Gemcitabine with or without docetaxel and resection for recurrent osteosarcoma: the experience at Children's Memorial Hospital.

It remains unclear how to optimally incorporate gemcitabine and docetaxel into the management of patients with recurrent osteosarcoma. We describe 4 pediatric patients with recurrent osteosarcoma who were treated with gemcitabine ± docetaxel and resection. One patient had a partial response and 2 had stable disease. Two patients subsequently underwent surgical resections. Median duration of response was 8 months and was longer for patients who underwent resection. One patient remains disease-free 57 months from recurrence. Our limited series provides additional support for the use of gemcitabine ± docetaxel for recurrent osteosarcoma and suggests benefit of concurrent local control measures if possible.

Pre- and postoperative imaging and interventions for the meso-Rex bypass in children and young adults.

The meso-Rex bypass is a physiological and anatomical bypass procedure for relief of extrahepatic portal vein obstruction and restoration of mesenteric venous return to the liver. Most patients who are candidates for the bypass are children or young adults with portal hypertension and hypersplenism secondary to cavernous transformation of the portal vein. Most frequently, the bypass utilizes an autologous venous graft to connect the intrahepatic left portal vein to the infrapancreatic superior mesenteric vein (SMV) re-establishing first-pass portal perfusion. We describe the preoperative imaging of the 92 bypass candidates, the surgical anatomy as reflected in postoperative imaging, and the imaging of bypass complications at our institution.Preoperative imaging with US, CT and MR is directed to demonstrate patency and size of the left portal vein and SMV, to define the extent of cavernous transformation and splanchnic collaterals, and to assess for any associated abdominal vascular or solid organ abnormalities. Postoperative imaging is aimed at diagnosing meso-Rex bypass stenosis or occlusion and the interventional management of these complications.

Biplanar Technique for Breast Implant Replacement through Mastectomy Scar.

BACKGROUND: Implant-based breast reconstruction is the most commonly used modality for breast reconstruction. A 2-stage reconstruction is employed when the skin envelope is insufficient. In the first stage, a tissue expander is placed in a pocket created beneath the pectoralis major muscle and an acellular dermal matrix (ADM). In the second stage, the expander is replaced with a permanent implant. Though the second stage is safer, some studies have published an immediate complication rate of up to 11.4%, and even higher in the event of prior radiotherapy. METHODS: We present a novel biplanar technique for implant replacement through the mastectomy scar. The goal of our technique is to make incisions of the skin and the incorporated ADM in 2 separate planes, hopefully lowering the risk for dehiscence, deep infection, and reconstruction failure. We conducted a retrospective review of patients who underwent tissue expander or implant replacement surgery using the biplanar technique between January 2012 and January 2018 by the senior author. RESULTS: Eleven consecutively presenting patients underwent 8 tissue expanders and 6 silicone implant replacement surgeries. Three patients had received prior radiation therapy in the operated breast. None of the patients had complications nor needed a revision surgery. CONCLUSIONS: The biplanar technique for implant or tissue expander replacement through the mastectomy scar following breast reconstruction shows promising results in our series of patients and may prove useful in reducing postoperative incisional dehiscence, deep infection, and implant exposure. Nonetheless, further large-scale studies are required to evaluate the effectiveness of this technique.

Safety and efficacy of pressure-limited power injection of iodinated contrast medium through central lines in children.

OBJECTIVE: The purpose of this study was to evaluate the safety and efficacy of pressure-limited power injection of contrast medium through central lines for pediatric body CT examinations. SUBJECTS AND METHODS: All patients with a central line who were referred for body CT examinations requiring an i.v. contrast agent were prospectively evaluated. The power injector was pressure limited to 25 psi (172 kPa). A standard dose of 2 mL/kg of iodinated contrast medium was power-injected through the central line. Two pediatric radiologists scored all examinations on a scale of 1 (poor) to 5 (superior) for adequacy of contrast enhancement. Regression and receiver operating characteristic analyses were performed. RESULTS: The subjects were 63 patients 0.3-22 years old. Nineteen of these patients had tunneled lines, 18 had ports, and 26 had peripherally inserted central catheters. There were no complications related to power injection. Regression analysis showed a significant association between patient weight and contrast enhancement adequacy score (p < 0.001), higher patient weights yielding lower contrast enhancement adequacy scores. Receiver operating characteristic analysis showed a weight cutoff of 30 kg as a reasonable predictor of adequacy of contrast enhancement. For patients weighing 30 kg or more, the average contrast enhancement score was 2.4 (suboptimal to adequate). For patients weighing less than 30 kg, the average contrast enhancement score was 3.4 (adequate to good). CONCLUSION: Pressure-limited power injection through central lines in children is safe. The contrast enhancement obtained with 25 psi (172 kPa) pressure-limited injection is acceptable only for patients who weigh less than 30 kg.

Streptococcus pneumoniae empyema necessitatis.

Empyema necessitatis is a rare complication of empyema characterized by extension of suppuration from the pleural space through the chest wall. The most common etiologies are tuberculosis and actinomycosis. We describe a 1-year-old boy with Streptococcus pneumoniae empyema necessitatis and review previously reported cases.

Association between lenticulostriate vasculopathy (LSV) and neonatal intraventricular hemorrhage (IVH).

OBJECTIVES: To determine whether there is an unconfounded association between neonatal intraventricular hemorrhage (IVH) and lenticulostriate vasculopathy (LSV (also known as thalamostriate or mineralizing vasculopathy)). STUDY DESIGN: During the conduct of the Magnesium and Neurologic Endpoints Trial (MagNET), a randomized controlled trial involving maternal, hence fetal, exposure to antenatal magnesium sulfate in the context of preterm labor, head ultrasounds were obtained for each of the surviving neonates. Because of our previous experience in the diagnosis of LSV, when ascertaining the presence of IVH, as called for by the research protocol of our study, the presence or absence of LSV was also determined. RESULTS: We found LSV to be relatively prevalent (10% (14 of 140) among surviving babies). More importantly, it was significantly associated with the occurrence of neonatal IVH, even when controlled for possible confounding (adjusted OR 9.8, 95% confidence interval 1.3 to 73.1; p=0.03). CONCLUSION: Given the known relationships between IVH and neonatal morbidity and mortality, the finding of a statistically significant association between neonatal IVH and LSV may suggest more substantial implications for the latter than previously believed.

Successful nontransplant resection of POST-TEXT III and IV hepatoblastoma.

BACKGROUND: Liver transplantation is increasingly advocated as primary surgical therapy for children with hepatoblastoma involving 3 or 4 sectors of the liver after neoadjuvant chemotherapy. This study evaluated the results of nontransplant hepatectomy in children who might otherwise have been considered for liver transplantation. METHODS: All children who underwent resection at a single institution from 1998 to 2009 for POST-TEXT IV or centrally located POST-TEXT III hepatoblastoma after neoadjuvant chemotherapy were reviewed. RESULTS: Fourteen children (7 boys) with a median age of 8 months at diagnosis met study criteria. Pulmonary metastases in 3 patients were resected in 2 and resolved with chemotherapy in 1 patient. Preoperative grouping after neoadjuvant chemotherapy was POST-TEXT IV in 3 patients and POST-TEXT III in 11 patients. Thirteen of 14 (93%) children who underwent aggressive resection despite being potential candidates for primary transplantation were alive and tumor-free with a median follow-up of 57 months. Observed survival rates at 1, 2, and 5 years were 93%, 91%, and 88% respectively. Event-free survival rates at 1, 2, and 5 years were 93%, 91%, and 75%, respectively. CONCLUSIONS: Excellent survival (93%) was obtained with aggressive resection in children with POST-TEXT III and IV hepatoblastoma meeting criteria for transplant referral. The 1 death occurred in a patient with unfavorable small cell histology. These children should be managed at institutions experienced in both advanced pediatric hepatobiliary surgery and transplantation. Operative exploration was frequently required to ultimately determine which tumors can be resected and which require transplantation.

Effectiveness of the computer enhanced visual learning method in teaching the society for fetal urology hydronephrosis grading system for urology trainees.

OBJECTIVE: A novel educational tool, Computer Enhanced Visual Learning (CEVL), has been used to improve resident performance of routine orchiopexy. Our objective was to assess the effect of a CEVL teaching module on the diagnostic accuracy of medical trainees in grading neonatal hydronephrosis on ultrasound using the Society for Fetal Urology (SFU) grading system. METHODS: The authors designed an online-based computerized tutorial to teach the grading of hydronephrosis using multimedia, practice cases and a grading checklist. In a crossover design trial, 29 residents and medical students were asked to grade 16 standard neonatal renal ultrasounds using the SFU grading system before and after viewing the web-based e-learning module. Primary outcome was percent improvement in grading accuracy. RESULTS: The mean percentages of ultrasounds that were graded correctly before and after CEVL intervention were 51% and 72% respectively (mean improvement 21%, 95% CI 3-13%, P < 0.001). Residents graded correctly 56% of ultrasounds before and 74% after CEVL (mean 18%, 7-28%, P = 0.002). Medical students graded correctly 37% before and 69% after CEVL (mean improvement 32%, 95% CI 16-48%, P = 0.002). CONCLUSION: Exposure to a computer-based learning module based on the CEVL platform improved urology residents' and medical students' correct assignment of SFU hydronephrosis grading to newborn renal ultrasounds.

Association between maternal serum ionized magnesium levels at delivery and neonatal intraventricular hemorrhage.

OBJECTIVES: To determine whether magnesium sulfate (MgSO(4)) exposure is associated with a reduced risk for neonatal intraventricular hemorrhage (IVH). STUDY DESIGN: In a randomized, controlled trial, women in preterm labor were randomly assigned to receive MgSO(4), "other" tocolytic, or saline control. At delivery, we collected maternal antecubital and umbilical cord blood for determination of serum ionized magnesium levels. Neonatal IVH was diagnosed by cranial ultrasonogram. RESULTS: Among 144 infants, 24 were diagnosed with IVH. Using crude intention-to-treat analysis, we found that 18% (13/74) of survivors exposed after birth to MgSO(4) had IVH compared with 16% (11/70) of babies who were not exposed. Infants who had IVH were more likely to have been delivered by mothers with higher serum ionized magnesium (Mg) levels (0.75 vs 0.56 mmol/L) (P =.01). Using multivariable logistic regression, we confirmed that higher Mg levels are a significant predictor of neonatal IVH (adjusted odds ratio, 15.8; 95% CI, 1.4-175.0) even when adjusted for birth weight, gestational age, antenatal hemorrhage, and neonatal glucocorticoid exposure. CONCLUSIONS: In mothers with preterm labor, our data indicate that antenatal MgSO(4) exposure may be associated with an increased risk for IVH among their newborns.