Lower risk of invasive meningococcal disease during pregnancy: national prospective surveillance in England, 2011-2014.

OBJECTIVE: To describe cases of invasive meningococcal disease (IMD) in women of childbearing age and to estimate the disease incidence and relative risk of IMD in pregnant compared with non-pregnant women. DESIGN: Prospective enhanced national surveillance for IMD. SETTING: England. POPULATION: Women of reproductive age (15-44 years) with laboratory-confirmed IMD. METHODS: Public Health England conducts enhanced national surveillance for IMD in England. Laboratory-confirmed cases are followed up with postal questionnaires to general practitioners. All cases confirmed in women of reproductive age from 1 January 2011 to 31 December 2014 were included. MAIN OUTCOME MEASURES: Annual IMD incidence and relative risk of IMD in pregnant compared with non-pregnant women of reproductive age. RESULTS: During the 4-year surveillance period, there were 1502 cases of IMD in females across England; of these, 310 (20.6%) cases were in women of reproductive age, including four women who were pregnant at the time of IMD confirmation (1.3%). Serogroup distribution of IMD cases in women of childbearing age was similar to the overall distribution. The four cases in otherwise healthy pregnant women were confirmed across all trimesters and all survived; one case in the first trimester had a septic miscarriage. The incidence of IMD was lower in pregnant than in non-pregnant women (0.16 compared with 0.76 per 100 000 pregnant and non-pregnant years, respectively), giving a lower risk of IMD in pregnant women (incidence rate ratio, IRR, 0.21; 95% confidence interval, 0.06-0.54). CONCLUSIONS: Pregnant women are nearly five times less likely to develop IMD compared with non-pregnant women, but the infection can be severe. TWEETABLE ABSTRACT: The risk of meningococcal disease is lower in pregnant women compared with non-pregnant women; the infection can occur across all trimesters and can be severe.

Surgical outcomes and sleep endoscopy for children with sleep-disordered breathing and hypotonia.

OBJECTIVE: To study the efficacy of surgical management for obstructive sleep apnea (OSA) syndrome in children with hypotonia, and to identify common anatomic sites of airway obstruction. METHODS: Retrospective chart review of polysomnographic parameters and quality of life instrument scores for seventy eight children with hypotonia who underwent surgical intervention for sleep-disordered breathing at two tertiary children's hospitals, and analysis of drug-induced sleep endoscopy data using a previously validated scoring system. RESULTS: Children undergoing surgical intervention had baseline severe OSA with a statistically significant improvement in apnea-hypopnea index from 23.6 to 11.1 after surgery, but persistent severe OSA. OSA-18 sleep-related quality of life measurement and overall quality of life score showed statistically and clinically significant improvements, from 72.0 to 43.4 and from 5.3 to 7.6 respectively. Sleep endoscopy showed an average obstructive score of 7.2/15 (n = 39), with multi-level obstruction in 49% of children. Greater than 50% obstruction was observed at the tongue base in 64% of patients, velum in 46%, lateral pharyngeal wall in 38%, supraglottis in 38%, and adenoid in 23%. CONCLUSION: OSA syndrome is challenging to treat in hypotonic children. Severe residual OSA is common after surgical intervention, but improvement in quality of life is clinically and statistically significant. The tongue base is the most common site of persistent airway obstruction. Drug-induced sleep endoscopy can identify sites of airway obstruction and may aid in surgical planning for high-risk patients.

Diagnostic capability of macular parameters of Stratus OCT 3 in detection of early glaucoma.

AIM: To report the diagnostic capability of Stratus OCT macular parameters in early glaucoma. MATERIAL AND METHODS: In a cross-sectional observational study, two groups of subjects (early glaucoma and normals) who satisfied the inclusion and exclusion criteria were recruited. The diagnosis of early glaucoma was based on a glaucomatous appearance of the optic disc correlating with visual-field defects (fulfilling at least two of three Anderson and Patella criteria, with a mean deviation better than or equal to -6 dB. All patients underwent a complete ophthalmic evaluation including visual-field examination (24-2/30-2 SITA standard programme) and imaging with Stratus OCT 3. The macular thickness map in Stratus OCT includes the fovea, inner macula and outer macula, with diameters of 1, 3 and 6 mm, a total of nine sectors. Sensitivity, specificity, area under the receiving operating characteristic curve (AUROC) and likelihood ratio were calculated for volume and thickness parameters in these nine sectors. RESULTS: 56 eyes (56 patients) with early glaucoma and 75 eyes (75 normals) were analysed. Only two parameters, the outer inferior average volume (p = 0.003) and the outer inferior average thickness (p = 0.002), were statistically significantly lower in the glaucoma group. Outer inferior average volume had a "best combination" of sensitivity and specificity (56% and 79% respectively). Both outer inferior average volume and thickness parameters yielded the best AUROCs of 0.66. CONCLUSIONS: Outer inferior macular thickness and volume parameters in early glaucoma are significantly different from normals. The moderate sensitivity and specificity suggest that the role of macular parameters in the diagnosis of early glaucoma is limited.

Pharyngocutaneous fistulae in laryngectomy patients: the Toronto Hospital experience.

OBJECTIVE: The purpose of this study was to determine the rate of post-laryngectomy pharyngocutaneous fistulae and its association with age, gender, preoperative radiation, TNM staging, patients comorbidity factors, choice of ablation, choice of reconstruction, modality of postoperative feeding, and whether or not a primary tracheoesophageal puncture was performed. DESIGN: Retrospective clinical study. SETTING: The Toronto Hospital/Princess Margaret Hospital, University of Toronto, Toronto, Ontario. METHOD: One hundred and twenty-five consecutive laryngectomy procedures performed between July 1, 1992, and October 1, 1996, were reviewed. RESULTS: There was an overall fistula rate of 22%. No association found was between fistula rates and age, gender, patient comorbidity factors, TNM stage, choice of ablation, choice of reconstruction, modality of postoperative feeding, or whether a primary tracheoesophageal puncture was performed or not. CONCLUSIONS: At this tertiary care head and neck oncology centre, pharyngocutaneous fistulae remain an unpredictable and serious complication with an estimated economic cost of Cdn $400,000 per year.

Retrieval of "old" foreign bodies from the cardiovascular system in children.

Several techniques have been developed to retrieve catheter and guide wire fragments that have embolized to the heart and pulmonary vasculature. In most instances, retrieval of the embolized fragments is performed soon after the event has occurred. In this report, we summarize our experience with the removal of these fragments in 3 children after a significant amount of time had elapsed since the time of embolization. The embolized catheter and guide wire fragments were removed without any complications. We also describe the techniques used for their removal, and the problems encountered during the removal of these "old" foreign bodies.

Prospective angiographic study of the abnormalities of systemic venous connections in congenital and acquired heart disease.

UNLABELLED: Angiographic definition of systemic venous connections was obtained prospectively in 780 consecutive patients with congenital heart disease and 102 patients with acquired valvular heart disease undergoing cardiac catheterization. Attempts were made to enter the innominate vein and perform a balloon occlusion angiogram in each patient. In patients with congenital heart disease, bilateral superior vena cava were present in 32/771 patients (approximately 4%) with levocardia and 3/9 patients with dextrocardia. Among patients with bilateral superior vena cava (n = 35), an innominate vein of variable size that could be entered was present in six patients. Small tributaries connecting the right and left superior vena cava were found and entered in six patients. The superior vena cava was entered via its connection to morphologic left atrium in five patients and via the coronary sinus in 17 patients. Abnormalities of the inferior vena cava were seen in 7/780 patients. The following abnormalities of the inferior vena cava were noted: azygous continuation of rightsided inferior vena cava in levocardia -- 3 patients, hemiazygos continuation of the leftsided inferior vena cava in levocardia -- 1 patient, azygos continuation of the leftsided inferior vena cava in dextrocardia -- 1 patient, interruption of inferior vena cava below the liver with a plexus of veins joining the azygos vein -- 1 patient, and an inferior vena cava draining into the leftward aspect of the common atrium -- 1 patient. Abnormalities of the systemic venous connections were seen in 2/102 patients with acquired heart disease: bilateral superior vena cava in 1 patient and bilateral inferior vena cava in 1 patient. CONCLUSIONS: Abnormalities of systemic venous connections were seen in approximately 5% patients with congenital heart disease and approximately 2% patients with acquired heart disease. Small tributaries or an innominate vein of variable size often connect left and right superior vena. Contrast material can be injected into these connections to document the presence of bilateral superior vena cava.

Liver abscess after hemorrhoidectomy. Report of two cases.

PURPOSE: Pyogenic liver abscess after hemorrhoidectomy is extremely rare. Only two such cases have been previously reported; the diagnosis in each was made intraoperatively. We report two additional cases of hepatic abscess after hemorrhoidectomy, both treated nonoperatively with a successful outcome. METHODS: The two cases were analyzed for history, presentation, laboratory data, radiologic studies, and bacteriology. RESULTS: In both cases, the patients presented within one week of the hemorrhoidectomy. Treatment with broad-spectrum intravenous antibiotics was successful in achieving significant clinical improvement. The liver function test values reverted back to normal and follow-up computed tomography (CT) scans of the liver revealed marked improvement of the abscesses. Laparotomy was avoided in both of the patients. CONCLUSIONS: Increased awareness of this serious complication will afford earlier diagnosis. In addition, proper aerobic and anaerobic bacterial isolation techniques will allow appropriate nonoperative therapy, decreasing the high morbidity and mortality rates associated with this complication.

Rings, slings and such things: diagnosis and management with special emphasis on the role of echocardiography.

Vascular anomalies of the aorta and pulmonary artery that cause tracheal, esophageal, or tracheoesophageal compression form an important group of congenital cardiovascular malformations. The diagnostic approach to the patient with possible vascular ring is variable. This article presents a systematic approach to the evaluation and management of this fascinating group of malformations, with special emphasis on the role and limitations of echocardiography. Using this approach between September 1990 and March 1992, we identified and defined vascular anomalies of aorta and pulmonary artery in eight children.

Ventricular function in the single ventricle before and after Fontan surgery.

To better delineate the importance of ventricular function in patients with a single ventricle and assess its relation to outcome after the Fontan procedure, 47 patients with a single ventricle were studied. Ventricular ejection fraction was estimated by radionuclide angiocardiography. Before Fontan surgery, ejection fraction was 0.57 +/- 0.10 (mean +/- standard deviation). This differed significantly from the normal mean left ventricular ejection fraction of 0.68 +/- 0.09 (p less than 0.001) derived in our laboratory by radionuclide angiocardiographic methods. Age, ventricular morphology and the presence of pulmonary artery band or systemic to pulmonary artery shunts had no statistical relation to ventricular ejection fraction in patients with a single ventricle. Serial preoperative evaluation in 15 patients over 3.8 +/- 1.3 years revealed no significant change in ventricular ejection fraction; however, increased atrioventricular valve regurgitation was documented in 4 of these 15. Modified Fontan procedure was performed in 24 of the 47 study patients; 7 have died, 1 has undergone cardiac transplantation and 1 faces possible transplantation. No difference was noted in preoperative ejection fraction between survivors and nonsurvivors. Ventricular morphology, age at Fontan surgery and operative factors such as bypass and cross-clamp time were not related to functional outcome. Preoperative ejection fraction of 0.52 +/- 0.08 decreased to 0.39 +/- 0.11 (p less than 0.001) when evaluated 1.16 +/- 0.44 years after Fontan surgery. In patients with a single ventricle (1) ventricular ejection fraction is less than that of the normal systemic ventricle; (2) during childhood, ejection fraction is not related to age or ventricular morphology; and (3) ventricular ejection fraction frequently decreases after a Fontan repair.(ABSTRACT TRUNCATED AT 250 WORDS)

Preoperative and postoperative "aneurysm" associated with coarctation of the aorta.

The reported incidence of aortic aneurysm after surgical repair or balloon angioplasty for aortic coarctation varies widely. To determine the incidence of aneurysm formation after surgery, preoperative and postoperative cineangiograms from 65 patients who underwent operation at age 1.5 +/- 3.4 years were examined. Repair included a prosthetic patch in 14 patients, end to end anastomosis in 28 and subclavian flap in 23. Aneurysm was documented by change in contour or irregularities in contour at the repair site or by abnormal dimensions at the repair site, defined by the ratio of the widest measurement at the repair site to the measurement of the aorta at the diaphragm. An aneurysmal bulge above the ductus diverticulum was identified in 14 (23%) of 60 patients preoperatively; the area showed no change 4.72 +/- 4.07 years after surgery. Significant changes at the repair site were seen in only three patients, all of whom had Dacron patch repair. One patient had a change in contour at the repair site, one had an abnormally high repair site to diaphragmatic aorta ratio and one had a progressive increase in this ratio. Thus, during childhood years, 3 (5%) of 65 patients were diagnosed as having aneurysm at the surgical repair site. In conclusion, 1) comparison with preoperative cineangiograms, especially for aneurysmal bulges above the ductus arteriosus, is essential before an aneurysm can be attributed to coarctation repair by any technique, and 2) aneurysm developed only in patients subjected to Dacron patch repair.

Abdominal surgery in the elderly patient.

The accurate diagnosis of abdominal disease is important in the elderly, both to avoid negative exploration and to plan timely and appropriate operation. Emergency abdominal surgery has a higher mortality than elective surgery and is best avoided. A definitive planned elective procedure in the well-prepared elderly patient will avoid multiple operations and reduce mortality and morbidity.

Hypernatremia due to amniotic fluid embolism during a saline-induced abortion.

A case of fatal amniotic fluid embolism leading to hypernatremia during a hypertonic saline-induced abortion is reported. This sequence of events has not, to our knowledge, been previously reported. Hypernatremia as a diagnostic aid for amniotic fluid embolism is discussed.

PIP: A case of fatal amniotic fluid embolism leading to hypernatremia following instillation of hypertonic saline is reported. This complication of saline-induced abortion has not been reported previously in the literature. The patient was an obese 16-year-old black female, gravida 1, para 0, whose gestational age at time of abortion was 21.5 weeks. 26 hours after the procedure, which was well tolerated by the patient, she complained of severe abdominal cramps with projectile expulsion of amniotic fluid. Generalized convulsions and shaking followed and the patient went into shock. Death occurred within 2 hours. At autopsy, microscopic examination of lungs revealed pulmonary edema with marked vascular congestion, focal areas of atelectasis, and intra-alveolar hemorrhages. Positive test results for mucin in a few pulmonary vessels and intra-alveolar capillaries confirmed a diagnosis of amniotic fluid embolism. There was marked congestion of the blood vessels of the kidneys, liver, brain, and spleen. Amniotic fluid embolism represents about 10% of the maternal mortality in the US; however, this complication generally occurs during labor, delivery, and the immediate postpartum period. Moreover, most such cases occur in older, multiparous women in the 3rd trimester of pregnancy. It is possible that hypernatremia following amniotic fluid embolism occurs more frequently than reported. Routine examination of blood during pregnancy and of the vitreous humor in cases of pregnancy-related mortality could be useful in establishing a diagnosis of amniotic fluid embolism.

[Levels of serum lipids during abortion induced by a hypertonic saline solution]. / Les taux des lipides sériques au cours de l'avortement provoqué par une solution saline hypertonique.

Studies were carried out on serum lipid levels in 30 women in good health who were pregnant for the first time with a pregnancy of between 15 and 20 weeks duration, who had the pregnancies terminated by the use of a hypertonic saline solution. They showed a rise only in the cholesterol level (5.83 mmol/l +/- 0.17) in the phase of actively aborting (a period of maximum stress) as compared with a level of cholesterol in the pre-abortion phase (4.93 mmol/l +/- 0.17). Between 12 and 15 hours after the termination the cholesterol level dropped sharply as did the levels of phospho-lipids and triglycerides. The levels became of the order of 4.1 mmol/l +/- 0.25, 2.73 mmol/l +/- 0.097 and 1.03 mmol/l +/- 0.06 respectively according to the phase the termination was in. The levels of serum lipids after the termination were, surprisingly, almost the same as those in non-pregnant women. The poor rise in serum lipids during termination induced by hypertonic saline solution shows that probably labour was of low intensity.