Background: There are few studies on neonatal cerebral sinovenous thrombosis (SVT). Objectives: To describe the presentations, treatments, and outcomes of neonatal SVT and to assess infarction as a predictor of outcome. Design: Retrospective chart study. Setting: A tertiary pediatric hospital in Indianapolis, Ind. Patients: Forty-two children with neonatal SVT identified using International Classification of Diseases, Ninth Revision code searches from 1986 through June 2005 and review of neurology clinic records. Interventions: None. Main Outcome Measures: Cognitive impairment, motor impairment, and epilepsy at last clinic visit. Results: Gestational or delivery complications or risk factors and comorbid conditions such as dehydration, sepsis, and cardiac defects were common (gestational/ delivery factors in 82% [31 of 38 with available maternal data]; comorbid conditions in 62% [26 of the 42]). Twenty-four (57%) presented with seizures. Twentyfive (60%) had infarcts, which were hemorrhagic in 22. Only 27 (64%) of 42 received prothrombotic evaluations; none had persistent deficiencies of protein C, protein S, or antithrombin III. Three (7%) received heparin sodium. All other children received only supportive care. One child died. Outcome data were available for 29 (71%) of the 41 survivors; of these, 23 (79%) had impairment(s). Two were known to be in early intervention, and no further information was available. Of the remaining 27, 16 (59%) had cognitive impairment, 18 (67%) had cerebral palsy, and 11 (41%) had epilepsy. Infarction was associated with the presence of later impairment (P=.03). Conclusions: The presentation of neonatal SVT is often nonspecific, the diagnosis can be difficult to make, treatment beyond supportive care is rarely used, and outcomes can be severe. Further work is needed to develop standardized guidelines for the evaluation and treatment of neonatal SVT.

OBJECTIVE.Dynamic cystoproctography was used to determine the frequency of associated urinary. genital. and anorectal abnormalities in women with pelvic floor dysfunction. SUBJECTS AND METHODS.We categorized, by pelvic floor compartments, the symptoms at presentation of 100 consecutive female patients who had been referred for dynamic cys- toproctography.We then analyzed the compartment defects seen on dynamic cystoproctography relative to those detected on clinical presentation. RESULTS.Of the 20 patients

A subgroup of children with perinatal stroke do not present clinically until after the perinatal period. Detailed epilepsy outcomes in these children have not been well studied. A retrospective cohort study of 45 children with delayed presentation of perinatal stroke identified by review of pediatric stroke clinic records, physician referral, and International Classification of Diseases, Ninth edition, code searches of hospital records, was performed at a tertiary pediatric hospital in Indianapolis, Indiana. A modified version of the Engel scale was used to grade epilepsy outcomes. The chi(2) test, Fisher's exact test, and relative risks were calculated to examine the association of epilepsy at time of last follow-up with initial presentation with seizures, infantile spasms, radiographic findings, and initial abnormal electroencephalogram (EEG). These tests were also used to examine the association of epilepsy with cognitive or motor disability and the association of initial abnormal EEG with motor disability. Patients presented with hemiparesis (40; 89%), seizures (4; 9%), or headaches (1; 2%). All had unilateral infarcts on cranial imaging. Four children (9%) had infantile spasms, 2 at presentation and 2 later. Nineteen children received at least 1 EEG for suspicious spells or frank seizures; initial EEG was abnormal in 16 patients (84%). At last follow-up, 17 patients (38%) had epilepsy, which was severe in 4 (24% of those with epilepsy). Initial presentation with seizures (relative risk = 3.2; 95% confidence interval, 2.0-4.9) and infantile spasms (relative risk = 3.2; confidence interval, 2.0-4.9) were associated with epilepsy at last follow-up. Infantile spasms were also associated with moderate-to-severe epilepsy at last follow-up (relative risk = 10.3; confidence interval, 1.9-54.4). Epilepsy at last follow-up was associated with cognitive disability (P = .05). Initial abnormal EEG was not associated with cerebral palsy (P = .30). Epilepsy is frequent in children with delayed presentation of perinatal stroke and is associated with initial presentation with seizures and infantile spasms at any point in time. Cognitive disability often accompanies epilepsy in these children.

Objective: Critically ill patients are at high risk for adverse events on transfer between intensive care unit and operating room. Patient safety concerns were raised within our institution during such transfers, and absence of a standardized patient handoff process was identified as an area of concern. Methods: The current state of the patient transfer processes between the intensive care units (ICUs) and the operating rooms (ORs) was mapped and failure modes were identified. A multidisciplinary team was convened and a standardized handoff process and tool (checklist) was developed. Adherence to the process and care team satisfaction was assessed at the end of a 60-day pilot period. Results: The process was successfully implemented hospital-wide covering all adult and pediatric ICUs. We observed a 90% compliance rate with ICU to the OR transfers and 95% compliance rate with transfers from OR to the ICU during the 60-day pilot period. The care team expressed overall satisfaction with the process and identified potential areas of improvement. Conclusion: A standardized patient handoff process between the ICU and the ORs can be successfully implemented in a large academic medical center. Universal application of this quality improvement tool can reduce patient harm, improve communication between providers, and enhance patient safety.

This series describes 5 neonates with meningitis associated with arterial ischemic stroke or cerebral sinovenous thrombosis identified from a tertiary children's hospital perinatal stroke database. A retrospective chart review was performed to collect data on clinical presentations, type of meningitis, radiographic and electroencephalographic findings, neonatal intensive care unit course and complications, additional risk factors associated with stroke, and outcomes. The proportion of arterial ischemic stroke and sinovenous thrombosis in the database associated with meningitis was calculated. Neonates came to medical attention because of seizures (2), hydrocephalus (1), and behavior changes (2). The median age of presentation was birth (range, 0-18 days). Meningitis was bacterial in 4 and viral in 1. The median time from symptom onset to identification of the causative organisms of meningitis was 16.8 days (range, 13-23 days) and from symptom onset to diagnosis of stroke was 11 days (range, 4-18 days). One child had arterial ischemic stroke. Four had cerebral sinovenous thrombosis. One child died in the neonatal intensive care unit. Outcome data were available for 3 of the 4 surviving children; all had some degree of neurological deficit. All 5 of the neonates described had risk factors for perinatal thrombosis or embolization in addition to meningitis. Meningitis is associated with 1.6% (1/63) of cases of arterial ischemic stroke and 7.7% (4/52) of cases of cerebral sinovenous thrombosis in our perinatal stroke database. Further work is needed to clarify when infarction occurs during meningitis and which children are at highest risk.

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Torsion of an Accessory Liver Lobe (ALL) is a rare cause of acute abdominal pain. The presence of ALL is associated with congenital abdominal wall abnormalities, such as omphalocele or umbilical hernia, and occurs secondary to abnormal liver morphogenesis and intraabdominal hypertension causing liver hypertrophy. Torsion may be triggered by blunt abdominal trauma. We report the case of a 29-year-old male who developed torsion of an ALL arising from hepatic segment 3 after falling. The patient required urgent operative intervention for the treatment of this torsion. This presentation and disease manifestation has been very rarely reported in the literature.