Central Nervous System Fungal Infections in Children With Leukemia and Undergoing Hematopoietic Stem Cell Transplantation: A Retrospective Multicenter Study

BACKGROUND

Central nervous system fungal infections (CNSFI) are seen in patients with hematologic malignancies and have high morbidity and mortality. Because of their rarity, there is limited data on CNSFI in children with no established treatment protocols or guidelines.

MATERIALS AND METHODS

In this multicenter retrospective study, 51 pediatric patients with leukemia, 6 of whom had undergone bone marrow transplantation, with proven or probable CNSFI were evaluated. Fungal infections were defined as proven or probable based on European Organisation for Research and Treatment of Cancer criteria. Proven CNSFI was diagnosed by appropriate central nervous system (CNS) imaging or tissue sample findings in combination with positive microbiological results of cerebrospinal fluid. A positive culture, microscopic evidence of hyphae, a positive result of the galactomannan assays are defined as positive microbiological evidence. Probable CNSFI was defined as appropriate CNS imaging findings together with proven or probable invasive fungal infections at another focus without CNS when there is no other explanatory condition. Data was collected by using the questionnaire form (Supplemental Digital Content 1, http://links.lww.com/JPHO/A541 ).

RESULTS

Seventeen patients had proven, 34 patients had probable CNSFI. Headaches and seizures were the most common clinical findings. The median time between the onset of fever and diagnosis was 5 days. The most common fungal agent identified was Aspergillus . Sixteen patients received single-agent, 35 received combination antifungal therapy. Surgery was performed in 23 patients. Twenty-two patients (43%) died, 29 of the CNSFI episodes recovered with a 20% neurological sequelae.

CONCLUSION

CNSFIs should be considered in the differential diagnosis in patients with leukemia and refractory/recurrent fever, headache, neurologicalocular symptoms, and a radiologic-serological evaluation should be performed immediately. Early diagnosis and prompt management, both medical and surgical, are essential for improving clinical outcomes.

Complications of Central Venous Catheters in Children Undergoing Hematopoietic Stem Cell Transplantation in Turkey

Although central venous catheters (CVCs) have become an integral element of the care of patients undergoing hematopoietic stem cell transplantation (HSCT), the associated complications can lead to treatment delays and negatively affect the child and family’s quality of life. The aim of this study was to identify the types, rate of, and risk factors for the complications relating to CVCs used in children undergoing HSCT in Turkey. One hundred children were followed prospectively to track catheter-related complications in the transplantation unit. Overall, 186 complications were documented. The most frequent complications were catheter-related infections and malfunctions. Children who had nonhematological disease had a higher rate of complications than those with hematological disease. HSCT nurses should follow and apply evidence-based clinical practice guidelines to support the management of catheters. Nurse staffing ratios and workload may be an issue in developing countries. The authors believe that proper maintenance of CVCs contributes to the reduction of catheter-related complications despite these issues and that problems can be overcome by hiring experienced staff, appropriate nursing education, and by organizing and improving home care programs for HSCT patients.

Contribution of thin-slice (1 mm) axial proton density MR images for identification and classification of meniscal tears: correlative study with arthroscopy

OBJECTIVE

To evaluate the diagnostic efficacy of thin-slice (1 mm) axial proton density-weighted (PDW) MRI of the knee for meniscal tear detection and classification.

METHODS

We prospectively assessed pre-operative MR images of 58 patients (41 males, 17 females; age range 18-62 years) with arthroscopically confirmed meniscal tear. First, we evaluated the performance of the sagittal and thin-slice axial MR images for the diagnosis of meniscal tears. Second, we compared the correlation of tear types presumed from sagittal and axial MRI with arthroscopy and tear classification from axial MRI. Tears were classified on the sagittal plane and the axial plane separately. The diagnostic performance and tear classification were compared statistically with arthroscopy results, which is accepted as the standard of reference.

RESULTS

8 of 58 patients were removed from the study group because they had complex or degenerative tears. A total of 62 tears were detected with arthroscopy in 50 patients. On the sagittal images, sensitivity and specificity values were 90.62% and 70.37%, respectively, for medial meniscus tears and 72.73% and 77.14%, respectively, for lateral meniscus tears. The corresponding values for axial images were 97.30% and 84.00%, respectively, for medial meniscus tears and 95.65% and 80.50%, respectively, for lateral meniscus tears. There was no significant difference in tear classification between the arthroscopy results and the thin-slice axial PDW MRI results (p>0.05).

CONCLUSION

thin-slice axial PDW MRI increases the sensitivity and specificity of meniscal tear detection and especially classification, which is important for surgical procedure decisions.

Effects of adding epinephrine plus fentanyl to low-dose lidocaine for spinal anesthesia in outpatient knee arthroscopy

BACKGROUND

This study investigated whether addition of 15 microg epinephrine plus 25 microg fentanyl to lidocaine spinal anesthesia for outpatient knee arthroscopy makes it possible to use a subanesthetic lidocaine dose. The aim was to assess the quality of anesthesia and the suitability of this protocol for outpatient knee arthroscopy.

METHODS

Seventy-five outpatients scheduled for knee arthroscopy were randomly assigned to one of three spinal anesthetic protocols: Group L10F25 received 10 mg of lidocaine plus 25 micro g fentanyl; Group L10F25E15 received 10 mg of lidocaine plus 25 microg fentanyl plus 15 microg epinephrine; and Group L20F25 received 20 microg lidocaine plus 25 microg fentanyl. Tourniquet pain and surgical pain were assessed using a visual analog scale. If spinal anesthesia was inadequate despite supplementary intravenous analgesia and sedation, the patient was converted to general anesthesia. Recovery times and side-effects in the early postoperative period were recorded.

RESULTS

The highest level of sensory block was above the T12 dermatome in all patients. Compared with the other groups, significantly more patients in Group L10F25 converted to general anesthesia. Group L10F25 had a significantly higher mean surgical pain score than the other groups. The mean tourniquet pain score was significantly higher in Group L20F25 than Group L10F25E15. Group L10F25E15 had a significantly shorter time to discharge than the other groups. Post-operative nausea and vomiting and drowsiness were more frequent in Group L10F25 than in the other groups.

CONCLUSION

The combination of 10 mg lidocaine and 25 microg fentanyl plus 15 microg epinephrine provides adequate spinal anesthesia and has favorable recovery characteristics for outpatient knee arthroscopy.