Medical complications in scoliosis surgery.

Several medical complications can occur after scoliosis surgery in children and adolescents. They include the syndrome of inappropriate antidiuretic hormone; pancreatitis; cholelithiasis; superior mesenteric artery syndrome; ileus; pnemothorax; hemothorax; chylothorax; and fat embolism. This review focuses on the pathophysiology, diagnosis, and treatment of the various conditions that occur after correction of spinal deformity. Attention is given to recent literature specifically related to scoliosis surgery. Surgical complications like urinary tract infection, wound infection, and hardware failure will not be addressed.

Incidence and risk factors for mitral valve prolapse in severe adolescent idiopathic scoliosis.

Mitral valve prolapse (MVP) is known to be associated with thoracic skeletal anomalies. To determine the incidence and risk factors for mitral valve prolapse in the adolescent population with severe idiopathic scoliosis (IS), a prospective follow-up study on 139 adolescent patients with IS from the Pediatric Orthopedic Service was undertaken. Data collected included age, sex, medical and family history, physical exam, electrocardiogram and echocardiogram, spinal x-rays, and pulmonary function tests. MVP was detected by echocardiogram in 13.6% (19/139) of patients with IS as compared with 3.2% in 154 age- and weight-matched controls (p < 0.006). All patients with MVP were asymptomatic and a systolic click or murmur was detected on the single preoperative exam only in 37% (7/19) of them. Patients with MVP and IS weighed less (45.1 +/- 2.0 vs 51.8 +/- 0.1 kg, p < 0.002) as compared with those IS patients without MVP. The electrocardiogram was abnormal in 21% (4/19) of patients with MVP as compared with only 1.6% (2/120) of patients with IS but no MVP. The two groups did not differ with respect to age at diagnosis, severity of scoliosis, positive family history of scoliosis, or the presence of restrictive lung disease. Though IS was more prevalent in females (79%), the presence of MVP was not related to gender. MVP was persistent in 10 of the 19 patients reevaluated by echocardiogram 2-4 years after spinal surgery. We conclude that MVP is four times more common in patients with severe IS than in the normal adolescent population, and is associated with a lower body weight in IS patients with MVP than in IS patients without MVP. The persistent nature of MVP, even after corrective spinal surgery, may be related to factors other than geometric changes of the heart caused by abnormal thoracic curvature.

The heart and conduction system in acute Kawasaki disease: report of fraternal cases--one lethal, one relapsing.

The heart and conduction system were studied in a 4 1/2-year-old boy with Kawasaki disease who died suddenly in the early phase of illness. Severe perivasculitis, neuritis, pancarditis, and involvement of all parts of the specialized conduction system were found. The boy's brother, born a year later, at the age of 12 months had relapsing Kawasaki disease. He received intravenous gamma globulin and recovered.

Clinical trial of single-dose intravenous gamma globulin in acute Kawasaki disease. Preliminary report.

Gamma globulin administered in a single dose of 1 g/kg of body weight intravenously caused prompt clinical improvement in 27 of 32 consecutive children with Kawasaki disease treated by the 12th day of illness. Response was equally good for the 20 children treated in the first week and the 12 treated in the second week. Fever and clinical signs abated within the first day after treatment, the mean white blood cell count normalized by 48 hours, and the sedimentation rate continued to be elevated for about 2 weeks, while the platelet count rose during the first 2 weeks after treatment and returned to normal approximately 1 month after treatment. Five children with incomplete relief needed more than the single dose before resolution of signs and symptoms occurred. Coronary aneurysms in 2 patients before treatment regressed by 2 weeks. No patient developed coronary aneurysms. No child had sequelae of Kawasaki disease at a follow-up of 2 to 31 months. We believe that although this was a one-arm, uncontrolled pilot study, the results suggest that this protocol provides a safe, flexible, and effective treatment for acute Kawasaki disease.

Rug shampoo and Kawasaki disease.

Following personal interviews with 63 families of children with Kawasaki disease and with 63 control families with children paired for race, sex, and age, no epidemiologic differences were seen except for use of rug shampoo within 1 month of onset in 16 episodes in 15 children with Kawasaki disease in 14 families (24% of children, 22% of families) compared with two families of control children (3%, P less than .005). Explanations for this strong association of recent rug shampoo and Kawasaki disease include the question of recall bias as well as the possibility that an agent in the shampooing process does cause or does contribute to illness.

Epidemiologic aspects of Kawasaki disease in a Manhattan hospital.

Epidemiologic and clinical features of Kawasaki disease in 106 patients seen between 1980 and 1986 at The New York Hospital in midtown Manhattan were compared with those in large series from the United States, Canada, and Japan. Dissimilarities in our Kawasaki disease experience included ethnic heterogeneity of our patients (50% white, 18% black, 16% Hispanic, and 16% Oriental) and, in comparison with the Japanese experience, an older mean age (3 1/2 vs 1 1/2 years) with fewer children less than 2 years of age (32% vs 50% to 60%). In comparison with the general population of the geographic urban and suburban referral area for our hospital and in comparison with our general pediatric population, Oriental children with Kawasaki disease were overrepresented (16% vs 2%). More families of children with Kawasaki disease were members of the upper and middle class (73%) than were the population seen in general pediatrics (31.7%) at our hospital. Personal interviews with 63 families of children with Kawasaki disease and 63 control families with children paired for ethnic group, sex, and age revealed no epidemiologic differences except for use of rug shampoo within 1 month of onset in 16 episodes in 15 children with Kawasaki disease in 14 families (22% of families) compared with two families of control children (3%) (P less than .001).

Pulmonary function in preterm infants following treatment with intravenous indomethacin.

Pulmonary function tests, including measurements of arterial blood gas levels, total pulmonary compliance, and arterial-alveolar oxygen ratios, were performed in 38 ventilator-dependent preterm infants with respiratory distress syndrome who weighed less than 1500 g at birth. Twenty-seven had a physiologically significant patent ductus arteriosus (PDA). Twelve were assigned at random to receive three doses of intravenous indomethacin, 0.2 mg/kg per dose, on the fourth day of life. This treatment resulted in ductal closure in seven infants by the seventh day of life. Another concurrently observed group of 15 infants with PDA received no indomethacin. A third group of 11 infants lacked evidence of a PDA. Pulmonary function in the infants who received indomethacin did not differ significantly from that in the other two groups.

Correlation of electrocardiographic and echocardiographic changes in Kawasaki syndrome.

To determine whether changes in ECGs correlated with abnormalities in echocardiograms in children with acute and convalescent Kawasaki syndrome, we undertook a retrospective analysis of 44 patients examined during the first 2 weeks of illness and followed for at least 6 months, 31 for longer than 1 year. We analyzed 360 ECGs, 282 echocardiograms, and clinical status. Results of echocardiography showed 18 children with myocardial dysfunction, pericardial effusion, and/or coronary arterial abnormalities (41%); 26 children had no abnormalities. All 18 of the former and all but 10 of the latter had abnormalities on serial ECGs that normalized on recovery. Thirty-four of 44 patients (77%) had ECG abnormalities. These abnormalities were most prevalent in the first month: 68% appeared in the first week, about 50% in the second to fourth weeks, 16% at 2 months, and 10% at 3 months. The type of ECG change did not predict the type of echocardiographic abnormality, except that low voltage of QRS was found only with pericardial effusion. The most frequent early changes were in T waves, which were flattened in 28 (64%). Later 12 patients had high, peaked, abnormal T waves. Prolonged PR interval occurred in 13 patients, seven of whom had echocardiographic abnormalities. Of six with prolonged QT interval, four had abnormal echocardiograms. The possibility of having an abnormal echocardiogram increased with the number of ECG changes: from 0 risk with no change to 37% for one, 47% for two, 80% for three, and 100% for four changes in serial ECGs. Both ECGs and echocardiograms are important in early and subsequent evaluation of these patients. Inasmuch as the ECGs showed abnormalities in 77% whereas echocardiograms showed changes in 41%, we believe that serial ECGs in comparison with prior tracings offer the more sensitive noninvasive indicator of pancarditis in young children during acute and convalescent Kawasaki syndrome.

Coronary artery involvement in Kawasaki syndrome in Manhattan, New York: risk factors and role of aspirin.

Since January 1980, 110 children having 113 attacks of Kawasaki syndrome were studied. Age at onset was 7 weeks to 12 years (mean 3 6/12 years, median 2 9/12 years); 77% were younger than 5 years of age; the male to female ratio was 1.8; racial distribution was 52% white, 19% black, 14% Hispanic, and 16% Asian. Protocol of management consisted of high-dose aspirin (100 mg/kg/d) until afebrile, and then 81 mg every day until free of coronary aneurysm. Two-dimensional echocardiograms were done weekly during the acute stage, at 2 and 6 months after onset, and yearly if a coronary abnormality was detected. At 1 month, 51 coronary arterial abnormalities were present in 25 patients. Risk factors for a coronary abnormality were duration of fever greater than or equal to 2 weeks, level of platelet count, marked elevation of ESR, and age younger than 5 years. No statistically significant difference in incidence of aneurysms was detected between patients on high-dose aspirin and those on medium-or low-dose aspirin.

[Myocardial infarction in the young: evolution and clinico-coronarographic correlation (author's transl)]. / L'infarto miocardico in età giovanile. Evoluzione e correlazioni clinico-coronarografiche.

Fifty patients who suffered from an acute myocardial infarction at age 40 or below and underwent coronary arteriography, were studied from 8 to 184 months after the infarction (mean follow-up 56 months). Hyperlipidaemia (60%) and cigarette-smoking (82%) were the most common risk factors, while hypertension and diabetes mellitus were found in 10% of all patients. Thirty-seven patients had two or more risk factors. Preinfarction angina was present in 7 subjects. Death rate was 14% within five years and was related to the severity of symptoms. Out of the patients with normal coronary arteriogram (6 patients) or with a single vessel disease 21 were free of angina and 30 did not suffer a reinfarction. Out of 17 patients with two or more coronary vessel disease, angina was present in 14 and reinfarction was seen in 5.

[Effects of nitroglycerin on pressure-volume diastolic relationships of the left ventricle in patients with coronary disease]. / Effetti della nitroglicerina sulla relazione diastolica pressione-volume del ventricolo sinistro del coronaropatico.

In fifteen patients with coronary artery disease who underwent hemodynamic studies, pressure measurements and left ventricular angiography were performed prior and 5' after the administration of 0.4 mg of spray nitroglycerin (TNG). Two different expressions of left ventricular diastolic compliance (dV/dP - V at end-diastole, delta V/delta P normalized by end-systolic volume-VTS) were assessed in basal conditions and after TNG. Nitroglycerin decreased left ventricular end-diastolic pressure (control 22.7 +/- 7.6 mmHg; TNG 11.4 +/- 6.1 mmHg, p less than 0.001) left ventricular end-diastolic volume (control 138 +/- 54 ml/m2, TNG 122 +/- 54 ml/m2, p less than 0.001) and improved compliance indexes (dV/dP - VED control 1.3 +/- 0.5 10(-2)/mmHg; TNG 4.6 +/- 4.3 10(-2)/MMHg; p less than 0.01; delta V/delta P - VTS control 0.071 +/- 0.04 mmHg-1; TNG 0.170 +/- 0.14 mmHg-1, p less than 0.01). TNG decreased the average value of modulus of chamber stiffness K (control 0.031 +/- 0.009; TNG 0.028 +/- 0.008, p less than 0.02) shifting the pressure-volume curve in some patients rightward and downward. Thus the increase of end-diastolic compliance (dV/dP - VED) is due to preload reduction and in patients who presented a marked decrease in K, also to the shift of the pressure-volume relation. These effects of TNG have important implications because they permit patients with coronary artery disease to engage in a given effort at a significantly lower end-diastolic pressure, avoiding pulmonary congestion.

[The electrocardiogram in cardiomyopathies]. / L'elettrocardiogramma nelle cardiomiopatie.

The electrocardiogram of 27 patients with congestive cardiomyopathy (CMC), 15 with obstructive (CMO) and 13 with hypertrophic without obstruction (CMH) have been studied. Cardiac catheterization, angiography, coronary arteriography, and, in some cases, echocardiography, were performed. The study was carried out in an attempt to define certain patterns of each CM with emphasis on the ischaemic-like features, as infarct pattern, symmetrical T wave inversion, ST elevation, non-typical troubles of ventricular repolarization and on the electrophysiology of these findings. Suggestive for CMC were: (1) prolonged PR, (2) high frequency of arrhythmias and conduction defects, especially complete left bundle branch block with abnormal left axis deviation, (3) left atrial enlargement and ventricular hypertrophy. Suggestive for CMO: (1) low incidence of arrhythmias and conduction defects, (2) left atrial enlargement and ventricular hypertrophy. Infarct pattern, symmetrical T wave inversion and other ischaemic-like features were equally found in all groups of CM, without any statistical difference. Pathogenesis of cardiomyopathy, particularly of CMH, is discussed, carrying out a review of literature.