Intraoperative ultrasound imaging in the surgical treatment of congenital hyperinsulinism: prospective, blinded study.

BACKGROUND: In congenital hyperinsulinism (CHI), preoperative prediction of the histological subtype (focal, diffuse, or atypical) relies on genetics and 6-[18F]fluoro-l-3,4-dihydroxyphenylalanine (18F-DOPA) PET-CT. The scan also guides the localization of a potential focal lesion along with perioperative frozen sections. Intraoperative decision-making is still challenging. This study aimed to describe the characteristics and potential clinical impact of intraoperative ultrasound imaging (IOUS) during CHI surgery. METHODS: This was a prospective, observational study undertaken at an expert centre over a 2-year interval. IOUS was performed blinded to preoperative diagnostic test results (genetics and 18F-DOPA PET-CT), followed by unblinding and continued IOUS during pancreatic resection. Characteristics and clinical impact were assessed using predefined criteria. RESULTS: Eighteen consecutive, surgically treated patients with CHI, with a median age of 5.5 months, were included (focal 12, diffuse 3, atypical 3). Focal lesions presented as predominantly hypoechoic, oval lesions with demarcated or blurred margins. Patients with diffuse and atypical disease had varying echogenicity featuring stranding and non-shadowing hyperechoic foci in three of six, whereas these characteristics were absent from those with focal lesions. The blinded IOUS-based subclassification was correct in 17 of 18 patients; one diffuse lesion was misclassified as focal. IOUS had an impact on the surgical approach in most patients with focal lesions (9 of 12), and in those with diffuse (2 of 3) and atypical (2 of 3) disease when the resection site was close to the bile or pancreatic duct. CONCLUSION: Uniform IOUS characteristics made all focal lesions identifiable. IOUS had a clinical impact in 13 of 18 patients by being a useful real-time supplementary modality in terms of localizing focal lesions, reducing the need for frozen sections, and preserving healthy tissue and delicate structures.

Self-biting with multiple finger amputations following spinal cord injury.

We have observed mutilative self-biting leading to multiple finger amputations in two patients following C4 complete spinal cord injury (SCI). Both men were of normal intelligence without psychosis and each had a neurotic personality and history of fingernail biting. They related the self-biting to anxiety and depression. We believe these to be the first English language reports of multiple finger amputations due to self-biting following SCI.

Intraspinal hematoma as a complication of anticoagulant therapy.

Two patients who developed intraspinal hematomas associated with anticoagulation therapy are described, and the pathology, clinical presentation, risks, evaluation and management of this rare hemorrhagic consequence, which results in spinal cord injury (SCI), are discussed. A 49-year-old man was taking warfarin sodium 7.5 mg orally every day for two weeks for thrombophlebitis. Prothrombin time (PT) was 24 sec (control = 17 sec). Two days after a dosage reduction for a PT of 36.5 sec (control = 11 sec), he developed severe neck pain, numbness and weakness of the legs, and then quadriplegia. Warfarin therapy was discontinued, and 25 mg of phytonadione was administered intravenously. An epidural hematoma was removed via a C3-C6 laminectomy, and the patient remains a C3 complete quadriplegic. The second patient was a 64-year-old man who was taking warfarin sodium 5 mg and 7.5 mg orally on alternate days following an aortic-valve replacement. PT was maintained at 1.5 times the control value. Four years later, he fell and sustained flexion distraction and compression injuries of the spine at the L1-L2 level. He complained of severe neck pain and headache. Warfarin therapy was stopped, and 10 mg of phytonadione was administered i.v. During a hospital transfer he developed complete paraplegia. PT was 12.4 sec (control = 10.8 sec). Twelve days later, a laminectomy was performed to remove the T6-L1 subdural hematoma revealed by computed tomography (CT). The patient remains a T5 complete paraplegic. Unlike intracranial hemorrhage, intraspinal hemorrhage usually occurs in the epidural space, most often in the dorsal thoracic spine.(ABSTRACT TRUNCATED AT 250 WORDS)

Baclofen toxicity associated with declining renal clearance after ibuprofen.

A 64-year-old male with an incomplete spinal cord injury had been taking baclofen 20 mg tid for 2 1/2 months without side effects. His blood urea nitrogen and serum creatinine rose from 13 and 0.9 mg%, respectively, to 59 and 2.8 mg% after ibuprofen 600 mg tid was begun. The patient displayed baclofen toxicity, developing confusion, disorientation, bradycardia, and hypothermia. His blood pressure dropped and he complained of blurred vision. Ibuprofen discontinuation and fluid repletion corrected the renal indices. Rapid tapering of baclofen was accompanied by reversal of baclofen toxicity. Patients taking baclofen must be monitored closely for toxicity when declining renal function is present. Clinicians should be alert to the possibility of renal insufficiency developing when ibuprofen is initiated. This case demonstrates the potential for ibuprofen-induced renal insufficiency to reduce baclofen clearance, thereby leading to baclofen toxicity. Published reports of ibuprofen-induced renal insufficiency are reviewed and pertinent pharmacokinetics of baclofen discussed.

Telogen effluvium: hair loss after spinal cord injury.

A 26-year-old man sustained a C5 complete spinal cord injury (SCI) and displayed hysteric behavior which continued into the fourth month of hospitalization. Four months after injury, sudden loss of scalp hair was noted, consistent with psychogenic telogen effluvium. Other causes of hair loss were ruled out. During the sixth month, peak hair loss was noted over the back of the head. Four months after peak shedding, the loss of young club hairs was no longer observed. Recovery was complete seven months after peak loss, leaving a smaller permanent area of diffuse hair loss over the occiput. This pattern of hair loss has not been described previously in association with SCI.

Views of pharmacy supportive personnel in Florida.

Forty-eight supportive personnel, employed in Florida hospital and community pharmacies, were surveyed by written questionnaire to identify their views on the role of the supportive person in relation to other staff roles, to determine the confidence these individuals have in their abilities, and to establish the educational backgrounds and views on educational needs of supportive personnel. Results of the questionnaire are presented and discussed. Although most of the respondents were trained on the job and were confident in designated technical functions, 81.1 percent felt that a community college program for supportive personnel would be of benefit.