Pediatric Extramedullary Epidural Spinal Teratomas: A Case Report and Review of the Literature.

BACKGROUND: Teratomas in the pediatric population are most commonly found in the sacrococcygeal region. Pediatric intraspinal teratomas, however, are an exceedingly rare central nervous system (CNS) neoplasm. The clinical presentation of these intraspinal neoplasms can vary significantly and thus can be difficult to identify in infants less than one year of age where verbal expression and motor development are still lacking. Case Description. A 7-month-old, previously healthy male presented with a thoracic scoliosis and an asymptomatic right midupper thoracic spinal prominence present since birth. MRI revealed an extensive heterogenous mass in the right epidural space from T5-T6 and the right paravertebral space, resulting in severe spinal stenosis. Outcome. Complete resection of the tumor, including a three-level neurotomy, was achieved by posterior decompression/laminectomy. The final tumor was consistent with a mature teratoma. The surgical resection was performed without any immediate complications. CONCLUSIONS: Extramedullary epidural teratomas are exceptionally rare tumors in the pediatric population. Clinical presentation can be ambiguous, particularly in an infant. MRI was useful in suggesting a teratoma as a potential diagnosis and for postoperative surveillance for recurrence. However, histopathological analysis remains the gold standard for definitive diagnosis. Surgical resection is the mainstay of treatment, especially in the setting of cord compression and progressive loss of motor function. Close follow-up is crucial to monitor for progressive spinal deformity or recurrence.

The useful field of view test, normative data in children of school age.

PURPOSE: The incidence of early brain injury in children is rising, mainly because of changing reproductive demographics and better perinatal care. Early brain injury may be associated with altered visual perception and visuospatial attention. The useful field of view test (UFOV) has been developed to assess visual attention and processing speed in the elderly. The UFOV may have utility in the evaluation of children with early brain injury. The aim of this study was to collect age-specific normative data for the UFOV test. METHODS: Subjects were recruited from visitors at Glasgow Science Centre. One hundred thirty-five healthy children and young adults were tested (range: 5-22 years). After a comprehensive visual screening to establish normal visual function, all three subtests of the UFOV (1: Processing Speed; 2: Divided Attention; 3: Selective Attention) were performed. RESULTS.: All the children were able to understand and complete all subtests. UFOV scores improved monotonically with age, for all subtests, throughout the primary school years, with subtest 3 showing the greatest improvement. By age 14, UFOV scores had reached adult levels. DISCUSSION: UFOV performance shows measurable improvement during middle to late childhood, as has been previously found for abilities such as visual acuity. This is a simple test, which was easily understood and performed by all children in the study. Thus, we believe that our results are suggestive of continuing development in visual attention and processing during this period. CONCLUSIONS: The UFOV is an objective, standardized computer-based test of visual attention. This study indicates suitability for use with children. It remains to be determined how successful this test proves to be in discriminating between normal children and those with early brain injury.

Visual attention as an important visual function: an outline of manifestations, diagnosis and management of impaired visual attention.

Impaired visual attention is a common manifestation of cerebral dysfunction. In adults, closed head trauma, cerebral microvascular ischaemia and dementia are common causes. In children, aetiologies include periventricular leukomalacia, hydrocephalus, hypoxic ischaemic encephalopathy and brain damage caused by hypoglycaemia. The resultant visual disability can be profound even when visual acuities are unaffected, and can cause significant disability in the execution of daily activities. This can prompt consultation with an eye care specialist. Patients complain of poor vision, difficulty in identifying someone in a group, or finding an object on a patterned background or among other objects, but a thorough examination often does not reveal the clinical basis for these complaints. The diagnosis of attentional dysfunction is also easily missed because at present it can only be recognised on the basis of adequate history taking from both the patient and close relatives and friends. The Useful Field of View test facilitates the detection and quantification of this disorder. Management includes the implementation of strategies that diminish background pattern and foreground clutter.

Cognitive visual impairment with good visual acuity in children with posterior periventricular white matter injury: a series of 7 cases.

BACKGROUND: We describe a series of term and preterm children with occipito-parietal periventricular white matter abnormalities on magnetic resonance imaging (MRI) who manifest common clinical features of cognitive visual dysfunction. We also describe a strategy for taking clinical history that highlights the symptom complex and assists with management. PATIENTS AND METHODS: A retrospective observational case series study of seven children with cognitive visual difficulties despite good (20/32 or better) visual acuities and MRI findings of periventricular white matter pathology in the territory subserving visual function. Structured history taking was used to identify and characterize the visual difficulties. Objective clinical findings (visual acuity, color vision, stereoacuity, visual fields, ocular motility, refraction, and fundoscopy) were recorded. RESULTS: Seven children with visual acuities of 20/32 (0.200 logMAR) or better had symptoms of cognitive visual difficulties consistent with dorsal stream dysfunction. Four had strabismus of different types and were identified on the basis of parental concern expressed at the ocular motility clinic. The other three children presented to the general ophthalmology clinic. All seven children had various degrees of focal periventricular white matter pathology in a similar distribution on neuroimaging. CONCLUSIONS: Children born prematurely are susceptible to periventricular white matter pathology. Such pathology can also occur in children born at term. This case series demonstrates that cognitive visual impairment due to periventricular white matter injury can occur despite good central visual function. A range of strategies to help affected children is described.

The internet as a source of information for De Quervain's tendinitis.

BACKGROUND: Many individuals are turning to the Internet for information about various health conditions, and in our study we evaluated the quality and readability of information on the internet about De Quervain's tendinitis. METHODS: We chose the search terms "De Quervain's Tendinitis," "De Quervain's Tenosynovitis," and "De Quervain's Syndrome," and entered them into the search engines "Google," "Bing," and "Yahoo" and compiled the search results. The websites were then evaluated and assigned a quality score, a Flesch-Kincaid (FK) reading level, and a subjective quality score. They were then grouped according to the search term used, search engine used, and the order (priority) returned by the search engines. ANOVA analysis and pairwise comparisons of quality and readability among groups, as well as correlation analysis were performed. RESULTS: The FK readability average was 10.3, above the recommended level. The search term De Quervain's tenosynovitis returned the highest objective quality results. There was no statistical difference found between the different search engines. The first 10 results from the searches were of higher quality than results 11-20, and there was a positive correlation between objective and subjective quality scores but no correlation between readability and objective quality. CONCLUSIONS: We concluded that quality information about De Quervain's tendinitis is available on the internet and is most likely to be found using the search term De Quervain's tenosynovitis and in the first 10 results of an internet search. However, most information is written above the recommended 6th grade reading level.

Isolated Lactobacillus chronic prosthetic knee infection.

Lactobacillus is a gram-positive rod bacteria found primarily in the gastrointestinal and female genital tracts. Prosthetic infections in implants are being increasingly reported. The authors present a case of a 58-year-old patient with Lactobacillus septic prosthetic knee joint infection. To the authors' knowledge, this is the first reported case of chronic prosthetic knee infection with isolated Lactobacillus species. Lactobacillus has been most commonly implicated with bacteremia and endocarditis and rarely with pneumonia, meningitis, and endovascular infection, and a vast majority of the cases are reported in immunocompromised patients. In the current case, diabetes mellitus, hepatitis, malnutrition, anemia, and liver failure were comorbid conditions, placing the patient at increased risk of infection. The findings suggest that further case series are necessary to establish the significance of Lactobacillus as an etiologic agent in chronic low-virulence, and potentially vancomycin-resistant, prosthetic joint infection. The need also exists for further research aimed at the risk of prosthetic joint infection with oral intake of certain probiotic foods and supplements. The goal of this case report is to bring to light the potential of this organism to be a cause of subtle chronic prosthetic joint infection.

Detecting shapes in noise: tuning characteristics of global shape mechanisms.

The proportion of signal elements embedded in noise needed to detect a signal is a standard tool for investigating motion perception. This paradigm was applied to the shape domain to determine how local information is pooled into a global percept. Stimulus arrays consisted of oriented Gabor elements that sampled the circumference of concentric radial frequency (RF) patterns. Individual Gabors were oriented tangentially to the shape (signal) or randomly (noise). In different conditions, signal elements were located randomly within the entire array or constrained to fall along one of the concentric contours. Coherence thresholds were measured for RF patterns with various frequencies (number of corners) and amplitudes ("sharpness" of corners). Coherence thresholds (about 10% = 15 elements) were lowest for circular shapes. Manipulating shape frequency or amplitude showed a range where thresholds remain unaffected (frequency ≤ RF4; amplitude ≤ 0.05). Increasing either parameter caused thresholds to rise. Compared to circles, thresholds increased by approximately four times for RF13 and five times for amplitudes of 0.3. Confining the signals to individual contours significantly reduced the number of elements needed to reach threshold (between 4 and 6), independent of the total number of elements on the contour or contour shape. Finally, adding external noise to the orientation of the elements had a greater effect on detection thresholds than adding noise to their position. These results provide evidence for a series of highly sensitive, shape-specific analysers which sum information globally but only from within specific annuli. These global mechanisms are tuned to position and orientation of local elements from which they pool information. The overall performance for arrays of elements can be explained by the sensitivity of multiple, independent concentric shape detectors rather than a single detector integrating information widely across space (e.g. Glass pattern detector).

Global emergence of trimethoprim/sulfamethoxazole resistance in Stenotrophomonas maltophilia mediated by acquisition of sul genes.

Trimethoprim/sulfamethoxazole (TMP/SMX) resistance remains a serious threat in the treatment of Stenotrophomonas maltophilia infections. We analyzed an international collection of 55 S. maltophilia TMP/SMX-sensitive (S) (n=30) and -resistant (R) (n=25) strains for integrons; sul1, sul2 and dhfr genes; and insertion element common region (ISCR) elements. sul1, as part of a class 1 integron, was detected in 17 of 25 TMP/SMX-R. Nine TMP/SMX-R strains carried sul2; 7 were on large plasmids. Five TMP/SMX-R isolates were positive for ISCR2, and 4 were linked to sul2; 2 others possessed ISCR3. Two ISCR2s were adjacent to floR. Six TMP/SMX-S isolates harbored novel ISCR elements, ISCR9 and ISCR10. Linkage of ISCR3, ISCR9, and ISCR10 to sul2 and dhfr genes was not demonstrated. The data from this study indicate that class 1 integrons and ISCR elements linked to sul2 genes can mediate TMP/SMX resistance in S. maltophilia and are geographically widespread, findings that reinforce the need for ongoing resistance surveillance.

Italian metallo-beta-lactamases: a national problem? Report from the SENTRY Antimicrobial Surveillance Programme.

OBJECTIVES: As part of the SENTRY Antimicrobial Surveillance Programme, 383 non-replicative randomly collected Pseudomonas aeruginosa isolates were collected during 1999-2002. These strains originated from three geographically distinct hospitals within Italy: Genoa (Northern Italy); Rome and Catania (Sicily), and were further studied to identify the prevalence of metallo-beta-lactamase (MbetaL) alleles across Italy and to determine their genetic details. METHODS: Multidrug-resistant (MDR) strains were identified by MIC analysis followed by genotyping and PCR-based strategies. RESULTS: Initial MIC analysis identified 31 MDR isolates that displayed an Etest MbetaL-positive phenotype. Of these, 25 produced either the MbetaL VIM-1 or IMP-13 as detected by PCR and sequencing. VIM-1-producing isolates were found at all sites, whereas IMP-13-producing isolates were only found in Rome. MbetaL-producing isolates were found at all Italian SENTRY sites and together amounted to 6.5% of all P. aeruginosa isolates. Genetic analysis indicated that many strains contained multiple integrons and identified two novel MbetaL integrons, one from the site in Genoa and one from Sicily. Integrons identical in structure and sequence to In70, the first identified and characterized bla(VIM)-containing integron from Verona, were found in isolates with distinct ribotypes at the Roman and Sicilian sites indicating that this integron has recently disseminated across Italy. All 25 MbetaL-producing isolates were genetically linked in that all isolates contained Tn5051 sequences and all harboured the insertion sequence IsPa7 which may be involved in the mobilization of these resistance alleles. CONCLUSIONS: Taken together, these results indicate that Italy has a nationwide problem of MDR P. aeruginosa produced by mobile MbetaL genes.