Longitudinal associations between exposure to anesthesia and neurocognitive functioning in pediatric medulloblastoma.

AIM: To examine whether anesthesia exposure is associated with neurocognitive decline in pediatric medulloblastoma. METHODS: Patients were treated at St. Jude Children's Research Hospital and completed ≥2 protocol-directed neurocognitive assessments (n = 107) as part of a multisite clinical trial for pediatric medulloblastoma (NCT00085202). Patients received risk-adapted craniospinal photon irradiation, followed by four cycles of high-dose chemotherapy and stem cell rescue. Neurocognitive testing was completed at study baseline (after surgery and <2 weeks of starting radiation therapy) and annually for 5 years. Data on anesthesia exposure during treatment was abstracted from medical records. RESULTS: Patients were 10.2 years at diagnosis on average (SD = 4.5; 37% female, 73% average-risk). Mean cumulative anesthesia duration was 20.4 h (SD = 15.2; range 0.7-55.6 h). In the overall group, longer anesthesia duration was associated with greater declines in IQ (Estimate = -0.08, P < 0.001), attention (Estimate = -0.10, P < .001) and processing speed (Estimate = -0.13, P < 0.001). Similar results were shown in subgroups of patients who were <7 years at diagnosis (IQ = -0.14, P = 0.027; Attention = -0.25: P = 0.011), ≥7 years at diagnosis (Attention = -0.07, P = 0.039; Processing Speed = -0.08, P = 0.022), treated for high-risk disease (IQ = -0.09, P = 0.024; Attention = -0.11, P = 0.034; Processing Speed = -0.13, P = 0.001), or treated for average-risk disease (IQ = -0.05, P = .022; Attention = -0.08, P = 0.011; Processing Speed = -0.10, P < 0.001). CONCLUSION: Greater anesthesia exposure is a risk factor for clinically significant neurocognitive decline, in addition to factors of age at diagnosis and treatment risk arm. This result is notable as there are evidence-based strategies that can limit the need for anesthesia. Limiting anesthesia exposure, as feasible, may mitigate neurocognitive late effects, and thus, improve quality of life for survivors.

Correlation between Patellar Tilt Angle, Femoral Anteversion and Tibial Tubercle Trochlear Groove Distance Measured by Computer Tomography in Patients with non-Traumatic Recurrent Patellar Dislocation.

Introduction: Recurrent patellofemoral dislocation (RPD) is a disabling condition with a variety of anatomical risk factors. Its management remains difficult and controversial. Patients with RPD are known to have increased femoral anteversion (FA) and tibial tubercle trochlear groove (TT-TG) distance, but their effect on the patellar tilt angle (PTA) is less studied. Aims: The aims of this study are to compare PTA, TT-TG distance and FA between RPD patients and healthy controls and to establish a relation between these parameters and the type of surgery indicated for this pathology. Materials and methods: A total of 63 knees (57.1% females, 28.1±6.2 years), of which 33 from subjects with RPD and 30 from healthy controls, were assessed by computed tomography (CT) scan under supine position, with the measurement of TT-TG distance, FA and PTA. Results: The values of PTA, FA and TT-TG distance were significantly higher in the RPD group compared to the control group (CI 95% 9.52-11.64, CI 95% 5.87-11.8, CI 95% 6.44-9.72, respectively, with p value <0.0001 in all cases). In the RPD group, PTA significantly correlated to the FA (r=.53, p=0.001) and TT-TG (r=.39, p=0.02), while TT-TG correlated to FA (r=.53, p=0.001) too. Further analysis in the RPD group showed a significant correlation of PTA, FA and TT-TG (r=.96, r=.89, respectively, p=0.0001) when FA >25 degrees, but no significant correlation between TT-TG and FA or PTA when FA<25 degrees. Moreover, higher values of PTA and FA positively correlated with TT-TG distance (r=.44, r=.74, r=.20, p=0.03) when TT-TG was >20 mm, but no correlations were found between TT-TG and FA on less than 20 mm. Conclusion: In patients with RPD, FA, TT-TG and PTA have significantly higher values than controls. Higher PTA, TT-TG and FA are associated with an anteversion angle greater than 25 degrees and a TT-TG distance more than 20 mm, which might indicate a derotational femoral osteotomy to these patients in order to correct this pathology.

Respiratory morbidity of preterm infants of less than 33 weeks gestation without bronchopulmonary dysplasia: a 12-month follow-up of the CASTOR study cohort.

The aim of this study was to describe the incidence and risk factors for respiratory morbidity during the 12-month period following the first respiratory syncytial virus (RSV) season in 242 preterm infants [<33 weeks gestational age (GA)] without bronchopulmonary dysplasia and 201 full-term infants (39-41 weeks GA) from the French CASTOR study cohort. Preterm infants had increased respiratory morbidity during the follow-up period compared to full-terms; they were more likely to have wheezing (21% vs. 11%, P = 0·007) and recurrent wheezing episodes (4% vs. 1%, P = 0·049). The 17 infants (14 preterms, three full-terms) who had been hospitalized for RSV-confirmed bronchiolitis during their first RSV season had significantly more wheezing episodes during the follow-up period than subjects who had not been hospitalized for RSV-confirmed bronchiolitis (odds ratio 4·72, 95% confidence interval 1·71-13·08, P = 0·003). Male gender, birth weight <3330 g and hospitalization for RSV bronchiolitis during the infant's first RSV season were independent risk factors for the development of wheezing episodes during the subsequent 12-month follow-up period.

Nerve sheath catheter analgesia for forequarter amputation in paediatric oncology patients.

In a single centre over two years, four children (7 to 10 years old) with upper limb osteosarcoma underwent chemotherapy followed by forequarter amputation. All patients had preoperative pain and were treated with gabapentin. Nerve sheath catheters were placed in the brachial plexus intraoperatively and left in situ for five to 14 days. After surgery, all patients received local anaesthetic infused via nerve sheath catheters as part of a multimodal analgesia technique. Three of the four patients were successfully treated as outpatients with the nerve sheath catheters in situ. All four children experienced phantom limb pain; however, it did not persist beyond four weeks in any patient.

Hospitalizations for respiratory syncytial virus bronchiolitis in preterm infants at <33 weeks gestation without bronchopulmonary dysplasia: the CASTOR study.

This study was conducted during the 2008-2009 respiratory syncytial virus (RSV) season in France to compare hospitalization rates for bronchiolitis (RSV-confirmed and all types) between very preterm infants (<33 weeks' gestational age, WGA) without bronchopulmonary dysplasia and full-term infants (39-41 WGA) matched for date of birth, gender and birth location, and to evaluate the country-specific risk factors for bronchiolitis hospitalization. Data on hospitalizations were collected both retrospectively and prospectively for 498 matched infants (249 per group) aged <6 months at the beginning of the RSV season. Compared to full-term infants, preterm infants had a fourfold [95% confidence interval (CI) 1·36-11·80] and a sevenfold (95% CI 2·79-17·57) higher risk of being hospitalized for bronchiolitis, RSV-confirmed and all types, respectively. Prematurity was the only factor that significantly increased the risk of being hospitalized for bronchiolitis. The risk of multiple hospitalizations for bronchiolitis in the same infant significantly increased with male gender and the presence of siblings aged ⩾2 years.

Long-term use of nerve block catheters in paediatric patients with cancer related pathologic fractures.

We report three cases of children with osteosarcoma and pathologic fractures treated with long-term continuous nerve blocks for preoperative pain control. One patient with a left distal femoral diaphysis fracture had a femoral continuous nerve block catheter for 41 days without complications. Another with a fractured left proximal femoral shaft had three femoral continuous nerve block catheters for 33, 26 and 22 days respectively. The third patient, whose right proximal humerus was fractured, had a brachial plexus continuous nerve block catheter for 36 days without complication. In our experience, prolonged use of continuous nerve block is safe and effective in children with pathologic fractures for preoperative pain control.