Bradford W. Betz

Therapy of Parapneumonic Effusions in Children: Video-Assisted Thoracoscopic Surgery Versus Conventional Thoracostomy Drainage

OBJECTIVE. Controversy surrounds the optimal treatment of parapneumonic effusions. This trial of pediatric patients with community-acquired pneumonia and associated parapneumonic processes compared primary video-assisted thoracoscopic surgery with conventional thoracostomy drainage. DESIGN. A prospective, randomized trial was conducted at DeVos Childrens Hospital (Grand Rapids, MI) between November 2003 and May 2005. All of the patients under 18 years of age with large parapneumonic effusions were approached for enrollment in the study. After enrollment, each patient was randomly assigned to receive either video-assisted thoracoscopic surgery or thoracostomy tube drainage of the effusion. Subsequent therapies (fibrinolysis, imaging, and further drainage procedures) were similar for each group per protocol. RESULTS. Eighteen patients were enrolled in the study: 10 in video-assisted thoracoscopic surgery and 8 in conventional thoracostomy. The groups were demographically similar. No mortalities were encountered in either group, and everyone was discharged from the hospital with acceptable outcomes. Yet, there were multiple variables that demonstrated statistical difference. Hospital length of stay, number of chest tube days, narcotic use, number of radiographic procedures, and interventional procedures were all less in the patients who underwent primary video-assisted thoracoscopic surgery. In addition, no patient in the video-assisted thoracoscopic surgery group required fibrinolytic therapy, which was also statistically different from the thoracostomy drainage group. CONCLUSIONS. The outcomes of this study strongly suggest that primary video-assisted thoracoscopic surgery for evacuation of parapneumonic effusions is superior to conventional thoracostomy drainage.

Observer variability assessing US scans of the preterm brain: the ELGAN study

BackgroundNeurosonography can assist clinicians and can provide researchers with documentation of brain lesions. Unfortunately, we know little about the reliability of sonographically derived diagnoses.ObjectiveWe sought to evaluate observer variability among experienced neurosonologists.Materials and methodsWe collected all protocol US scans of 1,450 infants born before the 28th postmenstrual week. Each set of scans was read by two independent sonologists for the presence of intraventricular hemorrhage (IVH) and moderate/severe ventriculomegaly, as well as hyperechoic and hypoechoic lesions in the cerebral white matter. Scans read discordantly for any of these four characteristics were sent to a tie-breaking third sonologist.ResultsVentriculomegaly, hypoechoic lesions and IVH had similar rates of positive agreement (68–76%), negative agreement (92–97%), and kappa values (0.62 to 0.68). Hyperechoic lesions, however, had considerably lower values of positive agreement (48%), negative agreement (84%), and kappa (0.32). No sonologist identified all abnormalities more or less often than his/her peers. Approximately 40% of the time, the tie-breaking reader agreed with the reader who identified IVH, ventriculomegaly, or a hypoechoic lesion in the white matter. Only about 25% of the time did the third party agree with the reader who reported a white matter hyperechoic lesion.ConclusionObtaining concordance seems to be an acceptable way to assure reasonably high-quality of images needed for clinical research.

Resolution of subependymal cysts in neonatal holocarboxylase synthetase deficiency

Holocarboxylase synthetase deficiency is typically a biotin responsive disorder that presents with lactic acidosis, tachypnea, temperature instability, and shock in neonates (Briones et al. 1989 and Fuchshuber et al. 1992). The primary defect in cases studied to date appears to be the decreased affinity of HCS for its substrate, biotin (Gompertz et al. 1971). Supplemental biotin can provide sufficient substrate to increase HCS enzymatic function and thereby permit biotinylation of the four carboxylase apoenzymes (Briones et al. 1989). We report an infant with HCS deficiency who presented with lactic acidosis, shock, and hypertonia. Subependymal cysts were identified on cranial ultrasound and subsequently confirmed by MRI. Six months following biotin supplementation, she is developmentally normal and MRI of the brain shows complete resolution of the cysts.

Mechanisms of injury to white matter adjacent to a large intraventricular hemorrhage in the preterm brain.

The purpose of this article is to investigate the hyperechoic lesion seen adjacent to a lateral ventricle that contains blood but is not distended. The literature on ependymal barrier dysfunction was reviewed in search of mechanisms of injury to the white matter adjacent to an intraventricular hemorrhage. The clinical literature on the clinical diagnosis of periventricular hemorrhagic infarction was also reviewed to find out how frequently this diagnosis was made. Support was found for the possibility that the ventricular wall does not always function as an efficient barrier, allowing ventricular contents to gain access to the white matter where they cause damage. Hemorrhagic infarction may not be the only or the most frequent mechanism of white matter damage adjacent to a large intraventricular hemorrhage.

Reader Variability in the Use of Diagnostic Terms to Describe White Matter Lesions Seen on Cranial Scans of Severely Premature Infants: The ELGAN Study

To evaluate reader variability of white matter lesions seen on cranial sonographic scans of extreme low gestational age neonates (ELGANs).

Three malformation complexes related to neural crest development

We present an individual with three distinct malformation complexes, DiGeorge syndrome, CHARGE association and Dandy-Walker malformation. An extensive literature review has shown that DiGeorge syndrome and CHARGE association rarely occur simultaneously. The presence of both these malformation complexes with Dandy-Walker malformation has not been previously reported. These three malformation complexes may all be related by neural crest maldevelopment.

Peronea arteria magna.

A 10-year-old girl was evaluated with MR angiography forleft lower extremity varicosities. The arterial phase MIP(Fig. 1) demonstrated an incidental peronea arteria magna(PAM ) of the right calf and a conventional left trifurcation(AT anterior tibial artery, P peroneal artery, PT posteriortibial artery).Anomalous branching of the trifurcation results in adominant peroneal artery in 7–12% of the population, andPAM, in which the peroneal artery is the only vascularsupply to the foot, occurs in 0.2–5.3% [1, 2]. Patients withcongenital or acquired peroneal arterial dominance, espe-cially PAM, are at risk of foot ischemia if this vessel istraumatized, affected by stenoocclusive disease, or har-vested as part of a free fibular graft. Preharvest imaging,such as with MR angiography, has been advocated becausepatients with peroneal arterial dominance can have normaldistal pulses [1].References