Laser doppler line scan burn imager (LDLS-BI): sideways move or a step ahead?

OBJECTIVE: To assess the accuracy of a Laser Doppler Line Scanner (LDLS) in predicting burn wound healing in children compared to conventional Laser Doppler Imaging (LDI). METHODS: A prospective study comparing a LDLS with a conventional LDI to assess burn wound Healing Potential (HP) was performed in 50 paediatric patients presenting to our institution between February 2010 and March 2011, as part of a multi-centre, international trial. Inclusion criteria were superficial to deep dermal burns that were able to be scanned between 42 h and 5 days of the burn. RESULTS: Of the 50 patients enrolled, one was excluded from subsequent analysis as they were unable to present for wound reviews at 14 and 21 days. Ninety scans were performed of 59 burn wounds in the remaining 49 patients. The mean age was 4 years and 9 months (range 8 months to 16 years) and the mean Total Body Surface Area burnt was 8.3% (range 0.1-15%). The most common mechanism of injury was a scald, followed by contact and flame burns. A limb was the most common site of injury. Overall accuracy of the scanners was 94.5% (LDI) and 95% (LDLS), with accuracy lowest for indeterminate burns that healed within 14-21 days. CONCLUSION: The LDLS was found to be as accurate as the LDI in predicting burn wound HP in children. Whilst the LDLS scan resolution was lower, with more scans of larger burns required, its smaller size and greater scan speed proved valuable in children.

Long-term outcome of asymptomatic patients with congenital cystic adenomatoid malformation.

PURPOSE: Congenital cystic adenomatoid malformation (CCAM) represents a rare congenital anomaly of the lung. It remains controversial whether patients with asymptomatic lesions warrant early surgical intervention. Our aim was to review the outcome of asymptomatic CCAM patients at a paediatric tertiary centre. METHODS: The medical case notes of all children with CCAM presenting to our institution between 1986 and 2007 were reviewed. Data on pre- and post-natal investigations, clinical presentation, lesion site, type of surgical procedure, timing, and outcomes of surgery were reviewed. RESULTS: A total of 35 patients were diagnosed with CCAM during the 21-year study period (1986-2007). Sixty percent (n = 21) were asymptomatic at birth including eight patients with prenatal ultrasound scan confirming CCAM. In this group, 18 patients (86%) subsequently developed symptoms (median age 2 years, range 1 month-13 years) and required surgery. Symptoms included pneumonia with or without infected CCAM (43%), respiratory distress (14%) and spontaneous pneumothorax (14%). Eight patients underwent multiple hospital presentations with complications related to CCAM. Of the 21 initially asymptomatic patients, 17 (81%) underwent surgical resection. Only one of these patients was completely asymptomatic prior to surgery. There were eight post-operative complications and no mortality. One patient underwent a second thoracotomy for residual CCAM. The median length of hospital stay was 9 days (range 3-32 days). CONCLUSION: This study suggests patients who present with asymptomatic CCAM will subsequently become symptomatic. Early surgical referral and intervention may be beneficial to avoid the development of complications.

Tracheomalacia, timing of symptoms, and thymic enlargement: cause or coincidence?

The authors report a case of severe primary tracheomalacia in a 3-month-old boy. The left lobe of the enlarged thymus was resected at operation to facilitate aortopexy. The authors suggest a possible role for the enlarging thymus contributing to the delayed onset of the symptoms of tracheomalacia, despite the presence of the tracheal lesion from birth.

Adverse outcome of congenital diaphragmatic hernia is determined by diaphragmatic agenesis, not by antenatal diagnosis.

BACKGROUND/PURPOSE: The authors studied their congenital diaphragmatic hernia (CDH) cases retrospectively to ascertain if classical CDH and diaphragmatic agenesis (DA) have separate clinical manifestations, whether antenatally diagnosed cases behave differently from those not diagnosed antenatally, and if antenatal diagnosis before 25 weeks carries a worse prognosis. METHODS: The authors performed a retrospective review of 23 infants with CDH treated at their institution between January 1996 and March 1999. The patients were divided into 3 groups that were analyzed: DA and classical CDH, antenatally diagnosed and nonantenatally diagnosed, and antenatally diagnosed before 25 weeks and after 25 weeks. RESULTS: There were 8 cases of DA and 11 cases of classical CDH. Four infants died without operation and could not be classified. Neonates with DA had significantly longer mean duration of preoperative stabilization compared with classical CDH (5.25+/-2.76 days v 1.36+/-1.0 days) and postoperative mechanical ventilatory support (15.7+/-3.0 days v 4.9+/-3.0 days). Fifty percent of DA patients died; all classical CDH patients survived. Twelve cases were diagnosed antenatally, 6 before 25 weeks' gestation. Antenatally diagnosed cases had no statistically significant difference in mortality rates from those not diagnosed antenatally; 50% of those diagnosed before 25 weeks survived. CONCLUSIONS: DA cases require more preoperative preparation and postoperative ventilation and have a bad prognosis compared with classical CDH. Antenatal diagnosis of CDH does not convey a different prognosis. Fifty percent of CDH patients with antenatal diagnosis before 25 weeks survive.

Suicide among the young--the size of the problem.

It is widely recognized that official suicide rates conceal the real scale of non-accidental self-injurious fatal behaviour, including among children and young people. There are many reasons for this including the constraints of registration policy and practice, uncertainty about the circumstances surrounding a death, an unwillingness-often for the family's sake-to affix a suicide label on a child, and perhaps the belief that the term "suicide" is not quite accurate. The present study examined all records over a 17-year period from an inner London coroner's office in order to make some quantitative assessment of the extent to which non-accidental self-injurious deaths might be underestimated by suicide returns among those under 20 years. It is suggested on the basis of this examination that the real rate of what might be termed "suicide" among this group may be up to three times the official recorded level. This finding received general confirmation from a smaller-scale comparison in an out of London location.

Hirschsprung's disease, colonic atresia, and absent hand: a new triad.

Colonic atresia (CA) has been reported in association with Hirschsprung's Disease (HSCR) on 11 previous occasions. In most reported cases the atresia has involved the right side of the colon; but in this, the twelfth case report, the atresia involved the left side of the colon, with aganglionosis of the entire distal gut. In addition, the child had an absent hand. The authors believe that this triad has not been reported previously. The literature is reviewed, and possible mechanisms are discussed.

Disappearing lung echogenicity in fetal bronchopulmonary malformations: a reassuring sign?

Congenital bronchopulmonary malformations detectable on prenatal ultrasound include cystic adenomatoid malformation (CAM), lobar sequestration, and upper airway atresia. We describe three fetuses with prenatally detected intrathoracic lesions in which the associated pulmonary hyperechogenicity disappeared before delivery. In the first case of pulmonary sequestration, the infant was asymptomatic after birth. However, in a case of CAM and another with laryngeal atresia, respiratory distress developed after delivery, despite recent scans showing apparently normal lung fields. This experience suggests that ultrasonic resolution of hyperechogenic lung lesions in utero does not necessarily indicate resolution of the underlying pathology.

Inner urban and national suicide rates, a simple comparative study.

The authors have calculated the suicide rate per million for individual causes of death in the Inner North London Coroner's jurisdiction and also a composite rate for all methods of self-destruction. These have been compared with the rates for England and Wales in the years 1979-1985 inclusive. Also calculated has been a total 'non-accidental' death rate comprising all deaths by self-destructive behaviour. For certain causes the two rates are similar but for the remainder there are wide differences. The effect of the law relating to suicide verdicts has been described and its effects discussed.

Uterine torsion in a child.

This paper describes the apparent first reported case of torsion of the uterus in a 3-year-old child, its management, and discussion of the anatomy.

Review of thoracic neuroblastoma.

Twenty-seven cases of thoracic neuroblastoma were reviewed. Thirteen cases (48%) survived, 11 for more than 2 years and two for more than 14 months. Surgery is the treatment of choice and complete excision appears to give the best result. However, radical surgery is discouraged if the tumor is not readily removable. The use of chemotherapy and radiotherapy should be limited to Stage III and Stage IV disease and for palliation of soft tissue and bony secondaries. The clinical presentation was generally non-specific with respect to the final diagnosis in this series. Significantly raised catecholamines were seen in 13 of 16 patients assessed (81%). Prognosis was related to the age at diagnosis, stage of disease and the histological type. The better prognosis seen in thoracic neuroblastoma in comparison with abdominal neuroblastoma may be related to the earlier presentation of the disease and the higher incidence of better differentiated tumours in the thorax. There appears to be an unknown additional factor that confers a better prognosis in patients under 1 year old.

Henoch-Schönlein purpura--a surgical review.

A review of the complications associated with Henoch-Schönlein purpura is presented with particular reference to those requiring surgical management. Gastrointestinal involvement occurred in 105 patients and was complicated by intussusception in three patients and by perforation in one. Laparotomy was undertaken in 10 patients. Involvement of the scrotum and testis occurred in 29 patients and suggested torsion of the testis on occasion. Renal involvement occurred in 45 patients and was associated with renal impairment in six. Recommendations for the management of surgical complications are discussed.

Drug-related mortality in an inner city area.

A comprehensive survey of mortality amongst addicts was carried out in an inner city area of London over a period of 9 years (1971-1979). One hundred and seventy-five deaths were noted during this period with a sharp rise occurring in the latter 2 years. Overdose was the predominant cause of death with barbiturates being implicated in 60% of the fatalities. Almost all the addicts who died were under the age of 35 years and about half were not known to the authorities.

A comparison of the traumatic effects of vascular clamps.

The mature and extent of damage to the wall of the femoral artery of the dog caused by five different vascular clamps is reported. This is related to the ability of the clamp to both occlude the vessel and to hold the wall without slipping. Intimal damage was assessed by supravital staining, scanning electron microscopy of the surface and the histological appearance of sagittal sections of the arterial wall. The Atraugrip, Satinski and Potts clamps caused more apparent damage to the vessel wall and achieved occlusion by holding of the vessel at higher pressures than did the Blalock and Fogarty clamps. There is a difference between the damage produced when closure is sufficient to just occlude the vessel and that produced when the clamp is fully closed.

Congenital chylothorax: report of unique case associated with 'H' -type tracheo-oesophageal fistula.

A case of congenital chylothorax associated with a congenital 'H'-type tracheo-oesophageal fistula is reported. The development of the thoracic duct is described and the possible embryological association with tracheo-oesophageal fistula is discussed. The management of the case is reviewed.

An unusual complication of colonic interposition for oesophageal replacement.

We report a case of delayed fibrosis of the interposed left colon in a 65-year-old man after an operation for peptic oesophageal stricture and suggest that short-term postoperative ventilation should be used in patients undergoing oesophageal replacement by means of colonic interposition.