Search

The organization and management of a pediatric dialysis unit is a multi-faceted endeavor which requires a unique mindset and perspective for services provided. The environment of care is not an outpatient clinic or a critical care ward, but rather a merging of the two. Providing safe and effective patient care that enhances the life experiences of patients, their families, and staff is the ultimate goal of care and treatment in the pediatric dialysis unit. This chapter will review operational management – culture, organization, regulatory, physical space, human factors influences, and staffing – as well as components of care implementation, modality selection, patient/family education, patient care plans, patient/family support, quality improvement, infection prevention, and safety.

The preferred vascular access for hemodialysis recipients is an arteriovenous fistula in the nondominant arm. Prior placement of a peripheral intravenous (PIV) catheter can lead to vascular injury and limit options for arteriovenous fistula creation, a particular problem for children, who may need hemodialysis for their entire lifetime. We instituted an initiative to increase the frequency of PIV catheter placement in the dominant arm for hospitalized pediatric patients with advanced chronic kidney disease (CKD).Quality improvement initiative.Children with CKD stage 3-5, receiving dialysis, and/or following kidney transplantation who were hospitalized at one children's hospital between September 2018 and August 2020.Retrospective data on PIV catheter location for patients from January 1 to June 30, 2017, served as baseline data. Quality improvement activities consisted of: 1) education of the multidisciplinary treatment team, patients, and parents regarding importance of vein preservation; 2) placement of individualized notes in the electronic medical record identifying the preferred arm for PIV catheter placement; 3) use of "restricted extremity" arm bands; and 4) vascular access team participation to minimize attempts for PIV catheter placement.Monthly compliance with placement of PIV catheters in dominant arms.Location of PIV catheter placements were determined monthly and used to create run charts describing compliance.At baseline and before institution of this initiative, 34 of 72 (47%) PIV catheters were placed in patients' dominant arms, with only 2 of 8 (25%) PIV catheters placed in the dominant arm for children aged5 years. After instituting the initiative, 345 of 371 (93%) PIV catheters were placed in the dominant arm of 93 children; in children aged5 years, 58 of 62 (94%) PIV catheters were placed in the dominant arm. Only 38 of 371 (10%) PIV catheters were placed in the antecubital vein.Single-center study.Education regarding the importance of vein preservation, along with implementation of a standardized process for identifying children for whom vein preservation is important, can help direct PIV catheter placement and potentially preserve vasculature in pediatric patients with CKD.

The term orbital tumor covers a wide range of benign and malignant diseases affecting specific component of the orbit or developing in contact with them. They are found incidentally or may be investigated as part of the assessment of a systemic disorder or because of orbital signs (exophthalmos, pain, etc.). Computed tomography, MRI and Color Doppler Ultrasound (CDU), play a varying role depending on the clinical presentation and the disease being investigated. This article reflects long experience in a reference center but does not claim to be exhaustive. We have chosen to consider these tumors from the perspective of their usual presentation, emphasizing the most common causes and suggestive radiological and clinical presentations (progressive or sudden-onset exophthalmos, children or adults, lacrimal gland lesions, periorbital lesions and enophthalmos). We will describe in particular muscle involvement (thyrotoxicosis and tumors), vascular lesions (cavernous sinus hemangioma, orbital varix, cystic lymphangioma), childhood lesions and orbital hematomas. We offer straightforward useful protocols for simple investigation and differential diagnosis. Readers who wish to go further to extend their knowledge in this fascinating area can refer to the references in the bibliography.

OBJECTIVES To better understand the gene expression patterns in tumor-associated stroma, laser-capture-microdissections from clinical specimens were analyzed by genome-wide-expression microarray technology. The epithelial-stromal interaction plays a critical role in prostate development, reactive changes, and tumorigenesis. Diverse microarray technologies have been used to characterize the molecular changes in prostate cancer. Even though these gene expression studies are compromised by the heterogeneity of the tumor, as well as by the difficulty associated with collecting appropriate counterparts to represent normal prostate cells, the gene array data from tumors have shown promising results. Currently, little is known about the tumor-associated stromal gene expression profile in prostate cancer. METHODS Matching benign and malignant epithelial cell-related stroma cells were subjected to microarray platforms. RESULTS The prostatatic stroma expressed several osteogenic molecules. In particular, one of the genes, OSF2, was upregulated in tumor-associated stroma compared with benign epithelial cell associated stroma, which was further validated by immunohistochemical examination. CONCLUSIONS These data show that the combination of laser capture dissection with computational enhancement of epithelial and stromal microarray data is a useful tool to assess gene expression changes in prostate cancer stroma.

To assess the role of colour Doppler flow imaging (CDFI) in the diagnosis and management of lacrimal fossa lesions. Institutional ethical committee approval was obtained. Fifty-one patients with 62 lacrimal fossa lesions were retrospectively included from 2003–2015. All patients underwent conventional ultrasonography and CDFI, with a qualitative and quantitative analysis of the vascularization. All patients had lacrimal gland surgery. Definitive diagnosis was based on pathological examination. The study included 47 non-epithelial lesions (NEL) and 15 epithelial lesions (EL), with 24 (39 %) malignant lesions and 38 (61 %) benign lesions. NEL were significantly more likely to present with septa (p

Ten patients with orbital fractures and optic nerve trauma are reported. Fractures of the optic canal could be demonstrated by computed tomography in six cases and fractures of the orbital apex in another three cases. Surgical decompression of the optic canal was performed in seven cases. Computed tomography enhanced decision for surgery in cases of intraorbital haematoma with exophthalmus and narrowing of the canal by bony fragments, especially in those patients presenting with incomplete or progressive visual disturbance. Language: de

The assessment of viral load in the blood, tissues, and bodily fluids of persons infected with human immunodeficiency virus is fundamental to defining the stage of disease (1-3), the effect of antiviral treatments to abate disease (4, 5), disease progression (6-8), and propensity for the transmission of disease (9,10) as well. Now accepted as a surrogate for all of these features of HIV-1 disease, specific guidelines have been adopted for the use of viral load measures in the clinical management of the disease (11).

Twenty-two patients suffering from syringomyelia were treated operatively. Different shunt procedures were performed. Most often syringo-subarachnoid shunt (seven cases) and syringopleural shunt (eight cases) were used. Operative findings and complications were discussed. Postoperative improvement was observed in five patients, twelve were stable-unchanged, four showed further deterioration and one died. Operative treatment should be performed before gross neurological deficit is established.

Depending on the surgical approach, involving either total or subtotal extirpation of pituitary tumors, the recurrence rates have varied from 10.4% (intra- and suprasellar tumors without parasellar enlargement) to 35% (large tumors with parasellar configuration) in patients examined by us (Rauhut et al. 1986). In the literature there are many reports of a high risk of tumor recurrence in cases of a primary supra- and parasellar tumor configuration with infiltration of the neighboring structures (Fahlbusch et al. 1978; Guiot 1978; Wilson 1984).

This paper deals with the histological alterations found in the ischiadic nerve of the domestic fowl after compression with aneurysm clips. The corresponding clinical and electrophysiological findings are described elsewhere in this volume (Nau et al.).

The damage to peripheral nerves by entrapment is due to compressive mechanisms that occur where the nerves are normally confined to narrow anatomic passage pathways and are therefore susceptible to compression. This definition does not include any details about the pathogenetic mechanisms in entrapment syndromes. It is also known that the peripheral nerves are more susceptible to mechanical injury in special metabolic conditions such as alcoholism, diabetes mellitus, malnutrition syndromes, and endocrine disturbances. The best known entrapment neuropathy is the carpal tunnel syndrome (CTS) of the median nerve. Other syndromes of the ulnar and radial nerves as well as of the peroneal nerve are less frequent and therefore less well investigated. Only little attention has been paid to the “painful hand” (interosseous ramus of radial nerve syndrome, IRS).

The term “syringomyelia” was first introduced by Charles P. Ollivier d’Angers in 1827. Pathological and clinical descriptions of this condition were given in earlier times by Estienne in 1546, Brunner in 1688, Morgani in 1740, and Portal in 1804 [3]. There has been extensive documentation of this entity in the literature. The clinical picture, diagnosis, and natural course of syringomyelia are well known. The diagnosis of syringomyelia has been significantly facilitated by the introduction of magnetic resonance imaging. In contrast, the pathogenesis and treatment of syringomyelia still present unsolved problems.

In 1938, electrophysiological investigations after nerve compression in rats were conducted by Allen. Since then, various models of nerve compression have been described by Aguayo et al. (1971), Bentley and Schlapp (1943), Denny-Brown and Brenner (1944a, b), Duncan (1948), Dyck (1969), Lehmann and Pretschner (1966), Mayer and Denny-Brown (1964), and Weiss and Davis (1943). The investigations generally had no comparable clinical, electrophysiological, or morphological findings in a single animal. In addition, pressure neuropathies have been examined in quadrupeds. The hen with its two legs seemed to be not only a simple model for pressure neuropathy studies and comparison with man but also a cheap one. In 1958, Henschler used hens for testing neurotoxic substances, and in 1961 Glees and White did so in experimental fiber studies. In 1955, Koch and Heim pointed to the high body temperature and the higher rate of metabolism. The quick appearance of clinical and morphological alterations were described by Blank in 1966. Therefore clinical symptoms, electrophysiological, and morphological findings following nerve compression should be described in these animals.

The shorter the duration of symptoms and the less their severity, the better seems the prognosis for improvement in complaints and disorders of a disease. One can suppose that the clinical symptoms correlate with objective findings. In carpal tunnel syndrome, preoperative findings and outcome seem to be connected with weakness or atrophy of abductor pollicis brevis muscle and failure of long-term benefit [9]. Electrophysiological tests have proved their value in early [1, 7, 24] and differential diagnosis [12, 19, 22]. But it is not certain that there is a significant correlation between the degree of electrophysiological alterations and the degree of nerve compression [10]. In spite of different opinions about the preoperative value of electrophysiological examinations, the improvement or normalization of nerve conduction velocity after operation is generally supposed to correspond to the relief of symptoms [3–6, 14, 17, 20].

In a neurosurgical intensive care unit 26 patients with unconsciousness and unresponsiveness were investigated by means of multimodality evoked potentials and electroencephalography in order to obtain information on the functional state of the nervous system. Multimodality evoked potential techniques allowed us to differentiate patients with EEG alterations due to drug treatment from those without therapy. The functional state and prognosis can be better evaluated by means of evoked potential techniques. Patients with raised intracranial pressure seem to undergo some characteristic alterations in FEP and far field potential derivations.

A 48-year-old man had a 3-year history of progressive sensory and motoric disturbance of the lower extremities. Computed tomography and magnetic resonance imaging revealed an extensive epidural lipoma

Cases of optic nerve lesions of various origins are described. These were seen in a systematic study of 59 autopsy cases with underlying neurological or neurosurgical diseases. The characteristic morphological signs of direct and indirect as well as primary and secondary lesions are discussed. Circulatory complications in cases with increased intracranial pressure are stressed.

Electroencephalographic investigations were done in 24 patients suffering from medulloblastoma. All underwent subtotal or total removal of the tumour and a shunt procedure, foowed by irradiation therapy. The most frequent pre-operative finding was general slowing, the degree of which could be correlated to the amount of papilloedema and obstructive hydrocepalus. In about one third of the patients we found abnormal rhythmic theta and delta activities, especially marked in the occipital regions. This could be explained by the pathogenesis of hydrocephalus in the child. In the acute post-operative stage in some cases only the general slowing was worse. A return to normal of the EEG disturbances was seen in the later post-operative course and after irradiation therapy. This return to normal seemed to depend only on the time factor, but not on the mode of treatment.

In the course of 2 1/2 years the authors saw five patients with blindness of one or both eyes. All patients were admitted to their clinic after accidents and trauma in an unconscious state. All five patients had a midfacal fracture. In two instances where X-ray photography indicated a clearcut mechanical compression they performed a decompression of the canal. However, the effect was negligible. The disappointing experience was compared with the literature.In particular, in case of unconsciousness of the patients the problem of the exact diagnosis is very difficult. The experiences with visual evoked potentials are not very reliable. It is still very difficult to arrive at a proper diagnosis without the patient's collaboration. Consequently, up to now it is very difficult to lay down definite rules for the therapy. It is equally impossible to give a proper prognosis in all those cases that are suspected of a lesion of the optic nerve.

Seventy-four patients with tumors in the sellar region were examined by means of encephalotomography and axial computerised tomography. In nearly all cases, the localisation and expansion of tumors could be exactly determined by encephalotomography. In addition, a graduation according to the degree of hypothalamic compression was possible. In cases of density differences between tumor and brain tissue and contrast enhancement more information of the inner structure of a tumor (cystic or solid) could be obtained by computerised tomography. But in cases of missing density differences or/and contrast enhancement tumor diagnosis is easier by encephalotomography because of the high efficiency of encephalotomography. The indication for the form of operative treatment, transsphenoidal or transcranial, depends on the exact knowledge of tumor growth, especially of the degree of hypothalamic compression. Therefore, in all uncertain computerised diagnosis encephalotomography has to be undertained.

18 patients with post-traumatic visual disease of the optic nerve are presented. In the post-traumatic stage, visual evoked potentials were monitored. In amaurosis there was a high incidence of midface or frontobasal fractures. The severity of the trauma is not correlated with the severity of visual deficits. Flash evoked potential (FEP) findings were different: In most cases there was a correlation of clinical and FEP findings. In some we found false positive potentials in the acute stage. In smaller visual field deficits the alterations of FEP could not be correlated with the clinical disorders. FEP alterations depended on time. The pathophysiological mechanisms are discussed in regard to the pathological findings in 51 unselected autopsies with an investigation of the visual pathway from the intraorbital optic nerve to the visual cortex. Because of the different morphological alterations the clinical, neurological and ophthalmological examination should be followed by standard CT scanning to evaluate intracranial haematomas and by CT scanning with thin slices of the optic nerves and the soft tissue of the orbit. Visual evoked potentials (VEP) and in the unconscious patient, flash evoked potentials (FEP) do not give much more security for therapeutic decisions in comparison with former times. The histological findings do not support the hypothesis that operative decompression is successful.

Electroencephalographic (EEG) investigations were done in 36 patients with intracranial aneurysms, before and after surgery. Thirty five of them suffered from subarachnoid hemorrhage (SAH). Pre-operatively, there was no correlation between patients' age or sex and localisation of the aneurysm or degree of EEG disturbances. The most frequent finding was a generalised slowing, the degree of which depended on the time from bleeding to EEG. Focal abnormalities were due to spasms of the vessels or intracerebral haematomas. There was a high correlation with neurological deficits. Post-operatively, EEG disturbances became worse in 21 cases. Generalised and focal abnormalities increased. These were due to focal oedema and the operative approach. The EEG could be correlated very well with the findings from other investigative methods (CT scanning, angiography). The EEG, as a functional method, showed very well the whole state of the brain after bleeding and after operation.

Causes of head injury in childhood depend on age. In contrast to the adults there are differences in pathophysiological mechanisms and in the site of lesions. Brain stem disorders are more frequent, superficial brain damage is less frequent than in children. Multiple lesions of the limbic system are as well important as those ones of the mesencephalon. Most of the cases of apallic syndromes in childhood can be due to these lesions. Language: de

Ten patients suffering from intramedullary pilocytic astrocytomas (WHO-classification: astrocytoma grade I) were investigated catamnesticly. Combined surgery and radiotherapy was performed. Seven patients received neutron irradiation postoperatively. In four cases the neurological symptoms were improved after follow-up periods ranging from 33 to 89 months. The three other patients died after 6 to 21 months. The autopsy findings of a 14 year old child are presented. Our results are compared with reports in the literature. In addition, long-term problems of the spinal column are discussed. It seems that the combined surgical and neutron therapy improves the prognosis of pencil gliomas.

In the neurosurgical intensive care unit 135 patients were studied by means of multi-modality evoked potentials. The majority part of them had low scores on the Glasgow Coma Scale and a higher lever of coma according to WFNS. This fact explains the high mortality (52 per cent). These patient data were compared with the changes of evoked responses (ER) in order to learn something about the value of ER in localisation of lesions, staging, and predicting the outcome of the patients. A classification of EP alterations is introduced. There was no correlation between alteration of evoked potentials and coma stage. The analysis of latencies and inter-peak latencies revealed no correlation between comatous and alert patients. Cerebral conduction time (CCT) did not give further information. In cases of brainstem lesions the alteration of evoked responses were more marked than in the other patients. Most of the patients died who had initially marked changes in ER. The sensitivity of BAER was greater than of SSEP. A loss of response was more frequent in BAER. In deep coma stages the motor evoked responses disappeared. This fact induces problems in diagnosing brain death. Evoked potentials yield further information in patients with coma and drug therapy. They are useful in follow-ups, esp. in predicting the outcome. Evoked responses complete clinical and findings obtained via the diagnostic equipment.

Three cases of hypertrophic peripheral neuropathy are presented and their different aetiology is discussed. Hypertrophic peripheral neuropathy involving spinal nerve roots may act as a space occupying lesion mimicking tumors especially neurinomas. Therefore the neurosurgical approach may have a therapeutic as well as a diagnostic value.

Event-related potential recording and neuropsychologic testing were carried out on 18 severely head-injured patients and on a control group. At early stages of injury the patients had prolonged P3 latencies and reduced psychometric scores. In the assessment of individual patients the P3 latency proved to be a measure that diagnosed cognitive impairment with clinically acceptable levels of accurate classification. On retesting 4.6 +/- 1.6 months after trauma, normal values were found for the neuropsychologic measures and a residual latency prolongation for P3, indicating the P3 latency to be a sensitive index of subtle residual brain dysfunction due to head injury.

The case of a 35-year-old woman with a cystic astrocytoma of the cervical spinal cord is presented. The use of CT investigations is stressed. The value of reformatting procedures in regard to the differential diagnosis is discussed.

Tumours in the sellar region may still present diagnostic problems. We therefore compared encephalotomographic and CT findings in sellar tumours and 91 patients were examined by both methods. For clinical purposes and operative treatment the degree of compression of the hypothalamus is of great importance. Encephalotomographic and CT findings are analysed and demonstrated. In cases of density differences between tumour and brain tissue shown by contrast enhancement, more information on the inner structure of a tumour (cystic or solid) can be obtained by computerized tomography. But if these are no density differences or/and contrast enhancement, tumour diagnosis is made easier by encephalotomography because of the great efficiency of this method.

On the basis of two case reports it is shown that circumstances a transitory or permanent ventriculopyeloureteral CSF shunt may be indicated in the treatment of hydrocephalus. The technique is explained. The examination methods for controlling the function during the postoperative period are explained.

An automatic programme is presented for evaluating somatosensory evoked potentials after double stimuli. The advantage of the programme is the computer-assisted procedure, the possibility of effecting changes at any time, and the imaging of both subtraction and addition curves. A variation of the programme for other modalities is possible.

Eighteen patients with skull defects after neurosurgical operations underwent electroencephalographic investigations. Six patients in whom skull tumours had been removed did not show any postoperative changes, when compared with the pre-operative EEG. Twelve patients in whom bone defects had been closed with alloplastic materials showed no changes in the basic frequency, and no focus or signs of general slowing. In three cases only, the amplitudes were decreased in the postoperative EEG follow-up. For routine clinical practice one may conclude that in the region of bone defects higher amplitudes can be seen and, in addition, brain pulsations may present as a biological artefact. Non-space-occupying lesions of the skull and alloplastic materials do not, as a rule, produce any EEG disturbances.

Sixty-six patients with tumours in the sellar region were examined. All were operated on either by the transfrontal or the transsphenoidal route. Pre- and postoperative longitudinal electroencephalographic investigations were performed. Preoperative electroencephalograms showed a normal frequency content in cases of intrasellar tumours or those reaching the chiasma. Nearly all cases had irregularities in the temporal regions. Tumours compressing the third ventricle had slower average frequencies and a general slowing in all cases. Besides these alterations unilateral delta waves or bitemporal dysrhythmic groups were sometimes found. A connection between extension of the tumour and its histological nature could not be found, but the operative approach influenced the electroencephalographic disturbances enormously. After a transfrontal approach and removal of the tumour the electroencephalogram was unchanged. Sometimes a mild transient bitemporal slowing was present. But after a transfrontal operative approach a general slowing was common, usually with focal marked slow activity in the right fronto-temporal area.

Reports of electroencephalographic changes in cases of the traumatic apallic syndrome in children and adolescents are very rare. We tried to correlate special electroencephalographic patterns with the three different stages that are usually seen. We found high voltage subdelta and delta activity in the initial symptom complex, an EEG with dominating delta-theta activity and voltage of medium height corresponding to the fully developed stage, and a flat theta EEG in the stage of remission. The difficulties in interpretation of the changes, especially in children, are discussed. Longitudinal electroencephalographic studies are recommended for diagnosing complications, such as haematomas or palsies, and for prognosis.

The evaluation of prognostic and risk factors has been one of the most important topics in neurotraumatology. These factors would enable the neurosurgeon to modify therapeutic procedures according to prognosis. Different authors have tried to determine the outcome of injured patients by analysis of clinical data: age9, ICP15,16 CBF and cerebral metabolic rate for oxygen4, motor posturing and oculocephalic reflexes1,2, and EEG patterns3,12. Studies based on neurological findings and their relations to patients’ outcome were given by different authors5,6,8,10,11,13,14.

To predict the patient’s outcome after a severe head injury, neurological findings, the posttraumatic course and other clinical data have been analyzed including the results of different treatments (1–6). This retrospective study correlates ICP with outcome and with other factors. We tried to analyze the possible differences between a group of survivors and compared them with the same number of patients who died.

As a rule the history and clinical symptoms of a prolapsed lumbar disc are characteristic. In some cases, however, this typical picture can also be found in other diseases, e.g. multpile sclerosis (6), spondylolisthesis (4), or spinal tumor (1, 3, 5, 8, 10, 11). In the present paper we have analysed a group of patients with lumbar spinal tumors originating symptoms of a protruded lumbar disc.

Between 1969 and 1979, seventy-nine patients suffering from a cerebrospinal fluid (CSF) leakage, were operated on in the neurosurgical department of the University Clinic Essen (West Germany). A modified classification, the onset of symptoms and the diagnostic procedures are described and some data are compared with the results of other investigators.

For defining the degree and prognosis of severe craniocerebral injuries, we not only need ancillary investigations, such as axial computerized tomography and angiography which provide information on the morphologic situation, but also measurements of the intracranial pressure and especially electroencephalography which reflect the current functional situation (20) of the patient’s brain. The latter is important for recognizing sequelae (32) and offers prognostic hints (2, 14, 33). Only a few reports deal with trauma in the child (22, 25, 34). Literature on severe trauma in children is still rare which is why we tried to do long-term EEG studies and thus to differentiate severe craniocerebral injuries by means of EEG.

Research in cognitive psychophysiology has shown that event-related potentials (ERPs) reflect specific processes of human information processing (Gaillard and Ritter 1983). We have carried out ERP recording and neuropsychological testing in patients with brain tumors and traumatic head injuries in order to obtain some information about the neuroanatomical substrate of ERPs and about the utility of ERPs for the evaluation of cognitive impairment.