Does Multisystem Inflammatory Syndrome Only Mimic Acute Appendicitis in Children or Can It Coexist: When Should We Suspect MIS-C?

Background and Objectives: Acute abdominal pain in children has been noticed to be a primary reason to seek medical attention in multisystem inflammatory disorder (MIS-C), which can prevail separately or together with acute appendicitis. Our aim was to distinguish regular appendicitis cases from MIS-C and to suggest the best clinical and laboratory criteria for it. Materials and methods: Cases of patients, admitted to the Pediatric Surgery Department over a six-month period in 2021, were retrospectively analyzed. Confirmed MIS-C or acute appendicitis cases were selected. MIS-C cases were either separate/with no found inflammation in the appendix or together with acute appendicitis. Acute appendicitis cases were either regular cases or with a positive COVID-19 test. Four groups were formed and compared: A-acute appendicitis, B-MIS-C with acute appendicitis, C-MIS-C only and D-acute appendicitis with COVID-19. Results: A total of 76 cases were overall analyzed: A-36, B-6, C-29 and D-5. The most significant differences were found in duration of disease A­1.4 days, B­4.5 days, C­4 days, D­4 days (p < 0.0001), C reactive protein (CRP) values A-19.3 mg/L B-112.5 m/L, C-143.8 mg/L and D-141 mg/L (p < 0.0001), presence of febrile fever A-13.9%, B-66.7%, C-96.6% and D-40% (p < 0.0001) and other system involvement: A 0%, B 100%, C 100% and D 20%. A combination of these factors was entered into a ROC curve and was found to have a possibility to predict MIS-C in our analyzed cases (with or without acute appendicitis) with an AUC = 0.983, p < 0.0001, sensitivity of 94.3% and specificity of 92.7% when at least three criteria were met. Conclusions: MIS-C could be suspected even when clinical data and performed tests suggest acute appendicitis especially when at least three out of four signs are present: CRP > 55.8 mg, symptoms last 3 days or longer, febrile fever is present, and any kind of other system involvement is noticed, especially with a known prior recent COVID-19 contact, infection or a positive COVID-19 antibody IgG test.

First-Time Acute Lateral Patellar Dislocation in Children and Adolescents: What About Unaffected Knee Patellofemoral Joint Anatomic Abnormalities?

Background and Objectives: Acute lateral patellar dislocation (LPD) is the most common acute knee disorder in children and adolescents, and may lead to functional disability. The purpose of this study was to identify key differences and correlations of the patellofemoral joint (PFJ) morphology between intact and contralateral injured knees in a first-time traumatic LPD population aged under 18 years. Materials and Methods: The data were gathered prospectively from a cohort of 58 patients (35 girls and 23 boys). The prevalence and combined prevalence of patella alta (PA) and trochlear dysplasia (TD) in both knees of patients were evaluated using X-ray by two radiologists. Results: The PFJ of patients' intact knees had a lower rate of TD (1.72% vs. 5.2%) and a less common combination of PA with shallow femoral sulcus (SFS) (22.4% vs. 44.8%) but more frequent PA (62.1% vs. 41.4%) compared with their injured knees. We noted statistically significant positive correlations (SSPCs) between the femoral sulcus angle (FSA) and PA in patients with intact (r = 0.37; p < 0.005) and contralateral injured knees (r = 0.33; p < 0.05). Conclusion: There were SSPCs between the FSA and PA in both gender and age groups of patients with intact and contralateral injured knees. The SSPCs between the FSA and PA of intact knees were higher in the patients with a more dysplastic PFJ anatomy (PA and TD) of the injured knees as compared to patients with only PA of the injured knees.

Did the COVID-19 Pandemic Prolong the Time Till Diagnosis and Worsen Outcomes for Children with Acute Appendicitis?

Background and Objectives: Our aim was to see if the COVID-19 pandemic led to an increase of time until diagnosis, operation, and time spent in Emergency room (ER), and if it resulted in more cases of complicated appendicitis and complication rates in children. Materials and Methods: We conducted a retrospective analysis of patients admitted to the Pediatric Surgery Department with acute appendicitis during a 4-month period of the first COVID-19 pandemic and compared it to the previous year data-the same 4-month period in 2019. Results: During the pandemic, the time spent in the ER until arriving at the department increased significantly 2.85 vs. 0.98 h p < 0.001, and the time spent in the department until the operation 5.31 vs. 2.66 h, p = 0.03. However, the time from the beginning of symptoms till ER, operation time and the length of stay at the hospital, as well as the overall time until operation did not differ and did not result in an increase of complicated appendicitis cases or postoperative complications. Conclusions: The COVID-19-implemented quarantine led to an increase of the time from the emergency room to the operating room by 4 h. This delay did not result in a higher rate of complicated appendicitis and complication rates, allowing for surgery to be postponed to daytime hours if needed.

Comparison of the Ponseti method versus early tibialis anterior tendon transfer for idiopathic clubfoot: A prospective randomized study.

OBJECTIVE: The aim of the study was to compare functional and radiological outcomes in clubfoot patients treated by early Tibialis anterior tendon transfer and Ponseti method. MATERIALS AND METHODS: A prospective, randomized study was conducted. A total of 39 children with a mean age of 17.05 days (55 clubfeet) were randomly allocated into one of two groups: first (conservative Ponseti method) group (n=28) or second (early tibialis anterior tendon transfer [TATT]) group (n=27). Foot function and radiographic measurements were evaluated. The condition of the subjects was observed until they reached the age of 2 years. RESULTS: The clinical and radiological data did not differ between groups at the age of 6 months. No statistically significant difference regarding Pirani and Dimeglio scale among the groups was observed at the last follow-up. A statistically significant difference was observed in the foot dorsal flexion; it was lower in the second group (P=0.03). Other clinical parameters did not differ between groups. According radiographic data, only the talocalcaneal angle (TCA) was significantly higher in the second group (P=0.003). Children who underwent TATT were 5.00-fold (P=0.002) and 1.67-fold (P=0.017) more likely to have TCA larger than 30° (which reflects the normal range of the TCA) in DP and lateral views, respectively, and 3.40-fold (P=0.019) more likely to have foot dorsal flexion of less than 15° than their counterparts undergoing the conservative Ponseti treatment. CONCLUSIONS: Early TATT allowed a significant reduction in the brace wear duration and resulted in the same outcomes as using the Ponseti method. Additionally, TATT can provide some improvement of hindfoot varus. However, a possible weakening of dorsiflexion should be also taken into account. Our experience has shown the need for a larger sample and longer term studies.

Doppler flowmetry of the superior mesenteric artery and portal vein: impact for the early prediction of necrotizing enterocolitis in neonates.

PURPOSE: Necrotizing enterocolitis (NEC) is a serious gastrointestinal disorder in newborns. Early diagnosis and rapid treatment is essential for seeking good outcome for neonates. The aim of our study was to evaluate intestinal blood flow in superior mesenteric artery (SMA) and portal vein (PV) in neonates with suspected or confirmed NEC and investigate the prognostic cut-off values to develop NEC. METHODS: Doppler flowmetry of SMA and PV was performed for 62 newborns. Resistive (RI) and pulsatility (PI) indexes were measured in SMA as well as Volumetric blood flow (Vflow) in PV. ROC curves were applied to estimate sensitivity and specificity and to identify cut-off values. RESULTS: There were 93.5% preterm neonates. 29 patients (46.8%) were diagnosed with NEC and 33 (53.2%) formed a control group. 96.3% NEC patients had RI >0.75 with sensitivity of 96.3% and specificity of 90.9% (OR 260). 88.9% NEC patients had PI >1.85 with sensitivity of 88.9% and specificity of 78.8% (OR 29). Portal Vflow lower than 37 ml/min was present in 89.7% patients with NEC (OR 11.7). CONCLUSION: Intestinal blood flow Dopplerography can be a useful tool for diagnosing and predicting NEC.

Really Asymptomatic? Health-Related Quality of Life and Objective Clinical Foot Characteristics among 5-10-Year-Old Children with a Flexible FlatFoot.

The potential effects of asymptomatic flexible flatfoot (FF) on children's health-related quality of life (QoL) and objective clinical foot characteristics have been poorly investigated in the literature. Therefore, this study aimed to analyse these indicators, comparing the children with asymptomatic FF and a control group. METHODS: In total, 351 children were enrolled in this cross-sectional study-160 children with asymptomatic FF and 191 controls (children with normal feet). The children and their parents completed the Paediatric Quality of Life Inventory (PedsQLTM 4.0). The objective foot characteristics included clinical foot posture measures, footprints, general hyperlaxity, and X-ray measurements. RESULTS: Children with asymptomatic FF had a significantly lower QoL (overall and all four dimensions). The parents' assessment of the QoL of their children with asymptomatic FF in most cases was lower compared to their children's self-reported QoL. Moreover, almost all clinical foot measures also had significantly worse profiles among asymptomatic FF cases compared to the controls. This was observed with the Foot Posture Index-6 (FPI-6), the navicular drop (ND) test, the Chippaux-Smirak Index (CSI), Staheli's Index (SI), the Beighton scale, and radiological angles (except the talo-first metatarsal angle). CONCLUSION: The findings suggest that asymptomatic FF not always reflects a normal foot development. This condition is related to decreased health-related quality of life, so the 5-10-year-old children's and their parents' complaints should be considered more closely in identification, treatment, and monitoring plans.

Challenging diagnosis of abdominal tuberculosis in children: case report.

Tuberculosis (TB) remains a significant cause of morbidity and mortality in the modern world. Abdominal TB is a rare form of extrapulmonary TB that has been found to affect children without comorbidities in particular, although exact numbers are unavailable because of lack of data and its rarity. The diagnosis of abdominal TB remains a challenge because of its unspecific clinical features and unclear recommendations regarding the best diagnostic tools. We report 4 cases of children with abdominal TB diagnosed at The Hospital of Lithuanian University of Health Sciences Kaunas clinics from 2008 to 2018 at the Department of Paediatric Surgery. All these cases are exceptional. The final diagnosis of abdominal TB was confirmed only after diagnostic laparoscopy and biopsy. Moreover, we suggest that QuantiFERON test and ascitic fluid analysis with serum ascites albumin gradient and adenosine deaminase tests should be performed before more invasive interventions. Laparoscopy with biopsy should be performed only in unclear cases.

Comparison of multiple flatfoot indicators in 5-8-year-old children.

BACKGROUND: The foot posture is age dependent. The purpose of this study was to investigate the relationship between the 6-item version of the foot posture index (FPI) and other clinical, foot anthropometric, radiological measurements for the foot position in 5-8-year-old children. METHODS: A total of 301 participants with a mean age of 6.4  ±â€¯ 1.14 years were enrolled in the study. Children were examined physically, clinically, and radiologically to measure the FPI and navicular drop (ND) test, resting calcaneal stance position (RCSP) angle, Chippaux-Smirak index (CSI), Staheli index (SI), calcaneal pitch (CP) angle, talocalcaneal angle (TCA), and the first lateral metatarsal angle. Tibial torsions, internal rotation of the hip as an indirect method of femoral anteversion, and Beighton scale were analyzed for factors associated with flatfoot prevalence. RESULTS: The study included children with normal and flexible flatfeet. Statistical analysis showed a significant FPI score correlation with other parameters (SI, CSI, RCSP, ND, CP, TMA, and TCA showed strong and moderate correlations, p < 0.001). Overall, the strongest associates are CSI (ß = 0.34) and ND (ß = 0.28). Other indicators have relatively small relationships with the FPI. CONCLUSION: A positive correlation was observed between FPI-6 and ND test, CSI in 5-8-year-old children. All three prominent foot posture indicators (FPI-6, ND, and CSI) might be used as a primary or preferred tool in clinical practice.

Systemic postoperative pain management following minimally invasive pectus excavatum repair in children and adolescents: a retrospective comparison of intravenous patient-controlled analgesia and continuous infusion with morphine.

PURPOSE: Optimal postoperative pain management following minimally invasive surgical repair of pectus excavatum is not established. We compared efficacy and adverse effects in patients treated with patient-controlled analgesia (PCA) with those treated with continuous infusion (CI) with morphine in addition to nonsteroidal anti-inflammatory drugs. METHODS: 33 patient records were examined retrospectively: 21 given PCA and 12 CI with morphine. Main outcome variables were used doses of morphine, pain scores every 3 h and adverse effects. RESULTS: Median (range) used morphine dose was 0.58 (0.21-1.12) and 0.52 (0.34-0.84) mg/kg on the day 1 and 0.3 (0.02-0.6) and 0.33 (0.09-0.53) mg/kg on the day 2 in PCA and CI groups, respectively (p > 0.05). Pain scores were within moderate and low levels during 42 h after surgery and did not differ between the groups. Median (range) oxygen saturation was 96.5 (93-100) and 97 (94-100) in PCA and CI groups, respectively (p > 0.05). Additional oxygen therapy was required in 14.3% in PCA group and 25% in CI group (p > 0.05). The incidence of pulmonary adverse effects was rare and did not differ between the groups. CONCLUSION: Both methods of systemic analgesia in addition to non-opioid analgesics were equally effective and resulted in a low incidence of pulmonary adverse effects.

Epigenetic Regulation of APAF-1 Through DNA Methylation in Pancreatic Cancer.

BACKGROUND/AIM: Apoptotic peptidase activating factor 1 (APAF-1) is essential regulator of apoptosis and inactivation by DNA methylation is common event in numerous cancer types. We investigated the regulation of APAF-1 through DNA methylation in pancreatic cancer. MATERIALS AND METHODS: Datasets from 44 patients after pancreatoduodenectomy and the pancreatic adenocarcinoma (PDAC) cell lines Capan-2 and MIA PaCa-2 treated with decitabine were analyzed by RT-PCR, immunoblotting, methylation-specific PCR analysis, apoptosis and viability assays to identify effects of APAF-1 regulation. RESULTS: APAF-1 mRNA and protein levels were significantly down-regulated, and APAF-1 methylation status was associated with perineural invasion in PDAC. Decitabine inhibited cell viability and increased apoptosis rates, however failed to restore APAF-1 mRNA and protein levels in cells. CONCLUSION: APAF-1 gene hypermethylation may contribute to the progression of PDAC through perineural invasion. Decitabine could sensitize pancreatic cancer cells to apoptosis and growth retardation, however, not directly through the APAF-1 demethylation process.

Radiological changes after Nuss operation for pectus excavatum.

UNLABELLED: The objective of this study was to evaluate sternovertebral distance and the chest wall deformation after Nuss procedure. MATERIALS AND METHODS: Anteroposterior and lateral chest radiographs were performed before Nuss procedure, 1, 6, and 12 months after operation and finally 1 month after bar removal. Sternovertebral distance and transversal chest dimension were measured on radiographs, as well as Haller and vertebral indexes were calculated. RESULTS: A total of 84 children with funnel chest were operated on. Preoperative sternovertebral distance was 79.81+/-6.96 mm; 1 month after operation, 97.84+/-17.08 mm; 6 months, 110.55+/-13.85 mm; and 12 months, 113.6+/-14.61 mm. After removal of the bar, the distance was 105+/-11.95 mm. The mean increase in sternovertebral distance during the first month was 18 mm (P<0.0001); 1-6 months, 12.8 mm (P=0.0006); and 6-12 months, 3 mm (P=0.48). The mean decrease in sternovertebral distance after removal of the bar was 8.6 mm (P=0.47). The decrease in transversal chest dimension during the first month was significant (13.3+/-12.86 mm, P=0.012). CONCLUSIONS: The sternovertebral distance was significantly increased after Nuss operation. Restoration of deformation proceeds during all the first year after operation. The dynamics of deformation is better depicted by means of vertebral index rather than Haller index.

The accuracy of different imaging techniques in diagnosis of acute hematogenous osteomyelitis.

OBJECTIVE: The aim of this study was to establish and compare diagnostic accuracy (sensitivity, specificity, and diagnostic odds ratio) of plain x-ray, ultrasonography, bone scintigraphy, computed tomography (CT), and magnetic resonance imaging (MRI) in pediatric acute hematogenous osteomyelitis. MATERIAL AND METHODS: Analysis of patients' data, hospitalized at the Department of Pediatric Surgery with suspected acute hematogenous osteomyelitis in the period of 2002-2008, was carried out prospectively. Inclusion criteria were age of 1-18 years, pain in bone area, fever, functional disorder, and (or) signs of infection. Plain x-ray, ultrasonography, bone scintigraphy, computed tomography, and magnetic resonance imaging were performed. The recommendations of Standards for Reporting of Diagnostic Accuracy were used in study design. RESULTS: A total of 183 patients were included into the study. Acute hematogenous osteomyelitis was diagnosed in 156 (85%) patients, and 27 (15%) had other diseases. A total of 169 early plain x-rays (median on the first day of hospital stay), 142 late x-rays (15th day of hospital stay), 82 ultrasonographies (second day), 76 bone scintigraphy (third day), 38 MRI scans (seventh day), and 17 CT (15th day) were performed. The sensitivity of ultrasonography was 0.55 (95% CI, 0.43-0.67); specificity, 0.47 (95% CI, 0.24-0.7); and diagnostic odds ratio, 1.08 (95% CI, 0.3-3.84). The sensitivity of CT was 0.67 (95% CI, 0.38-0.88); specificity, 0.5 (95% CI, 0.01-0.98); and diagnostic odds ratio, 2.0 (95% CI, 0.02-172.4). The sensitivity of early x-ray was 0.16 (95% CI 0.1-0.23); specificity, 0.96 (95% CI, 0.78-1.0); and diagnostic odds ratio, 4.34 (95% CI, 0.63-186.3). The sensitivity of MRI was 0.81 (95% CI, 0.64-0.93); specificity, 0.67 (95% CI, 0.22-0.96); and diagnostic odds ratio, 8.67 (95% CI, 0.91-108.5). The sensitivity of late x-ray was 0.82 (95% CI, 0.75-0.88); specificity, 0.92 (95% CI, 0.62-1.0); and diagnostic odds ratio, 51.17 (95% CI, 6.61-2222.0). The sensitivity of bone scintigraphy was 0.81 (95% CI, 0.68-0.90); specificity, 0.84 (95% CI, 0.60-0.97); and diagnostic odds ratio, 22.30 (95% CI, 4.9-132.7). CONCLUSIONS: Our analysis showed that late x-ray is the most valuable radiologic method in the diagnosis of acute hematogenous osteomyelitis, but bone scintigraphy and magnetic resonance imaging are the most valuable tests at the onset of the disease.

Human antigen R mediated post-transcriptional regulation of inhibitors of apoptosis proteins in pancreatic cancer.

AIM: To determine the association of human antigen R (HuR) and inhibitors of apoptosis proteins (IAP1, IAP2) and prognosis in pancreatic cancer. METHODS: Protein and mRNA expression levels of IAP1, IAP2 and HuR in pancreatic ductal adenocarcinoma (PDAC) were compared with normal pancreatic tissue. The correlations among IAP1/IAP2 and HuR as well as their respective correlations with clinicopathological parameters were analyzed. The Kaplan-Meier method and log-rank tests were used for survival analysis. Immunoprecipitation assay was performed to demonstrate HuR binding to IAP1, IAP2 mRNA. PANC1 cells were transfected with either anti-HuR siRNA or control siRNA for 72 h and quantitative reverse transcription polymerase chain reaction (RT-PCR), western blot analysis was carried out. RESULTS: RT-PCR analysis revealed that HuR, IAP1, IAP2 mRNA expression were accordingly 3.3-fold, 5.5-fold and 8.4 higher in the PDAC when compared to normal pancreas (P < 0.05). Expression of IAP1 was positively strongly correlated with HuR expression (P < 0.05, r = 0.783). Western blot analysis confirmed RT-PCR results. High IAP1 expression, tumor resection status, T stage, lymph-node metastases, tumor differentiation grade, perineural and lymphatic invasion were identified as significant factors for shorter survival in PDAC patients (P < 0.05). Immunohistological analysis showed that HuR was mainly expressed in the ductal cancer cell's nucleus and less so in cytoplasm. RNA immunoprecipitation analysis confirmed IAP1 and IAP2 post-transcriptional regulation by HuR protein. Following siHuR transfection, IAP1 mRNA and protein levels were decreased, however IAP2 expression levels were increased. CONCLUSION: HuR mediated overexpression of IAP1 significantly correlates with poor outcomes and early progression of pancreatic cancer. Further studies are needed to assess the underlying mechanisms.

Lichen sclerosus et atrophicus in pediatric and adult male patients with congenital and acquired phimosis.

Lichen sclerosus et atrophicus is a chronic inflammatory sclerotic and atrophic disease of unknown cause that predominantly affects male and female genital skin. This study was designed to evaluate histological characteristics of congenital and acquired phimoses among pediatric (n=60) and adult (n=60) male patients who were admitted for circumcision to the Clinics of Urology and Pediatric Surgery of Kaunas University of Medicine Hospital between 2000 and 2003 and to determine the rate of lichen sclerosus et atrophicus and other histological diagnoses among them. This study demonstrates that 45.1% of congenital and 62.3% of acquired phimoses show histological signs of lichen sclerosus et atrophicus. The rate of lichen sclerosus et atrophicus was statistically significantly higher among patients with acquired than congenital phimosis. Boys with acquired narrowing of prepuce were statistically significantly 3.9 times more likely to develop lichen sclerosus et atrophicus than those with congenital phimosis. There were no statistically significant differences between rates of lichen sclerosus et atrophicus and other dermatological diagnoses among pediatric and adult male patients if the type of phimosis (acquired or congenital) was considered. Histological features of lichen sclerosus et atrophicus and other histological diagnoses in boys and men with phimosis were detected with equal frequency irrespective the age of the subjects. The rate of lichen sclerosus et atrophicus was similar among all boys (56.7%) and men (53.3%) treated for phimosis. Only the type of phimosis had a statistically significant influence on the rate of lichen sclerosus et atrophicus and other histological diagnoses.

Some aspects of long-term results of treatment of acute hematogenous osteomyelitis.

OBJECTIVE: The aim of the study was to evaluate the treatment results of acute hematogenous osteomyelitis over 10 years and to determine the relationship between them and clinical course of the disease. MATERIALS AND METHODS: The patients with acute hematogenous osteomyelitis diagnosed 10 years ago (1995-1996) were enrolled in the study. The post mail or phone contacts with them or their parents were obtained, the questions were submitted, and the patients were invited for medical examination. The current complaints and limitations in physical activity were assessed. The amplitude of joint movements, tenderness during palpation, and deformations were evaluated during physical examination. Patients were divided into two groups: with and without complaints. The duration and severity of the disease, age, gender, presence of sepsis, arthritis, and subperiosteal abscess, the type of bone affected and bone lesion on x-ray, duration of fever, and maximal erythrocyte sedimentation rate during the acute period were compared between groups. RESULTS: We made 50 phone calls and sent seven letters to the patients with acute hematogenous osteomyelitis who were treated in our department. In 14 (28%) cases, phone contact was obtained, and 7 of them were examined. Five answers (71%) to the letters were received. The overall response rate was 33%. Thirteen (68%) former patients had no any complaints; six (32%) had minor complaints, which were probably linked to acute hematogenous osteomyelitis. Fifteen (79%) former patients had no limitations in any physical activities, and four (21%) of them limit their physical activities. Seven patients were examined, but neither visible deformities and tenderness nor limitations in movement amplitude were found. Comparing the groups with complaints and without complaints by age, gender, presence of sepsis and arthritis, duration of the disease, and the presence of periosteal abscess, no statistically significant difference in any of variables was found. CONCLUSIONS: According to our data, 37% of the patients have complaints 10 years after acute hematogenous osteomyelitis, and these complaints are not associated with the clinical course of the disease.

Safety and Tolerability of Doripenem in Hospitalized Children With Complicated Intra-Abdominal Infection, Complicated Urinary Tract Infections and Pneumonia.

Three multicenter, randomized, controlled studies evaluated doripenem in children 3 months to <18 years of age, with complicated intra-abdominal or urinary tract infections and bacterial pneumonia.In the 66 patients treated with doripenem before early termination of the studies for nonsafety reasons, doripenem was safe and generally well tolerated. Low enrollment limited ability to assess benefits and risks of doripenem in children.

Common pleural cavity in combination with pectus excavatum.

A very rare case is being described; common pleural cavity was accidentally diagnosed in a 3-year-old boy operated for funnel chest (pectus excavatum). During 36 years 516 patients were operated in our department and we often notice pectus excavatum associated with other types of congenital pathology but only one had the common pleural space. In normal human beings pleural space is divided into left and right chambers separated by the mediastinum with no communication in between. In some mammals such as pigs, cows etc. a congenital communication is found between the pleural cavities, but this type of communication is very rare in humans and most often is of acquired origin. Pleural communication may also develop after major cardiothoracic surgery. In this case a 3-year-old male patient was admitted for the elective surgery on pectus excavatum. Clinical examination showed a very deep funnel chest. Both the heart and the mediastinum are left-shifted by the deformed breastbone; it is clearly demonstrated on a plain and lateral X-ray. On the left, beside the main vessels, an indistinct patch is noted. Typical M. Ravitch procedure was performed, by accident the pleural space was opened. Both pleural cavities had an evident communication along the anterior mediastinum. The torn pleura was sutured, the excess air removed by a puncture. Postoperative period was uneventful, additional treatment was not needed; currently the boy is feeling well. The postoperative X-ray showed the heart and the mediastinum to return to normal position.

Lipoma of the greater omentum in a child.

Lipoma of the greater omentum is observed very rarely, particularly in the childhood. We report a case of large 10x11x8 cm asymptomatic lipoma of the greater omentum, which was diagnosed incidentally. Well-encapsulated mass with a homogeneous internal structure and high echogenicity--these signs of ultrasound and computed tomography allowed us to suggest a lipoma. At laparotomy lipoma of greater omentum in torsion was found. The excision of the tumor and omentectomy was performed. The histopathological diagnosis was lipoma with focal necrosis areas.

Single shot intercostal block for pain management in pediatric patients undergoing the Nuss procedure: a double-blind, randomized, controlled study.

PURPOSE: The aim of this study was to investigate the efficacy of a single shot intercostal block for pain control in pediatric patients undergoing the Nuss procedure. METHODS: A double-blind, randomized, controlled study was performed. Thirty patients received a single shot bilateral intercostal block with levobupivacaine (L group) and 30 patients with 0.9 % saline (S group). Standardized baseline analgesia was applied for all patients. Morphine consumption, pain scores, respiratory depression, nausea and vomiting, and urinary retention were recorded every 3h for 48h after surgery. RESULTS: The loading dose of morphine was lower (p<0.00001) in the L group. There were significantly lower morphine doses up to 6h after surgery and VAS scores up to 3h after surgery in the L group (p<0.001 and p=0.0003, respectively). The incidence of nausea and vomiting was lower in the L group (<0.00001). The incidence of urinary retention was lower in the L group (p=0.019). CONCLUSIONS: A single shot IB is an effective additional treatment for pediatric patients undergoing the Nuss procedure and results in the reduced consumption of morphine, less postoperative pain, and fewer opioid-related adverse effects.

Postoperative pain management in pediatric patients undergoing minimally invasive repair of pectus excavatum: the role of intercostal block.

PURPOSE: There are no published data regarding value of intercostal block following pectus excavatum repair. Our aim was to evaluate the efficacy of intercostal block in children following minimally invasive repair of pectus excavatum (MIRPE). METHODS: Forty-five patients given patient-controlled analgesia (PCA) with morphine postoperatively were studied. Twenty-six patients were given bilateral intercostal blocks after induction of anesthesia (PCA-IB group), and nineteen patients were retrospective controls without regional blockade (PCA group). All patients were followed up 24 h postoperatively. RESULTS: A loading dose of morphine (0,1±0,49 mg/kg) before starting PCA was used in seventeen patients in PCA group vs. no patient in PCA-IB group. Cumulative used morphine doses were lower up to 12 h after surgery in PCA-IB group (0,29±0,08 µg/kg) than in the PCA group (0,46±0,18 µg/kg), p<0,01. There were no differences in pain scores, oxygen saturation values, sedation scores, and the incidence of pulmonary adverse events between the two groups. There was a tendency towards less morphine-related adverse effects in PCA-IB group compared to PCA group (p<0,05). No complications related to the intercostal blocks were observed. CONCLUSION: Bilateral intercostal blocks following MIRPE are safe and easy to perform and can diminish postoperative opioid requirement. Double-blind randomized study is required to confirm the potential to diminish opioid related side effects.