MON-458 Radiological Alterations Of The Hypothalamic-pituitary Region After Craniospinal Irradiation For Medulloblastoma During Childhood

Background Hypothalamic-pituitary (HP) dysfunction after craniospinal irradiation (CSI) is frequently observed in childhood brain tumor survivors (CBTS). The risk increases with higher dose and younger age at time of radiation exposure. Whether radiological alterations of the HP-region or alterations in brain volume are predictive of HP dysfunction remains unknown. Aim The aim of this (retrospective) study was to quantify radiological alterations of the HP-region in time in CBTS after CSI and to correlate these alterations to the occurrence of HP dysfunction. Methods Ninety survivors of childhood medulloblastoma (mean age at diagnosis: 8.3 years) from a previously reported nationwide cohort, treated with CSI between 2002-2012, were included. Sixty CBTS (67%) were diagnosed with HP dysfunction during follow-up (FU). All MRI scans were collected from time of diagnosis, post-neurosurgical intervention, post-radiation and 3 and 5 years of FU. Pituitary height (PH) and width (PW) were measured on mid-sagittal images. The pituitary stalk (PS) width was assessed by measuring the ratio of the PS to basilar artery (BA) on axial images on the same plane in the middle of the PS. Volume measurements of the PG (PGV) were performed. Observers were blinded for outcome of HP function. Separate analyses were performed for children < 6 years at time of CSI. All measurements were corrected for age and gender using Z-scores. Statistical analyses were performed by SPSS (General Linear Model repeated measures with Bonferroni correction). Results Mean PH (p<0.01, 95% CI [0.25, 1.27], PW (p<0.01, 95% CI [0.85-2.32], width of the PS (p<0.01, 95% CI [0.38-3.0] and PGV (p<0.05, 95% CI [0.12-1.29] declined during FU. No correlation was observed between radiological alterations in time and the presence of HP dysfunction. On a marginal trend level, an interaction effect was seen for PS/BA ratio and the presence of HP dysfunction (p= 0.097, F= 2.44). HP dysfunction occurred more frequently in CBTS treated with CSI < 6 years (71% vs 58%). Radiological alterations in this age group could also not be related to occurrence of HP dysfunction. Conclusion When compared to age and gender reference values, CBTS treated with CSI show radiological alterations of the HP region in time. Exposure to cranial irradiation in childhood seems to have a negative effect on PH, PW, width of PS and PGV. However, these effects cannot be related to the development of HP dysfunction or age at time of CRT. Prospective studies are needed to confirm these results, with systematic evaluation of the HP function in time.

Unexpected overnight stay following ENT day-case surgery: a 5-year audit

Unexpected overnight stay following ENT day-case surgery: a 5-year audit.

PROBLEMS/OBJECTIVES

Recent decades have seen a steady reduction in the average duration of hospitalization for all surgical patients, including those undergoing ENT procedures. Correspondingly, the proportion of day surgeries relative to in-patient surgeries has progressively increased. In the present observational study, we aimed to evaluate the proportion of unplanned overnight stays following planned day surgeries in our ENT unit, and the major causes of these unexpected overnight admissions.

METHODS

From databases, we collected data from all patients who underwent ENT day-case surgery in Ziekenhuis Oost- Limburg between January 2008 and December 2013.

RESULTS

A total of 10,440 patients underwent ENT day-case surgery during this period. The overall rate of unexpected overnight admission was 1.86%, with these overnight admissions most commonly due to anaesthetic (46.91%), surgical (19.59%), and organizational (17.01%) reasons. The types of ENT surgery at the greatest risk for prolonged hospitalisation were hemithyroidectomy (12.50%), tympanoplasty (12.15%), and uvulopalatopharyngoplasty (UPPP) (7.81%). We further identified a clear difference in the rate of unexpected overnight stay between surgery scheduled in the morning (1.17%) versus in the afternoon (12.98%).

CONCLUSIONS

Our present findings highlight the various reasons for unexpected overnight admission after day-case surgery. To reduce the rate of unexpected overnight stays, we need to better understand these different reasons to support the ongoing search for possible solutions.

Specific medical and surgical treatment for chronic inflammatory diseases in children

Treatment for chronic inflammatory conditions in children should take into account the specific pathophysiological and clinical processes underlying these disorders. These guidelines provide a framework for both the medical and surgical treatment of chronic inflammatory diseases such as otitis media, allergic rhinitis and chronic rhinosinusitis, chronic inflammation of tonsils and adenoids, and laryngitis. In addition, the role of vaccinations and immunomodulatory therapies is discussed. Whenever possible, the evidence levels for specific treatments comply with the Oxford Levels of Evidence.

Information disclosure to terminally ill patients and their relatives: self-reported practice of Belgian clinical specialists and general practitioners

Objective of this study is to examine physicians' practices regarding information disclosure to terminally ill patients and to their relatives, without informing the patient. A questionnaire had been sent to a random sample of 3014 Belgian physicians from different specialties frequently involved in end-of-life care. Responses were analysed using weighted percentages, Chi-square, Mann-Whitney U-tests and a multivariate ordinal logistic regression. Response rate was 58%. Both clinical specialists and general practitioners (GPs) discuss most topics related to terminal illness with their patients except end-of-life hastening options, spirituality, life expectancy and options to withhold/withdraw life-sustaining treatment. The topics which most physicians always discuss with relatives without informing the patient are the aim of treatment, palliative care and incurability. There is a significant difference between clinical specialists and GPs. Clinical specialists and GPs discuss most end-of-life topics with the patient but omit important issues such as end-of-life hastening options and life-expectancy.

Near infrared reflectance spectroscopy for the fast identification of PVC-based films

Near infrared (NIR) reflectance spectroscopy was used to develop a non-destructive and rapid qualitative method for the analysis of plastic films used by the pharmaceutical industry for blistering. Three types of films were investigated: 250 microm PVC [poly(vinyl chloride)] films, 250 microm PVC films coated with 40 g m(-2) of PVDC [poly(vinylidene dichloride)] and 250 microm PVC films coated with 5 g m(-2) of TE (Thermoelast) and 90 g m(-2) of PVDC. Three analyses were carried out using different pre-treatment options and a PLS (partial least squares) algorithm. Each analysis was aimed at identifying one type of film and rejecting all types of false sample (different thickness, colour or layer). True and false samples from four plastics manufacturers were included in the calibration sets in order to obtain robust methods that were suitable regardless of the supplier. Specificity was demonstrated by testing validation sets against the methods. The tests showed 0% of type I (false negative identification) and 1% of type II errors (false positive identification) for the PVC method, 13 and 3%, respectively, for the PVC-PVDC method and no error for the PVC-TE-PVDC method. Type II errors, mostly due to the slight sensitivity of the methods to film thickness, are easily corrected by simple thickness measurements. This study demonstrates that NIR spectroscopy is an excellent tool for the identification of PVC-based films. The three methods can be used by the pharmaceutical industry or plastics manufacturers for the quality control of films used in blister packaging.

Interstitial lung disease more than 40 years after a 5 year occupational exposure to talc

A 62 yr old woman was initially diagnosed with sarcoidosis until a thoracoscopic biopsy revealed the presence of numerous birefringent particles in fibrotic areas of the centrilobular lung zones. These particles were examined by electron microscopy and X-ray spectrometry and characterized as impure talc. Further inquiry into her occupational history revealed that she had worked from the age of 14-18 yrs in a factory making rubber hoses, where she had had an intense exposure to talc. There was no evidence of silicosis or asbestosis, and other significant causes of interstitial lung disease were excluded. This case emphasizes the importance of a thorough occupational history, which may reveal a remote and forgotten exposure to a significant cause of interstitial lung disease. Although this presentation of talcosis is unusual, this case suggests that even a relatively short, but presumably intense exposure to talc more than 40 yrs previously may be a cause of progressive lung fibrosis.

Relief of sleep apnoea after treatment of acromegaly: report of three cases and review of the literature

Sleep apnoea syndrome (SAS) is common in acromegalic patients. Occasionally, the relief of apnoeas after treatment of the acromegaly has been documented. We report the cases of three patients with acromegaly and severe obstructive sleep apnoea, who demonstrated a manifest improvement (respiratory disturbance index (RDI) <20) after treatment with octreotide, indicating that this drug may be effective in this disturbance. In one case, SAS disappeared although the growth hormone level was not fully normalized. This raises the intriguing hypothesis that octreotide has an effect on respiratory control or on the upper airway, that is not directly related to its action on production of growth hormone.

Ifosfamide in the treatment of pediatric malignancies

Neuroblastomas, nephroblastomas, malignant mesenchymal tumors, including rhabdomyosarcomas, Ewing's sarcomas, osteosarcomas, brain tumors, and non-Hodgkin's lymphomas respond to ifosfamide monotherapy. Ifosfamide has found an established place in the treatment of these pediatric malignancies. Ifosfamide has been shown to be an especially valuable agent in brain tumors in patients with a poor-prognosis medulloblastoma. The combination of ifosfamide with other cytotoxic drugs is more effective than ifosfamide medication alone. Ifosfamide has to be given with mesna to prevent bladder toxicity, but other toxic side effects, such as neurotoxicity, nephrotoxicity, and gonadal damage, are more difficult to prevent. Ifosfamide has proven to be an important asset in the treatment of cancer in children.

Isolated lung transplantation; initial experience at the University Hospitals Leuven. Leuven Lung Transplant Group

Lung transplantation nowadays has become a therapeutic modality in the treatment of patients with a variety of end-stage lung diseases. Between July 1991 and December 1992, twelve patients received an isolated lung transplant (eight single lungs and four double lungs) at the University Hospitals of Leuven. The indication for transplantation was emphysema in five patients, pulmonary fibrosis in three, cystic fibrosis in three and primary pulmonary hypertension in one. There were four early, in-hospital deaths (30%): two from sepsis and multi-organ failure, one from anoxia following a bronchial dehiscence and another patient exsanguinated following stent insertion for a partial bronchial dehiscence. Three more patients have died during follow-up: two from chronic respiratory failure secondary to the development of obliterative bronchiolitis (one at 8 months and one at 17 months), and one from a late bronchovascular fistula 4 months following transplantation. The overall actuarial one and two year-survival was 50.0% and 41.6% respectively. All patients discharged from hospital were oxygen free with an improved lung function and exercise capacity. We conclude that lung transplantation is a viable therapeutic option for selected patients with end-stage, irreversible lung disease. In our experience, the bronchial anastomosis remains an important keystone in the early success. Lung transplantation provides a good quality of life in patients free from infection and rejection. Nevertheless, chronic rejection resulting in obliterative bronchiolitis is a major problem in long-term survivors.

Pitfalls of transthoracic needle aspiration biopsy

Four cases are presented in whom transthoracic aspiration biopsy with the rotex needle provided a specific diagnosis, which, on thoracotomy was proved incomplete or wrong. Two cases of abscess were in fact excavated squamous cell carcinomas, one case of tuberculosis was in fact accompanied by a scar-adenocarcinoma, and a fourth case of supposed small cell carcinoma was found to be a muco-epidermoid carcinoma. In all cases, the final diagnosis after thoracotomy led to a change in therapy.

Infectious osteitis pubis

One month after a Burch operation, performed because of urinary stress incontinence, a 65-yr-old woman developed progressive suprapubic pain and a characteristic waddling gait. Initial treatment with bed rest, non-steroidal antiphlogistics and corticosteroids was unsuccessful. Six months later, a biopsy of the symphysis performed because of persisting disabling pain yielded a positive culture of Pseudomonas aeruginosa. A longlasting treatment with intravenously administered antibiotics followed by ofloxacin orally, resulted in complete clinical cure and progressive radiological improvement. The distinction between noninfectious osteitis pubis and infectious symphysitis or osteomyelitis of the pubis is discussed.