A questionnaire survey on patients' willingness to pay with reference to the waiting time of public in-vitro fertilization treatment in Hong Kong

OBJECTIVE

To evaluate patients' willingness to pay (WTP) with reference to the waiting time of public in-vitro fertilisation (IVF) treatment in order to improve the public IVF service in Hong Kong.

STUDY DESIGN

A prospective multi-centred questionnaire survey. Infertile women attending infertility clinics of nine public hospitals in Hong Kong between October 2017 and August 2018 were asked to complete a questionnaire in their first clinic visit.

RESULTS

Out of 1092 respondents, 10.4 % had private IVF cycles prior to their first visit at public hospitals. In general, patients were willing to pay more for a shorter waiting time for public IVF service. The proportion of respondents who were willing to pay more than HK$10,000 (US$1282) for one IVF cycle increased from 54.6% to 80.7% if the waiting time for public IVF service were hypothetically shortened from four years to one year. Likewise, 22.5 % versus 45.5 % were willing to pay more than HK$ 25,000 (US$3205) with a waiting time of four versus one year respectively. Assuming the cost per IVF cycle was HK$ 25,000 (US$3205), 23.4 % of respondents could afford one IVF cycle, 40.0 % of them could afford two IVF cycles and 31.5 % could afford three IVF cycles. A multivariate regression model demonstrated that only family income and presence of existing child(ren) were significant independent determinants of the maximum amount that an individual was willing to pay for IVF (p < 0.05). Those with family monthly income below HK$100,000 ($12,820) were less than half as likely, and those without existing child(ren) were more than double as likely, to be willing to pay higher for IVF.

CONCLUSION

Patients were willing to pay more for a shorter waiting time for public IVF service. Those with family income below HK$100,000 (US$ 12,820) were less than half as likely, and those without existing children were more than double as likely, to be willing to pay higher for IVF.

Timing of gangrene tissue debridement after autologous bone marrow cell implantation in patients with superficial femoral arterial occlusion: preliminary experiences

AIM

Although implantation of bone marrow mononuclear cells (BMI) was shown to improve outcomes in patients with severe peripheral arterial occlusive disease (PAOD), little experience has been reported in patients with an arterial occlusion level above the knee, ischemic gangrene, and high cardiovascular risk. This study sought to investigate the timing of gangrene tissue debridement and the safety of BMI in these patients.

METHODS

Six "no-option" PAOD patients were enrolled with an arterial occlusion level above the knee, ischemic gangrene, and 3 systemic diseases related to a high cardiovascular risk. The ischemic status was evaluated by measuring the ankle-brachial index (ABI), transcutaneous oxygen pressure (TcPO2), and wound healing after BMI.

RESULTS

All patients safely underwent the procedures with intravenous general anesthesia by titrating propofol. Major lower extremity amputation, minor debridement amputation, and debridement surgery were performed in 2 (33.3%), 1 (16.7%), and 2 (33.3%) patients, respectively, 3.1 2.8 months after BMI. Compared to the amputation group (N=3), the salvage group (N=3) had a significantly higher baseline ABI (P=0.02) and a shorter distance between the gangrene site and arterial occlusion site (P=0.01). In the 3 patients who underwent debridement, ABI and TcPO2 significantly improved 1 month after BMI, and gangrenous tissues were debrided 3.8 ± 3.6 (range, 1~8) months after BMI with complete healing within 1 month.

CONCLUSION

Autologous BMI therapy is safe in patients at high cardiovascular risk with an arterial occlusion level above the knee and ischemic gangrene. Effective predictors of BMI include the baseline ABI and distance to the ischemia. Gangrene tissue should be debrided at least 1 month after BMI.

Randomized, phase III study results of clobazam in Lennox-Gastaut syndrome

OBJECTIVE

To evaluate efficacy and safety of clobazam, a 1,5-benzodiazepine, as adjunctive therapy for Lennox-Gastaut syndrome (LGS).

METHODS

Patients aged 2-60 years were randomized to placebo or clobazam 0.25, 0.5, or 1.0 mg/kg/day. Study consisted of 4-week baseline, 3-week titration, and 12-week maintenance phases, followed by a 2- or 3-week taper or continuation in an open-label extension. Primary endpoint was percentage decrease in mean weekly drop seizure rates during maintenance vs baseline phases for modified intention-to-treat (mITT) population. Secondary outcomes included other seizure types, responder rates, and physicians' and caregivers' global assessments.

RESULTS

A total of 305 patients were screened, 238 were randomized, and 217 composed the mITT population. Of patients enrolled after a protocol amendment, 125/157 (79.6%) completed. Average weekly drop seizure rates decreased 12.1% for placebo vs 41.2% (p = 0.0120), 49.4% (p = 0.0015), and 68.3% (p < 0.0001) for the clobazam 0.25-, 0.5-, and 1.0-mg/kg/day groups. Responder rates (≥50%) were 31.6% (placebo) vs 43.4% (p = 0.3383), 58.6% (p = 0.0159), and 77.6% (p < 0.0001) for clobazam 0.25-, 0.5-, and 1.0-mg/kg/day groups. Physicians' and caregivers' assessments indicated clobazam significantly improved symptoms. Somnolence, pyrexia, upper respiratory infections, and lethargy were the most frequent adverse events reported for clobazam.

CONCLUSIONS

Clobazam significantly decreased weekly drop seizure rates in LGS. No new safety signals were identified.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that clobazam as adjunctive therapy is efficacious, in a dosage-dependent manner, in reducing mean weekly drop seizure rates of patients with LGS over 12 weeks.

Surgical resection of hypothalamic hamartomas for severe behavioral symptoms

Hypothalamic hamartomas (HHs) are associated with treatment-resistant epilepsy. Many patients also experience severe and sometimes disabling psychiatric problems. The most common behavioral symptoms consist of paroxysms of uncontrolled anger related to poor frustration tolerance. These can include violence, resulting in disrupted family or school relationships, and legal consequences including incarceration. In a large cohort of patients undergoing surgical resection of HHs for refractory epilepsy, 88% of families described an improvement in overall behavioral functioning [1]. Here, we describe four patients (three males, mean age=11.9 years) who underwent surgical resection of HHs largely for behavioral indications. Three patients had relatively well controlled seizures, and one had no history of epilepsy. All patients had striking improvement in their psychiatric comorbidity. HH resection can result in significant improvement in behavioral functioning, even in patients with relatively infrequent seizures. Further investigation under approved human research protocols is warranted.

Intravenous levetiracetam in children with seizures: a prospective safety study

In 2006, intravenous levetiracetam received US Food and Drug Administration (FDA) approval for adjunctive treatment of partial onset seizures in adults with epilepsy, 16 years or older. We have established the safety, tolerability, and dosage of intravenous levetiracetam in children. This prospective study included 30 children (6 months to <15 years of age). Patients were administered a single dose of intravenous levetiracetam (50 mg/kg, maximal dose 2500 mg) over 15 minutes. A blood level of levetiracetam was performed 10 minutes after the infusion. The treated children's average age was 6.3 years (range 0.5-14.8 years). The mean levetiracetam level was 83.3 microg/mL (range 47-128 microg/mL). There were no serious adverse reactions. Minor reactions included sleepiness, fatigue, and restlessness. An apparent decrease in seizure frequency across all seizure types was noted. The dose of 50 mg/kg was well tolerated by the patients and is a safe, appropriate loading dose.

Central precocious puberty due to hypothalamic hamartomas correlates with anatomic features but not with expression of GnRH, TGFalpha, or KISS1

BACKGROUND/AIMS

Hypothalamic hamartomas are the most common identifiable cause of central precocious puberty (CPP). Hamartoma characteristics proposed to be associated with CPP include specific anatomic features and expression of molecules such as gonadotropin-releasing hormone (GnRH), transforming growth factor alpha (TGFalpha), and GRM1A, which encodes the type 1 metabotropic glutamate receptor alpha isoform. We sought to determine whether hamartomas that cause CPP could be distinguished by anatomic features, expression of these molecules, or expression of KISS1, whose products signal through the receptor GPR54 to stimulate GnRH release.

METHODS

Clinical records and radiologic images were reviewed for 18 patients who underwent hamartoma resection for intractable seizures; 7 had precocious puberty. Resected tissue was examined for expression of GnRH, GnRH receptor (GnRHR), TGFalpha, KISS1, GPR54, and GRM1A.

RESULTS

Hypothalamic hamartomas associated with CPP were more likely to contact the infundibulum or tuber cinereum and were larger than hamartomas not associated with CPP. GnRH, TGFalpha, and GnRHR were expressed by all hamartomas studied. Expression of KISS1, GPR54, and GRM1A did not differ significantly between hamartomas associated and not associated with CPP.

CONCLUSION

Anatomic features rather than expression patterns of candidate molecules distinguish hypothalamic hamartomas that are associated with CPP from those that are not.

Dramatic first words spoken in 2 children after vagus nerve stimulation

Vagus nerve stimulation has become an accepted adjunctive treatment for refractory epilepsy with more recent FDA approval in the treatment of depression. Many "positive" effects have been noted in patients with epilepsy namely increased alertness, improved cognition, behavior and mood. These changes appear to be independent of seizure reduction and antiepileptic drug decrease. We present two children (aged 8 and 9 years) who were non-verbal and spoke their first words shortly after vagus nerve stimulators were implanted. The mechanism is unclear although vagus nerve stimulation has been clearly shown to induce neuronal, chemical and perfusion changes in both subcortical and cortical regions of the brain. There is likely a combined effect on primary speech areas as well subcortical and mamillothalamic tracts, and possibly even stimulation and changes at the local vocal cord level contributing to this phenomenon. Our observation has important implications in encephalopathic patients both with and without epilepsy.

Reversible lamotrigine-induced neurobehavioral disturbances in children with epilepsy

A retrospective review was performed in patients who developed neurobehavioral adverse reactions to lamotrigine. Data were obtained from interviews, examinations, and routine medical records. There were 7 male and 2 female patients with epilepsy with a mean age of 5 years. All 9 patients became hyperactive and agitated over a broad range of lamotrigine dosing (0.7-14.0 mg/kg per d). Five patients developed self-injurious and violent behaviors. Two patients developed severe insomnia. The most affected patient was a 6-year-old boy whose mood and affect became extremely volatile. He also experienced threatening visual and auditory hallucinations and insomnia. All 9 patients had dramatic improvement and/or resolution of the adverse neurobehavioral effects following discontinuation or reduction of lamotrigine. Reversible, severe neurobehavioral disturbances associated with lamotrigine therapy have not been reported in the literature. While idiosyncratic and uncommon, this is a potentially significant, clinical side effect. Further studies are necessary to clarify the population at risk.

Stimulus-induced diffuse voltage attenuation (SIDVA): a previously undescribed EEG pattern in a critically ill child

We report the case of a 15-month-old critically ill child with stimulus-induced diffuse voltage attenuation, a previously unreported electroencephalogram pattern. No clinical evidence of seizure activity was associated with these EEG changes. The patient went on to have a full recovery. This case suggests that critically ill children have distinct stimulus induced electrographic patterns from those seen in adults. Additional research is needed to define the significance of these patterns.

Endoscopic resection of hypothalamic hamartoma for refractory epilepsy: preliminary report

The intrahypothalamic subtype of hypothalamic hamartoma (HH) is usually associated with refractory epilepsy, cognitive impairment, and organic behavioral disturbance. It is often a devastating disorder for both patient and family. The gelastic (laughing) seizure is the hallmark seizure type. However, multiple other seizure types can often develop during the course of the disease, and are typically refractory to antiepilepsy drugs (AEDs). Previously it was uncertain if HH tissue was responsible for seizure genesis or whether resection of the HH would result in improvement of the seizures. Recently both of these questions have been answered in the affirmative. Surgical resection using a transcallosal, interforniceal approach has recently been shown to be efficacious and generally safe for the treatment of the refractory seizures. However, even more recently, we have been performing the majority of HH surgical resection by using an endoscopic technique with a transventricular approach. This article presents the details of the operative technique and discusses preliminary outcome data, particularly with comparison to the transcallosal technique. Using an endoscope holder with micromanipulator facilitates endoscopic resection. Linking the endoscope to a system of frameless stereotaxis is essential for successful resection. Forty-four patients age 8 months to 44 years have undergone endoscopic resection. The ideal candidate for endoscopic removal has a hamartoma completely or nearly completely involving one wall of the third ventricle and is 1 cm or less in greatest diameter. Because it is essential to be able to visualize the lesion within the third ventricle for resection, there must be at least 6 mm of space between the top of the lesion and the roof of the third ventricle. Patients with intractable epilepsy caused by HH can be rendered seizure free or show marked improvement in seizure frequency by surgical removal, surgical disconnection, or radiosurgical ablation of the lesion. Which of these options should be recommended for an individual patient is not yet clear. One of the options involves resection or disconnection of the HH with a transventricular endoscopic approach. In selected patients, endoscopic resection of HH is effective in the treatment of intractable epilepsy, with lower complication rates and shorter hospital stays than transcallosal resection.

The Histopathology of Hypothalamic Hamartomas

Hypothalamic hamartomas (HHs) are rare developmental tumors that cause seizures or pituitary axis dysfunction, usually beginning in childhood. We analyzed HH tissue from 57 patients whose tumors were resected through recently developed transcallosal interforniceal and transventricular endoscopic surgical approaches. All cases were composed of abnormally distributed but cytologically normal neurons and glia, including fibrillary astrocytes and oligodendrocytes. Neuronal elements predominated in most cases, but a relative increase in astrocytic elements was seen with increasing age. All had various sized nodular foci of neurons as well as areas of diffusely distributed neurons with interspersed glial cells. Smaller neurons predominated, and most cases had only a few interspersed large ganglion cells. Immunohistochemistry demonstrated extensive production of synapse-associated proteins. Immunohistochemistry for phosphorylated and nonphosphorylated neurofilament and alpha-internexin demonstrated staining patterns consistent with mature neurons. In contrast to cortical dysplasia, atypical large ganglion-like balloon cells were almost never seen. In summary, although their number and distribution vary, mature smaller neurons were the most prominent and most consistent histologic feature of HH. Nodules of these small neurons were a universal feature of the microarchitecture of HH lesions associated with epilepsy. Characterization of these neurons may aid in understanding the mechanism of seizure development in HH.

Hypothalamic Hamartoma and Infantile Spasms

PURPOSE

A small number of patients with hypothalamic hamartoma (HH) present with infantile spasms (IS) as an initial or early seizure type. We describe the clinical features of IS associated with HH.

METHODS

Our series of patients with HH and epilepsy was reviewed to identify cases with a history of IS. The clinical features and neuroradiological findings in this study group were compared to a control group of patients with HH and refractory epilepsy, but without a history of IS.

RESULTS

We identified six patients with HH and a history of IS in this series (n = 122, 4.9%). Five of the six are male. Four of the six patients (67%) developed IS as their first seizure type. The mean age for onset of IS was 6.2 months (range 4-9 months). Results of electroencephalographic (EEG) study at the time of IS diagnosis showed hypsarrhythmia in two (33%). Five patients were treated with adrenocorticotropic hormone (ACTH), and four of the five (80%) responded with control of IS. However, these patients developed other seizure types, and were ultimately refractory to medical management. Aside from the IS, no significant differences in clinical and imaging features were determined between the study group and the control group.

CONCLUSIONS

HH should be included in the differential diagnosis for infants presenting with IS. These patients may have hypsarrhythmia on initial EEG, and may respond to ACTH treatment with improvement of IS. However, all became refractory with other seizure types, more commonly seen in HH patients. Focal pathologies associated with IS may be subcortical, as well as cortical, in nature. We have not identified any predictive features for the occurrence of IS in the HH population.

Clobazam

Catastrophic childhood epilepsies such as infantile spasms (IS), progressive myoclonic epilepsy, and Lennox-Gastaut syndrome (LGS) are rare but debilitating and frequently persist into adulthood. Early, targeted use of medications that have demonstrated efficacy in the management of LGS or its associated epilepsies may simplify the patient's treatment regimen and reduce the incidence of adverse events. Key to the overall benefit to the patient is to maximize seizure control while minimizing adverse effects, especially behavioral and cognitive problems. Clobazam has demonstrated clinical benefit and has been administered safely in more than 50 European studies in which data were reported on greater than 3000 pediatric and adult patients with epilepsy, 300 of whom were diagnosed with LGS; therefore, its use is now being investigated in the U.S. This review will explore the use of clobazam in the treatment of epilepsy, particularly with regard to its potential benefit in LGS. Though not currently approved for use in the U.S., a program is underway to gain Food and Drug Administration approval for the treatment of pediatric and adult patients with refractory epilepsy, specifically in LGS. A phase 2 study will be completed in late 2006 to investigate the safety and efficacy of clobazam as adjunctive therapy in 68 pediatric and adult patients with LGS.

Transcallosal resection of hypothalamic hamartoma for intractable epilepsy

PURPOSE

To present the results of transcallosal surgical resection of hypothalamic hamartoma (HH) in 26 patients with refractory epilepsy in a prospective outcome study.

METHODS

Patients with refractory epilepsy symptomatic to HH were referred for surgical resection of their HH (mean age, 10.0 years; range, 2.1-24.2 years). A transcallosal, interforniceal approach was used to remove and/or disconnect the hamartoma. Volumetry was obtained on pre- and postoperative brain MRI scans to determine percentage of resection. Outcome assessment included determination of postoperative seizure frequencies in comparison to baseline and the incidence of postoperative complications. Postoperative changes in cognitive and behavioral functioning, in comparison to baseline, were elicited by parental report.

RESULTS

The average postoperative follow-up interval was 20.3 months (range, 13-28 months). Fourteen (54%) patients were completely seizure free, and nine (35%) had at least a 90% improvement in total seizure frequency. Parents reported postoperative improvement in behavior in 23 (88%) patients and in cognition in 17 (65%) patients. Transient postoperative memory disturbance was seen in 15 (58%) patients, but persisted in only two (8%). Two (8%) patients had persisting endocrine disturbance requiring hormone replacement therapy (diabetes insipidus and hypothyroidism in one each). With univariate analysis, the likelihood of a seizure-free outcome correlated with younger age, shorter lifetime duration of epilepsy, smaller preoperative HH volume, and 100% HH resection.

CONCLUSIONS

Refractory epilepsy associated with HH can be safely and effectively treated with surgical resection by a transcallosal, interforniceal approach. Short-term memory deficits appear to be transient for most patients, and family perception of the impact of surgery on cognitive and behavioral domains is favorable. Complete resection yields the best result.

Childhood mesial temporal sclerosis

The prevalence and clinical characteristics of mesial temporal sclerosis have not been well studied in children. All brain magnetic resonance imaging (MRI) reports of children less than 14 years of age were reviewed from two tertiary institutions. A 52-month period from one institution and a 37-month period from the other were reviewed. All reports of definite or possible mesial temporal sclerosis were noted. These patients' MRIs were then reviewed to confirm the MRI diagnostic criteria of mesial temporal sclerosis. The charts of the patients who satisfied these criteria were reviewed in detail. Three thousand one hundred brain MRI reports were reviewed. Twenty-six reports of mesial temporal sclerosis were found. Twenty-four of the 26 films satisfied the criteria of mesial temporal sclerosis by MRI after the films were reviewed. The prevalence among all pediatric brain MRI studies was 0.77%. All patients had presented with seizures, that is, there were no "incidental" findings of mesial temporal sclerosis. Four patients had a history of febrile seizures. Mesial temporal sclerosis is an uncommon finding in children, but when it occurs, it is always associated with epilepsy. Asymptomatic mesial temporal sclerosis or mesial temporal sclerosis not associated with a seizure disorder did not occur in our series. Febrile seizures can occur in association with mesial temporal sclerosis presenting in childhood.

The hypothalamic hamartoma: a model of subcortical epileptogenesis and encephalopathy

Although uncommon, the hypothalamic hamartoma (HH) is often associated with a devastating clinical syndrome, which may include refractory epilepsy, progressive cognitive decline, and deterioration in behavioral and psychiatric functioning. Contrary to conventional thinking which attributed seizure origin to cortical structures, the hamartoma itself has now been firmly established as the site of intrinsic epileptogenesis for the gelastic seizures (i.e., characterized by unusual mirth) peculiar to this disorder. It also appears that the HH contributes to a process of secondary epileptogenesis, with eventual cortical seizure onset of multiple types in some patients. Anticonvulsant medications are known to be poorly effective in this disorder. Treatment, including some innovative approaches to surgical resection, is now targeted directly at the HH itself, with impressive results. Younger patients, in particular, may avoid the deteriorating course described earlier. Access to tissue from larger numbers of patients at single or collaborating centers specializing in HH surgery will allow for research into the fundamental mechanisms producing this little understood disorder. Refractory epilepsy associated with HH is the premier human model for subcortical epilepsy and an excellent model for secondary epileptogenesis and epileptic encephalopathy.

Neurologic complications associated with respiratory syncytial virus

Encephalopathy has been demonstrated to be associated with respiratory syncytial virus bronchiolitis. In this study, the data on all patients less than 14 years of age hospitalized with respiratory syncytial virus bronchiolitis over the past 4 years was reviewed. Patients who had concomitant diagnoses consistent with neurologic disease underwent detailed chart review. There were 964 patients (age 0.1 to 13.6 years) with a diagnosis of respiratory syncytial virus bronchiolitis. Thirty-six of these patients had concurrent neurologic diagnoses. Twenty-four patients were excluded because of preexistent neurologic disorders, probable simple febrile seizures, or a history of epilepsy. Twelve respiratory syncytial virus-positive patients had definite neurologic complications without another recognized cause. Seven of these patients had seizures (predominantly generalized tonic-clonic and one with status epilepticus), three had generalized encephalopathy (marked hypotonia and decreased responsiveness) of whom two also developed esotropia. Two patients developed isolated esotropia. There was an incidence of neurologic complications of 1.2% (0.7% seizures) in a total of 964 patients with respiratory syncytial virus bronchiolitis. This percentage does not include presumed simple febrile seizures or exacerbations of preexisting seizure disorder (further 1.3%). Neurologic complications occur with respiratory syncytial virus bronchiolitis, and physicians and other caregivers should be aware of this entity as well as the favorable prognosis.

Emergency transcallosal resection of hypothalamic hamartoma for "status gelasticus"

Hypothalamic hamartomas are rare developmental malformations of the inferior hypothalamus. Typically they result in symptomatic, refractory mixed seizure disorder with trademark gelastic or laughing seizures. We present a 30-month-old boy with a hypothalamic hamartoma and a nearly 2-month history of near-continuous gelastic seizures, which we have labeled "status gelasticus." The seizures were refractory to multiple antiepileptic drugs (AEDs), and emergency transcallosal resection of the hypothalamic hamartoma was performed with resultant near-immediate cessation of the seizures. At 12-month follow-up, the patient was averaging one brief gelastic seizure every 2 weeks, with a longest seizure-free period of 2 months.

Successful resection of a hypothalamic hamartoma and a Rathke cleft cyst

The authors report the case of a 12-year-old girl with Pallister-Hall syndrome, long-standing refractory, symptomatic epilepsy, mental retardation, and panhypopituitarism in whom two rare, deep midline lesions were detected. She underwent successful transsphenoidal resection of the Rathke cleft cyst and transcallosal resection of the hypothalamic hamartoma within a 4-day period without complications. Neuropathological studies confirmed the neuroimaging diagnoses for the two lesions. The patient has been seizure free for 6 months postoperatively.

Treatment of Refractory Status Epilepticus with Hemispherectomy

A 7-year-old boy with left hemiparesis secondary to right hemispheric cortical dysplasia was admitted to the hospital with increasing numbers of seizures. Magnetic resonance imaging showed a small dysplastic right hemisphere with abnormally thickened gyri and an apparently normal left hemisphere. Previous video-electroencephalogram (EEG) monitoring showed bilateral independent spikes and generalized slow spike-and-wave episodes on EEG and [18F]fluorodeoxyglucose (FDG) positron emission tomography scan demonstrated scattered areas of regional hypometabolism bilaterally; therefore hemispherectomy was not undertaken at that time. During this hospital stay, nonconvulsive status epilepticus developed and was refractory to multiple medical therapies including pentobarbital (PTB) coma. Burst-suppression pattern during PTB coma appeared to be generalized spike and wave, but when EEG was reviewed with increased time resolution spikes suggested a right hemisphere origin. The patient underwent bilateral intracarotid amobarbital spike-suppression test that showed only minimal suppression of epileptiform discharges with injection of the left carotid, but complete suppression of spike activity after right-sided carotid injection. A right hemispherectomy was performed with complete cessation of status epilepticus. Postoperative EEG showed no epileptiform discharges. Patient follow-up was limited to 12 months after surgery. The patient had regained the ability to walk unaided and was seizure free with a single antiepileptic medication. This case illustrates a potentially life-saving procedure for refractory status epilepticus and several techniques including a spike-suppression test to aid in prediction of cessation of seizures after hemispherectomy.

Agenesis of the corpus callosum is associated with feeding difficulties

Our objective was to characterize the common occurrence of feeding and swallowing disorders noticed by our speech therapy department among patients with agenesis of the corpus callosum. All patients with suspected or presumed agenesis of the corpus callosum undergoing therapy for feeding and/or swallowing disorders, including oral and/or pharyngeal dysphagia and oral-sensory disorder, were identified. Their brain magnetic resonance imaging (MRI) studies and charts were reviewed in detail. Seven patients with striking oral-motor and oral-sensory disorder met the criteria for agenesis of the corpus callosum. Particular difficulties noted include oral-sensory defensiveness in five of these seven patients, oral dysphagia/weakness in all seven patients, and pharyngeal dysphagia with risk of aspiration in three of these seven patients. The oral-motor weakness observed in all of the patients affected the strength and coordination necessary for functional oral-phase swallowing. We conclude that feeding and swallowing disorders are significant in children with agenesis of the corpus callosum. Although the pathophysiologic mechanism is not known, recognition of this phenomenon is important because early detection and intervention can facilitate functional feeding and swallowing patterns earlier in these patients, therefore avoiding the adverse and more severe disorders that can arise when dysphagias and/or oral-sensory disorder persist over extended periods of time.

Magnetic resonance imaging detection of mesial temporal sclerosis in children

The objective of this study was to investigate the prevalence and clinical characteristics of mesial temporal sclerosis as diagnosed by brain magnetic resonance imaging in children. A total of 390 consecutive brain magnetic resonance imaging studies in children were reviewed for evidence of mesial temporal sclerosis. Subsequently, the magnetic resonance imaging scans and charts of patients with mesial temporal sclerosis were reviewed and their clinical details were evaluated. The magnetic resonance imaging studies had been performed for multiple indications, including seizures, headache, and developmental problems. In children, the prevalence of mesial temporal sclerosis among all brain magnetic resonance imaging studies was 3.1% (12 of 390 studies) and 12.1% (12 of 99 studies) among all brain magnetic resonance imaging studies performed for seizures. These children all presented with a history of seizure disorder, often had other medical problems, and histopathology (when available) nearly always (5 of 6 patients) confirmed their magnetic resonance imaging diagnosis of mesial temporal sclerosis. The prevalence of mesial temporal sclerosis is low among all pediatric patients who had magnetic resonance imaging brain studies. All our mesial temporal sclerosis patients had clinical seizures; i.e., it was never an "incidental finding". Children with mesial temporal sclerosis often had comorbid conditions, and the diagnosis of mesial temporal sclerosis made by magnetic resonance imaging was accurate when compared with the available histopathology.

Successful neurosurgical treatment of childhood complex partial status epilepticus with focal resection

The treatment of complex partial status epilepticus continues to be controversial, especially with regard to the intensity of the treatment. Medical therapy and drug-induced coma are sometimes required. Rarely this may not be effective. A healthy 4-year old girl was first seen in complex partial status epilepticus. She had a 1-year history of cryptogenic partial-onset seizures. Detailed magnetic resonance imaging (MRI) studies were normal. Her course was refractory to multiple medical therapies and multiple subpial transection (MST). An urgent epilepsy surgery evaluation resulted in a focal cortical resection being performed over the right mesial parietal region with resultant seizure freedom and no significant neurologic deficit 2 years later. This patient illustrates the need to consider occult focal cortical dysplasia as a cause of nonconvulsive status epilepticus (NCSE) in children, and if it is not responsive to medical management, the utility of performing an urgent epilepsy surgery evaluation.

Levetiracetam in refractory pediatric epilepsy

Levetiracetam, one of the newer-generation antiepilepsy drugs, is not currently approved for use in children. Given its favorable efficacy, pharmacokinetic, and, particularly, safety profile in adults, we felt that it may be a useful antiepilepsy drug for children with refractory epilepsy. We treated 39 patients (mean age 8.6 years) with open-label levetiracetam for up to 9 months. Seizure frequency, drug dosages, adverse events, and neurologic examinations were documented at baseline and routine follow-up visits. Levetiracetam, as add-on therapy, was effective in reducing seizure frequency in a variety of seizure types but was most effective for partial-onset seizures. Fourteen patients were discontinued for lack of efficacy or adverse events. Ten patients reported improvements in cognition or behavior. Levetiracetam was generally effective and well tolerated in this open-label study. Its apparent positive effects on cognition in some patients are encouraging. Large, well-controlled studies are needed to fully define levetiracetam's potential in children with refractory epilepsy.

Lumbar spinal stenosis causing congenital clubfoot

Congenital lumbar spinal stenosis is believed to rarely cause neurologic symptoms during childhood. We present a 16-year-old boy with bilateral congenital clubfeet surgically corrected by tendo Achillis releases at 2 years of age who presented with progressive, bilateral footdrop. Magnetic resonance imaging of his lumbosacral spine showed severe spinal stenosis at the L3-5 vertebrae. Congenital lumbar spinal stenosis is probably an under-recognized cause of lower extremity neurologic abnormalities, including clubfoot deformity. Magnetic resonance imaging has made this eminently treatable disorder easier to recognize.

Sphenoid sinusitis masquerading as migraine headaches in children

The sphenoid sinus is often referred to as the "neglected sinus." Isolated sphenoid sinusitis is a rare disease with potentially devastating complications. It occurs at an incidence of about 2.7% of all sinus infections. Although headache is the most common presenting symptom, there is no typical headache pattern. Three cases of children with isolated sphenoid sinusitis presenting with acute, subacute, and chronic headache symptoms are presented. The sensory innervation of the sphenoid sinus is derived from the ophthalmic and maxillary branches of the trigeminal nerve, which may explain the pathophysiology of the headache, similar to the trigeminovascular pain theory of migraine. There are few reports on sphenoid sinusitis and headache; however, modern neuroimaging has made this probably under-recognized disorder easier to diagnose and treat. Although the diagnosis can be difficult to differentiate from migraine headache, early and appropriate treatment usually results in an excellent outcome without morbidity.

Encephalopathy associated with respiratory syncytial virus bronchiolitis

Respiratory syncytial virus is an extremely common cause of childhood respiratory infections resulting in significant morbidity and mortality. Although apnea is a well-known complication in young infants with respiratory syncytial virus bronchiolitis, the encephalopathy associated with this infection is not well recognized. Our study reveals an incidence of encephalopathy of 1.8% in a total of 487 patients with respiratory syncytial virus bronchiolitis studied over a period of almost 4 years. Seizures were the presenting complication. Based on our study of a cohort of children with respiratory syncytial virus bronchiolitis, we believe that neurologic complications, although relatively uncommon, represent a significant component of this common childhood illness. Furthermore, respiratory syncytial virus has been shown to release several mediators that could directly or indirectly be neurotoxic and induce an encephalopathy associated with the respiratory illness.

Visual-evoked potentials in the assessment of optic gliomas

The most effective method for the screening and monitoring of optic pathway gliomas in children with neurofibromatosis type 1 remains a dilemma. Children less than 6 years of age are the group at highest risk for the development of optic pathway gliomas. Although an annual ophthalmologic examination currently is recommended as the most efficient method to screen for optic pathway gliomas, this method is often unreliable and inaccurate in young children. Magnetic resonance imaging remains the most sensitive test; however, cost and the need for sedation or general anaesthetic preclude its use as a routine screening test. We previously have recommended visual-evoked potentials (VEPs) as a possible alternative or aid in the assessment of optic pathway gliomas in this group of patients. The aims of this study were to ascertain the sensitivity of VEPs in detecting optic pathway gliomas and to determine whether VEPs are useful in monitoring the progress of optic pathway gliomas. This study provides further evidence of the sensitivity of VEPs in detecting optic pathway gliomas. In addition, VEPs may provide additional useful information concerning the progression of optic pathway gliomas once they have been detected.

Clinical rhabdomyolysis

Although rhabdomyolysis is an uncommon disorder, especially in children, it can present as a severe, life-threatening event. Paediatricians need to be aware of this important, probably underdiagnosed disorder in order to implement appropriate early treatment. In this report, seven children with rhabdomyolysis of both forms, endogenous and exogenous, are presented. Despite comprehensive 'up-to-date' investigations being performed on paediatric patients with endogenous (often recurrent) rhabdomyolysis, the majority of these patients' underlying disorders will remain undiagnosed. Overall, these patients usually have a very good prognosis even if repeated, severe life-threatening episodes occur. It is recommended that a regimen of early therapy with fluids and sodium bicarbonate be instituted in all patients with rhabdomyolysis.

Local supplementation of ketoprofen reduces the incidence of low back pain after lumbar epidural anesthesia

BACKGROUND

Backache is a common postoperative complaint after lumbar epidural anesthesia. Our study was aimed to compare the effect of the local addition of ketoprofen on the incidence of postepidural backache after nonobstetric surgery.

METHODS

One thousand patients scheduled for hemorrhoidectomy were randomly given 4 ml of 1% lidocaine with ketoprofen 1:400 (ketoprofen group) or without ketoprofen (control group) for local skin infiltration prior to epidural needle placement. Each of them received a single epidural injection of 25 ml 2% lidocaine with epinephrine 1:200000, and was interviewed 24, 48, and 72 hours postoperatively using a standard visual analog scale (VAS) for evaluation of postepidural backache.

RESULTS

The incidence of postepidural backache in the ketoprofen-group patients for the 3 days was 9.8%, 4.6%, and 1.8%, all rates which were significantly less than those observed in the control-group patients (22.8%, 17.4%, and 9.2%, p < 0.001). There was also a significant association between postepidural backache and multiple attempts at epidural needle insertion.

CONCLUSION

In summary, the local addition of ketoprofen reduced the incidence and severity of postepidural backache.

Drug therapy in juvenile dermatomyositis: follow-up study

A series of 33 patients with juvenile dermatomyositis was reviewed in terms of their prognosis in relation to their drug therapy. This retrospective study was intended to help clarify the use of various therapies in this rare, heterogeneous disease from our hospital's experience in the last 24 years. The results confirmed that oral corticosteroids should remain the undisputed first line of treatment. For more refractory, chronic patients, the results suggest that azathioprine should be the favored drug of first choice (in addition to corticosteroids). There may be a role for cyclosporine as a "rescue" treatment, but this needs to be further defined.

Anesthetic management of a parturient implanted with a permanent pacemaker--a case report

At the present time, a patient with a pacemaker who undergoes an anesthesia for a surgical procedure is very common, but a parturient with a permanent pacemaker scheduled for elective cesarean section (c/s) is very rare. Complete heart block in pregnancy is not a common event and it may be congenital or acquired, particularly secondary to cardiac surgery. In normal women, the heart rate is physiologically increased commensurate with need, whereas in a parturient with installment of an implanted fixed rate pacemaker of VVI mode her heart rate cannot accelerate to cope with increased physiological demand because of the fixed pacing rate. For cesarean section, because of destabilized cardiovascular adaptation, an anesthesiologist must focus on detecting the early signs of compromised cardiac output in order to avoid maternal as well as fetal distress. He may run considerable risk to administer general or regional anesthesia to this kind of parturient. We present a case report in managing the parturient installed a with non-rate response type pacemaker undergoing C/S under epidural anesthesia.

Neonatal status in cesarean section under epidural anesthesia with supplementary oxygen

Simple O2 mask has been used in patient under regional anesthesia for increasing the FiO2, especially in the aged and the pregnant. The relationships between maternal FiO2 and umbilical arterial (UA) and venous (UV) PO2, PCO2, pH, and neonatal Apgar score were studied in 45 patients receiving Cesarean section under epidural anesthesia. 2% xylocaine 18-20 ml with adrenaline 1:200,000 was used to attain the sensory level of T-4. Patients were allocated randomly into three groups. Group I, acting as a control group, breath only room air during the course of anesthesia. Group II was breathing through a simple face mask with an oxygen inflow of 6L/min. Group III was breathing oxygen with a flow rate of 10L/min through a simple face mask. UA and UV blood samples were collected separately at the time of delivery for blood gas analysis. The 1-min, and 5-min Apgar scores were recorded also. Mean values of the UA blood samples for the 3 groups (Gp. I, Gp. II and Gp. III respectively) were: PO2--16.50 mmHg, 20.20 mmHg and 19.50 mmHg; PCO2--49.20 mmHg, 48.10 mmHg and 50.3 mmHg; pH--7.31, 7.30 and 7.30. Mean values of the UV blood samples for the 3 groups (Gp. I, Gp. II and Gp. III respectively) were: PO2--28.6 mmHg, 36.9 mmHg and 36.5 mmHg; PCO2--38.20 mmHg, 38.80 mmHg and 40.40 mmHg; pH--7.36, 7.36 and 7.34. There was a significant increase in UA and UV PO2 when using a simple O2 mask (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

The evaluation of subarachnoid administration of fentanyl for surgery and postoperative analgesia in patients undergoing cesarean section

The use of spinal opioids for postoperative analgesia has gained popularity in recent years. In this study, subarachnoid fentanyl 20 micrograms was evaluated to determine its efficacy for postoperative analgesia, its possible side effects and its effects on the newborn. Sixty ASA class I or II at-term parturients undergoing elective cesarean section were randomly divided into two groups. In one group fentanyl 20 micrograms (0.4 ml) with 0.5% heavy marcaine 2.0 ml was given intrathecally and in the other group only 0.5% heavy marcaine 2.0 ml with CSF 0.4 ml was given intrathecally. The average time for patients in the fentanyl group to demand the first dose of narcotic for pain was 6.8 +/- 3.2 h and in the control group it was 3.9 +/- 1.1 h. The incidences of postoperative nausea and vomiting were higher in the fentanyl group than in the control group. Pruritus was only found in the fentanyl group and amounted to 50%. Early or late respiratory depression was not found in the fentanyl group. During operation, all patients were wakeful and alert. Neonatal condition as determined by 1-min and 5-min Apgar score was satisfactory and showed no significant difference in both groups. Examination on neurobehavior and reflexes done at the baby room showed no abnormality in both groups.

Ilioinguinal nerve block with 0.375% marcaine for postoperative pain relief in cesarean section

Bilateral ilioinguinal nerve block with local anesthetic drugs to treat postoperative pain in lower segment cesarean section (Pfannestiel incision) under general anesthesia had show profound effective by P. Bunting and I. McConachie. We used the same method but with lower concentration 0.375% marcaine 10 ml to each side in 12 patients. We compare the pain score and the requirement for pethidine intramuscular injection to 12 patients as control group. Pain score were less in the block patients within 8h after surgery, and total amount of pethidine given was 700 mg. In control group, the pain score were higher at the first 8 h than nerve block group during the study (p less than 0.05), and the total amount of pethidine requirement was 1250 mg. There were no observed adverse effect during the study.

[Ilioinguinal nerve blockade with or without epinephrine for analgesia after caesarean section]

The analgesic effect of bilateral ilioinguinal nerve blockade with or without epinephrine after caesarean section with Pfannenstiel incision was investigated in 36 ASA class 1-2 parturients. They were randomly classified into 3 groups of 12 each. Before the patients were extubated from standard general anesthesia, bilateral ilioinguinal nerve blockade was performed. Group A patients were the control group. Group B patients received 0.375% plain marcaine 10 mL to each side. Group C patients received 0.375% plain marcaine with 1:200000 epinephrine 10 mL to each side. The pain scores and requirement for post operative analgesia of group B and C were compared with the control group A. The pain scores of group B and C were decreased 30% and 37% respectively during the first eight hours after operation. However, group C patients had lower pain scores during the first day after operation. There was an increased time from anesthesia to the first injection of pethidine in group B and C when compared with group A (4.57 +/- 2.94, 4.38 +/- 2.72 and 1.8 +/- 0.9 hr, respectively). However, no significant difference between group B and C. The total pethidine requirement were decreased in group B and C although the mean pethidine dose was not statistically significant. The results suggest that bilateral ilioinguinal nerve blockade improve the quality of postoperative analgesia. The adding epinephrine can prolong the duration of nerve blockade.

Establishment and characterization of a new human cell line derived from ovarian clear cell carcinoma

A new cell line, designated OCC1, was established from the ascitic fluid of a patient with a clear cell carcinoma of the ovary. The cell line grew well without interruption for over 12 months and over 80 passages. The doubling times of OCC1 were 36 and 38 hr at the 10th and 40th passages, respectively. Chromosomal analysis of the cell line showed hypertriploidy with modal number around 70-77. Several structural chromosomal abnormalities were consistently found. Electron microscopy revealed that OCC1 produced a basement membrane-like structure in vitro. Histological evaluation of xenografts from OCC1 in the 33th passage implanted and grown in nude (athymic) mice revealed a morphology identical to that of the original tumor.

[Anesthesia for hepatoma resection]

Hepatocellular carcinoma is one of the leading cancers in Taiwan and is responsible for 20% of cancer deaths. Since long-term survival of hepatocellular carcinoma patients cannot be expected with any treatment other than surgery, the therapeutic value of hepatic resection has become more important than ever before. In Keelung Chang Gung Memorial Hospital, twenty-one patients with hepatoma received hepatic resection during the period of August 1985 to July 1989 were reviewed. These patients were induced for anesthesia with thiopental, succinylcholine and fentanyl; maintenance of anesthesia with isoflurane, N2O and O2. Four of them have abnormal coagulopathy preoperatively. Common intraoperative problems were metabolic acidosis and hypotension. Estimated blood loss showed great variety among these patients. Eighteen patients needed respiratory support and intensive care postoperatively. One patient was noted to have pulmonary edema. Otherwise, the overall procedure was smooth and satisfactory. In addition, there is no significantly difference in liver function test after a month of hepatoma resection. All the patients survived except one who died within two months after surgery.