Hemispherectomy for intractable unihemispheric epilepsy etiology vs outcome.

BACKGROUND: Surgical removal of one hemisphere has been performed for several decades to treat intractable unihemispheric epilepsy. A prior case series focused on the outcomes after 58 surgeries at Johns Hopkins Hospital in 1997. This series, and an additional 53 cases, were reviewed to bring the outcomes up to date. METHODS: Charts of the 111 patients undergoing hemidecortications at the Pediatric Epilepsy Center from 1975 to 2001 were reviewed and families were contacted. Three children died in the immediate perioperative period and three were lost to follow-up immediately after surgery. Follow-up ranged from 3 months to 22 years. RESULTS: Two children died several years later due to intractable seizures. Overall, 65% are seizure-free, 21% have occasional, non-handicapping seizures, and 14% have troublesome seizures. Eighty percent are on one anticonvulsant or none and 89% are able to walk without assistance. Etiology strongly predicted seizure outcome. Patients with migrational disorders are less likely to be seizure-free than all other etiologies (predominantly Rasmussen and congenital vascular injuries) combined (51% vs 71%, p = 0.05). CONCLUSIONS: Hemidecortication continues to be a beneficial procedure in reducing seizure frequency in cases of unilateral cortical epilepsy. Fewer children with migrational disorders are seizure-free.

The postoperative course and management of 106 hemidecortications.

RATIONALE: The excellent long-term outcome for most children undergoing hemispherectomy is well documented. However, the condition of these children in the immediate postoperative period is poorly described. The purpose of this study was to evaluate the short-term issues surrounding hemispherectomy and their management in a series of patients from our institution. METHODS: 106 hemispherectomies were performed at our institution from 1975 to 2001 (102 hemidecortications). Medical records were retrospectively examined for information regarding immediate postoperative problems and care. RESULTS: Three children died in the immediate perioperative period, while 3 others had significant postoperative morbidity. 82% of these children had postoperative fevers (temperature >38.5 degrees C). Of these children, 62% had lumbar punctures. Ten cases had positive CSF growth, of which 6 cases were felt to have actual meningitis. Patients with CSF growth had a significantly longer prior duration of steroid therapy and higher maximum temperature peaks. CSF pleocytosis and an ill clinical appearance neared significance for prediction of CSF growth. Shunting was performed in 19% of all children and was associated with CSF growth. CONCLUSIONS: Postoperative fevers are common after hemidecortication, but meningitis is not. Children with CSF growth tended to appear more ill and have higher temperature spikes and CSF pleocytosis. Shunting was related to CSF growth.

Recurrent hypoglycemic hemiparesis and aphasia in an adolescent patient.

A 12-year-old diabetic female with right-side hemiparesis and aphasia occurring after a hypoglycemic episode is reported. Her clinical course improved over a 24-hour period, and further investigation revealed only electroencephalographic slowing, which was more prominent on the left. Ten months later, she had a recurrence of the same symptoms, which also resolved rapidly. This potential complication of hypoglycemia is often mistaken for a cerebrovascular accident.

Tourette syndrome: clinical characteristics and current management strategies.

Tourette Syndrome (TS) is a disorder comprised of involuntary motor and phonic tics often associated with psychiatric conditions. The etiology for TS is unclear, with both genetic and immunological theories being studied to date. When pharmacotherapy is considered by the patient and physician to be required, owing to either functional impairment from tics or comorbid psychiatric illness, dopamine receptor antagonists are commonly used. Our first-line agents for tic suppression include clonidine, guanfacine, clonazepam and baclofen. Should these agents be ineffective, we would recommend pimozide, fluphenazine, risperidone or haloperidol. The potential benefit of other agents, such as olanzapine, ziprasidone, pergolide and botulinum toxin, is encouraging. Despite many years of concern, we have found little exacerbation of tics with stimulant medications for attention deficit hyperactivity disorder, but clearly clonidine and guanfacine can ameliorate both comorbid conditions. Obsessive compulsive disorder, when associated with TS, may be treated with either a selective serotonin reuptake inhibitor in association with a dopamine receptor antagonist or risperidone alone. New therapies for all aspects of TS and its comorbid conditions are in active clinical trials.

Levetiracetam psychosis in children with epilepsy.

PURPOSE: Levetiracetam is a new anticonvulsant (AED) with a novel mechanism of action. Although it is generally well tolerated with a good cognitive profile, irritability and hostility have been reported in some adults taking levetiracetam. Observations in children are limited; levetiracetam is not yet approved by the Food and Drug Administration for use in children. METHODS: In four young patients, acute psychosis developed within days to months of initiation of levetiracetam for seizures. RESULTS: A 5-year-old girl began having visual hallucinations of spiders in her room 14 days after starting levetiracetam. A 13-year-old boy began having auditory hallucinations, insomnia, and screaming behavior 3 months after initiation of levetiracetam. A 16-year-old girl became acutely agitated, hyperreligious, and had persecutory delusions within 7 days of starting levetiracetam. A 17-year-old girl had auditory hallucinations telling her to sing and yell after 30 days of taking the drug. All four children had dramatic improvement within days of either discontinuing or decreasing the dose of levetiracetam. The three adolescents had historical findings consistent with mild behavioral problems before initiating levetiracetam, and all four patients had prior cognitive deficits. CONCLUSIONS: Reversible treatment-emergent psychosis associated with levetiracetam therapy was observed in four children and adolescents. Whether rapid initiation or prior neurobehavioral problems predispose to this side effect is not established.

Early clinical experience enhances third-year pediatrics clerkship performance.

PURPOSE: To determine whether clinical experiences in the preclinical years improve medical students' performances in a third-year clerkship. METHOD: A cohort study reviewed the pediatrics clerkship performances of 400 Eastern Virginia Medical School students in the graduating classes of 1996 through 1999. The first two classes completed a traditional preclinical curriculum with limited clinical experience. The final two classes participated in a mentorship program that provided 18 months of early clinical experience, consisting of one-on-one half-day sessions every other week with a generalist community faculty. The authors compared the clinical clerkship performances of the groups using clinical skills (CS) scores, history and physical examination (H&P) scores, and scores on the NBME pediatrics shelf examination. They also looked at the mean MCAT and USMLE scores for each group. The authors also looked at the scores within each class, comparing students who completed one of the first two pediatrics clerkship rotations with their classmates who completed clerkships later in the academic year. RESULTS: The students' NBME scores rose significantly (p < .05, r2 = 0.95) over the four-year study, paralleling a significant rise in MCAT scores (p < .03, r2 = 0.73). The CS and H&P scores did not rise. Students who had the traditional preclinical curriculum and who completed their clerkships early in the year had significantly lower CS and H&P scores than did their classmates. In contrast, the scores of students who had the early clinical experiences did not differ significantly according to the timing of their rotation. CONCLUSION: Students who had participated in a mentorship program that provided early clinical experience demonstrated significantly improved clinical skills in the pediatrics clerkship early in the academic year.

Candidemia in a neonatal intensive care unit: trends during fifteen years and clinical features of 111 cases.

OBJECTIVE: To determine changes in the incidence of candidemia in a neonatal intensive care unit (NICU) during a 15-year period (1981 to 1995) and to compare the prevalence and case fatality rates of Candida albicans and Candida parapsilosis infections. METHODS: A retrospective study was conducted of candidemia occurring in infants in a NICU between January 1, 1981, and December 31, 1995. Cases were identified through computerized searching of a microbiology blood culture database. Candidemia was considered contributory to mortality if death occurred within 3 days of positive blood cultures or if there was autopsy evidence of disseminated candidiasis. RESULTS: One hundred eleven cases of candidemia occurred in 107 infants, representing 1% of all NICU patients during the study period. The rate of candidemia in the NICU increased from 2.5 cases per 1000 admissions in 1981 to 1985, to 4.6 per 1000 admissions in 1986 to 1990 and to 28.5 per 1000 in 1991 to 1995 (P = 0.001). C. albicans was the predominant cause of candidemia between 1981 and 1990. C. parapsilosis was the most prevalent species between 1991 and 1995, causing 53 of 89 cases (60%). The mortality from C. albicans, 13 of 50 cases (26%), was significantly higher than the mortality from C. parapsilosis, 2 of 54 (4%) (P = 0.002; relative risk, 7; 95% confidence interval, 1.7 to 30). CONCLUSIONS: The rate of candidemia in our neonatal intensive care unit increased >11-fold in the 15 years from 1981 to 1995; the prevalent Candida species shifted from C. albicans to C. parapsilosis; and candidemia associated with C. albicans has significantly higher mortality than with C. parapsilosis.

Peripherally inserted central venous catheter fracture and embolization to the lung.

We report an adolescent patient with a peripherally inserted central venous catheter fracture and subsequent migration of the catheter fragment through the heart and into the lower lobe of the right lung. Physical findings were unremarkable for indications of this pulmonary embolization. With the increasing use of such devices for prolonged venous access, the practicing pediatric emergency physician should be aware of this potential complication.