Central nervous system (CNS) tumors in the first six months of life: the Children's Hospital Los Angeles experience, 1979-2005.

BACKGROUND: The authors report the experience at the Children's Hospital Los Angeles with brain tumors diagnosed before 6 months of age, describing the characteristics of the patients, their tumors, treatment strategies, and prognostic factors. METHODS: Thirty-three children who were identified between 1979 and 2005 were included. Twelve were female (36%). There were 11 gliomas, 9 choroid plexus tumors, 8 medulloblastomas and supratentorial primitive neuroectodermal tumors (PNET), 2 atypical teratoid/rhabdoid tumors (ATRT), and 1 each of ependymoma, craniopharyngioma, and immature teratoma. Locations of primary tumors included 21 supratentorial (64%) and 7 posterior fossa, and 5 tumors involved both compartments. The treatment strategies included 5 patients with biopsy only, 18 less than gross total resections (

A new, pluronic-based, bone hemostatic agent that does not impair osteogenesis.

OBJECTIVE: Intraoperative bone hemostasis can be accomplished using surgical beeswax (bone wax). However, bone wax locally interferes with osteogenesis, and its use is avoided when bone fusion is critical. We describe the use of a Pluronic copolymer blend as a biocompatible, absorbable, hemostatic agent. METHODS: A rat femur defect model and a femur gap nonunion model were used. For each surgical model, 24 rats were divided into three treatment groups, i.e., those receiving bone wax implants, Pluronic (90% Pluronic P85/10% Pluronic F88) implants, or no implants (control group). After 10, 21, or 42 days, animals were killed and femora were removed for radiographic analysis and hematoxylin and eosin staining. RESULTS: In the femur defect model, no differences were observed between the Pluronic-treated and control groups; hematoxylin and eosin staining demonstrated bone formation and osteocytes within the defect. In the femur gap nonunion model, no fusions occurred in any group. Development of an osseous callus at the gap site was observed for the control and Pluronic-treated groups. In both models, rats that received bone wax implants exhibited no osseous growth. CONCLUSION: The Pluronic blend exhibits handling properties similar to those of bone wax, readily achieves hemostasis, and does not inhibit bone regrowth. Pluronic compounds may serve as effective absorbable hemostatic agents for the treatment of bone bleeding in sites where fusion is critical. In addition, this copolymer blend may find use as a vehicle for the short-term release of pharmacological agents, which may further reduce the incidence of infections, reduce inflammation, and improve fusion rates.

Proximal and distal cannulation of the internal jugular vein for ECMO in a primate.

Extracorporeal membrane oxygenation (ECMO) is lifesaving for infants with severe respiratory distress but is complicated by severe intracranial hemorrhage in 10% to 30% of patients. Intracranial venous hypertension, as a result of ligation of the internal jugular vein (IJV), has been hypothesized as a contributing factor to cerebral edema and subsequent hemorrhage. Accessory cephalad IJV cannulation may serve as a means of additional venous drainage to the pump as well as protection against intracranial venous hypertension. Proximal and distal cannulation of the IJV were studied in a primate model. The parameters monitored included sagittal sinus, right and left ventricular pressures as well as venous pressure in the ECMO circuit. The cephalad venous cannula was clamped and unclamped at 30-minute intervals. There was no significant difference in sagittal sinus or intracranial pressures during periods of cephalad cannula clamping or unclamping. Venous return was augmented when the cephalad cannula was unclamped. Cephalad cannulation has no demonstrable protective effect on intracranial, subarachnoid or venous pressures but does improve venous return to the ECMO circuit. It is concluded that cephalad venous cannulation is not necessary in all cases and should be reserved for those patients requiring additional venous drainage to support pump flow.

Outcome following cardiopulmonary resuscitation in severe pediatric near-drowning.

Between April 1979 and September 1984, 66 children were admitted to the intensive care unit (ICU) at Childrens Hospital of Los Angeles after a severe near-drowning episode. Each patient required full cardiopulmonary resuscitation and had an initial Glasgow coma score (GCS) of 3 in a referring emergency room. Patients were reclassified according to results of a neurologic examination (GCS) on arrival in the ICU. The overall results showed 16 patients (24%) with apparently intact survival, 17 patients (26%) with vegetative survival, and 33 deaths (50%). No patient who arrived at the ICU with a GCS of 3 (flaccid) survived neurologically intact. Out of 37 such patients arriving in flaccid coma, 26 patients died and 11 patients suffered severe brain damage. The majority of patients with GCS of less than 6 underwent intracranial pressure (ICP) monitoring and aggressive therapy directed to control ICP. Despite adequate control of ICP and maintenance of cerebral perfusion pressure, 12 monitored patients survived in a vegetative neurologic state. The results justify aggressive emergency room resuscitation of severe pediatric near-drowning victims but suggest that cerebral resuscitative measures must be subjected to critical prospective evaluation.