Showing papers by "Leslie N. Sutton published in 1991"

Improved survival with the use of adjuvant chemotherapy in the treatment of medulloblastoma.

Abstract: Between 1975 and 1989, 108 children with newly diagnosed medulloblastoma/primitive neuroectodermal tumor (MB/PNET) of the posterior fossa were treated at the authors' institution. The patients were managed uniformly, and treatment included aggressive surgical resections, postoperative staging evaluations for extent of disease, and craniospinal radiation therapy with a local boost. Beginning in 1983, children with MB/PNET were prospectively assigned to risk groups; those with "standard-risk" MB/PNET were treated with radiation therapy alone, while those in the "poor-risk" group received similar radiation therapy plus adjuvant chemotherapy with 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU), vincristine, and cisplatin. The 5-year actuarial disease-free survival rate for all patients treated between 1975 and 1982 was 68%, and 73% when patients who died within 2 weeks after operation were excluded. This survival rate was statistically better for patients treated after 1982 (82%) compared to those treated between 1975 and 1982 (49%) (p less than 0.004). There was no difference in disease-free survival rates over time for children with standard-risk factors; however, there was a significant difference in the 5-year survival rate for poor-risk patients treated prior to 1982 (35%) compared to those treated later (87%) (p less than 0.001). For the group as a whole, a younger age at diagnosis correlated with a poorer survival rate; however, this relationship between age and outcome was significant only for children treated before 1983 (p less than 0.001). These results demonstrated an encouraging survival rate for children with MB/PNET, especially those treated with aggressive surgical resection followed by both radiation therapy and chemotherapy. The results strongly suggest that chemotherapy has a role for some, and possibly all, children with MB/PNET.

Fusiform dilatations of the carotid artery following radical surgery of childhood craniopharyngiomas

Abstract: Between 1982 and 1990, a series of 31 children with craniopharyngiomas underwent initial surgery at the Children's Hospital of Philadelphia with an attempt at total tumor removal. Nine (29%) of them were found to have fusiform dilatation of the supraclinoid carotid artery either at the time of surgery for recurrence (one patient) or on routine surveillance with enhanced computerized tomography 6 to 18 months postoperatively (eight patients). The finding of carotid enlargement was confirmed in seven cases with magnetic resonance angiography and in one case with a formal arteriogram. Eight of the nine patients remain alive at a mean of 3.7 years after diagnosis. None have experienced hemorrhage or other symptoms referrable to fusiform dilatation of the carotid artery, which is believed to result from surgical manipulation of the carotid artery.

Global cerebral ischemia in piglets under conditions of mild and deep hypothermia.

Abstract: To investigate the effects of hypothermia on the rate of change and degree of recovery of brain adenosine triphosphate and phosphocreatine concentrations and intracellular pH, we have developed a model that allows phosphorus nuclear magnetic resonance spectroscopy of the intact piglet brain during circulatory arrest. Three groups of piglets were studied. Three control animals underwent cardiopulmonary bypass at normothermia for 1 hour; five group 1 animals underwent bypass at a brain temperature of 15 degrees C, followed by a period of circulatory arrest such that adenosine triphosphate was absent for 21 minutes, followed by 1 hour of reperfusion; and five group 2 animals underwent bypass at a brain temperature of 37 degrees C, followed by a period of circulatory arrest such that adenosine triphosphate was absent for 21 minutes, followed by reperfusion for 1 hour. Control animals showed no significant metabolic effects of bypass. Group 1 animals showed a slower decay of the adenosine triphosphate and phosphocreatine concentrations than group 2 animals, consistent with a lower metabolic rate, and had a higher pH at the onset of ischemia. Recovery of the adenosine triphosphate concentration was significantly better in group 1 animals (95%) than in group 2 animals (30%) (p less than 0.02), and recovery of the phosphocreatine concentration was also better in group 1 animals (93%) than in group 2 animals (32%) (p less than 0.02). Intracellular pH recovered in group 1 animals, but not in group 2 animals. Regional biochemical assays of metabolites performed in the group 2 piglets and in five pilot piglets exposed to deep hypothermia generally confirmed the spectroscopic findings but demonstrated considerable regional variation, specially in the group 2 piglets' brains. We conclude that hypothermia exerts a protective effect on the piglet brain during global ischemia even after the adenosine triphosphate pool has been completely depleted.

Distribution of bacteria in the operating room environment and its relation to ventricular shunt infections: a prospective study

Abstract: In order to study the distribution of bacteria in the operating room environment, cultures were obtained during 111 unselected shunt operations throughout a 10-month period. After routine skin preparation, bacteria were collected by placing Millipore filters on the patient's prepped skin underneath the drapes, on top of the drapes in the operative field, and/or on the sterile instrument table, and left in place for the duration of the case. In 48 patients, full-thickness skin biopsies taken at the initial incision were cultured in lieu of skin surface cultures. Perioperative cerebrospinal fluid cultures and subsequent shunt infections were monitored. Of the 288 environmental (skin and surfaces) cultures, 24 were positive (20 coagulase-negative Staphylococcus and 4 Staphylococcus aureus). Positive cultures were found in 15 of 111 drape cultures (13.5%), 7 of 77 instrument table cultures (9.1%), and 2 of 97 skin cultures (2.1%). Positive environmental cultures were not correlated with the surgeon, length of case, time of day, or type of shunt operation, but were more likely to occur in a room other than the designated neurosurgical operating room. There was a correlation between the occurrence of positive environmental cultures and positive cerebrospinal fluid cultures, although the organisms were not always the same. Coagulase-negative Staphylococcus was the most common organism isolated from all sites. We conclude that bacteria most often associated with shunt infections are airborne in the operating room, rather than originating from the patient's skin, and are distributed in the highest concentration near the surgical team. Maintaining a designated operating room in which traffic is limited, as well as strict adherence to covering skin surfaces of the operating room personnel, may help to reduce shunt infection rates.

Congenital forms of intracranial teratoma

Abstract: Intracranial teratoma in the newborn is a well-recognized but infrequent entity. We describe two such cases: one with a massive intracranial teratoma replacing the cerebral hemispheres and the other, a smaller tumor extending into the orbit. Forms of congenital intracranial teratoma and theories of pathogenesis and management are briefly discussed.

Torticollis in children.

Abstract: Torticollis is a common clinical sign that is found in a variety of disorders. Childhood torticollis differs from the adult form in that congenital types are common and many frequently encountered disorders found in adults are unusual. Pediatric torticollis related to otolaryngologic conditions is reviewed, and three illustrative cases are presented.