Association of Mycoplasma pneumoniae infection with Henoch-Schonlein purpura.

We present a child with Henoch-Schonlein purpura and Mycoplasma pneumoniae infection, an association that was rarely described in the literature. The infection was confirmed serologically and by using PCR.

The diversity of juvenile sarcoidosis symptoms.

We report a case of juvenile sarcoidosis, emphasizing the variety of clinical manifestations. The child had uveitis, which is among the most common manifestations of the disease. However, fever of unknown origin, glomerulonephritis and lymphadenopathy were also noticed, underscoring the diversity of the clinical spectrum of the disease.

Off-label use in Germany - a current appraisal of gynaecologic university departments.

OBJECTIVE: The off-label use, referring to the applicability of pharmaceutical drugs beyond the submitted and from the Federal Institute for Drugs and Medical Devices (BfArM, Bundesamt für Arzneimittel und Medizinprodukte) certified and approved administration, is the subject of controversial discussions. The application can be considered in case of severe illness - if no therapeutic alternatives are available - or it exists as a founded perspective for achieving therapeutic success. METHODS: A latitudinal study for evaluating the application of off-label use supplements was performed at 43 German university and academic teaching hospitals. Five doctors at each hospital applied off-label pharmaceutical drugs and were called upon to share their personal experience to the application of those medications. RESULTS: 75 (35%) questionnaires were returned out of 22 (51%) medical centres with 215 contacted physicians. Off-label use was common for 65 (91%) of the physicians. Only 9% of them obviate the application of off-label drugs. About a half of the medication is related to application in obstetrics (54%) and in most cases on an every day basis. Uterotonics were the most commonly used off-label medications (34%). The main part of information about off-label use is obtained from personal information of colleagues (66%) and personal experience (58%). 34% of physicians think that off label use is risky. Interestingly, the view about off label use of medication varies considerably among physicians from various hospitals. CONCLUSIONS: The application of off-label pharmaceutical drugs in Germany seems to be a well established practice. More than 90% of participators of our trial use at least one medication outside the administration. This includes particularly prostaglandins, anti-hypertonic therapeutics and chemotherapeutics.

Menetrier's disease associated with Helicobacter pylori: three cases with sonographic findings and a literature review.

Menetrier's disease is a rare cause of protein-losing gastropathy characterised by hypertrophy of the gastric folds. Three cases are reported. Helicobacter pylori was detected by culture and CLO test in two cases and on follow-up gastroscopy in the other. The first two patients were given eradication therapy and hypertrophic gastropathy resolved whereas in the third the disease remitted prior to the eradication treatment. Typical sonographic features were thickened gastric wall with preservation of the wall stratification. A review of the literature found eight cases of Menetrier's disease associated with H. pylori in children and these cases are briefly reviewed. H. pylori infection should be considered in all children with Menetrier's disease and, if isolated, eradication treatment should be administered.

Uveitis: an isolated complication of post-streptococcal syndrome.

A child with anterior uveitis as the sole manifestation of group A streptococcal infection is described. There was a history of a 'viral' upper respiratory tract infection 2 weeks before the onset of uveitis. A post-streptococcal phenomenon was diagnosed on the basis of serial ASO titre (ASOT) monitoring. There are few reports of patients with post-streptococcal uveitis. ASOT monitoring should be included in the work-up of uveitis of undetermined aetiology.

Splitting the dose of neonatal BCG vaccination: a naïve practice.

Bilateral axillary lymphadenitis complicating BCG vaccination in both arms (0.025 ml) in an immunocompetent 13-month-old boy is described. Prompt administration of isoniazid and erythromycin did not prevent suppuration of the affected lymph nodes. It was managed by bilateral surgical excision of the nodes.

Clinical notations on bacteremic cavitating pneumococcal pneumonia in nonvaccinated immunocompetent children.

We describe 10 children who developed lung cavitation during the treatment of bacteremic pneumococcal lobar pneumonia. Chest CT scan showed extensive consolidation with several small lucencies and air-filled cavities. Invasive procedures like aggressive pleural intervention were not needed and the children recovered attaining normal lung function on long-term follow-up.

Endothelin 1 levels in relation to clinical presentation and outcome of Henoch Schonlein purpura.

BACKGROUND: Henoch Schonlein purpura (HSP) is a common vasculitis of small vessels whereas endothelin-1 (ET-1) is usually reported elevated in vasculities and systematic inflammation. The aim of the present study was to investigate whether ET-1 levels are correlated with the clinical presentation and the outcome of HSP. METHODS: The study sample consisted of thirty consecutive patients with HSP. An equal number of healthy patients of similar age and the same gender were served as controls. The patients' age range was 2-12.6 years with a mean +/- SD = 6.3 +/- 3 years. All patients had a physical examination with a renal, and an overall clinical score. Blood and urinary biochemistry, immunology investigation, a skin biopsy and ET-1 measurements in blood and urine samples were made at presentation, 1 month later and 1 year after the appearance of HSP. The controls underwent the same investigation with the exception of skin biopsy. RESULTS: ET-1 levels in plasma and urine did not differ between patients and controls at three distinct time points. Furthermore the ET-1 were not correlated with the clinical score and renal involvement was independent from the ET-1 measurements. However, the urinary ET-1 levels were a significant predictor of the duration of the acute phase of HSP (HR = 0.98, p = 0.032, CI0.96-0.99). The ET-1 levels did not correlate with the duration of renal involvement. CONCLUSION: Urinary ET-1 levels are a useful marker for the duration of the acute phase of HSP but not for the length of renal involvement.

Basal cell carcinomata: Risk factors for incomplete excision and results of re-excision.

INTRODUCTION: Re-excision of incompletely excised basal cell carcinomas (BCCs) can be unsatisfactory in the absence of residual tumours. Recommended guidelines do suggest re-excision as a treatment modality; however, its value has been questioned due to low or variable residual tumour presence. We analysed the incomplete excision and re-excision rates and the presence of residual tumours over an 18-month period in a single unit. METHOD: Using pathology results and case notes, 2586 primary excisions of BCCs in 1717 patients were reviewed. RESULTS: The incomplete excision rate was reported to be 7.1% (184/2586). Excision of a lesion by multiple excision lesion procedure was associated with a higher rate of incomplete excision when compared to single lesion excision procedure (61.5% vs. 38.5%). Of the incompletely excised BCCs, 33.6% (62/184) were re-excised, of which 62.9% (39/62) had residual tumours. Although the figures are small, most anatomical sites examined had a residual tumour presence >50%. CONCLUSION: After evaluating each patient individually, considering the high residual tumour rate, re-excision of an incompletely excised BCC would be a worthwhile procedure.

Does post-mastectomy radiotherapy affect the outcome and prevalence of complications in immediate DIEP breast reconstruction? A prospective cohort study.

INTRODUCTION: The decision to perform immediate deep inferior epigastric perforator (DIEP) flap reconstruction in patients requiring post-mastectomy radiation therapy (PMRT) is controversial, and often influenced by the increased potential of complications. We assessed the outcome and complications of irradiated immediate DIEP-reconstructed flaps in a two-surgeon series in our department. METHODS: Data collected prospectively from all patients undergoing immediate DIEP reconstruction under the two senior authors' care over 24 months were reviewed. Patients receiving previous radiation were excluded. Included patients were divided into two groups - requiring or not requiring PMRT. Primary outcome measures were fat necrosis, surgery for removal of fat necrosis, volume loss requiring surgery, wound complications and flap survival. All patients with a clinical diagnosis of post-radiation fat necrosis had an ultrasound scan. RESULTS: The series included 112 patients with a total of 156 flaps (44 bilateral, 68 unilateral). In 61/156 flaps the patients received PMRT (Group A) whilst 95/156 did not (Group B). Demographics in both groups were similar. Outcomes in PMRT vs. no PMRT, respectively were: fat necrosis 11.5% vs. 6.35% (p = 0.199); surgery for removal of fat necrosis 6.6% vs. 4.2% (p = 0.383); volume enhancement surgery 4.9% vs. 5.2% (p = 0.617); minor wound healing delay, 3.2% vs. 7% (p = 0.433); major wound healing delay 2.5% vs. 5.7% (p = 0.558). 0/61 flaps were lost in group A and 2/95 in group B. CONCLUSION: Although studies have shown the deleterious effects of post-operative radiotherapy on breast free flaps, our department offers immediate breast reconstruction with the acceptance of the risk/benefit profile. We found no increase in complication rates in patients undergoing immediate DIEP reconstruction receiving PMRT, and the outcome was not adversely affected. As part of an ongoing study, we do not feel that post-mastectomy radiotherapy precludes the decision for immediate free-flap breast reconstruction.

Relation of serum leptin levels to lipid profile in healthy children.

The association of leptin with body fat concentration is well established. There is also experimental evidence of a direct effect of leptin on lipid metabolism. The aim of this study was to evaluate whether leptin levels are related to the corresponding serum lipid levels independently of body fat mass. The study population consisted of 294 phenotypically healthy school children aged 6 to 12 years. Age, sex, body weight, height, Tanner stage, and triceps skinfold thickness were recorded for all participating subjects. A blood sample was drawn in the morning after a 12-hour fast, and serum total, high-density lipoprotein (HDL), and low-density lipoprotein cholesterol; triglyceride; and leptin levels were determined. Multiple regression analysis showed that triglyceride values were positively correlated with the ln(log(e))-transformed leptin levels (beta =.01, P <.001), whereas HDL levels were inversely associated with lnleptin values (beta = -.06, P =.05) after controlling for age, sex, Tanner stage, and body mass index when each of the lipid parameters was tested separately in the regression model. However, the introduction of both triglycerides and HDL values in the same model eliminated the significance of association of HDL with lnleptin, and the positive relationship of triglycerides with lnleptin remained significant. Our results indicate that triglycerides are independently associated with leptin levels after controlling for any known confounder.

The impact of Greece's childhood tuberculosis screening programme on the epidemiological indexes in the greater Athens area.

SETTING: A hospital referral centre for childhood tuberculosis in Athens. OBJECTIVE: To evaluate the effectiveness of the screening programme implemented for childhood tuberculosis, through its impact on the epidemiological index. DESIGN: In Greece, tuberculosis has been systematically screened for in children since 1991 using the tuberculin skin test. The epidemiological and clinical profiles of all tuberculous children who attended the TB clinic were compared. The children were divided into those who attended in 1982-1990 and those who did so in 1991-1999. RESULTS: A total of 1122 TB patients were screened. In the second period there was an increase in numbers of immigrant children (3% vs. 28%, P = 0.0001), the rate of extra-pulmonary TB decreased (16% vs. 7.6%, P = 0.0001), patients identified by the screening programme increased (19% vs. 57%, P = 0.0001) and the number of symptomatic children fell (51% vs. 16%, P = 0.0001). The proportion of children who failed to attend for regular follow-up was lower during the second period (20% vs. 7%, P = 0.0001). CONCLUSIONS: Our study suggests that the screening programme applied in Greece during the last decade has contributed to the early identification of tuberculosis, and the limitation of symptomatic patients and extrapulmonary TB cases.

Is there an association between wheezing and pneumonia?

OBJECTIVE: The aim of this study was to investigate whether there is a relationship in school aged children between wheezing and pneumonia prior, during, or following the pneumonia episode. PATIENTS-METHODS: One hundred and three children with community acquired pneumonia who were hospitalised were recruited along with 55 controls. RESULTS: During hospitalisation wheezing was audible in 11/103 (10.6%) patients with pneumonia and in none of the controls (p=0.009). Wheezing ever or asthma was elicited in 29/103(28%) patients with pneumonia and in 8/55 (14.5%) of the controls and this difference was not significant. Two years after the hospitalisation with pneumonia, wheezing episodes occurred in 12/103 with pneumonia and 1/55 of the controls (p=0.034). Among those who developed asthma following pneumonia 11/12 also had wheezing prior to pneumonia. CONCLUSION: There is an excess of wheezing prior, during, and after an episode of pneumonia in school aged children and therefore children with pneumonia should be followed up carefully.

Home and leisure activities and childhood knee injuries.

AIM: To assess the relative occurrence of non motor-vehicle knee injuries and identify important clusters that can be targeted for preventive interventions. METHODS: The study subjects covered 2167 children (0-14 years) who suffered non motor-vehicle knee injuries out of 66870 registered during a three-year period in an established Emergency Department Injury Surveillance System (EDISS). A more serious joint injury was identified in 263 (12%) children, whereas the remaining 1904 children had only soft tissue knee injuries. RESULTS: The incidence of non motor-vehicle knee injuries was estimated at 6.5 per 1000 children-years. Both the incidence of knee injuries and the male-to-female ratio increase with increasing age, reflecting the gender and age pattern of physical activity. Three clusters were identified: The first consisted of more serious knee injuries among older children, frequently resulting after a fall from stairs or a collision in school during winter months; the second cluster consisted of rather minor knee injuries occurring mostly among younger girls at home or in playgrounds, following a fall after stumbling or hit by an object while playing, especially during the summer; the third cluster comprised injuries among older boys, sustained mainly subsequent to overexertion in a sports area. CONCLUSION: Knee injuries tend to be more common among boys but more serious among girls. More and less serious knee injuries tend to fall into distinct clusters that could facilitate prioritization of preventive measures.

Human factors in the causation of road traffic crashes.

Road traffic crashes (RTCs) are responsible for a substantial fraction of morbidity and mortality and are responsible for more years of life lost than most of human diseases. In this review, we have tried to delineate behavioral factors that collectively represent the principal cause of three out of five RTCs and contribute to the causation of most of the remaining. Although sharp distinctions are not always possible, a classification of behavioral factors is both necessary and feasible. Thus, behavioral factors can be distinguished as (i) those that reduce capability on a long-term basis (inexperience, aging, disease and disability, alcoholism, drug abuse), (ii) those that reduce capability on a short-term basis (drowsiness, fatigue, acute alcohol intoxication, short term drug effects, binge eating, acute psychological stress, temporary distraction), (iii) those that promote risk taking behavior with long-term impact (overestimation of capabilities, macho attitude, habitual speeding, habitual disregard of traffic regulations, indecent driving behavior, non-use of seat belt or helmet, inappropriate sitting while driving, accident proneness) and (iv) those that promote risk taking behavior with short-term impact (moderate ethanol intake, psychotropic drugs, motor vehicle crime, suicidal behavior, compulsive acts). The classification aims to assist in the conceptualization of the problem that may also contribute to behavior modification-based efforts.

Benign hypermobility syndrome in Greek schoolchildren.

Since the incidence of benign hypermobility syndrome is significantly high in otherwise healthy children, paediatricians should consider this benign entity when they evaluate musculoskeletal complaints in childhood.

Person, time and place coordinates of pedestrian injuries: a study in Athens.

UNLABELLED: The aim of this study was to investigate whether socioeconomic status of town of residence is associated with risk for childhood pedestrian injuries. The study population consisted of all pedestrian victims, aged 0-14 y, who lived in towns of Greater Athens and who presented to the Emergency Department of a major Children's Hospital during the period 1996-98. The towns were divided into three categories by socioeconomic status according to the proportion of (a) adult household heads with a higher education degree and (b) households with less than one person per room. The rate of pedestrian injuries was estimated by socioeconomic status of the residential town and by place of accident (inside or outside the respective town). The pedestrian injury rate ranged from 5.5 to 12 injured children among a 10000 childhood population per year, with an almost twofold excess among children residing in the less wealthy towns compared with the wealthier ones. The social gradient was steeper for injuries occurring outside the residential town. The population fractions of pedestrian injury rates attributable to educational level and household crowding differentials, regardless of the place of accident, were 39% and 25%, respectively. CONCLUSIONS: There is a considerable social gradient for childhood injuries irrespective of place of accident, a finding that could be partly attributable to lower socioeconomic background rather than to adverse environmental factors prevailing in less wealthy towns. Our findings indicate that there is a need for preventive programmes targeting people as well as places of low socioeconomic status.

How common is abuse in Greece? Studying cases with femoral fractures.

AIMS: To examine the extent of undiagnosed child abuse in Greece by studying young children with femoral fractures, which may be associated with abuse. METHODS: Fifty seven consecutive cases of children under 6 years of age with femoral fracture were identified from the Emergency Department Injury Surveillance System database. Controls were 4162 children with other orthopaedic injuries from the same database. RESULTS: Whereas in the literature about one third of femoral injuries among young children are attributed to child abuse, no child in the studied series had been diagnosed or even investigated in this context. Nevertheless, the pattern of occurrence of femoral injuries was compatible with that of child abuse, in that patients were frequently very young boys of low socioeconomic status, and the accident had frequently occurred under poorly identified or implausible conditions at time periods when most family members were crowded at home. CONCLUSIONS: Epidemiological risk factors for child abuse characterise femoral fractures in young children in Greece. It appears that child abuse is present in this country as in most other cultures. There is a clear need for refocusing medical personnel and hospital social services so that the problem is revealed, quantified, and appropriately dealt with.