John Mealey

Origin of Organisms Infecting Ventricular Shunts

&NA; Results of skin cultures obtained before 413 of 505 operations for cerebrospinal fluid‐diverting ventricular shunt placement or revision in a pediatric population from April 1980 to May 1983 are analyzed and compared to results of cultures from 20 subsequent shunt infections. Sensitivities to 11 different antibiotics were determined for each isolate cultured. The total operative infection rate was 20 of 505 (4%). Gram‐negative bacilli alone accounted for 3 of 20 (15%) shunt infections. One gram‐negative bacillus/Staphylococcus aureus infection occurred. Factors predisposing for gramnegative bacillus shunt infection were found in all 4 cases. The majority of shunt infections were caused by typical resident skin organisms: Staphylococcus epidermidis alone, 9/20 (45%); Staphylococcus aureus alone, 4/20 (20%); Corynebacterium sp., 1/20 (5%); &agr;‐Streptococcus with S. epidermidis, 1/20 (5%); and Micrococcus with S. epidermidis, 1/20 (5%). Only 4 (20%) of the 20 shunt infections were due to organisms identical to those originally grown from the skin. Another 4 (20%) seemed to be infected with a strain of organism different from that initially recovered from the skin. The remaining skin organism shunt infections may or may not have come from the patients skin. The data suggest that not all skin organism shunt infections arise from contamination by resident skin bacteria at the incision sites at the time of operation. Alternate sources for the infecting organisms are discussed. The antibiotic sensitivity data on skin isolates and shunt isolates suggest that vancomycin is the antibiotic best suited for prophylaxis against shunt infection at our institution.

Optic Chiasmatic Glioma in Children

We reviewed the records of 29 patients with optic nerve or chiasm glioma, or both, seen from 1955 to 1966. Sixteen patients were girls and 13 were boys. At the time of diagnosis, 14 patients were less than 2 years old. Optic atrophy was the most frequently seen physical finding, present in 26 of 29 patients. Twelve patients had diencephalic syndrome (41%). Proptosis was seen in eight. Eleven patients (38%) had associated neurofibromatosis. Pneumoencaphalogram was done on 26 patients and was abnormal in 23. The diagnosis was confirmed at surgery in 27 patients. All tumors were astrocytomas. Eighteen patients underwent radiotherapy. Surgery and radiotherapy were used as treatment for optic-chiasmatic glioma with diencephalic syndrome.

Candida albicans Shunt Infection

Seven cases of successfully treated Candida albicans cerebrospinal fluid shunt infections are reported. Treatment consisted of shunt removal and intravenous Amphotericin B in all cases and intraventricular Amphotericin B in 4 cases. Serious underlying medical illness, recent antibiotic therapy, indwelling intravascular and/or Foley catheters, coincident candidiasis and low birth weight prematurity are major risk factors for candida shunt infection. Candida shunt infection appears to occur by either contamination at the time of shunt placement or by hematogenous dissemination.

Brain tumor chemotherapy with mithramycin and vincristine.

Mithramycin chemotherapy with or without concomitant use of vincristine sulfate, either by continuous arterial infusion or by protracted intravenous administration, failed to produce worthwhile results in 15 patients seriously ill with malignant gliomas or metastatic brain tumors. Their postoperative survival was not prolonged. Although one individual showed short‐term improvement after a 4‐day carotid infusion of mithramycin and another seemed better temporarily after 3 weeks of daily intravenous treatment with this drug, the overall morbidity associated with either method of treatment controverted the significance of these isolated favorable responses. A child with a disseminated glioma tolerated but did not benefit from 2 infusions of mithramycin into the cisterna magna at 0.01 and 0.015 times the daily intravenous dose. The effect of mithramycin and vincristine on 8 of the malignant gliomas in this series was assessed in vitro. The susceptibility of the cultured tumor cells to these drugs ranged from slight to extreme, according to a morphological grading of acute cytotoxic alterations which did not correlate with the clinical results.

Superiority of PCNU over AZQ in the treatment of primary brain tumors: results of a prospective randomized trial (81-20) by the Brain Tumor Study Group.

SummaryPurposeA two-arm randomized clinical trial was performed to determine the efficacy of PCNU and AZQ in the treatment ofde novo or recurrent primary brain tumors. An additional objective was to gather information on the administration and toxicity of these compounds, supplementing that obtained previously in phase I/II studies.MethodsDuring 1982 and 1983 the Brain Tumor Study Group randomized 152 adult patients with primary brain tumors to receive PCNU 75–100 mg/m2 intravenously (IV) every 8 weeks or AZQ 15 mg/m2 IV once a week for 4 weeks, every 6–8 weeks. All patients who had not received ‘full dose’ radiotherapy before randomization received it concurrently with the first course of protocol chemotherapy. The data were analyzed for the total randomized population (RP), and for 130 patients in the valid study group (VSG) formed by excluding 22 patients for whom the histologic diagnosis was not documented by central review.ResultsMedian survival times were 11.0 months for the PCNU group and 8.4 months for the AZQ group. The difference in survival curves was statistically significant for the RP (p=0.01) and the VSG (p=0.02). Lifetable analysis of the VSG showed estimated 2-year survivals of 34% for PCNU and 11% for AZQ. The advantage of PCNU remained significant (p=0.006) after adjustment for histopathologic category, age, initial performance status, and interval from initial reported surgery. Myelosuppression was the principal toxicity in both groups.

Brain scanning in childhood

Radioisotope scanning is of value in the diagnosis and localization of brain tumorsand other nonneoplastic intracranial lesions, but it is utilized much less frequently in children than in adult patients, and its role as a neurodiagnostic adjunct in pediatric medicine is not completely defined. This report reviews the results of brain scanning with radioactive mercury and radioiodinated human serum albumin in 50 children. The indications, particular usefulness, and limitations of this procedure are discussed.

Alterations in Cerebrospinal Fluid Dynamics in Syringomyelia, Hydromyelia, and Myelomeningocele

Syringomyelia is a relatively uncommon disease of cystic cavitation of the spinal cord, generally found at the cervical and thoracic levels. Characteristically, the syringomyelic cyst lies separate from the spinal central canal, as distinct from hydromyelia, in which the central canal is distended with cerebrospinal fluid (CSF). However, the two conditions may coexist and may be difficult to distinguish histologically.24 Furthermore, some investigators, noting that syringomyelia and hydromyelia may share a common etiology, have substituted the term syringohydromyelia.3

Infantile Subdural Hematomas

Analysis is provided of a series of subdural hematomas in infants treated at the James Whitcomb Riley Hospital for Children, Indianapolis, Indiana. Etiology, pathology, clinical findings, treatment, and results are discussed.