The effects of repeated antenatal glucocorticoid therapy on the developing brain.

Antenatal glucocorticoid (GC) therapy improves infant outcome following preterm birth. As approximately 50% of women given a first course of antenatal GCs remain undelivered 7-14 d later, many clinicians administer further courses. GCs are known to be neurotoxic and there is concern that exposure during early development may have adverse effects on the immature brain. The aim of this investigation was to compare magnetic resonance (MR) indices of brain maturation in infants exposed to repeated antenatal GC therapy and born at or close to term, with non-GC exposed control infants. MR images were obtained during quiet sleep without sedation. T1 weighted volume images were obtained in the sagittal plane and T1, T2 weighted spin echo and inversion recovery images in the transverse plane. Brain volume and surface area were calculated from segmented image slices, and a measure of the complexity of cortical folding, the whole cortex convolution index (WCCI), from computerized analysis of a vector coded contour following algorithm. Analysis of covariance was used to compare the two groups after allowing for the effect of postmenstrual age. There were 10 infants in the GC group (range of antenatal GC exposure, 3-11 courses) and 6 controls. Each GC course comprised two 12-mg IM doses of betamethasone 24 h apart. GC exposed infants had a significantly lower WCCI (p = 0.001) and smaller surface area (p = 0.02), after allowing for postmenstrual age. There was no significant difference in brain volume (p = 0.5). Repeated antenatal GC exposure results in measurable differences in brain maturation when compared with gestational age matched non-GC exposed controls. The clinical relevance of these observations is not known.

The introduction of breast milk donation in a Muslim country.

Breast milk donation (wet-nursing) for full-term babies is a well-known practice in Kuwait, but it has never been organized formally in a neonatal intensive care unit (NICU) for preterm babies. Donor milk banking as conducted in Western society is not considered to be ethical in Muslim society, where the milk donor and the recipient are required to know each other. Human milk is known to decrease the incidence of necrotizing enterocolitis; improve host defenses, digestion, absorption of nutrients, gastrointestinal function, and neurodevelopment of the child; and contribute to maternal physical and psychological well-being. A culturally accepted approach to donor milk banking is proposed as a means of overcoming the ethical issues surrounding milk donation in Muslim society. This report addresses the first step in raising awareness of the valuable contribution of donor milk to preterm babies and the organization of human milk donation for use in an NICU.

Assessment of neonatal encephalopathy by amplitude-integrated electroencephalography.

OBJECTIVE: To define normal and abnormal patterns, test interobserver variability, and the prognostic accuracy of amplitude-integrated electroencephalography (aEEG) soon after the onset of neonatal encephalopathy. METHODS: Consecutive cases of neonatal encephalopathy (n = 56; gestation median, 40; range, 35-42 weeks) and healthy infants (n = 14; gestation median, 40; range, 39-40 weeks) were studied. aEEG was recorded using a cerebral function monitor, at median, 0, range, 0-21 days of age. Of the infants, 24 of the 56 with encephalopathy and all of the normal infants were studied within 12 hours of birth (median, 5; range, 3-12 hours). Forty infants were suspected of having suffered birth asphyxia. Criteria for normal and abnormal patterns were defined and the interobserver variability of these classifications determined. Results were compared with neurodevelopmental outcome assessed at 18 to 24 months of age. aEEG also was compared with a standard EEG and with magnetic resonance imaging. RESULTS: The median upper margin of the widest band of aEEG activity in the control infants was 37.5 microV (range, 30-48 microV), and median lower margin was 8 microV (range, 6.5-11 microV). We classified the aEEG background activity as normal amplitude, the upper margin of band of aEEG activity >10 microV and the lower margin >5 microV; moderately abnormal amplitude, the upper margin of band of aEEG activity >10 microV and the lower margin

Parotid gland tumours: a 15-year experience.

Between 1973 and 1988, 302 patients underwent surgical operations for parotid gland swelling. Primary operations were performed in 293 cases, while secondary operations for recurrent tumour were performed in nine cases. A total of 244 patients (80.8%) were found histologically to have either a benign parotid tumour or a tumour-like lesion, while 58 patients (19.2%) were diagnosed as having malignant tumours. Two hundred and eighty-nine patients underwent superficial and total conservative parotidectomy and in 13 cases a radical parotidectomy was performed. The median follow-up was 5 years (range 1-15 years). Permanent facial nerve palsy, tumour recurrence, Frey's syndrome and parotid fistula were recorded as 0.7, 0.7, 2.1 and 0.4%, respectively. Thus, with full understanding of the surgical anatomy of the parotid gland and correct tumour identification, preservation of the facial nerve and serious postoperative complications can be minimized following superficial and/or total conservative parotidectomy.

Thyroid lobectomy for removal of a fish bone.

A 42-year-old female Jordanian patient presented with a history of sudden painful dysphagia following swallowing of a fish bone. Though soft tissue X-rays showed a foreign body in the neck, repeated oesophagoscopies failed to reveal it. Computed axial tomography was done and showed a fish bone embedded in the left thyroid lobe. Left thyroid lobectomy was carried out and the fish bone was seen within the lobe surrounded by an area of acute inflammation.

Serial determinations of serum CEA in monitoring management of patients with colorectal carcinoma.

Serum concentrations were determined serially in two groups of patients with colorectal carcinoma: in 123 after curative resection and in 34 with residual cancer. Of the first group, in 98 serum CEA fluctuated within the normal range or with a 2-fold larger amplitude evidencing effective surgery because only 9 had recurrence; in 25 serum CEA rose persistently from a postoperative nadir indicating relapse, mostly liver metastases. Of the 34 patients with relapse, 3 had clinically and 7 CEA-directed second-look laparotomy; although 7 had operation with curative intent, only 3 remained disease-free. In the second group, there were 26 patients after palliative surgery and 8 during nonsurgical treatment. Serum CEA fluctuated within the normal range in 2 patients in remission and in 3 with progressive cancer, and rose in parallel to cancer progression in 29. Thus, serum CEA within or slightly above the normal range was 88% predictive that the patient might be free of disease or in remission; whereas elevated or rising level indicated disease progression. Accordance between serum CEA and clinical status occurred in 145 of 157 (92%) patients.

Preoperative and longitudinal serum levels of CA 125 and CA 15.3 in patients with breast cancer.

Serum levels of ovarian carcinoma antigen (CA 125) and breast carcinoma antigen (CA 15.3) were determined in 237 patients with breast carcinoma, 121 before any therapy and 116 after initial treatment, during uneventful follow-up or at the time of relapse. The aim was to assess how often the CA 125 test failed, i.e., was false-negative in patients in whom the CA 15.3 test was true-positive and, more important, whether it gave diagnostic information in patients in whom the CA 15.3 test failed. Before surgery or other initial therapy, serum CA 125 and CA 15.3 gave similar information in 85.1 percent of the patients: true-positive in 4.1 percent and false negative in 81.0 percent: CA 125 gave less information in 13.2 percent; and more information in only 1.7 percent. During follow-up, serum CA 125 and CA 15.3 gave similar information in 73.3 percent of the patients: true-positive (i.e., rising persistently from a nadir or elevated above 65 U/ml) in 23.3 percent, true-negative in 36.2 percent, and false-negative in 13.8 percent; CA 125 gave less information in 25.0 percent: false negative in 22.4 percent and false-positive in 2.6 percent; and more information in only 1.7 percent. Therefore, the CA 125 test appears useless for staging and is redundant when the CA 15.3 test is employed, for management of patients with breast cancer.

Serum levels of CA 125 in patients with gastrointestinal cancers.

Serum levels of CA 125 and markers reputed as specific for cancers in relevant locations (squamous cell carcinoma, SCC, carcinoembryonic antigen, CEA, CA 19.9, alpha-fetoprotein, AFP) were determined in 107 patients with gastrointestinal (GI) carcinomas. The aim of this study was to assess their individual and combined sensitivities, and the power of CA 125 in excluding primary ovarian epithelial cancer from GI primary. Serum CA 125 levels (in U/ml) ranged from nondetectable to 400 in patients with esophageal, to 570 in those with gastric, and to 300 in patients with colorectal carcinoma. The levels for liver secondaries, pancreatic, and hepatocellular carcinoma were 480, 2,720 and 1,100 U/ml, respectively. Serum SCC antigen was elevated in all patients with esophageal cancer, CEA or CA 19.9 in 52% of patients with gastric cancer and in 63% with liver secondaries, and CEA in 95% of patients with colorectal cancer; whereas serum CA 125 above 65 U/ml was found in 25% of this subgroup, but only in those with already an elevated concentration of specific marker(s). Serum CEA or CA 19.9 was elevated in 71%, CA 125 in 59% of patients with pancreatic cancer; the latter mostly in those with already elevated CEA or CA 19.9. Serum AFP was elevated in 84% and CA 125 in 40% of patients with hepatoma; the latter mostly in those with already an elevated AFP. CA 125 values exceeding 1,000 U/ml were found in 1 patient with pancreatic cancer (2,720 U/ml) and in 2 with hepatoma (1,050 and 1,100 U/ml). These findings illustrate the nonspecificity of the CA 125 antigen, its small if any advantage compared to the specific markers, and they diminish its role as a marker for primary ovarian cancer from GI primary unless it exceeds 2,800 U/ml.

Carcinoembryonic antigen and breast carcinoma antigen (CA 15.3) in preoperative staging and postoperative monitoring of patients with carcinoma of the breast.

Serum levels of carcinoembryonic antigen (CEA) and breast carcinoma antigen (CA 15.3) were determined in patients with breast carcinoma: in 129 before initial surgical or nonsurgical treatment and in 134 afterwards. Before any initial treatment, CEA was elevated in 15% of patients with Stage IV disease and CA 15.3 was high in 11% with Stage III and 48% with Stage IV. While monitoring management active disease was associated with elevated serum CEA in 66% of the patients, with elevated CA 15.3 in 73% and with at least one of the markers elevated in 86%. Both tests had high specificity (93% and 98%). The rise in serum CEA and, even more so, of serum CA 15.3 roughly paralleled the increase in bulk of the tumor: from locoregional disease through metastases to the lungs, bones, lungs with bones, and liver. Decreases in the levels of serum CEA and CA 15.3 reflected response to therapy, increases in the level of at least one marker-treatment failure, and levels fluctuating above the normal range indicated stationary disease. During follow-up, the predictive value of a negative test (levels within the normal range), suggesting that the patient might be free of disease, was 61% for CEA alone, 67% for CA 15.3 alone, and 80% for the two tests combined. We conclude that an elevated serum level of only one of the markers was useful for staging, implying advanced disease. Determination of both markers jointly was useful for monitoring the effectiveness of the therapy and for follow-up aimed at detection of relapse.

Congenital benign mesenchymoma of the head and neck.

Congenital benign mesenchymoma of the head and neck is rare. One such case, presenting as a mass in the neck, is reported and the literature reviewed. Pathologic nature of the lesion is discussed. Prognosis after adequate local excision is good.