[Acute neonatal osteomyelitis, an incidental life-changing diagnosis]. / Cas clinique. Une ostéomyélite aiguë néonatale, un diagnostic parfois fortuit qui peut changer une vie.

Acute neonatal osteomyelitis is a challenging disease and its diagnostic is important to avoid comorbidities. Staphylococcus aureus is the most often involved germ. The diagnostic challenge lies in its pauci-symptomatology in the premature infant in contrast to a more obvious clinical presentation in the term infant or child. The risk factors inherent to prematurity are invasive monitoring, repeated blood sampling, prolonged central catheterization, immature immune response and length of hospital stay. We report the case of an osteomyelitis secondary to staphylococcal sepsis in a preterm infant born at 25 weeks and 3 days of gestational age. The diagnosis was made incidentally on an abdominal x-ray. The low parental compliance for the child's follow-up does not allow us to affirm a future without sequelae even if the elements at our disposal at 8 months suggest a favorable outcome. Acute neonatal osteomyelitis remains a difficult but crucial diagnosis for the future development of the child.

L'ostéomyélite aiguë néonatale est un diagnostic rare, mais qui doit être posé pour en diminuer les comorbidités. Le staphylocoque doré est le germe le plus souvent en cause. La difficulté diagnostique réside dans sa pauci-symptomatologie, en particulier chez le prématuré. La voie de contamination la plus fréquente est hématogène. Les facteurs de risque inhérents à la prématurité sont le monitoring invasif, les prélèvements à répétition, le cathétérisme central prolongé, une réponse immunitaire immature et la durée d'hospitalisation. Nous rapportons le cas d'une ostéomyélite secondaire à un sepsis à staphylocoque doré chez un prématuré né à 25 semaines et 3 jours d'aménorrhée. Le diagnostic a été réalisé fortuitement sur une radiographie d'abdomen à blanc. La faible compliance parentale pour le suivi de l'enfant ne nous permet pas d'affirmer un futur sans séquelle, même si les éléments à notre disposition lors d'une consultation à 8 mois laissent penser une évolution favorable. L'ostéomyélite aiguë néonatale est un diagnostic difficile à poser, mais crucial pour le développement futur de l'enfant.

[Non-specific interstitial pneumonia : a rare clinical entity in adolescents]. / Pneumopathie interstitielle non spécifique : une entité rare chez l'adolescent.

Non-specific Interstitial Pneumonia (NSIP) is an anatomo-clinical entity within the group of Diffuse Infiltrative Pulmonary Diseases (DPID). It is very rarely found in pediatrics. Main symptoms are dry cough and dyspnea. Bronchoalveolar lavage and biology are non specific. The thoracic CT scan suspects the diagnosis, but histological examination of a lung biopsy remains the reference examination and makes the diagnosis highly probable according to the ATS / ERS criteria. An autoimmune assessment should be performed because NSIPs are often associated with connective tissue disease or may even be the first sign of connectivitive tissues diseases. The treatment of the acute phase is mainly based on the administration of corticosteroids and the prognosis is generally good. In this article, we describe the management of NSIP, based on a pediatric clinical case.

La Pneumopathie Interstitielle Non Spécifique (PINS) est une entité anatomo-clinique au sein du groupe des Pneumopathies Infiltrantes Diffuses (PID). Elle est très rarement retrouvée en pédiatrie. Elle se manifeste principalement par une toux sèche et une dyspnée. Le lavage broncho-alvéolaire et la biologie sont aspécifiques. Le scanner thoracique permet de suspecter le diagnostic, mais c'est l'examen histologique d'une biopsie pulmonaire qui reste l'examen de référence et qui permet, selon les critères de l'ATS/ERS, de poser un diagnostic avec grande probabilité. Un bilan auto-immun doit être réalisé car la PINS est très souvent associée à des connectivites ou peut même en être le premier signe. Le traitement de la phase aiguë repose, essentiellement, sur l'administration de corticoïdes, et le pronostic est, en général, bon. Dans cet article, nous décrivons la prise en charge d'une PINS, à partir d'un cas clinique rencontré en pédiatrie.

First-Ever Stroke and Transient Ischemic Attack Incidence and 30-Day Case-Fatality Rates in a Population-Based Study in Argentina.

BACKGROUND AND PURPOSE: Epidemiological data about stroke are scarce in low- and middle-income Latin-American countries. We investigated annual incidence of first-ever stroke and transient ischemic attack (TIA) and 30-day case-fatality rates in a population-based setting in Tandil, Argentina. METHODS: We prospectively identified all first-ever stroke and TIA cases from overlapping sources between January 5, 2013, and April 30, 2015, in Tandil, Argentina. We calculated crude and standardized incidence rates. We estimated 30-day case-fatality rates. RESULTS: We identified 334 first-ever strokes and 108 TIAs. Age-standardized incidence rate per 100 000 for Segi's World population was 76.5 (95% confidence interval [CI], 67.8-85.9) for first-ever stroke and 25.1 (95% CI, 20.2-30.7) for first-ever TIA, 56.1 (95% CI, 48.8-64.2) for ischemic stroke, 13.5 (95% CI, 9.9-17.9) for intracerebral hemorrhage, and 4.9 (95% CI, 2.7-8.1) for subarachnoid hemorrhage. Stroke incidence was slightly higher for men (87.8; 95% CI, 74.6-102.6) than for women (73.2; 95% CI, 61.7-86.1) when standardized for the Argentinean population. Thirty-day case-fatality rate was 14.7% (95% CI, 10.8-19.5) for ischemic stroke, 24.1% (95% CI, 14.2-36.6) for intracerebral hemorrhage, and 1.9% (95% CI, 0.4-5.8) for TIA. CONCLUSIONS: This study provides the first prospective population-based stroke and TIA incidence and case-fatality estimate in Argentina. First-ever stroke incidence was lower than that reported in previous Latin-American studies, but first-ever TIA incidence was higher. Thirty-day case-fatality rates were similar to those of other population-based Latin-American studies.

[Hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations in children]. / Le cas clinique du mois. Maladie de Rendu-Osler et malformations artério-veineuses pulmonaires chez l'enfant.

Hereditary hemorrhagic telangiectasia is a constitutional vascular dysplasia characterized by chronic epistaxis, mucocutaneous and visceral telangiectasias and arteriovenous malformations. Apart from family screenings, the disease is rarely diagnosed during the pediatric age given the late advent of typical clinical symptoms. Nevertheless, arteriovenous malformations are sometimes already present at a young age with significant morbidity risk. Therefore, it is important to establish an early diagnosis. We describe two pediatric cases of hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations with divergent clinical presentation.

La maladie de Rendu-Osler, ou télangiectasies hémorragiques héréditaires, est une dysplasie vasculaire constitutionnelle. Elle se caractérise par des épistaxis spontanées et récidivantes, des télangiectasies cutanéo-muqueuses et viscérales et des malformations artério-veineuses. En dehors d'un dépistage familial, cette maladie est rarement diagnostiquée à l'âge pédiatrique étant donné l'apparition tardive des symptômes cliniques typiques. Cependant, les malformations artério-veineuses sont parfois présentes dès le plus jeune âge avec des risques importants de morbidité, d'où l'importance d'un diagnostic précoce. Nous décrivons deux cas pédiatriques de maladie de Rendu-Osler et de malformations artério- veineuses pulmonaires avec des présentations cliniques très différentes.

Central element in liver masses, helpful, or pitfall?

A central element was first described in focal nodular hyperplasia (FNH) as a so-called "central scar," and is normally associated with this entity. However, many other liver masses may present with a central element. Depending on its appearance, and the lesion itself, central elements can be essential, helpful, or confusing for diagnosis. Indeed, nodules that develop on liver vascular disorders, fibrolamellar hepatocellular carcinoma, large hemangioma, peripheral cholangiocarcinoma, or epithelioid hemangioenthelioma often present with a central element, thus increasing the level of diagnostic confidence when present. On the other hand, central elements are rare or atypical in liver metastases, hepatocellular adenoma, or hepatocellular carcinoma. In this setting, the presence of a central element can lead to a misdiagnosis. The description and details of the imaging features of these different central elements, especially on MRI, as well as a thorough evaluation of the entire lesion, can improve the diagnostic performance in these cases.

Estimating the prevalence of active Helicobacter pylori infection in a rural community with global positioning system technology-assisted sampling.

We investigated a possible outbreak of H. pylori in a rural Northern Plains community. In a cross-sectional survey, we randomly sampled 244 households from a geocoded emergency medical system database. We used a complex survey design and global positioning system units to locate houses and randomly selected one eligible household member to administer a questionnaire and a 13C-urea breath test for active H. pylori infection (n = 166). In weighted analyses, active H. pylori infection was detected in 55·0% of the sample. Factors associated with infection on multivariate analysis included using a public drinking-water supply [odds ratio (OR) 12·2, 95% confidence interval (CI) 2·9-50·7] and current cigarette smoking (OR 4·1, 95% CI 1·7-9·6). People who lived in houses with more rooms, a possible indicator of decreased crowding in the home, were less likely to have active H. pylori infections (OR 0·7, 95% CI 0·5-0·9 for each additional room).

Local colorectal cancer recurrence: pelvic MRI evaluation.

Surveillance of colorectal cancer is currently based on dosage of tumoral markers, colonoscopy and multidetector row computed tomography. However, pelvic magnetic resonance imaging (MRI) and PET-CT are two second-line useful imaging modalities to assess colorectal cancer local recurrence (LR). The anatomical information derived from MRI combined to the functional information provided by diffusion-weighted imaging currently remain of value. Pelvic MRI is accurate not only for detection of pelvic colorectal recurrence but also for the prediction of absence of tumoral invasion in pelvic structures, and it may thus provide a preoperative road map of the recurrence to allow for appropriate surgical planning. As always, correlation of imaging and clinical findings in the multidisciplinary forum is paramount. MRI can also be used to follow-up LR treated with radiofrequency ablation. The aim of this review is to discuss clinical practice and application of MRI in the assessment or pelvic recurrence from colorectal cancer.

[Clinical case of the month. Idiopathic mediastinal fibrosis]. / Fibrose médiastinale idiopathique.

Fibrosing mediastinitis is a rare condition characterized by an excessive growth of dense fibrous tissue within the mediastinum. The etiology of the disease is most often a fungal infection and may in some cases be idiopathic. We present the case of a patient with chronic obstructive pulmonary disease (COPD) suffering from fibrosing mediastinitis of undetermined origin and in whom the diagnosis was established by histopathological analysis after mediastinoscopy.

Polychlorinated biphenyls, polychlorinated dibenzo-p-dioxins, polychlorinated dibenzofurans, pesticides, and diabetes in the Anniston Community Health Survey follow-up (ACHS II): single exposure and mixture analysis approaches.

Dioxins and dioxin-like compounds measurements were added to polychlorinated biphenyls (PCBs) and organochlorine pesticides to expand the exposure profile in a follow-up to the Anniston Community Health Survey (ACHS II, 2014) and to study diabetes associations. Participants of ACHS I (2005-2007) still living within the study area were eligible to participate in ACHS II. Diabetes status (type-2) was determined by a doctor's diagnosis, fasting glucose ≥125 mg/dL, or being on any glycemic control medication. Incident diabetes cases were identified in ACHS II among those who did not have diabetes in ACHS I, using the same criteria. Thirty-five ortho-substituted PCBs, 6 pesticides, 7 polychlorinated dibenzo-p-dioxins (PCDD), 10 furans (PCDF), and 3 non-ortho PCBs were measured in 338 ACHS II participants. Dioxin toxic equivalents (TEQs) were calculated for all dioxin-like compounds. Main analyses used logistic regression models to calculate odds ratios (OR) and 95 % confidence intervals (CI). In models adjusted for age, race, sex, BMI, total lipids, family history of diabetes, and taking lipid lowering medication, the highest ORs for diabetes were observed for PCDD TEQ: 3.61 (95 % CI: 1.04, 12.46), dichloro-diphenyl dichloroethylene (p,p'-DDE): 2.07 (95 % CI 1.08, 3.97), and trans-Nonachlor: 2.55 (95 % CI 0.93, 7.02). The OR for sum 35 PCBs was 1.22 (95 % CI: 0.58-2.57). To complement the main analyses, we used BKMR and g-computation models to evaluate 12 mixture components including 4 TEQs, 2 PCB subsets and 6 pesticides; suggestive positive associations for the joint effect of the mixture analyses resulted in ORs of 1.40 (95% CI: -1.13, 3.93) for BKMR and 1.32 (95% CI: -1.12, 3.76) for g-computation. The mixture analyses provide further support to previously observed associations of trans-Nonachlor, p,p'- DDE, PCDD TEQ and some PCB groups with diabetes.

Interpreting borderline BeLPT results.

BACKGROUND: The beryllium lymphocyte proliferation test (BeLPT) identifies persons sensitized to beryllium (BeS) and thus at risk for chronic beryllium disease (CBD). BeLPT test results are abnormal (AB), borderline (BL), or normal (NL). This manuscript addresses the predictive value and interpretation of BL BeLPT results. METHODS: The various three-result combinations that meet or exceed a nominal referral criteria of 1 AB + 1 BL are assessed with probability modeling and compared. RESULTS: At 2% prevalence, the three-result combinations that meet or exceed this referral criteria and associated probabilities of BeS are: (a) 1 AB + 1 BL + 1 NL (72%); (b) 3 BL (91%); (c) 2 AB + 1 NL (95%); (d) 1 AB + 2 BL (99%); (e) 2 AB + 1 BL (100%); and (f) 3 AB (100%). CONCLUSION: These results suggest that BL results are meaningful and that three BL results predict BeS across a broad range of population prevalences. An analysis of longitudinal BeLPT results and clinical findings from an actual surveillance program is warranted to confirm the model's predictions.

Investigation of a spatiotemporal cluster of verotoxin-producing Escherichia coli O157 infections in eastern England in 2007.

An outbreak of verotoxin-producing Escherichia coli O157 (VTEC O157) infections linked to an open farm occurred in eastern England in April and May 2007. This paper describes the investigation and highlights the importance of multidisciplinary collaboration for successful control of such outbreaks. There was a temporal cluster of 12 confirmed symptomatic cases of VTEC O157 and one asymptomatic carrier, from five families. The investigation revealed that four of these cases formed part of an outbreak involving two families who visited an open farm. The phenotypic and genotypic characteristics of the isolates from the two families and the putative farm animal contacts were indistinguishable, indicating that the animals were the source of the primary infections. No epidemiological link could be established between the remaining three families affected and the open farm or people having visited the farm. Control measures included improved hand washing facilities on the farm, information for visitors and staff, restricted access and suspended petting and feeding of animals, and thorough cleaning and disinfection of affected areas.

Massive blood loss protocol 'Code Red' at Papworth Hospital: A closed loop audit.

AIM: To investigate if the massive blood loss protocol 'Code Red' at a specialist cardiothoracic hospital was activated according to local and national guidelines by a closed loop audit. METHODS: Electronic and paper patient care systems were searched in 2015 and 2018 to access records for the 'Code Red' activations. Activation of the massive blood loss protocol was compared against the national standards set by The British Committee for Standards in Haematology. The percentage of cases meeting each of the ten standards in the specialist cardiac unit's Protocol for the Management of Massive Blood Loss in Adults (adapted from the national standards) were evaluated. RESULTS: 'Code Red' protocol was activated on 18 occasions in 2015 and nine occasions in 2018, representing just 0.83 and 0.26% of emergency surgeries, respectively. Between 2015 and 2018, there was a 6% increase of 'Code Red' cases being appropriately activated, a 26% increase in the prompt notification of the haematology department upon activation, alongside a 30% increase in the timely delivery of blood products, and a 25% decrease in the average amount of blood transferred prior to 'Code Red' activation. CONCLUSION: There has been an improvement in the standards of care and management of massive blood loss this specialist cardiac centre despite the target timeframe being reduced from 30 to 15min between 2015 and 2018. Preparation for and anticipation of massive blood loss has likely decreased the number of incidences requiring 'Code Red' activation, permitting delivery of safe patient care.

Differences in right ventricular-pulmonary vascular coupling and clinical indices between repaired standard tetralogy of Fallot and repaired tetralogy of Fallot with pulmonary atresia.

PURPOSE: The purpose of this study was to compare ventricular vascular coupling ratio (VVCR) between patients with repaired standard tetralogy of Fallot (TOF) and those with repaired TOF-pulmonary atresia (TOF-PA) using cardiovascular magnetic resonance (CMR). MATERIALS AND METHODS: Patients with repaired TOF aged>6 years were prospectively enrolled for same day CMR, echocardiography, and exercise stress test following a standardized protocol. Sanz's method was used to calculate VVCR as right ventricle (RV) end-systolic volume/pulmonary artery stroke volume. Regression analysis was used to examine associations with exercise test parameters, New York Heart Association (NYHA) class, RV size and biventricular systolic function. RESULTS: A total of 248 subjects were included; of these 222 had repaired TOF (group I, 129 males; mean age, 15.9±4.7 [SD] years [range: 8-29 years]) and 26 had repaired TOF-PA (group II, 14 males; mean age, 17.0±6.3 [SD] years [range: 8-29 years]). Mean VVCR for all subjects was 1.54±0.64 [SD] (range: 0.43-3.80). Mean VVCR was significantly greater in the TOF-PA group (1.81±0.75 [SD]; range: 0.78-3.20) than in the standard TOF group (1.51±0.72 [SD]; range: 0.43-3.80) (P=0.03). VVCR was greater in the 68 NYHA class II subjects (1.79±0.66 [SD]; range: 0.75-3.26) compared to the 179 NYHA class I subjects (1.46±0.61 [SD]; range: 0.43-3.80) (P<0.001). CONCLUSION: Non-invasive determination of VVCR using CMR is feasible in children and adolescents. VVCR showed association with NYHA class, and was worse in subjects with repaired TOF-PA compared to those with repaired standard TOF. VVCR shows promise as an indicator of pulmonary artery compliance and cardiovascular performance in this cohort.

[Diffusion-weighted MR imaging of liver pathology: principles and clinical applications]. / Imagerie par résonance magnétique de diffusion (IRMD) en pathologie hépatique: principe et applications cliniques.

Due to ongoing technological advances, the range of clinical applications for diffusion-weighted MR imaging has expanded to now include abdominal pathology. Current applications for liver pathology include two main directions. First, oncologic imaging with detection, characterization and follow-up of lesions. Second, evaluation of diffuse liver diseases, including hepatic fibrosis. The diagnostic impact and role of diffusion-weighted MR imaging remain under investigation, but appear promising. Because of its short acquisition time, sensitivity, and additional information it provides, diffusion-weighted MR imaging should be included in routine liver imaging protocols.

Pulmonary embolism in a trauma patient with liver and orthopedic injuries.

We report the case of a 41-year-old man admitted for lower limb and liver trauma following a car accident. Surgical repair of a tibial fracture was performed under general anesthesia 5 days after admission while the liver injury was managed conservatively. At the time of tourniquet inflation, the patient presented a pulmonary embolism. Low-molecular-weight heparin administration had been delayed for 72 hours after admission due to the liver injury. Risk factors for bleeding and thromboembolism in trauma patients with liver injury are discussed.

Tailgut cysts: MRI findings.

Magnetic resonance imaging (MRI) features of 11 surgically resected pelvic tailgut cysts were analyzed with reference to histopathologic and clinical data. Homogeneity, size, location, signal intensity, appearance and presence of septa and/or nodules and/or peripheral rim and involvement of surrounding structures were studied. Histological examination demonstrated 11 tailgut cysts (TGC), including one infected TGC and one TGC with a component of adenocarcinoma. Lesions (3-8 cm in diameter) were exclusively or partly retrorectal in all cases but one, with an extension down the anal canal in five cases. Lesions were multicystic in all patients but one. On T1-weighted MR images, all cystic lesions contained at least one hyperintense cyst. The peripheral rim of the cystic lesion was regular and non or moderately enhancing in all cases but the two complicated TGC. Nodular peripheral rim and irregular septa were seen in the degenerated TGC. Marked enhancement of the peripheral structures was noted in the two complicated TGC. Pelvic MRI is a valuable tool in the preoperative evaluation of TGC.