers.

Method for automated entry of a dental chart schematic using a computer card reader

A method was developed in which a dental chart schematic, printed on a standard 80-column computer card, could be used to record DMF data for analysis using mark sensing technology. The binary image of each column was read by a standard card reader and this information was used to create a detailed DMF analysis. This method uses readily available technology and could be modified for many research purposes.

Empirical verification of confidence intervals computed from dental data

Sampling experiments were conducted on five distributions of dental epidemiological data which varied in degree of positive skew. The tendency of nominal confidence intervals to be underestimated and asymmetric in the two tails increased with skew and decreased with increasing sample size. The findings conform to theoretical expectations and demonstrate the importance of the normality assumption regarding sampling distributions. A rule is presented which identifies a sample size so that the 95% confidence probability statement would be incorrect no more than 6% of the time.

Acoustic augmentation and inhibition of the human eyeblink

The human eyeblink elicited by a mechanically produced tap to the glabella was inhibited by a mild acoustic stimulus presented 200 msec prior to the tap and was augmented when the same acoustic stimulus was presented simultaneously with the tap. Monaural presentation of the acoustic stimulus prior to the tap yielded more reflex inhibition than when that same stimulus was presented binaurally. Binaural presentation of the acoustic stimulus simultaneously with the tap yielded more reflex augmentation than when that same stimulus was presented monaurally. These findings lend credence to the proposition that reflex inhibition and reflex augmentation are mediated by separate neural pathways.

Extraneural metastases in childhood brain tumors

Although extraneural metastases are known to occur with primary tumors of the central nervous system, they are considered a rarity. Large autopsy series have placed the frequency at 0.4 to 0.5%. At the Roswell Park Memorial Institute, 36 children with brain tumors have been treated with a combination of surgery, radiotherapy, and chemotherapy in the past 12 years. We recently reviewed the autopsies obtained on 15 of these children and found that 4 (26%) had extraneural metastases. An additional child, who was not autopsied, had extraneural extension diagnosed during life. This inordinately high incidence of metastases outside the nervous system in children with aggressively treated brain tumors raises questions about their cause. The prolonged survival of these patients may have allowed growth of sufficient generations of extracranial metastatic cells for the extraneural disease to become clinically significant. Another possibility is that chemotherapy may alter the patients' immune system and thus promote extracranial tumor growth. As larger numbers of childhood brain tumors are managed with multimodality therapy, it may be possible to evaluate the extent to which treatment allows intracranial neoplasms to spread outside the nervous system.

Primitive neuroectodermal tumors of childhood. An approach to therapy

Primitive neuroectodermal tumors are found in the cerebrum of children and young adults. The are clinically highly malignant and have rapid course from diagnosis to death. Their microscopic pathology reveals 90% to 95% nondifferentiation, frequent mitoses, and small dark cells with no observable cytoplasm. This paper discusses the treatment of three children with this tumor with a combination of surgery irradiation, and combination chemotherapy. The results of this approach are compared with previous reports in the literature. The average survival in this series is 24 months versus approximately 8 months reported in the literature.

Salivary concentrations and plasma protein binding of carbamazepine and carbamazepine 10,11-epoxide in epileptic patients

1. The relationships between saliva, free and total plasma concentrations of carbamazepine (CBZ) and carbamazepine 10,11-epoxide (CBZ-EP) were studied in 24 chronically medicated epileptic patients. Four patients were taking CBZ alone, while 20 were taking one or more additional anticonvulsant drugs. 2. The free fraction of CBZ in plasma ranged from 0.19 to 0.33 (mean 0.24) while the saliva:plasma (S:P) concentration ratios ranged from 0.20 to 0.35 (mean 0.27). The free fraction of CBZ-EP in plasma ranged from 0.16 to 0.50 (mean 0.32), while the S:P ratios ranged from 0.14 to 0.70 (mean, 0.43). The plasma protein binding and S:P ratios of these compounds appeared to be independent of age, sampling time and concurrently administered anticonvulsant drugs. 3. Significant linear relationships between saliva and total plasma concentrations and between saliva and free plasma concentrations were observed for both compounds (P less than 0.001). However, salivary concentrations of CBZ and CBZ-EP were significantly more reliable as predictors of their respective free plasma concentrations than of their respective total plasma concentrations (P less than 0.01). 4. It is concluded that measurement of CBZ and CBZ-EP in the saliva of chronically medicated epileptic patients provides a more reliable estimate of the pharmacodynamically active, free concentrations of these compounds in plasma.

Prognostic indicators in hemiparetic cerebral palsy

In an attempt to define prognostic indicators of intelligence and seizures in the hemiparetic cerebral palsy population, birth histories, electroencephalograms, and computerized tomographic (CT) scans were reviewed in 52 children with hemiparetic cerebral palsy. Cases were excluded when the hemiparesis might have been related to events beyond the neonatal period, such as meningitis, trauma, focal seizures, tumor, or vascular insults. Detailed neurological histories and examinations were done in all patients. Intellectual evaluations, electroencephalograms, and CT scans were obtained. There was no significant relationship of birth history to subsequent seizure development or mental retardation. In contrast, findings in electroencephalograms and CT scans correlated well with the development of seizures and abnormal intelligence. Children who shared anatomical abnormalities of commissural pathways, association pathways, or cerebral cortex were found to have a much higher incidence of seizures and abnormal intelligence.

Multimodality therapy for medulloblastoma

Eight patients with recurrent medulloblastoma were treated with a chemotherapy regimen consisting of vincristine, BCNU, dexamethasone and intrathecal and intermediate dose intravenous methotrexate (500 mg/m2). Five also received local low dose radiotherapy (RT). All 8 patients responded to treatment; 6 completely and 2 partially. These latter 2 were in their second and third recurrences. Three remain in remission. The median duration of response was 18.8 months, and median time from start of chemotherapy to death was 32 months using the Kaplan-Meier technique. In addition, 9 other patients with newly diagnosed medulloblastoma were treated with craniospinal radiation and the same adjuvant chemotherapy as above. The first 5 patients also received intraventricular methotrexate and/or intravenous BCNU during radiotherapy. The toxicity in the 5 patients was very severe. There were three toxic deaths, one death from cancer; one patient survives disease-free, but he is demented. With the discontinuance of intraventricular methotrexate and the postponement of myelo-suppressive chemotherapy until after the completion of radiotherapy, the regimen has been well tolerated. All 4 patients treated this way remain alive, well, and disease-free at intervals up to 36 months. We conclude that recurrent medulloblastomas are sensitive to multiagent chemotherapy and that prolonged remissions may occur. With primary adjuvant chemotherapy, extreme caution with myelo-suppressive drugs must be exercised during the period of craniospinal radiotherapy. We also do not recommend the use of intraventricular methotrexate. When these two criteria were followed, the preliminary results with adjuvant chemotherapy appear encouraging.

Computed tomography and childhood seizure disorders

Computerized tomography (CT) was performed on 256 children with seizure disorders. The incidence of abnormal scans was closely related to seizure type, and permitted separation of patients into a low-yield and a high-yield group. Low-yield groups included children with idiopathic generalized seizures, children in whom both the neurologic examination and electroencephalogram (EEG) were normal, and children with a generalized seizure of unknown etiology in whom the neurologic examination and the EEG were normal. The high-yield groups included children with partial seizures with elementary symptomatology, partial seizures with complex symptomatology, generalized seizures with known etiology, neonates with seizures, and children whose seizures began as neonates. The overall incidence of abnormalities in the entire group was 33 percent. An abnormal neurologic examination increased the incidence of abnormal CT scans to 64 percent. EEGs were abnormal in 65 percent of the children, but only focal slowing resulted in a significant increase in the incidence of abnormal CT scans. Seven children (2.7 percent) had intracranial abnormalities requiring surgery. If the neurologic examination and EEG were normal, the yield of abnormal CT scans was only 5 percent of the total.

Liquid-chromatographic assay of diazepam and its major metabolites in plasma

We describe a method for simultaneous quantitation of diazepam and its metabolites, N-desmethyldiazepam and oxazepam, by reversed-phase liquid chromatography with ultraviolet detection at 254 nm. After extraction with chloroform at pH 11.0, the organic extract is evaporated, and the residue is reconstituted in a small volume of mobile-phase and chromatographed. Concentrations as low as 12 to 20 microgram/L can be detected after extraction of only 250 microL of plasma. The maximum within-day and day-to-day coefficients of variation for each compound at concentrations of 50, 250, and 1000 microgram/L are 8.0 and 10.3%, respectively. Of 14 commonly used anticonvulsant, sedative, and psychotherapeutic drugs, only carbamazepine and lorazepam may interfere with analysis for oxazepam or N-desmethyldiazepam, or both. Total chromatography time for a single sample is less than 10 min. Applicability of the method to diazepam disposition studies in children is illustrated.

Liquid-chromatographic assay of diazepam and its major metabolites in plasma

We describe a method for simultaneous quantitation of diazepam and its metabolites, N-desmethyldiazepam and oxazepam, by reversed-phase liquid chromatography with ultraviolet detection at 254 nm. After extraction with chloroform at pH 11.0, the organic extract is evaporated, and the residue is reconstituted in a small volume of mobile-phase and chromatographed. Concentrations as low as 12 to 20 microgram/L can be detected after extraction of only 250 microL of plasma. The maximum within-day and day-to-day coefficients of variation for each compound at concentrations of 50, 250, and 1000 microgram/L are 8.0 and 10.3%, respectively. Of 14 commonly used anticonvulsant, sedative, and psychotherapeutic drugs, only carbamazepine and lorazepam may interfere with analysis for oxazepam or N-desmethyldiazepam, or both. Total chromatography time for a single sample is less than 10 min. Applicability of the method to diazepam disposition studies in children is illustrated.

Cystic fibrosis with brain abscess

A 21-year-old patient with cystic fibrosis developed bilateral brain abscesses due to anaerobic Streptococcus. This rare association presents an interesting etiologic study.

Combination chemotherapy in recurrent medulloblastoma

Five children with recurrent medulloblastomas were treated with Vincristine, BCNU, Methotrexate and Dexamethasone. All five patients responded to therapy. Two of the patients are alive and well 30 and 48 months later; one died of disease 19 months after first recurrence; one developed a further recurrence at 18 months but responded to additional chemotherapy and is alive; and the fifth patient developed a second recurrence after 28 months but has responded to repeat chemotherapy and radiotherapy and is now asymptomatic. These results support the concept that medulloblastomas are sensitive to chemotherapy and suggest that chemotherapy should be considered in cases of recurrent medulloblastomas. In addition, the importance of trials now in progress which employ both adjuvant chemotherapy and radiotherapy in newly diagnosed medulloblastomas is apparent.

Ethosuximide pharmacokinetics in a pregnant patient and her newborn

Ethosuximide concentration in serum was monitored during the last trimester of pregnancy in a patient. After delivery, the decline in serum concentration of ethosuximide was observed in the nonnursing neonate. The half-life of elimination of transplacentally acquired ethosuximide in this neonate was 41.3 hr. The ratio of breast milk to maternal serum concentration of ethosuximide was approximately 1. A total daily exposure to ethosuximide of 12.8 to 38.4 mg (3.6 to 11.0 mg/kg) as a result of nursing was predicted.

Calcification in brainstem gliomas

Calcification in brainstem gliomas is an unusual histologic and and radiologic finding. To date, radiologic evidence of calcification in these tumors has not been reported. The two patients described here had evidence of calcification on either computerized tomography (CT) or plain skull films. Increasing availability of CT scans may provide a more accurate estimate of the incidence of calcification in these tumors.

Central core disease in one of identical twins

A case of central core disease in one of identical twins is presented. The light and electron microscopic pathology is reviewed. We believe that these entities are not genetic in this sibship and may be an example of isolated maturational arrest of non-specific aetiology.

Peripheral neuropathy as a complication of cis-dichlorodiammineplatinum(II) treatment: a case report

A 19-year-old woman with a diagnosis of osteosarcoma was initially treated with amputation of her right leg and adjuvant adriamycin. She developed pulmonary metastases 18 months following diagnosis. She was then given cis-dichlorodiammineplatinum(II) (DDP) at a dose of 100 mg/m2 iv approximately every 4 weeks as the sole drug. Following the fifth dose of DDP, she complained of numbness and tingling in her hands and leg. A distal sensory loss extending to both elbows and her remaining knee was found on examination. Nerve conduction tests were compatible with peripheral neuropathy of the "glove and stocking" type. DDP was withheld and her sensory loss improved over the next 2 months, but became worse after another course of DDP was administered. The temporal relationship between the findings and the administration of DDP implicates this drug as the causative agent in the peripheral neuropathy.

Electroencephalographic and neurological correlates of deep hypothermia and circulatory arrest in infants

At present there is much interest in the use of surface-induced deep hypothermia with circulatory arrest in infants undergoing an open-heart procedure for repair of congenital defects. This paper presents our experience with infants who have been monitored by preoperative, intraoperative, and postoperative electroencephalograms as well as by preoperative and postoperative neurological assessments. Our results indicate that young infants tolerate deep hypothermia with circulatory arrest quite well, and we therefore continue to advocate use of this procedure in operations for congenital cardiac disease.

Stimulation of uterine nonhistone protein phosphorylation and nuclear protein kinase activity by estradiol-17beta

Changes in the phosphorylation of nonhistone chromosomal proteins have been followed in rat uterus stimulated by 17beta-estradiol. Isolated uteri were found to incorporate 32Pi into nonhistone proteins via an endogenous neclear protein kinase reactin. The rate of 32P labeling of nonhistone proteins and the activity of nuclear protein kinase(s) were found to be elevated over three- and two-fold respectively in uteri obtained from ovariectomized animals treated with estrogen. A dramatic change was observed in the radioactivity profile of 32P-labeled proteins fractionated via sodium dodecyl sulfate-polyacrylamide gel electrophoresis. These observations are compatable with the hypothesis that phosphorylation of nonhistone proteins plays a role in the regulation of gene activity in the uterus.

Effect of extradiol-17beta on the synthesis of specific uterine nonhistone chromosomal proteins

The synthesis of specific nonhistone chromosomal proteins in the uterus of the ovariectomized rat was examined as a function of time after treatment with estradiol-17beta. Sequential stimulations in the rates of synthesis of at least five nonhistone chromosomal proteins having molecular weights of 96,000, 70,500, 29,400, 20,700, and 16,400, respectively, were observed. The rate of synthesis of the nonhistone chromosomal protein having a molecular weight of 70,500 was increased at 1 hr after hormone treatment. This was the first nonhistone chromosomal protein to be induced by estrogen, and its induction was blocked by pretreatment with actinomycin D. The data reported suggest but do not prove that this protein is the 4.5 S estrogen receptor, and that it is the induced nuclear acidic protein described earlier by Teng and Hamilton. The rates of synthesis of the nonhistone proteins with molecular weights of 96,000, 29,400, 20,700, and 16,400 were increased at 3,5,24, and 24 hr, respectively, after hormone treatment.

Retarded adult's discrete work performance in a sheltered workshop as a function of overall productivity and motivation

Production times of high and low retarded adults in a sheltered workshop were analyzed in terms of actual time working as opposed to actual time not working and under conditions of standard and high motivation. Under standard conditions, low productivity was primarily the result of more time spent not working. High motivation attenuated this effect. The results were discussed in terms of cognitive vs. motivational interpretations of individual differences in work performance.

Infantile spasms associated with histidinemia

A case of infantile spasms associated with histidinemia is presented. Histidinemia was well-documented through biochemical assays. The patient was treated with the standard anticonvulsant regimen for infantile spasms, as well as an elimination diet for histidinemia. Despite low levels of histidine and adequate anticonvulsant therapy, the child continues to have seizures and is markedly retarded. The natural history of infantile spasms and its possible association with histidinemia is discussed.

A comprehensive rehabilitation program for chronic patients in a state mental hospital

In the program described in this manuscript, the author suggests that comprehensive planning for the rehabilitation of long-term hospitalized mentally ill patients includes a variety of specific approaches that utilize staff creativity and involve the patient in a structured milieu. The rehabilitation team organizes the daily responsibilities of each patient (including individual work assignments, recreation, group discussion, and training classes which teach adaptive skills) and provides meaningful rewards and incentives through the use of a graded evaluation system, based on community standards and requirements. The milieu created by the staff is specifically geared toward cultivating and strengthening the potential resources of every individual patient.