Managing women who decline HIV testing in pregnancy and their infants? A multidisciplinary team guideline.

OBJECTIVES: The management of women at high risk of HIV infection who repeatedly decline HIV testing in pregnancy is not covered in any national guideline. In Leeds, we had a case which prompted us to consider maternal rights plus our duty of care to the infant once born. METHODS: Leeds has an established HIV and Syphilis in Pregnancy Multidisciplinary Team (MDT). The main issues pertaining to a pregnant woman persistently declining HIV testing were discussed within the MDT: identification of pregnant women declining testing; universal testing versus testing by risk stratification of their infants; calculation of vertical transmission risk; definition of unacceptable risk; timing of the decision to request court authority to test the infant; advanced preparation of court authority request papers. RESULTS: It was decided that an HIV transmission risk > 1 in 1000 justified testing an infant at birth. The MDT decision to request court authority for infant HIV testing would be made at 32-34 weeks of gestation, allowing the court papers to be prepared in advance of delivery. The Leeds Obstetrics and Paediatric Guidelines were reviewed, amended and approved by the Trust Guideline Group, Risk Management team and legal team. These guidelines are outlined within the article. The Neonatal guideline also is accessible via this link: http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=177 CONCLUSIONS: If a woman at high risk declines HIV testing in pregnancy, it remains possible to significantly reduce the risk of vertical transmission once the child is born, but the window of opportunity is small. Therefore, it is vital to have pathways already in place to address this prior to delivery.

Subcutaneous oxyntomodulin analogue administration reduces body weight in lean and obese rodents.

OBJECTIVE: To determine the efficacy of a long-acting oxyntomodulin (OXM) analogue, OXM6421, in inhibiting food intake and decreasing body weight in lean and diet-induced obese (DIO) rodents. RESEARCH DESIGN AND METHODS: The glucagon-like peptide-1 (GLP-1) receptor binding affinity and efficacy, sensitivity to enzymatic degradation in vitro and persistence in the circulation after peripheral administration were investigated for OXM6421 and compared with native OXM. The chronic effect of OXM6421 on food intake, body weight and energy expenditure was examined in lean rats, and its anti-obesity potential was evaluated in DIO mice. RESULTS: OXM6421 showed enhanced GLP-1 receptor binding affinity and cyclic adenosine monophosphate (cAMP) stimulation, and higher resistance to enzymatic degradation by dipeptidyl peptidase IV (DPP-IV) and neutral endopeptidase (NEP) compared with native OXM. OXM6421 persisted longer in the circulation than OXM after peripheral administration. Acute administration of OXM6421 potently inhibited food intake in lean rodents, with cumulative effects lasting up to 24 h. In lean rats, daily subcutaneous (s.c.) administration of OXM6421 caused greater weight loss than the pair-fed animals, and a higher rate of oxygen consumption than both the pair-fed and the saline controls. In DIO mice, continuous s.c. infusion of OXM6421 resulted in a significant weight loss, accompanied by an improvement in glucose homeostasis and an increase in circulating adiponectin levels. Once-daily s.c. administration of OXM6421 for 21 days caused sustained weight loss in DIO mice. CONCLUSION: OXM6421 induces negative energy balance in both lean and obese rodents, suggesting that long-acting OXM analogues may represent a potential therapy for obesity.

The carriage of pro-inflammatory cytokine gene polymorphisms in recurrent pregnancy loss.

PROBLEM: Recurrent pregnancy loss (RPL) affects 2-4% of couples, and remains largely unexplained. Recent studies have examined the role of cytokines in the maintenance of normal pregnancy, which is linked with an increased expression of Th2 cytokines. Overexpression of Th1 cytokines is associated with RPL. Knowing that functional polymorphisms exist for certain cytokines, it has therefore been suggested that women with RPL may have a genetic predisposition to overexpress Th1 cytokines. METHOD OF STUDY: The genes for interleukin-1 beta (IL-1beta) and tumor necrosis factor alpha (TNF-alpha) carry functional gene polymorphisms. In both cases these are biallelic polymorphisms that can be detected by polymerase chain reaction followed by restriction fragment length polymorphism. The aim of this pilot study was to assess whether carriage of the rarer alleles (TNF*2 and IL-1B*2) could act as independent risk factors in recurrent miscarriage. RESULTS: We found an increased incidence in the carriage of TNF*2, more pronounced in those women with two or more miscarriages. Carriage of the IL-1B*2 either alone or in association with TNF*2 was not associated with recurrent miscarriage. CONCLUSION: There may be a role for these cytokine gene polymorphisms in RPL.

An exclusive group of "pediatric neurosurgeons"?--No!

In the past several years there has been a movement created by a small group of neurosurgeons, who advocate the segregation of the practice of pediatric neurosurgery from the rest of neurosurgery, and the creation of separate training standards and even a qualifying board independent of the American Board of Neurological Surgery. Some thoughts on the matter are presented, and caution is advised.

Pediatric lumbar disc surgery: 20 patients under 15 years of age.

BACKGROUND: Patients in their first or second decades of life who present with back pain without sciatica or painless scoliosis have been found to have a central lumbar disc protrusion. This study was elected to determine the difference between pediatric and adult disc symptomatology, surgical findings, and the results of surgery. METHODS: Review of office and Children's Hospital records from 1958 through 1995 yielded a total of 60 patients under the age of 20 years who had lumbar discectomy by the author. Twenty were under the age of 15. This group is reported herein. All but 3 have been followed for up to 20 years. RESULTS The youngest was a boy 10 years and 8 months at operation. Only 20% complained initially of sciatic pain; 60% had it by the time of surgery; 20% never had it. The offending disc was at L5-S1 in 75%. The disc protrusion was central in 75%; no disc had ruptured. The posterior spinal ligament had ossified in the protruded position in 40%. Computed tomography (CT) scans were particularly useful. Significant antecedent trauma was present in 45%. Sixty percent were males. There was a family history of disc disease in 60%. The whereabouts of 3 of the 20 patients is unknown; their operations were 20-36 years ago. CONCLUSIONS: Lumbar disc disease in the first 2 decades may be missed because of the absence of sciatica. Once diagnosed, conservative therapy for as long as 2 years has failed. Lumbar discectomy in children under 15 years was safe in all cases and known to be successful in 88%.

Long-term lumboureteral shunt removed secondary to iatrogenic meningitis.

With the advent of ventriculoperitoneal cerebrospinal fluid shunts for communicating hydrocephalus, rarely does the physician see patients with alternate types of shunting devices. The once popularized lumboureteral shunt is unique for its potential complications of dehydration, electrolyte imbalances, infection, and the sacrifice of a functioning kidney. This article presents the case of a woman with a longstanding lumboureteral shunt that was removed after the onset of iatrogenic meningitis secondary to an ascending urinary tract infection.

Bladder functional changes resulting from lipomyelomeningocele repair.

From 1986 to 1991, 12 boys and 23 girls underwent surgery for lipomyelomeningocele removal. Of these patients 29 were 15 months old or younger (average age 3 months), while 6 were 4.5 to 19 years old (average age 10 years). Preoperative and postoperative urodynamic studies, including external urethral sphincter electromyography, were done on everyone. All 29 infants had a cutaneous lesion overlying the lower back and 14 had an abnormal neurological examination. Preoperative urodynamic studies were abnormal in 11 patients, consisting of an upper motor neuron lesion in 6, and a mixed upper and lower motor neuron lesion in 5. Postoperatively, 10 of 14 children with an abnormal neurological examination improved, while 9 of 11 with abnormal lower urinary tract function normalized. In 1 of 18 children (6%) with normal preoperative urodynamic studies detrusor-sphincter dyssynergia developed postoperatively. In all 6 older children urinary incontinence developed, and this led to the diagnosis. Everyone had an abnormal neurological examination and abnormal preoperative urodynamic studies. One child had a lower motor neuron lesion, and 5 had a mixed upper and lower motor neuron lesion. Postoperatively, the neurological examination improved in only 1 patient (16%), and the urological symptoms and urodynamic findings improved in another child. Lipomyelomeningocele has a progressive effect on lower spinal cord function because infants tend to present with fewer urinary manifestations and physical findings than older children. Individuals who escape early detection tend to have a more subtle cutaneous abnormality. As a result, older children are more likely to present with urological and neurological complaints. Surgical correction in infancy provides a degree of reversibility not seen in older children. It is imperative that early identification, evaluation and treatment be undertaken to prevent this progression and permanency of neurological changes and urinary dysfunction.

A plea for early operation for craniosynostosis.

In times when much is written of complex craniofacial operations for synostosis, it is important to reassess the efficacy of simpler operations on the cranium when carried out in the first few weeks of life. Examples of sagittal, coronal, and lambdoid synostosis are shown, as well as one patient with multiple suture involvement.

Craniopharyngiomas in children. Long-term effects of conservative surgical procedures combined with radiation therapy.

Thirty-seven patients with craniopharyngioma were treated at Children's Hospital, Boston, between 1972 and 1981, the mean follow-up period now being 10.5 years. Twenty of these patients are old enough to have finished high school and have been queried about their college or job activity. None of the four patients who had undergone radical excision of their tumor and who had reached the age of finishing high school was able to work independently. Among the 16 patients who reached this age and who were treated by more conservative operations and irradiation or irradiation alone, job performance or college attendance varied considerably, indicating that psychosocial impairment occurred in this group, but suggesting that the risk was less. The rate of tumor recurrence or of failure to respond to treatment was 57% (four of a total of seven survivors) following radical surgery and 7% (two of 27 survivors) after conservative operations and irradiation. The overall mortality rate was 8%; the causes of the three deaths were: "hypothalamic crisis" 1 year after radical resection; progressive tumor growth despite two attempts at resection and irradiation; and a brain-stem glioma in the field of irradiation 8 years after treatment.

Intestinal perforation by peritoneal shunt tubing: report of two cases.

Patients with cerebrospinal shunts have multiple complications. Two cases are reported in which peritoneal tubing perforated the intestine and intermittently protruded through the anus. The literature is reviewed and therapeutic considerations are discussed.

Cushing and epilepsy surgery: two successfully treated cases with long-term follow-up.

Two of Dr. Harvey Cushing's patients who were successfully treated surgically for epilepsy are presented to illustrate his understanding of the problem. Both cases include his operative sketches and long-term follow-up, one includes the patient's recent brain computed tomography scan and autopsy specimen. Cushing's operative sketching habits and their importance are discussed.

Neurourological implications of the changing approach in management of occult spinal lesions.

Occult lesions of the spine in children are a rare but recognizable cause of neurogenic dysfunction involving the lower extremities, and lower urinary and gastrointestinal tracts. We report the preoperative and postoperative urodynamic findings in 40 children with varying spinal abnormalities. Of these patients 28 were neonates or infants (average age 8.7 months) and 12 were older children (average age 11.7 years). Preoperative urodynamic testing revealed normal function in 18 of 28 children (64 per cent) in the younger age group in contrast to 1 of 12 (8 per cent) in the older age group. Of the 10 infants with abnormal studies postoperative urodynamic findings returned to normal in 6, while 2 others remained abnormal but were improved. In contrast, of 11 older children with abnormal preoperative evaluations 3 (27 per cent) reverted to normal postoperatively. The neurourological changes seen in these occult lesions are variable, may occur at any age, are progressive and are potentially reversible by surgical correction but this reversibility diminishes with age.

Medulloblastoma at the joint center for radiation therapy between 1968 and 1984. The influence of radiation dose on the patterns of failure and survival.

In order to assess the efficacy of high-dose irradiation to the posterior fossa and low-dose irradiation to the spinal axis, we reviewed the results of 60 patients with biopsy-proven medulloblastoma treated at the Joint Center for Radiation Therapy (JCRT) between 1968 and 1984. The 5- and 10-year actuarial survival rates for all patients were 68% and 44%, respectively. The median time to recurrence was 19 months. Extent of surgery, age, and radiation dose to the posterior fossa all were of prognostic value. Complete or subtotal gross resection appeared to be a favorable prognostic indicator compared with biopsy only (P less than 0.05), with a 69% versus 40% actuarial survival rate at 5 years, respectively. Infants 2 years of age or less had a diminished 5-year actuarial survival rate of 48% (P less than 0.05) compared with older age groups. The posterior fossa was the predominant site of recurrence and accounted for 78% of all failures. Local control in the posterior fossa was dose dependent. Seventy-nine percent of the tumors that received 5000 cGy or greater were controlled versus only 33% of the tumors that received less than 5000 cGy (P less than 0.02). There were no supratentorial failures, and there was only one isolated spinal cord failure. There were no solitary spinal failures in 24 patients who received a median dose of only 2400 cGy to the spinal axis. We concluded that low-dose irradiation to the spine and whole brain may be indicated with maintenance of a posterior fossa dose of greater than 5000 cGy.

Transorbital penetrating injuries to the frontal lobe.

Three cases of transorbital penetrating trauma to the frontal lobe are reported. These cases are remarkable in that minimal ocular trauma was incurred and excellent vision was preserved. These cases underscore the importance of suspecting the possibility of intracranial injury when evaluating penetrating orbital trauma.

Balloon occlusion of a recurrent carotid-cavernous fistula previously treated by carotid ligations.

A carotid-cavernous fistula recurred 16 years after a Hamby procedure. The recurrence was manifested by subarachnoid hemorrhage originating from dilated draining pial veins. The fistula was closed with a balloon catheter introduced through a patent remnant of the cervical carotid artery. Patients who have previously undergone Hamby trapping and embolization should be reassessed for an occult fistula that could predispose them to intracranial bleeding.