A Comparison of Dressing Techniques for Presurgical Closure of Myelomeningocele in the Neonate.

BACKGROUND: Myelomeningoceles are routinely closed surgically within 24 to 48 hours after birth; the defect and exposed placode must be protected from further damage from excoriation and contamination until surgery. PURPOSE: Two methods to keep the defect moist and clean are used at our large Midwestern children's hospital: the occlusive and the drip. There was no agreement between the neonatal and neurosurgical teams as to which technique was superior, hence the need for a formal evaluation. METHODS: A prospective, randomized trial was conducted to compare the ease of nursing care, cost of supplies, neonatal temperature, and moisture of the placode at the time of closure in neonates with a myelomeningocele. RESULTS: Nurses categorized the occlusive group as easy care (100%) compared with 60% for the drip group, although the difference was not statistically significant (P = .18). The mean temperatures of the 2 groups before surgery were identical (36.9°C) in both groups. The cost of the drip was 6 times higher than that of the occlusive technique. The placode was assessed as moist in all 13 cases (100%). CONCLUSION: The occlusive technique was easier to care for by all the nurses and was 6 times more cost effective. Both methods kept the placode moist and did not affect the temperature of the baby.

The Rare Association of Spina Bifida and Extrarenal Wilms Tumor: A Case Report and Review of the Literature.

BACKGROUND: The diagnosis of nephroblastoma outside of the kidneys, in the absence of a renal primary tumor, is known as extrarenal Wilms tumor (ERWT). ERWT is an uncommon entity that typically involves the embryonic path of the developing kidneys and gonads. The occurrence of ERWT in a dysraphic spine is uncommon, with no reported cases of preoperative diagnosis, with all cases diagnosed at pathology. These tumors are malignant and ideally should be completely excised. Thus, preoperative diagnosis would be highly desirable. CASE DESCRIPTION: A newborn female was found to have a lumbar lipoma. Magnetic resonance imaging (MRI) was performed to rule out lipomyelomeningocele. The MRI showed a dorsal lipoma on the terminal spinal cord, as well as a 2 × 2 cm uniformly enhancing mass abutting the bifid posterior elements of L5. The lesion was completely excised, and the pathological diagnosis was ERWT. We report this case with a review of the literature to raise awareness of this association, illustrate the key imaging findings, and document the clinical outcome. CONCLUSIONS: The lack of pathognomonic radiologic features makes the preoperative diagnosis extremely difficult, but a diagnosis of ERWT should be considered in the context of a soft tissue mass without the typical imaging features of a hemangioma or teratoma.

Lumbar puncture opening pressure is not a reliable measure of intracranial pressure in children.

There is very little data correlating lumbar puncture pressures to formal intracranial pressure monitoring despite the widespread use of both procedures. The hypothesis was that lumbar puncture is a single-point measurement and hence it may not be a reliable evaluation of intracranial pressure. The study was therefore carried out to compare lumbar puncture opening pressures with the Camino bolt intracranial pressure monitor in children. Twelve children with a mean age of 8.5 years who had both lumbar puncture and intracranial pressure monitoring were analyzed. The mean lumbar puncture opening pressure was 22.4 mm Hg versus a mean Camino bolt intracranial pressure of 7.8 mm Hg (P < .0001). Lumbar puncture therefore significantly overestimates the intracranial pressure in children. There were no complications from the intracranial pressure monitoring, and the procedure changed the treatment of all 12 children avoiding invasive operative procedures in most of the patients.

Quantification of in vivo Photofrin uptake by human pituitary adenoma tissue.

OBJECT: Photofrin is widely distributed in the body after intravenous injection. This study was designed to quantify the preferential uptake of Photofrin by pituitary adenoma tissue for intraoperative photodynamic therapy. METHODS: Eight patients (seven men) with recurrent pituitary adenomas who had undergone previous surgery and radiation therapy were recruited for a Phase I/II feasibility study of the application of photodynamic therapy to pituitary tumors. Photofrin was administered intravenously at a dose of 2 mg/kg body weight 48 hours before repeated transsphenoidal hypophysectomy was performed. At the time of the operation, pituitary adenoma tissue, muscle, fat, skin, and plasma were obtained for measurement of Photofrin content by fluorometric assay. The mean Photofrin level in pituitary adenoma tissue was 6.87 ng/mg (95% confidence interval [CI] 3.99-9.75), which was significantly higher than the uptake by skeletal muscle (2.24 ng/mg, 95% CI 1.28-3.2; p = 0.008), or fat (2.54 ng/mg, 95% CI 0.66-4.42; p = 0.007). Nevertheless, the mean drug concentration in pituitary adenoma tissue was not significantly different from the level in plasma (7.65 microg/ml, 95% CI 5.38-9.90; p = 0.558). Skin specimens were available in four patients, and these showed a mean uptake of 2.19 ng/mg. CONCLUSIONS: Photofrin is preferentially retained by pituitary adenoma tissue to levels both adequate for intraoperative photodynamic therapy and approximately 50% higher than those reported for gliomas.

"Mock herniations" to assess nurses' response times and accuracy in setting up ventriculostomies in the pediatric intensive care unit.

When an emergent ventriculostomy is required for relief of increased intracranial pressure, it is critical that participating physicians and nurses work as an efficient team for optimal outcomes. From our experience, problems in ventriculostomy insertion have occurred because of delays in obtaining correct supplies and lack of skill in assembling the drainage system. The goals of this study were to (a) decrease the response time and (b) increase competency for successful insertion and setup of a ventriculostomy by using a "mock herniation" scenario. Three different nursing shifts in the pediatric intensive care unit at the University of Missouri Health Care were presented with a mock scenario of a child with increased intracranial pressure and impending herniation. Each group was timed on its ability to gather the correct supplies and scored on accuracy in setting up the drainage system. Subsequently, all pediatric intensive care unit nurses underwent skills laboratory training on correct assembly of the drainage system. After training, three different groups of nurses were tested again using the mock herniation scenario. This time, there was improvement in all areas tested, particularly in the mean time taken for accurate assembly and setup of the emergency ventriculostomy drainage system. We conclude that skills laboratory training reinforced by periodic mock herniations significantly decreases response time and increases accuracy of assembling supplies and setting up the drainage system for ventriculostomy insertion.