Endoscopic implantation and patency evaluation of lumboperitoneal shunt: an innovative technique.

BACKGROUND: The placement of the lumboperitoneal (LP) shunt tube used in the management of idiopathic intracranial hypertension (IIH) and the evaluation of its patency necessitate an abdominal surgical incision. This procedure can now be done using a laparoscopic-assisted technique. This study was designed to evaluate the usefulness of this technique in treating patients with IIH in whom visual loss was progressive in spite of aggressive medical management, as well as for the evaluation of the function of the shunt tube after its placement. METHODS: Seventeen patients aged between 21 and 45 years (mean, 31) were included in the study. They were divided into two groups. Laparoscopy was used in the first group of 11 patients for primary placement of the peritoneal portion of shunt catheter in the right subphrenic recess. It was used in the second group, which consisted of six patients who had recurrence of symptoms after surgical LP shunt placement, for the evaluation of shunt patency and position inside the peritoneal cavity and for the repositioning of the displaced shunt, as needed. RESULTS: In the first group (n = 11), visual symptomatology was improved in 10 of 11 patients and became stable in the remaining one. In the second group (n = 6), two of six patients had a patent tube in a proper position; three had complete intraperitoneal migration of the shunt tubes, which were repositioned using a laparoscopic-assisted technique; and the last patient had occlusion of the peritoneal side of the shunt by omental adhesions that had been liberated by the laparoscopy. No complications related to laparoscopy were recorded in this series. CONCLUSION: This procedure was associated with better functional results, less postoperative pain and discomfort, a shorter hospital stay, an earlier return to normal activities, and cosmetic acceptability .

Cardiovascular changes in children with mucopolysaccharide disorders.

UNLABELLED: The aims of this study were to evaluate cardiac involvement, assess risk factors and mortality, and define the outcome of cardiac abnormalities with age in the different types of mucopolysaccharidoses (MPS). The echocardiograms of 99 patients with MPS, aged 1-24 y (median age 10.3 y) were reviewed between 1978 and 2000. Mitral regurgitation (MR) was detected in 29 patients (29%). MR was more frequent in types IH [n = 11 (38%)], II [n = 10 (24%)] and III [n = 4 (20%)]. Sixteen patients (16%) developed aortic regurgitation (AR), seen mostly in types II [n = 9 (56%)] and IV [n = 4 (24%)]. AR and/or MR was detected in 37 patients and 8 had both abnormalities of borderline significance (odds ratio 2.95, 95% confidence interval 1.0-8.85, p = 0.05). Of 99 patients, 47 had a normal study on their first echocardiogram, whereas only 7 had a normal study on subsequent echocardiograms. Fifty-four (54%) had a single echocardiogram. Of these, 27 (50%) were abnormal and 27 normal. Forty-five patients had more than one echocardiogram, of which 25 (56%) were abnormal and 20 normal. In 13/20 (65%) a cardiac abnormality developed on a subsequent echocardiogram which was statistically significant (p = 0.002). Overall mitral and aortic valve abnormalities showed a positive association with age. Univariate analysis of risk factors showed that increasing age, MPS I and ejection fraction were significant risk factors for death. However, left ventricular hypertrophy, mitral valve abnormalities and type II MPS were not significant risk factors for death, with borderline significance for aortic valve abnormalities. CONCLUSION: This study demonstrates the evaluation of ventricular function, which is a significant risk factor for death, along with increasing age and MPS I, and outlines the borderline significance of aortic valve abnormalities, which has not been mentioned in previous studies. It also shows that mitral valve lesions, commonly seen in MPS, were not a significant risk factor for death. The results emphasize the importance of performing serial echocardiograms in patients with MPS to assess ventricular function and the progression of cardiac abnormalities with age.

The utilization of a paediatric emergency room in a general hospital in Kuwait.

A descriptive study was conducted in Al-Amiri Hospital, Kuwait to evaluate the use of the paediatric emergency room (PER) by children under 12 years of age over an 11-week period. Socio-demographic data on the families, reasons for the visits, the pattern of referral and the diagnoses were reviewed and analyzed. A total of 277 children were enrolled in the study, the majority of whom (81%) were generally well, only 4% requiring admission to hospital. The paediatrician in the emergency room considered that 64% of visits were not emergencies. Some form of treatment and one to two routine investigations were needed in 21% and 21.6%, respectively. Stated reasons for seeking medical care were: symptoms of the child (34%), unavailability of primary clinic at night (22%) and perceived better services in hospital (20%). The median of parental satisfaction at the end of the visit was 95%. We conclude that most visits to the PER at Al-Amiri Hospital are inappropriate and that intensive health education is required to improve use of the PER and to increase public awareness of the difference between primary care and paediatric emergency facilities.

Use of 'very low-dose phenobarbital' to investigate compliance in patients on reducing doses of methadone (detoxification).

Incorporation of very low doses of phenobarbital into a methadone linctus has enabled us to monitor the compliance of 7 patients receiving a reducing dose of methadone (detoxification) for treatment for opioid addiction. By measuring both plasma phenobarbital and methadone we detected 4 patients who consumed extra illicitly obtained methadone during the detoxification regime. Treatment outcome was poor; 11 of the original 18 patients dropped out of treatment within 14 days and of those who remained, 4 patients relapsed and reabused illicit drugs and 2 returned to a fixed dose of methadone. Laboratory measurements were successfully used to detect poor methadone compliance.