Imaging Characteristics of CNS Neuroblastoma-FOXR2: A Retrospective and Multi-Institutional Description of 25 Cases.

BACKGROUND AND PURPOSE: The 5th edition of the World Health Organization Classification of CNS tumors defines the CNS neuroblastoma FOXR2 in the group of embryonal tumors. Published clinical outcomes tend to suggest a favorable outcome after resection, craniospinal irradiation, and chemotherapy. This multicenter study aimed to describe imaging features of CNS neuroblastoma-FOXR2, which have been poorly characterized thus far. MATERIALS AND METHODS: On the basis of a previously published cohort of tumors molecularly classified as CNS neuroblastoma-FOXR2, patients with available imaging data were identified. The imaging features on preoperative MR imaging and CT data were recorded by 8 experienced pediatric neuroradiologists in consensus review meetings. RESULTS: Twenty-five patients were evaluated (13 girls; median age, 4.5 years). The tumors were often large (mean, 115 [ SD, 83] mL), showed no (24%) or limited (60%) perilesional edema, demonstrated heterogeneous enhancement, were often calcified and/or hemorrhagic (52%), were always T2WI-hyperintense to GM, and commonly had cystic and/or necrotic components (96%). The mean ADC values were low (687.8 [SD 136.3] × 10-6 mm2/s). The tumors were always supratentorial. Metastases were infrequent (20%) and, when present, were of nodular appearance and leptomeningeal. CONCLUSIONS: In our cohort, CNS neuroblastoma FOXR2 tumors showed imaging features suggesting high-grade malignancy and, at the same time, showed characteristics of less aggressive behavior. There are important differential diagnoses, but the results of this study may assist in considering this diagnosis preoperatively.

[Necrotising fasciitis--a surgical challenge]. / Nekrotiserende fasciitt--en kirurgisk utfordring.

Necrotizing fasciitis is a severe, potentially fatal, soft tissue infection. Group A streptococci are the main infectious agents. Early surgical treatment is decisive for the outcome. This report includes 20 patients treated consecutively during a four and a half year period, ten women and ten men, 28 to 78 years of age. Condition at admission to hospital, time from symptom appearance to operation, treatment and results are described. All patients had signs of local infection with rubor and swellings. Severe localized pain was typical. Surgical diagnostic exploration confirmed the diagnosis and led to prompt surgical debridement of all affected tissues. Three patients died, 12 survived without severe sequela and five survived with amputated leg or arm. Necrotizing fasciitis has changed from being a rare disease primarily affecting immunocompromised patients to occurring more frequently also among otherwise healthy individuals. By diseases with local soft tissue infection a liberal use of surgical exploration leads to diagnosis. Increased knowledge of the disease and adherence to a treatment protocol based on antibiotic therapy and mandatory aggressive surgery has probably improved the results with no case fatality in the latter half of the study period.

Oral ciprofloxacin versus intravenous cefuroxime as prophylaxis against postoperative infection in vascular surgery: a randomised double-blind, prospective multicentre study.

OBJECTIVES: To test the hypothesis that oral ciprofloxacin is equally effective as intravenous cefuroxime in preventing postoperative infectious complications in patients undergoing peripheral arterial surgery involving the groins. DESIGN: Prospective, randomised, double-blind multicentre study. MATERIALS: 580 patients undergoing arterial surgery involving the groins were randomised to ciprofloxacin (Ciproxin, Bayer) 750 mg x 2 p.o. or cefuroxime (Zinacef, Glaxo) 1.5 g x 3 i.v. given only on the day of surgery. The primary endpoint was wound/graft infection within 30 days postoperatively. Wound infection was defined as pus. RESULTS: The wound infection rate in the ciprofloxacin group was 9.2% (27 patients) and in the cefuroxime group 9.1% (26 patients) according to intention to treat. For correct treatment the corresponding numbers were 9.5% (23 patients) and 9.7% (22 patients), respectively. There were three graft infections (0.5%). The infection rate was 7.1% (31/433) in the absence and 14.9% (22/147) in the presence of distal ulcers (p < 0.05). S. allreus was the most common bacteria isolated. Forty percent of the wound infections were localised to the groins. By multivariate analysis presence of distal ulcer was the only factor of prognostic significance. CONCLUSIONS: The infection rate was similar in the two groups. Thus, oral administration of ciprofloxacin is an attractive, cost-effective and safe alternative to prophylaxis in vascular patients capable of taking oral medication on the day of surgery.

Extravascular arteriovenous oxygen shunting in the cat stomach.

Venous appearance of oxygen and red cells labelled with methaemoglobin was compared in the gastric vascular bed. At 'resting' gastric blood flow the red cells appeared earlier than oxygen after simultaneous close i.a. injection, as would be expected from the intravascular laminar flow profile. However, when lowering arterial inflow pressure to the stomach by partially occluding the coeliac trunk, oxygen often appeared earlier than the red blood cells. When arterial pressure was lower than 50 mmHg this was always the case. This observation is taken to indicate that during these experimental conditions an extravascular shunting of oxygen occurs. It is suggested that this may occur in the submucosal vascular network and/or in the mucosa. The functional implications of such a mechanism are tentatively discussed.

Assessment of gastric blood flow with laser Doppler flowmetry.

The use of laser Doppler flowmetry (LDF) to measure gastric blood flow was evaluated in the cat and man. The reproducibility of laser Doppler flowmetry recordings was studied in the feline stomach. In five cats flowmeter signals and venous outflow of the stomach were simultaneously recorded. The flowmeter recordings were made during operation and gastroscopy in 140 patients by means of two different (PF1-4-kHz and PF2-12-kHz) laser Doppler systems. The flowmeter recordings were highly reproducible during the cat experiments, with a coefficient of variation varying between 4% and 13%. Angulation of the probe within 60-120 degrees against the tissue under study did not affect the flowmeter signal. Pressure of the probe against the studied tissue attenuated the flowmeter signal 42 +/- 13% (n = 10). A significant correlation coefficient (r = 0.76; p = 0.01; n = 30) was obtained between flowmeter signal and venous outflow of the stomach. In man the PF2-12-kHz system yielded a higher flowmeter signal (14.5 +/- 6.9 V; 32 patients) than the PF1-4-kHz system (7.9 +/- 2.5 V; 108 patients). Flow dimensions were calculated by using results previously obtained in the intestines. The estimated blood flow values amounted to 31 +/- 10 and 57 +/- 27 ml min-1 100 g-1 for the PF1-4-kHz and PF2-12-kHz systems, respectively. In conclusion, laser Doppler flowmeter is a promising technique for studying gastric perfusion during operation and endoscopy. Motion artifacts are the major drawback of the present laser Doppler systems.

Effect of cimetidine on augmented gastric blood flow in duodenal ulcer patients.

Blood flow in the human stomach was measured during operation with a 85Krypton washout method which made simultaneous determinations of total blood flow and intramural flow distribution possible. The antrum and the corpus of the stomach could be investigated separately. Eleven patients with duodenal ulcer disease were studied during pentagastrin infusion and after the addition of cimetidine, 3 mg/kg bw, to evaluate the effect of the drug on augmented gastric blood flow. Eight recordings were made over the corpus of the stomach and three recordings over the antrum. Cimetidine caused a 66 +/- 5% decrease (mean +/- SE; range 56-86) in acid secretion and a 62 +/- 5% decrease (range 44-91) in the corpus mucosal blood flow within 15 minutes. Changes were only seen in the acid secreting part of the stomach while the antral circulation remained unaltered. It is concluded that the decrease in pentagastrin induced vasodilatation in the stomach seen after giving cimetidine was secondary to an inhibition of acid secretion.

Effects of prophylactic antibiotics in vascular surgery. A prospective, randomized, double-blind study.

In a prospective, randomized, double-blind study the effects on infection rates of a 1-day and a 3-day course of cefuroxime versus placebo were studied in patients undergoing peripheral vascular surgery. During a 30-month study period 211 patients were randomized to one of three treatment groups: Group I Placebo; Group II cefuroxime 1 day; Group III cefuroxime 3 days. Cefuroxime was administered intravenously (1.5 g every 8 hours) and the first dose was given 1 hour before surgery. Wound infection rates in the three treatment groups were: Group I 16.7%; Group II 3.8% (p less than 0.05 vs placebo); Group III 4.3% (p less than 0.05 vs placebo). One graft infection occurred in 110 patients at risk (0.9%) and this occurred in the placebo group. No allergic reactions or other side effects were noted in any of the treatment groups. No cefuroxime-resistant bacteria were found in Group II or III. In conclusion, prophylactic administration of cefuroxime during 1 day significantly reduced the incidence of infectious complications following peripheral vascular surgery. Extension of the prophylaxis beyond the day of surgery offered no additional effect. The study supports the use of short-term prophylactic antibiotics in vascular surgery.

Treatment of acute massive gastroduodenal haemorrhage with cimetidine in elderly patients.

Ninety-two patients over the age of 60 with acute upper GI-haemorrhage were included in a prospective randomized doubleblind three-centre study of the effect of a five day treatment with cimetidine. Twenty patients had to be excluded because of different reasons. The remaining 72 patients bled from either erosive gastritis, gastric ulcer or duodenal ulcer. Thirty-two patients received cimetidine and 39 placebo. There was no difference in the number of transfusions, rebleedings or operative interventions. Mortality was 1/33 (3%) in the cimetidine group compared to 5/39 (13%) in the placebo group (NS). In the gastric ulcer group there was no mortality among 10 cimetidine patients compared to a mortality of 4 of 12 (33%) patients receiving placebo (p less than 0.05). It is concluded with caution that cimetidine might be effective in haemorrhage from gastric ulcer in patients 60 years and older. For convincing conclusions a larger study of patients with bleeding ulcers is desirable.

Ranitidine in the treatment of gastric, prepyloric and duodenal ulcer--a controlled prospective double-blind trial.

Fifty adult outpatients with endoscopically proven gastric, prepyloric or duodenal ulcers were included in a prospective, randomised double-blind trial of ranitidine (40 mg X 3 daily and 80 mg at bedtime) versus placebo. After 4 weeks the ulcers had healed in 21 of 25 patients receiving ranitidine compared with 7 of 23 in patients receiving placebo (p less than 0.001). The ranitidine treated patients had fewer days of pain (p less than 0.001) and lower consumption of antacids (p less than 0.01) than placebo patients. Patients whose ulcers were not healed after 4 weeks went into an open 4 weeks trial with ranitidine. After the second 4 week period there were still 5 unhealed ulcers, all located in the prepyloric region. No serious side effects or haematological or biochemical abnormalities were observed. It is concluded that ranitidine is a very potent and safe ulcer healing substance. Patients with prepyloric ulcers may need a higher dose or a longer period of treatment.

Intraoperative measurements of gastric blood flow in man: effects on blood flow of acid secretory stimulation and inhibition.

Gastric blood flow in man can be measured with an isotope washout technique, utilizing 85Krypton . Measurements are performed intraoperatively, during general anesthesia, after intraarterial injections of the tracer into the stomach wall. Both total blood flow to the stomach and the flow distribution to the separate wall layers can be estimated. The antrum and the body of the stomach can be studied separately. Repeat measurements are possible, enabling the blood flow to be studied both at rest and/or after induction or inhibition of acid secretion.

The influence of antiserotonin treatment with ketanserin on the pulmonary lodgement of circulating tumour cells in normal and traumatized rats.

As shown in earlier studies, the lodgement of circulating tumour cells in the lungs is reduced by thrombocytopenia in both normal and traumatized rats. Other experiments have shown that thrombocytopenia and antiserotonin treatment with ketanserin, which has a selective effect on 5-HT2 receptors, decrease the hepatic lodgement of intraportally injected tumour cells. The present studies show that treatment with ketanserin also reduces the lodgement of i.v.-injected tumour cells in the lungs in both normal and traumatized rats.

Gastric blood flow and distribution in anesthetized cat and man as studied by an inert gas elimination method.

Gastric blood flow and its intramural distribution were studied in anesthetized cat and man by recording the elimination of intra-arterially injected krypton-85. The elimination was monitored with two external detectors--a scintillation detector recording the disappearance of gamma-activity from the entire gastric wall and a G-M tube recording the disappearance of beta-activity from the muscle layer only. Total and muscle layer blood flow could be calculated from the washout curves, and, knowing these variables, the blood flow to the mucosa-submucosa could be indirectly calculated. Gastric blood flow in the cat and man closely resembled each other, both in magnitude and distribution. Total blood flow in man 'at rest' was 12 +/- 4 ml/min and 100 g tissue (mean +/- S.D.; no. = 20), muscle blood flow amounting to 7 +/- 3 and mucosa-submucosa flow to 16 +/- 8 ml/min and 100 g muscle and mucosa-submucosa tissue, respectively. The distribution to the muscle layer was 26 +/- 14% and to the mucosa-submucosa 74 +/- 14% of total gastric blood flow.

Gastric blood flow and distribution: the effect of pentagastrin in anesthetized cat and man as studied by an inert gas elimination method.

Using a krypton-85 elimination method previously described, the effect of pentagastrin on gastric blood flow has been studied in 28 anesthetized patients, 12 control patients, and 16 patients with duodenal ulcer disease. Both in control and duodenal ulcer patients a significant increase in total blood flow was found, reflecting an increase of flow in the mucosa-submucosa layer of the corpus. In normal subjects a 5-fold increase in flow was found in this tissue layer, whereas the corresponding increase in duodenal ulcer patients was 12-fold. Concomitantly, a significant decrease of flow distribution to the muscle layer was seen. In the antrum pentagastrin did not cause any significant changes in either mucosa-submucosa or muscle layer blood flow. No qualitative differences in the response to pentagastrin, with regard to the gastric blood flow, was found between normal subjects and duodenal ulcer patients.

Short-term systemic prophylaxis with cefoxitin and doxycycline in colorectal surgery. A prospective, randomized study.

The efficacy of cefoxitin or doxycycline as antibiotic prophylaxis in colorectal surgery was compared in 102 elective operations. Both drugs were used perioperatively only. Cefoxitin was used in 55 cases and doxycycline in 47. Ten patients in the cefoxitin group and 4 in doxycycline group had wound infections. Three intraabdominal abscesses were seen, one after cefoxitin and two after doxycycline prophylaxis. All three were due to anastomotic leakage. Bacteriologic studies revealed no negative ecologic effects of prophylaxis. The short-term prophylaxis used did protect against serious infectious complications. The extended spectrum of cefoxitin provided no added benefit in prophylaxis. Patients with inflammatory bowel disease treated preoperatively with salicylazosulfapyridine run a greater risk of postoperative infection in spite of the prophylaxis.