Primary paediatric chest wall tumours necessitating surgical management

INTRODUCTION

Limited literature exists on oncological chest wall reconstruction in the paediatric population, with the field still largely undecided on the best surgical reconstructive techniques to employ. The use of biological grafts/meshes is gaining popularity in certain adult surgical procedures but their use in paediatric procedures is rarely reported in the literature. We present the outcomes of our institution's multidisciplinary approach to managing paediatric chest wall tumours as well as our experience with the use of biological grafts for chest wall reconstruction following oncological resections.

METHODS

Data were analysed retrospectively from eight paediatric patients who were treated for primary chest wall tumours between 2010 and 2018.

RESULTS

The tumours comprised two lipoblastomas, three Ewing's sarcomas, an undifferentiated sarcoma with osteosarcomatous differentiation, a high grade undifferentiated sarcoma and a myofibroma. Seven of the eight patients underwent chest wall reconstruction with a biological graft. There were no postoperative mortalities and no evidence of recurrence in any of the patients in the series. No further chest wall operations were required and there were no postoperative infection related complications.

CONCLUSIONS

We support the use of biological grafts for chest wall reconstruction after oncological resections and maintain that a multidisciplinary approach is essential for the management of paediatric chest wall tumours.

Testicular atrophy following paediatric primary orchidopexy: A prospective study

BACKGROUND

With the Nordic consensus statement advocating orchidopexy at an earlier age, the present study sought to investigate the outcomes of primary paediatric orchidopexy at a tertiary UK centre.

OBJECTIVE

To prospectively assess testicular atrophy following primary orchidopexy for undescended testes in a paediatric population. Secondary outcomes were complication rates and whether outcomes were dependent on grade of operating surgeon.

STUDY DESIGN

Prospective data regarding age at operation, classification of the undescended testis, length of follow-up, and subjective comparison of intraoperative and postoperative testicular volumes compared with the contralateral testis were collected. Testicular atrophy was defined as >50% loss of testicular volume or a postoperative testicular volume <25% of the volume of the contralateral testis. Patients were excluded for incomplete data and follow-up <6 months.

RESULTS

Data for 234 patients were analysed. Testicular atrophy occurred in 2.6% of cases. There was no reported testicular re-ascent. All secondary acquired cases underwent a previous ipsilateral hernia repair. There was no significant difference in outcomes comparing the grade of surgeon (consultant n = 8, trainee/staff-grade surgeon n = 7-8). There was a trend towards postoperative catch-up growth in approximately one fifth of cases.

DISCUSSION

Previous studies have reported a testicular atrophy rate of 5%. The present study reported a similar rate of 2.6%. In agreement with a previous publication, it was also found that testicular atrophy was not dependent on the grade of operating surgeon. The mechanism for testicular catch-up growth is not well understood. Animal studies have supported the hypothesis that increased temperature has a detrimental effect on testicular volume. However, follow-up in the present cohort was short (median 6.9 months), making interpretation of this finding difficult. It is acknowledged that clinical palpation alone to determine testicular volume potentially introduces intra-observer and inter-observer error. However, prospective studies using ultrasound to determine testicular volumes following orchidopexy have reported catch-up growth.

CONCLUSION

This study represented one of the larger collections of prospective assessments of outcomes following primary orchidopexy. It was acknowledged that subjectively assessing testicular volume is not ideal; however, the data correlated with similar studies.

Aspergillus epiglottitis in a non-immunocompromised patient

The authors present a case that highlights an atypical example of a fungal epiglottis in an otherwise well adult patient with no medical history of fungal infection or an immunocompromised state. As current medical literature presents this fungus as only manifesting in the immunocompromised, the authors suggest, by this case report, that fungal pathogens be considered as a potential cause of epiglottitis in non-immunocompromised patients.

Alignment delays in the N = Z nuclei (72)Kr, (76)Sr, and (80)Zr

The ground state rotational bands of the N = Z nuclei (72)Kr, (76)Sr, and (80)Zr have been extended into the angular momentum region where rotation alignment of particles is normally expected. By measuring the moments of inertia of these bands we have observed a consistent increase in the rotational frequency required to start pair breaking, when compared to neighboring nuclei. (72)Kr shows the most marked effect. It has been widely suggested that these "delayed alignments" arise from np-pairing correlations. However, alignment frequencies are very sensitive to shape degrees of freedom and normal pairing, so the new experimental observations are still open to interpretation.

Benefit-cost analysis of residential and outpatient addiction treatment in the State of Washington

A benefit-cost analysis of full continuum (FC) and partial continuum (PC) care was conducted on a sample of substance abusers from the State of Washington. Economic benefits were derived from client self-reported information at treatment entry and at 9 months postadmission using an augmented version of the Addiction Severity Index (ASI). Average (i.e., per client) economic benefits of treatment from baseline to follow-up for both FC and PC were statistically significant for most variables and in the aggregate. The overall difference in average economic benefit between FC and PC was positive ($8,053) and statistically significant, favoring FC over PC. The average cost of treatment amounted to $2,530 for FC and $1,138 for PC (p < .01). Average net benefits were estimated to be $17,833 (9.70) for FC and $11,173 (23.33) for PC, with values showing statistical significance (p < .05). Results strongly indicate that both treatment options generated positive and significant net benefits to society.

Treatment services received by supplemental security income drug and alcoholic clients

This study examined self reported problems and treatment services received by 237 recipients of Supplemental Security Income (SSI) benefits for "drug abusers and alcoholics" who had been assigned and entered into substance abuse treatment. All were administered the Treatment Services Review (TSR), a brief interview in which patients describe treatment services they have received during the past month and substance-related problems they are currently experiencing. In addition to describing serious alcohol and drug problems, SSI recipients reported a need for treatment for medical and psychiatric problems. The TSR data revealed that these clients primarily received drug and alcohol services and more limited medical, psychiatric, and employment services during treatment. There was relatively little indication of the provision of legal or family/social treatment services. The data are consistent with other findings that indicate that treatment for substance dependence provides only limited services other than those for alcohol and drug abuse.

Does clinical case management improve outpatient addiction treatment

This project evaluated whether clinical case managers (CCMs) could increase access and utilization of social services in the community; and thereby improve outcomes of addiction treatment. No case management (NoCM)--patients received standard, group-based, abstinence-oriented, outpatient drug abuse counseling, approximately twice weekly. Clinical case management (CCM)--patients were treated in the same programs but also were assigned a CCM who provided access to pre-contracted, support services such as drug free housing, medical care, legal referral, and parenting classes from community agencies. CCM patients received more alcohol, medical, employment, and legal services than NoCM patients during treatment. At 6 month follow-up CCM patients showed significantly more improvement in alcohol use, medical status, employment, family relations, and legal status than NoCM patients. We conclude that CCM was an effective method of improving outcomes for substance abuse patients in community treatment programs. Essential elements for successful implementation included extensive training to foster collaboration; and pre-contracting of services to assure availability.

Supplemental social services improve outcomes in public addiction treatment

AIMS

To evaluate the effectiveness and value of social services added to standard addiction rehabilitation.

DESIGN

A controlled, quasi-experimental, field study with repeated measures.

SETTING

Conducted in two groups of publicly supported outpatient addiction treatment programs. Control programs provided standard, twice-weekly, outpatient group counseling. "Enhanced" programs provided standard counseling but also case managers to coordinate and expedite use of pre-contracted medical screenings, housing assistance, parenting classes and employment services.

MEASUREMENTS

The Addiction Severity Index was used to record the nature and severity of patient problems in seven areas at treatment admission and at 6-month follow-up. Services provided during treatment were measured with the Treatment Services Review. Measures were taken on consecutive samples of patients admitted to all programs--before enhancements (wave 1, N = 431)--and at 12 months (wave 2, N = 710); and 26 months following enhancements (wave 3, N = 187).

FINDINGS

There were no significant differences in patient characteristics, treatment services or 6-month outcomes of the two sets of programs in wave 1. Wave 2 and especially wave 3 enhanced programs provided significantly more social and medical services than control programs. Patients treated in enhanced programs showed significantly less substance use, fewer physical and mental health problems and better social function at 6-months than Controls.

CONCLUSIONS

Adding social services to public sector programs substantially improved the outcomes of addiction treatment. Changes in "real world" systems require time to implement; early evaluations may fail to capture the full impact of those changes.

Characteristics of recipients of Supplemental Security Income (SSI) benefits for drug addicts and alcoholics

This study examined symptom severity and level of functioning in recipients of Supplemental Security Income (SSI) benefits for drug addicts and alcoholics (DA&A). Although substantial numbers of substance abusers received these benefits until the program was canceled in 1997, little information has been available on the characteristics of these individuals. Approximately 2500 SSI DA&A recipients were assessed at the point in which they were to be referred for treatment services. Results indicated that in addition to long histories of alcohol abuse and recent problems with employment, these DA&A recipients were characterized by high levels of medical and psychiatric problems. Problem severities in these latter two areas were found to be consistently high across several subgroupings of recipients, including those who reported no alcohol or drug use in the prior 30 days. These findings suggest that SSI DA&A recipients are often significantly impaired beyond their alcohol and drug use.

"Intensive" outpatient substance abuse treatment: comparisons with "traditional" outpatient treatment

Do "intensive," freestanding outpatient substance abuse treatment programs actually provide more intensive services than "traditional" outpatient programs? Three hundred and thirty-eight patients in 6 "intensive" outpatient (IO) programs (three or more times weekly) were compared with 580 patients from 10 "traditional" outpatient (TO) programs (one or two times weekly) on severity of admission problems, treatment services received and six month outcomes.

RESULTS

1. IO subjects generally had the most severe medical, employment, legal and psychiatric problems at admission. 2. IO patients received more alcohol and drug focused services; but fewer medical and employment focused services than the TO patients. Both groups received very few psychosocial services. 3. There were not significant differences between the IO and TO program samples at follow-up. However, both groups showed significant reductions in substance use, improvements in personal health and social function.

Norepinephrine metabolism and psychoactive drugs in the endogenous depressions. 1968

After intraventricular injection of norepinephrine-H3, the concentration of norepinephrine, of normetanephrine and of the deaminated catechols in rat brains was determined, following action of imipramine, desmethylimipramine, chlorpromazine, lithium chloride or cocaine. Following administration of imipramine, desmethylimipramine, and chlorpromazine, norepinephrine concentration decreased significantly at first, had distinctly increased 4.5 hours after imipramine and desmethylimipramine but was normal once again after chlorpromazine. Normetanephrine concentration increased after imipramine and desmethylimipramine but was unchanged after chlorpromazine. Under the effect of these drugs, the deaminated catechols showed no changes compared with control values. Cocaine resembled the antidepressants, but the amount of deaminated compounds was reduced. Lithium chloride, on the other hand, increased the concentration of deaminated catechols under certain conditions, reduced normetanephrine concentration but did not influence norepinephrine concentration. In addition to the animal experiments, the following data of six patients with an "endogenous" depression were recorded over a period of several weeks: the clinical findings by means of the Hamilton Depression Rating Scale, and the excretion of normetanephrine and of vanillylmandelic acid (VMA) in the urine before, during and after treatment with imipramine. The therapy led to a significant reduction of VMA; however, this reduction cannot be correlated with an improvement in the clinical findings. On the other hand, excretion of normetanephrine is apparently not dependent on the administration of imipramine but seems to reflect the clinical state, since improvement of the depression was regularly combined with an increased excretion of normetanephrine.

Private substance abuse treatments: are some programs more effective than others?

There have been few studies of treatments for substance dependence among private programs. The present study compared the patient populations, treatment services provided and six-month outcomes of employed, insured patients referred by an employee assistance program to four private treatment programs (two inpatient and two outpatient). Subjects were alcohol and/or cocaine dependent males referred from a single employer. Ninety-four percent were successfully contacted at six-month follow-up, with confirmatory urinalysis and breathalyzer samples taken. Three results were obtained. First, there were significant and pervasive improvements shown in the total sample at follow-up. Fifty-nine percent were completely abstinent, 82% were working and only 8% required re-treatment. Second, there were significant differences among the programs in levels of improvement and six-month outcomes. Finally, the differences in efficacy were related to the differences in the nature and amount of treatment services provided.

Preventing substance abuse: the state of the art

While drug abuse among adolescents and young adults has begun to decline from the epidemic levels of the late 1970s, it remains a serious national health problem. Much information from research suggests that young people at the junior and senior high school levels are the most vulnerable to the social pressures that lead to experimental and then regular use of psychoactive substances. Well-designed prevention programs for youngsters in these age groups have the potential to prevent the onset and development of regular drug use. Primary prevention strategies developed over the past two decades--media campaigns, school drug education programs, and "generic" programs--are reviewed, and evaluative research is discussed. The authors describe two additional prevention approaches--the "macro" approach (creating a climate of nondrug use) and positive peer pressure strategies--for which early data suggest genuine promise for the future.

A stressful social situation as a precipitant of schizophrenic symptoms: an epidemiological study

Modern hypotheses as to the aetiology of schizophrenia are likely to be multifactorial and to include psychosocial factors. A typical aetiological hypothesis might propose that an “identity” crisis precipitated psychotic symptoms in an individual who was predisposed to schizophrenia; the predisposition could be due both to inherited biological factors and to abnormal personality traits caused by a faulty family environment or other social factors. Hypotheses such as these lead to the expectation that schizophrenia would be precipitated by psychological stress. However, statistical studies which have attempted to relate the onset of schizophrenia to psychological stress have not produced evidence consistent with such an expectation. For example, hospital admissions for psychosis were not increased in England during the blitz (10, 12, 13). Nor was a grossly increased rate of psychosis found in populations of concentration camp survivors (9, 16). Also, it has been claimed that the rate of psychosis was not increased by combat exposure among U.S. soldiers in World War II, whereas the rate of neurosis was clearly affected by combat exposure (6). Consistent with this last point it has been stated that the rate of hospitalization for psychosis in U.S. military personnel has remained relatively constant over the last 40 years apparently independent of war or peace (7, 1), whereas the rate of hospitalization for nonspsychotic disorders has fluctuated widely (7).

Antibodies affecting metabolism of chicken erythrocytes: examination of schizophrenic and other subjects

Human plasma contains an antibody which produces a complement-linked lysis of chicken erythrocytes and an associated marked stimulation of the cells' aerobic glycolysis. This appears to account for reported alteration in chicken erythrocyte metabolism produced by the plasmas of some schizophrenic patients.