Aplasia cutis congenita. Case report.

The authors report the use of intraoperative tissue expansion in the treatment of a neonate with aplasia cutis congenita, a congenital defect of the scalp and skull. The case for immediate surgical intervention is presented, and intraoperative tissue expansion and cranioplasty are recommended as components of an effective surgical approach.

Pyoderma gangrenosum and cranial osteolysis: case report and review of the paediatric literature.

Pyoderma gangrenosum is a poorly understood, ulcerating cutaneous disorder which is rarely seen in the paediatric age-group. We report a 3-year-old boy who developed an ulcer over the left frontoparietal scalp at the age of 1 year. A 9-cm area of underlying cranial bone was destroyed. The appearance on radiographs and CT scan was suggestive of eosinophilic granuloma, osteomyelitis, or other destructive processes. Biopsies of the scalp lesion and calvaria showed granulation tissue and degenerating bone. After the biopsies the scalp lesion increased in size, and wound dehiscence occurred. Ulceration developed at the site of a PPD skin test, which on biopsy was consistent with the diagnosis of pyoderma gangrenosum. Pyoderma gangrenosum should be added to the differential diagnosis of cutaneous disorders which can result in osteolytic/osteonecrotic defects.

Development of a user-defined surgical database using a personal computer network.

Advances in personal computer technology have made powerful methods for the collection and analysis of patient information available to clinical users. This report details the development of a multi-user database distributed across a network of personal computers that facilitates operative scheduling, and collection and analysis of operative data. Clinicians from each surgical service in our medical center developed customized data entry programs that contribute information centrally through a telephone-line network to prepare the daily operative schedule. Subsequently, information from the operating rooms is added to the preoperative database to form an operative log, which is distributed to client services for further analysis and modification. This system has improved the efficiency and accuracy of operative scheduling and information management and shifted the burden of data collection away from the physician. Widespread availability of these data has contributed to the development of an effective quality improvement program and facilitated effective management of personnel and resources.

Infections in neurologic surgery. The intraventricular use of antibiotics.

Intraventricular antibiotic therapy appears to be a useful treatment modality in those CSF infections in which systemic therapy may fail. Consideration should be given to using this form of treatment when infecting organisms are only sensitive to antibiotics with poor penetration of the CSF (e.g., aminoglycosides and vancomycin) and for cases in which intravenous therapy has failed to sterilize the CSF, toxicity from systemic therapy precludes further increases in dosages, and shunts or other CSF hardware might be expected to reduce the efficacy of systemic therapy by providing a foreign body to harbor organisms. Shunts or reservoirs that are infected may be successfully sterilized with IVT therapy alone or in conjunction with systemic therapy, but this has a lower success rate than cases in which the shunt is removed. There is a wealth of clinical experience with IVT vancomycin and gentamicin that suggests that they are relatively safe. Until more data are available on other aminoglycosides and newer antibiotics, these two agents should be considered the antibiotics of choice for IVT therapy. In situations in which the organism is sensitive to both vancomycin and gentamicin, vancomycin should be used in view of the documented neurotoxicity seen with gentamicin. When gentamicin resistance occurs, amikacin and tobramycin are appropriate alternatives. The high risk of epilepsy with the penicillins and cephalosporins makes them less suited for IVT therapy, although the newer cephalosporins have some promise for IVT therapy. CNS fungal infections can be treated effectively with IVT amphotericin B but with a high risk of significant toxicity. Miconazole appears to be safer than amphotericin B but there is less clinical experience with this drug. Table 1 summarizes the dosages, indications, and toxicity of those antibiotics commonly used for intraventricular administration, which have been reported previously.

A pilot study of hyperbaric oxygen in the treatment of human stroke.

We administered hyperbaric oxygen or air in a double-blind prospective protocol to 39 patients with ischemic cerebral infarction. We interrupted the study when we noticed what appeared to be a trend favoring the air-treated patients, whose neurological deficits were less severe (mean +/- SEM score on graded neurological examination: air, 25.6 +/- 4.9; oxygen, 34.5 +/- 7.5) and whose infarcts were smaller (air, 29.0 +/- 12.2 cm3; oxygen, 49.2 +/- 11.7 cm3) at 4 months. The trend, we decided, was probably an artifact of the randomization process. Nevertheless, we chose not to resume the trial because the treatment was difficult to administer by schedule (for various reasons the treatment protocol was broken in 15 of the 39 patients), was poorly tolerated (eight of the 39 patients refused to continue treatments), and did not produce dramatic improvement.