Dual-Layer Detector Cone-Beam CT Angiography for Stroke Assessment: First-in-Human Results (the Next Generation X-ray Imaging System Trial).

BACKGROUND AND PURPOSE: In patients with stroke, IV cone-beam CTA in the angiography suite could be an alternative to CTA to shorten the door-to-thrombectomy time. However, image quality in cone-beam CTA is typically limited by artifacts. This study evaluated a prototype dual-layer detector cone-beam CT angiography versus CTA in patients with stroke. MATERIALS AND METHODS: A prospective, single-center trial enrolled consecutive patients with ischemic or hemorrhagic stroke on initial CT. Intracranial arterial segment vessel conspicuity and artifact presence were evaluated on dual-layer cone-beam CTA 70-keV virtual monoenergetic images and CTA. Eleven predetermined vessel segments were matched for every patient. Twelve patients were necessary to show noninferiority to CTA. Noninferiority was determined by the exact binomial test; the 1-sided lower performance boundary was prospectively set to 80% (98.75% CI). RESULTS: Twenty-one patients had matched image sets (mean age, 72 years). After excluding examinations with movement or contrast media injection issues, all readers individually considered dual-layer cone-beam CT angiography noninferior to CTA (CI boundary, 93%, 84%, 80%, respectively) when evaluating arteries relevant in candidates for intracranial thrombectomy. Artifacts were more prevalent compared with CTA. The majority assessment rated each individual segment except M1 as having noninferior conspicuity compared with CTA. CONCLUSIONS: In a single-center stroke setting, dual-layer detector cone-beam CTA virtual monoenergetic images are noninferior to CTA under certain conditions. Notably, the prototype is hampered by a long scan time and is not capable of contrast media bolus tracking. After excluding examinations with such scan issues, readers considered dual-layer detector cone-beam CTA noninferior to CTA, despite more artifacts.

Arterial Spin-Labeling in Children with Brain Tumor: A Meta-Analysis.

BACKGROUND: The value of arterial spin-labeling in a pediatric population has not been assessed in a meta-analysis. PURPOSE: Our aim was to assess the diagnostic accuracy of arterial spin-labeling-derived cerebral blood flow to discriminate low- and high-grade tumors. DATA SOURCES: MEDLINE, EMBASE, the Web of Science Core Collection, and the Cochrane Library were used. STUDY SELECTION: Pediatric patients with arterial spin-labeling MR imaging with verified neuropathologic diagnoses were included. DATA ANALYSIS: Relative CBF and absolute CBF and tumor grade were extracted, including sequence-specific information. Mean differences in CBF between low- and high-grade tumors were calculated. Study quality was assessed. DATA SYNTHESIS: Data were aggregated using the bivariate summary receiver operating characteristic curve model. Heterogeneity was explored with meta-regression and subgroup analyses. The study protocol was published at PROSPERO (CRD42017075055). Eight studies encompassing 286 pediatric patients were included. The mean differences in absolute CBF were 29.62 mL/min/100 g (95% CI, 10.43-48.82 mL/min/100 g), I2 = 74, P = .002, and 1.34 mL/min/100 g (95% CI, 0.95-1.74 mL/min/100 g), P < .001, I2 = 38 for relative CBF. Pooled sensitivity for relative CBF ranged from 0.75 to 0.90, and specificity, from 0.77 to 0.92 with an area under curve = 0.92. Meta-regression showed no moderating effect of sequence parameters TE, TR, acquisition time, or ROI method. LIMITATIONS: Included tumor types, analysis method, and original data varied among included studies. CONCLUSIONS: Arterial spin-labeling-derived CBF measures showed high diagnostic accuracy for discriminating low- and high-grade tumors in pediatric patients with brain tumors. The relative CBF showed less variation among studies than the absolute CBF.

Qualification and quantification of seventeen natural steroids in plasma by GC-Q-MS and GC-IT-MS/MS.

Studying the plasma steroid profile offers information about the possible existence of endocrinological alterations. This study describes the development and validation of gas chromatographic-mass spectrometric and gas tandem mass spectrometric methods for the simultaneous identification of 17 steroid hormones in human plasma using five different solvents. The n-hexane/ethyl acetate solvent mixture, in a proportion of 70/30 (v/v) provided the best results. The extracts were derivatized with N-methyl-N-trimethylsilyl-trifluoroacetamide. The obtained limits of detection were below 1 ng/mL in the majority of the studied steroids and the limits of quantification were below 5 ng/mL; the method obtained good linearity, reproducibility, repeatability, accuracy and recoveries above 95% in most cases.

Dual candidemia detected by nested polymerase chain reaction in two critically ill children.

The use of improved microbiological procedures associated with molecular techniques has increased the identification of Candida bloodstream infections, even if the isolation of more than one species by culture methods remains uncommon. We report the cases of two children presenting with severe gastrointestinal disorders and other risk factors that contribute to Candida infections. In the first patient, C. albicans DNA was initially detected by a nested-amplification and C. tropicalis was found later during hospitalization, while blood cultures were persistently negative. In the second child, there was amplification of C. albicans and C. glabrata DNA in the same samples, but blood cultures yielded only C. albicans. Both patients received antifungal therapy but had unfavorable outcomes. These two cases illustrate that PCR was more successful than culture methods in detecting Candida in the bloodstream of high risk children, and was also able to detect the presence of more than one species in the same patient that might impact therapy when the fungi are resistant to azole compounds.

Bradycardia in the early postoperative period of liver transplantation in children.

The aim of this investigation was to describe the occurrence of bradycardia during the early postoperative period of liver transplantation in children. We retrospectively analyzed a cohort of 79 children with end-stage liver diseases who underwent liver transplantation. All children experienced >or=1 episode of a cardiac rate below the 2nd percentile of a 1-hour minimum duration, which was considered to be bradycardia. Patients <24 months were compared with older ones. The overall incidence of bradycardia was 37% (n = 31), including 25 patients who displayed bradycardia until postoperative day 3. In all cases, the electrocardiogram was normal, showing sinus rhythm. A comparison of the groups demonstrated an increased incidence of bradycardia among patients <24 months of age (P=.03). In all patients, there were no hemodynamic consequences; the cardiac rate returned to normal uneventfully. The explanations for bradycardia could not be applied to these patients because none of them had any volume change or electrolyte disturbances; liver function tests were not seriously altered. The mechanisms of this postoperative complications are unclear.

[Bilateral anterior opercular syndrome as a manifestation of a non-convulsive epileptic state]. / Síndrome opercular anterior como manifestación de estado epiléptico no convulsivo.

INTRODUCTION: Foix-Chavany-Marie syndrome, or bilateral anterior opercular syndrome, is characterised by facio-pharyngo-glosso-masticatory diplegia with 'automatic-voluntary dissociation', which consists in the abolition of voluntary movements while involuntary movements and reflexes are preserved. It is produced by bilateral involvement of the anterior or frontal opercular region. In adults it is related to ischemic lesions. In childhood it presents congenitally in perisylvian dysplasias and as an acquired disorder in encephalitis or can be episodic in symptomatic or idiopathic epilepsies such as benign rolandic epilepsy. CASE REPORT: A 13-year-old patient who presented, over five straight days, four episodes of facial dysplegia, anarthria, dysphagia, drooling, paralysis of the upper limbs, while involuntary facial expression was normal and the corneal, cough and gag reflexes were preserved. The first three come to an end spontaneously at 2, 4 and 20 hours, respectively; the fourth episode concluded an hour and a half after onset, following administration of intravenous phenytoin for 5 minutes. Computerised axial tomography and magnetic resonance images of the brain, as well as the interictal electroencephalograms (EEG), were normal. Administration of oxcarbazepine was started but at 8 months was stopped after a normal EEG during nocturnal sleep was obtained. After 15 months, the patient has not presented any more episodes. CONCLUSIONS: The paroxysmal character of the disorder together with normal interictal periods, the normality of the neuroimages, and the speedy recovery achieved after the administration of phenytoin support the notion of an epileptic origin. We believe that we are dealing with a bilateral anterior opercular syndrome due to a non-convulsive epileptic state, compatible with the presentation of benign rolandic epilepsy.

[Episodic disseminated inflammation of the central nervous system. Case mix review over a 13 year period]. / Inflamacion diseminada episodica del sistema nervioso central en niños. Revision casuistica de un periodo de 13 años.

INTRODUCTION: Episodic disseminated inflammation of the central nervous system (CNS) presents in processes that are difficult to differentiate, such as acute disseminated encephalomyelitis (ADE) and its multiphasic variants, and multiple sclerosis (MS). Magnetic resonance imaging allows these problems to be identified more frequently than in the past. PATIENTS AND METHODS: We carried out a retrospective study of the cases of episodic disseminated inflammation of the CNS, according to clinical features and compatible neuroimaging, at the Neuropaediatric Unit of the Hospital Infantil Miguel Servet, between May 1990 and August 2003. RESULTS: Of the 6777 children evaluated over this period, 10 met the eligibility criteria, with a minimum age at onset of 2 years and 2 months. In four cases there was a history of an infectious process or vaccination. Clinical involvement was multisymptomatic, the most frequent being ataxia, dysmetry, tremor, drowsiness, paresis and cranial nerve involvement. Six of them had cerebrospinal fluid disorders and only two presented disorders in the fundus oculi. Five of them were given corticoid treatment. Progress was favourable, except in two cases: one due to the persistence of a corticoid dependent optical neuropathy and the other because of dyskinesia in the right hand. DISCUSSION: Diagnosis of ADE is established by signs of multifocal clinical involvement and neuroimaging, and depends on a compatible progression. Prognosis is generally good and corticoids seem to be effective, at least in shortening the time the clinical features last. It is not possible to completely differentiate it from MS, especially in recurring forms. Clinical and magnetic resonance controls must be carried out.

[Expansile cyst, twin formation and possible parasagittal cerebral injury]. / Quiste insuflante, gemelaridad y posible daño cerebral parasagital.

INTRODUCTION: Prenatal intracranial anomalies of a cystic nature are mainly either malformations (arachnoid cysts) or disruptive (porencephaly). They are usually incidental findings and, unless they undergo a progressive increase in size and become expansile or offer clinical features, they are usually managed 'expectantly'. Disruptive defects are more frequent in twin pregnancies. CASE REPORT: A one and a half-month-old male patient, fruit of a bichorial twin pregnancy, with bouts of paleness, cyanosis around the mouth and movements of the mouth that initially responded to treatment with valproate. Physical exploration was normal except for a significant increase in the cephalic perimeter. A notable anaemia was observed and neuroimaging revealed a left temporal intraparenchymatous cystic lesion; in addition, magnetic resonance imaging showed alterations in the linear and symmetrical signals in the parasagittal region. At three months the seizures reappeared and the cyst had increased in size, which led to the implantation of a cyst peritoneal shunt. The seizures ceased and the size of the cyst became stable, without full re expansion of the brain tissue. DISCUSSION: It is necessary to carry out a differential diagnosis of an arachnoid cyst and porencephaly. Given the history of being a twin, the notable degree of anaemia at the age of one month and the image suggesting parasagittal cerebral injury (a pattern of hypoxic ischemic encephalopathy in the full term neonate), we think that our patient was suffering from antenatal or perinatal cerebrovascular damage, which conditioned the development of an expansile porencephalic cyst and cortical damage that accounted for the symptoms of epilepsy.

Nutritional follow-up of critically ill infants receiving short term parenteral nutrition.

Few studies have tried to characterize the efficacy of parenteral support of critically ill infants during short period of intensive care. We studied seventeen infants during five days of total parenteral hyperalimentation. Subsequently, according to the clinical conditions, the patients received nutritional support by parenteral, enteral route or both up to the 10th day. Evaluations were performed on the 1st, 5th, and 10th days. These included: clinical data (food intake and anthropometric measurements), haematological data (lymphocyte count), biochemical tests (albumin, transferrin, fibronectin, prealbumin, retinol-binding protein) and hormone assays (cortisol, insulin, glucagon). Anthropometric measurements revealed no significant difference between the first and second evaluations. Serum albumin and transferrin did not change significantly, but mean values of fibronectin (8.9 to 16 mg/dL), prealbumin (7.7 to 18 mg/dL), and retinol-binding protein (2.4 to 3. 7 mg/dL) increased significantly (p < 0.05) from the 1st to the 10th day. The hormonal study showed no difference for insulin, glucagon, and cortisol when the three evaluations were compared. The mean value of the glucose/insulin ratio was of 25.7 in the 1st day and 15. 5 in the 5th day, revealing a transitory supression of this hormone. Cortisol showed values above normal in the beginning of the study. We conclude that the anthropometric parameters were not useful due to the short time of the study; serum proteins, fibronectin, prealbumin, and retinol-binding protein were very sensitive indicators of nutritional status, and an elevated glucose/insulin ratio, associated with a slight tendency for increased cortisol levels suggest hypercatabolic state. The critically ill patient can benefit from an early metabolic support.

[Basis of nutritional support in pediatrics] / Princípios do suporte nutricional em pediatria.

OBJECTIVE: To present an update and systematic review of the basis of nutritional support in pediatrics, emphasizing the importance of nutrition in critically ill patient. METHODS: Relevant studies were selected from databases (Medline, Scielo, Lilacs, etc.). Textbooks and theses were analyzed, and the authors personal experience was also considered. RESULTS: Nutritional therapy is part of the treatment. In order to reach the objective, it is important to determine specific nutritional requirements of water, calories, proteins, macro and micronutrients. So, nutritional evaluation should consist of clinical, anthropometric, and laboratory assessment, so that the best nutritional therapy (parenteral and/or enteral) is chosen. Patient monitoring is also indicated in order to prevent complications. CONCLUSION: Nutritional therapy is essential for the treatment. When well indicated and well monitored, it helps in the patient s recovery, and in the decrease of morbidity and mortality.