Israel Medical Association Journal

Objectives: To retrospectively determine the clinical response to ¹³¹I-MIBG therapy at low doses in patients with refractory neuroblastoma.

Methods: We performed a retrospective chart review of 10 patients with neuroblastoma treated with ¹³¹I-MIBG at Rambam Health Care Campus from 1994 to 2012. Clinical data, number of ¹³¹I-MIBG courses delivered, toxicities, and clinical responses were reviewed. MIBG scan was performed after each course.

Results: Twenty-one courses of ¹³¹I-MIBG were delivered to 10 patients (3 girls, 7 boys). Their mean age was 3.8 years (range 1.5–6 years). All patients received several protocols of chemotherapy including the high dose form. Three patients received three courses of ¹³¹I-MIBG with a minimum of 6 weeks between each course, five patients received two courses, and two patients received only one course. An objective response to the first course was obtained in nine patients and to the second course in six of eight, and in three children who underwent the third course the pain decreased. One patient has no evidence of disease, four are alive with disease, and five died of the disease. No unanticipated toxicities were observed.

Conclusions: Low dose ¹³¹I-MIBG is an effective and relatively non-toxic treatment in neuroblastoma disease palliation. Rapid and reproducible pain relief with ¹³¹I-MIBG was obtained in most of the children. Treatment with systemic radiotherapy in the form of low dose ¹³¹I-MIBG was easy to perform and effective in cases of disseminated neuroblastoma, demonstrating that this primary therapy can be used for palliative purposes.

Background: Takayasu arteritis (TA) is a rare chronic granulomatous inflammatory disease of the aorta and/or its major branches and more frequently affects female patients before menopause. Since persistent inflammation may lead to arterial ischemia, hypertension is an important complication of TA. Objectives: To evaluate gestational results and complications in patients with TA arteritis.

Methods: We conducted a retrospective analysis of the medical records of patients with TA admitted to the high risk pregnancy clinic for women with systemic autoimmune diseases at Hospital Universitário Pedro Ernesto.

Results: From 1998 to 2011 we followed 11 pregnancies in 9 patients with TA; the patients’ age ranged from 17 to 42 years and disease duration from 2 to 28 years. In 7 of the 11 pregnancies, uncontrolled blood pressure occurred before labor and preeclampsia was diagnosed in one. Two deliveries were preterm, one newborn was treated for sepsis and four (36%) had intrauterine growth restriction (IUGR).

Conclusions: Close monitoring improves the perinatal outcomes in patients with TA who are more prone to develop hypertension, preeclampsia and IUGR. Disease activity was not observed in our group of patients during pregnancy. Coordinated care between the obstetric, rheumatologic and cardiologic teams is the ideal setting to follow pregnant women with TA.

Background: Delays in diagnosis and inadequate treatment of acute scaphoid fractures can lead to non-unions, presenting surgeons with unique challenges regarding optimal management.

Objectives: To evaluate the clinical and radiographic outcome of scaphoid non-unions treated with percutaneous screw fixation.

Methods: The study group comprised12 patients with scaphoid non-unions of an average duration of 8.7 months. There were 11 males and 1 female with an average age of 24 years (range 14–47 years). All patients were initially treated with percutaneous screw fixation without bone grafting. A volar percutaneous approach was used in eight patients and a dorsal percutaneous approach in four. Wrist range of motion (ROM) and disabilities of the arm, shoulder, and hand (DASH) questionnaires were used to assess clinical outcomes. Postoperative radiographs were reviewed to assess the fracture union, carpal alignment and screw position.

Results: Eleven of the 12 (92%) fractures united successfully with no additional procedures. These fractures achieved radiographic union at an average of 4 months. One patient with sickle cell anemia required revision fixation, which consisted of repeat percutaneous fixation and bone grafting. In this patient his non-union healed 3 months after the revision procedure. The average DASH score at final follow-up was 6 (range 0–16). Average wrist ROM was extension of 66 degrees (range 50–80) and flexion 71 degrees (range 55–90). None of the patients showed radiographic signs of osteoarthritis, osteonecrosis of the scaphoid, or hardware-related complications.

Conclusions: For scaphoid waist nonunions without collapse, percutaneous fixation without supplementary bone grafting provides satisfactory results with a high union rate, early return of function and minimal complications.
 

Background: The effectiveness of intensive versus standard physical therapy for motor progress in children with cerebral palsy is controversial. Sitting acquisition is considered an important developmental milestone.  

Objectives: To assess the acquisition of sitting and gross motor progress in infants with cerebral palsy treated with intermittent intensive physical therapy as compared to a matched group treated with a standard physical therapy regimen.

Methods: We conducted a randomized controlled crossover study in 10 infants aged 12–22 months with cerebral palsy; 5 were assigned to the intensive intermittent therapy group and 5 to the control group. After 4 weeks of baseline intervention, the intervention program was administered to the experimental group for 8 weeks and the regularly scheduled weekly program to the comparison group, targeting sitting as the treatment goal. Thereafter the comparison group crossed over. The Gross Motor Function Measure 66 and 88 (GMFM 66 and 88) were used at 4 week intervals.

Results: The intermittent intensive regimen yielded a mean improvement of 7.8% and 1.2% in the two groups respectively. However, these results were attributed to infants with a low functional level only (P < 0.01).

Conclusions: Goal-directed intensive intermittent regimen could possibly be beneficial in infants with a low functional level.
 

Background: The 20%–60% rate of acute anterior myocardial infarction (AAMI) patients with concomitant left ventricular thrombus (LVT) formation dropped to 10–20% when thrombolysis and primary percutaneous coronary intervention (PPCI) were introduced.

Objective: To test our hypothesis that prolonged anticoagulation post-PPCI will lower the LVT incidence even further.

Methods: Included in this study were all 296 inpatients with ST elevation AAMI who were treated with PPCI (from January 2006 to December 2009). Treatment included heparin anticoagulation (48 hours) followed by adjusted doses of low molecular weight heparin (3 more days). All patients underwent cardiac echocardiography on admission and at discharge. LVT and bleeding complications were reviewed and compared.

Results: LVT formation was present on the first echocardiogram in 6/296 patients. Another 8/289 patients displayed LVT only on their second echocardiogram (4.7%, 14/296). LVT patients had significantly lower LV ejection fractions than non-LVT patients at admission (P < 0.003) and at discharge (P < 0.001), and longer time to reperfusion (P = 0.168). All patients were epidemiologically and clinically similar. There were 6 bleeding episodes that required blood transfusion and 11 episodes of minor bleeding.

Conclusions: Five days of continuous anticoagulation therapy post-PPCI in inpatients with AAMI is associated with low LVT occurrence without remarkably increasing bleeding events.
 

Background: Carbon dioxide is the most widely used gas to establish pneumoperitoneum during laparoscopic surgery. Gastrointestinal trauma may occur during the peritoneal insufflation or during the operative phase itself. Early diagnosis of these injuries is critical.

Objectives: To assess changes in end-tidal carbon dioxide (E_TCO₂) following gastric perforation during pneumoperitoneum in the rat.

Methods: Wistar rats were anesthetized, tracheotomized and mechanically ventilated with fixed minute volume. Each animal underwent a 1 cm abdominal longitudinal incision. A 0.3 x 0.3 cm cross-incision of the stomach was performed in the perforation group but not in the controls (n=10/group), and the abdomen was closed in both groups. After stabilization, CO₂-induced pneumoperitoneum was established at 0, 5, 8 and 12 mmHg for 20 min periods consecutively, each followed by complete pressure relief for 5 minutes.

Results: Ventilatory pressure increased in both groups when pneumoperitoneal pressure ≥ 5 mmHg was applied, but more so in the perforated stomach group (P = 0.003). E_TCO₂ increased in both groups during the experiment, but less so in the perforated group (P = 0.04). It then returned to near baseline values during pressure annulation in all perforated animals but only in the 0 and 5 mmHg periods in the controls.

Conclusions: When subjected to pneumoperitoneum, E_TCO₂ was lower in rats with a perforated stomach than in those with an intact stomach. An abrupt decrease in E_TCO₂ during laparoscopy may signal gastric perforation.