Bacterial osteomyelitis in pediatric patients: a comprehensive review.

Bacterial osteomyelitis, an inflammatory response in the bone caused by microorganisms, typically affects the metaphysis in the skeletally immature. Bacterial osteomyelitis possesses a significant diagnostic challenge in pediatric patients due to its nonspecific clinical presentation. Because the metaphysis is the primary focus of infection in skeletally immature patients, understanding the normal physiologic, maturation process of bones throughout childhood allows to understand the pathophysiology of osteomyelitis. Timely and accurate diagnosis is crucial to initiate appropriate treatment, and prevent long-term sequelae and efforts must be made to isolate the causative organism. The potential causative organism changes according to the age of the patient and underlying medical conditions. Staphylococcus Aureus is the most common isolated bacteria in pediatric pyogenic osteomyelitis whereas Kingella Kingae is the most common causative agent in children aged 6 months to 4 years. Imaging plays a pivotal role in the diagnosis, characterization, evaluation of complications, and follow up of bacterial osteomyelitis. Imaging also plays a pivotal role in the evaluation of potential neoplastic and non-neoplastic mimickers of osteomyelitis. In children, MRI is currently the gold standard imaging modality when suspecting bacterial osteomyelitis, whereas surgical intervention may be required in order to isolate the microorganism, treat complications, and exclude mimickers.

The effect of interleukin-20 on periodontal tissue destruction in individuals with periodontitis.

BACKGROUND AND OBJECTIVE: Periodontitis is an inflammatory disease that destroys periodontal tissues. Interleukin-20 (IL-20), on the other hand, is known as a potent angiogenic, chemotactic, and pro-inflammatory cytokine associated with various chronic inflammatory disorders. IL-20 has a significant role in the regulation of osteoclastogenesis and osteoblastogenesis. This study aimed to evaluate the effect of IL-20 on periodontal destruction. METHODS: In this study, a total of 60 participants were included, 30 of whom were systemically and periodontally healthy (control group), and 30 were systemically healthy but had periodontitis (periodontitis group). Gingival crevicular fluid (GCF) and serum samples were collected from the participants for biochemical analysis. Enzyme-linked immunosorbent assay was used to determine the levels of IL-20, tumor necrosis factor (TNF)-α, IL1ß/IL-10, RANKL/osteoprotegerin (OPG), and matrix metalloproteinase-8 (MMP8). For statistical analysis, the independent t-test, Pearson correlation coefficients, and the Chi-square test were used. RESULTS: GCF IL-20, RANKL, RANKL/OPG, serum IL-20, RANKL, RANKL/OPG, MMP-8, TNF-α, IL-1B, and IL-1ß/IL-10 values were found to be statistically significantly higher in the periodontitis group than in the control group. GCF OPG and serum IL-10 values were found to be statistically significantly higher in the control group than in the periodontitis group. No statistically significant difference was observed between the groups in serum OPG values. A statistically significantly positive correlation was observed between serum IL-20 value and serum RANKL, RANKL/OPG, MMP-8, TNF-α, IL-1ß values, and periodontal clinical parameters. The ROC curves showed: AUC = 0.788 for GCF IL-20, and AUC = 1.000 for serum IL-20. CONCLUSION: According to the results of the study, IL-20 was found to be associated with periodontitis. The role of IL-20 in periodontal pathogenesis is related to osteoclastogenesis and collagen degradation. It is conceivable that IL-20 may increase bone destruction by both affecting the RANKL/OPG ratio and proinflammatory cytokines.

Radiologic and Clinical Features of Infantile Hemangioma: Potential Pitfalls and Differential Diagnosis.

Infantile hemangioma (IH) is the most common neoplasm in children, but it may mimic other types of vascular anomalies or nonvascular benign and malignant tumors. In most cases, the clinical appearance, time of onset, and pattern of involution facilitate its diagnosis. Imaging evaluation is not always needed since the IH features at clinical presentation are usually characteristic, but when needed, US and frequently MRI are the imaging modalities of choice. Clinical photography or photographic documentation plays a central role in monitoring these lesions over their clinical course. Photographic documentation can also add confidence and alert the radiologist when interpreting imaging studies. Some vascular anomalies, especially vascular malformations, are a frequent source of confusion, as these may resemble IHs clinically and at imaging. The lack of uniform terminology also hinders an accurate diagnosis. To unify the terminology and minimize confusion, the International Society for the Study of Vascular Anomalies created a helpful classification in 1994. In addition, radiologists need to be aware of and become familiar with other neoplasms in children that may resemble IH to avoid misdiagnosis and unnecessary procedures. Fibrous and lipomatous tumors are examples of benign tumors that can mimic IHs clinically and at imaging, whereas rhabdomyosarcoma, infantile fibrosarcoma, neuroblastoma, and lymphoproliferative disorders are examples of malignant neoplasms. The authors review the features of IH at clinical presentation and imaging evaluation, highlighting its different phases of evolution and stressing the importance of photographic documentation. The authors also review pitfalls of IH with helpful pearls for differentiation. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material. See the invited commentary by Khanna and Briones in this issue.

The effects of dexmedetomidine on early acute kidney injury in severely burned rats.

OBJECTIVE: Burns are a global medical and economic problem. In addition to high costs, the lengthy therapeutic process and the emotional trauma experienced by patients and their families indirectly worsen the socioeconomic damage caused. Kidney failure observed after burns is highly correlated with mortality. MATERIALS AND METHODS: Twenty-eight male Sprague-Dawley rats (age four months, weight 250-350 g) were included in the study. They were randomly assigned into four groups consisting of seven rats each with similar mean weights. Group 1 (n=7) represented the healthy control group (C), Group 2 (n=7) the Sham+dexmedetomidine (DEX) 100 mcg/kg (three doses) (S+DEX100) group, Group 3 (n=7) the 30% Burn (B), and Group 4 (n=7) the 30% Burn+DEX 100 mcg/kg/day group (B+DEX100) (three doses). Thiobarbituric acid reactive substances (TBARS), total thiol (TT), interleukin-1 (IL-1) and tumor necrosis factor-α (TNF-α) values in kidney tissues were investigated biochemically, and histopathological analyses were also performed. Nuclear factor κB (NF-κB)/p65 was measured using immunohistochemistry, and the TUNEL assay was applied to indicate apoptotic tubular epithelial cells. RESULTS: TBARS, IL-1, and TNF-α in kidney tissues decreased in the B+DEX100 group compared to the 30% burn group, while total thiol values increased. Histopathologically, atypical glomeruli, particularly necrotic tubules, and inflammation in peritubular areas decreased in the B+DEX100 group compared to the 30% burn group. In addition, apoptotic tubular epithelial cells exhibiting TUNEL positivity and tubular epithelial cells exhibiting NF-кß/p65 positivity also decreased in the B+DEX100 group compared to the 30% burn group. CONCLUSIONS: Dexmedetomidine reduced apoptotic activity in rats and exhibited anti-inflammatory antioxidant effects in the burn model in this study.

Prenatal Recognition of Hepatopulmonary Fusion in Right-Sided Congenital Diaphragmatic Hernia for Successful Operative Planning.

INTRODUCTION: Hepatopulmonary fusion (HPF) is a rare anomaly specifically associated with right-sided congenital diaphragmatic hernia (CDH). Fewer than 50 cases of HPF have been reported, most at the time of surgery or postmortem with an associated high morbidity and mortality rate. Prenatal diagnosis and optimal management of these rare cases have not been established. CASE PRESENTATION: We present a case of HPF diagnosed prenatally by fetal ultrasound and magnetic resonance imaging allowing postnatal and intraoperative planning leading to successful HPF separation and repair of the CDH. DISCUSSION: The prenatal recognition allowed the use of preoperative computed tomography angiogram and right cardiac catheterization to plan the surgical approach. Intraoperative ultrasound confirmed abnormal vasculature associated with the HPF facilitating a successful complete HPF separation and CDH repair was performed. The patient survived and continues to do well on long-term follow-up. Prenatal recognition may help reduce the high morbidity and mortality associated with HPF.

From Microcytosis to Macrodiagnosis.

A 12-year-old Hispanic girl presented with fatigue, lightheadedness, and intermittent headaches. She was depressed and appeared pale to her mother. Her examination was unremarkable except for palpebral conjunctival pallor and was otherwise noncontributory. She had a profound hypoproliferative microcytic anemia with low iron level, low transferrin saturation, and a normal ferritin level. The patient experienced improvement in clinical symptoms following transfusion of packed red blood cells and oral iron therapy. At follow-up 2 months later, she presented with similar symptoms and persistent microcytic anemia with low iron levels. Her ferritin level was increased along with markedly elevated C-reactive protein and erythrocyte sedimentation rate. An oral iron challenge demonstrated lack of absorption, and hepcidin level was also significantly elevated. Thorough gastrointestinal and rheumatologic evaluations were performed to search for a source of inflammation. Key components of the patient's social history supplemented by serology, radiographic, and pathologic findings ultimately cinched an unexpected diagnosis.

The Greulich-Pyle and Gilsanz-Ratib atlas method versus automated estimation tool for bone age: a multi-observer agreement study.

PURPOSE: To evaluate the agreement between observers using Greulich-Pyle (GP) and Gilsanz-Ratib (GR) methods, between four specialities (radiology, pediatrics, pediatric endocrinology and pediatric radiology) and between observers and automated tool in the bone age estimation. MATERIALS AND METHODS: A total of 99 observers participated in this questionnaire-based study. BoneXpert was used for the automated tool. Experienced, senior, and junior observers were defined by their experience, and the bone age determined by experienced observers was regarded as the ground truth. Agreement between observers was evaluated using the coefficient of variance (CV) and intraclass correlation coefficient (ICC), and they were reevaluated after adding BoneXpert to the observers. Agreement of BoneXpert, the senior, and the junior observers was also evaluated using the root-mean-square-error (RMSE) values and Blant Altman method by comparing with the ground truth. RESULTS: The CV ranged from 4.98% to 22.08%. The ICC were 0.980 for GP, 0.980 for GP and BoneXpert, 0.973 for GR, and 0.976 for GR and BoneXpert, and the ICC between four specialities ranged form 0.963 to 0.990. BoneXpert tool had the lowest RMSE values (0.504 years for GP atlas). CONCLUSION: Automated bone age estimation showed comparable results with GP and GR methods and its utilization may decrease inter-observer variability.

Early Hepatic Artery Thrombosis After Pediatric Living Donor Liver Transplantation.

AIM: Hepatic artery thrombosis is one of the major complications affecting patient and graft survival after liver transplantation. In this study, we analyzed the factors affecting the development of early hepatic artery thrombosis (eHAT) and its outcomes in pediatric liver transplantation. METHODS: A total of 175 pediatric patients underwent living donor liver transplantation between January 2013 and November 2018. Factors affecting eHAT and its outcomes were examined. RESULTS: Nine patients (5.1%) developed eHAT. In multivariate analysis, intraoperative hepatic artery revision and Roux-en-Y hepaticojejunostomy biliary reconstruction type were statistically significant (all, P < .05). Thrombectomy and reanastomosis was performed in 5 patients. Two of them were successful. In total, 3 retransplantations were performed and all of those patients are still alive. CONCLUSION: The factors affecting eHAT are still a matter of debate. Intraoperative hepatic artery anastomosis revision and Roux-en-Y hepaticojejunostomy reconstruction were independent risk factors for development of eHAT. In the present study, the confidence interval of the variables is high, therefore exact determination of the risk factors may not be possible. Early detection and thrombectomy and reanastomosis may be the first treatment of choice to rescue the patient and graft. When it fails, retransplantation must be an alternative. The results of the present study state that at least once a day the vascular anastomosis must be examined by Doppler ultrasonography in the post-transplant first week. It must be repeated when liver enzymes increase. The patients under high risk for eHAT may be followed up closer.

Clinical experience with two-point mDixon turbo spin echo as an alternative to conventional turbo spin echo for magnetic resonance imaging of the pediatric knee.

BACKGROUND: Two-point modified Dixon (mDixon) turbo spin-echo (TSE) sequence provides an efficient, robust method of fat suppression. In one mDixon acquisition, four image types can be generated: water-only, fat-only, in-phase and opposed-phase images. OBJECTIVE: To determine whether PD mDixon TSE water-only and, by proxy, PD in-phase images generated by one acquisition can replace two conventional PD TSE sequences with and without fat suppression in routine clinical MR examination of the knee. MATERIALS AND METHODS: This is a retrospective study of 50 consecutive pediatric knee MR examinations. PD mDixon TSE water-only and PD fat-saturated TSE sequences (acquired in the sagittal plane with identical spatial resolution) were reviewed independently by two pediatric radiologists for homogeneity of fat suppression and detection of intra-articular pathology. Thirteen of the 50 patients underwent arthroscopy, and we used the arthroscopic results as a reference standard for the proton-density fat-saturated and proton-density mDixon results. We used the Kruskal-Wallis rank test to assess difference in fat suppression between the proton-density mDixon and proton-density fat-saturated techniques. We used kappa statistics to compare the agreement of detection of intra-articular pathology between readers and techniques. We also calculated sensitivity, specificity and accuracy between arthroscopy and MR interpretations. RESULTS: Proton-density mDixon water-only imaging showed significant improvement with the fat suppression compared with proton-density fat-saturated sequence (P=0.02). Each observer demonstrated near-perfect agreement between both techniques for detecting meniscal and ligamentous pathology and fair to substantial agreement for bone contusions, and chondral and osteochondral lesions. CONCLUSION: Two-point mDixon water-only imaging can replace conventional proton-density fat-saturated sequence. When same-plane proton-density fat-saturated and non-fat-saturated sequences are required, proton-density water-only and proton-density in-phase image types acquired in the same acquisition shorten the overall examination time while maintaining excellent intra-articular lesion conspicuity.

Endoscopic treatment of biliary complications after living donor liver transplantation in a high volume transplant center in Turkey; a single-center experience.

BACKGROUND AND AIM: Biliary complications are an important cause of mortality and morbidity after living donor liver transplantation (LDLT). We present our endoscopic treatment results after LDLT as a single center with high volume. METHODS: Patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) after LDLT between 2005 and 2015 were included. Clinical data included patient demographics, ERCP indications (stricture or leak), and treatment outcomes, including need for percutaneous and surgical interventions. RESULTS: ERCP was performed in 446 (39.2%) patients with duct-to-duct anastomosis of 1136 LDLT patients. The most common biliary complication was stricture ± stone (70.6%, 315/446). Stricture and leak occurred in 60 (13.4%) patients. Only biliary leak was found in 40 (8.9%) patients. Our endoscopic treatment success rate in patients with biliary stricture after LDLT was 65.1%. Overall endoscopic success rates in our patients were 55.0% in patients with both leak and stricture, and only leak. In all, our percutaneous transhepatic biliary interventions (PTBI) and ERCP success rate was 90.6% in patients with biliary complications after LDLT. CONCLUSIONS: Endoscopic treatments are highly effective for biliary complications after LDLT. Effective use of percutaneous interventions in collaboration with endoscopic treatments significantly reduces the need for surgical treatment.

Totally laparoscopic resection and extraction of specimens via transanal route in synchronous colon and gastric cancer.

INTRODUCTION: Synchronous colon and gastric cancer is a rare clinical entity. In the present case, it is aimed to show that in a patient with synchronous colon and gastric cancer, laparoscopic resection can be safely performed and both specimens can be delivered through a natural orifice. In our knowledge, this is the first example showing the delivery of the gastric resection specimen through the anus in a human being. CASE REPORT: Sixty-six years old male patient with an upper gastrointestinal bleeding and obstruction symptoms was admitted to our department and the evaluation revealed an advanced stage gastric and a synchronous colon cancer. A laparoscopic palliative subtotal gastrectomy with a subtotal colectomy was performed. All anastomoses were performed intracorporeally and colectomy and subtotal gastrectomy specimens were successfully delivered via trans-anal route without any difficulty. Despite major abdominal organ resections, the patients required quite less analgesics in the postoperative period. DISCUSSION: Specimen extraction through the natural orifices eliminates the need and problems of performing additional abdominal incisions to the patients which also leads to reduced postoperative pain. Synchronous surgical procedures do not prevent the natural orifice surgery.

Alexithymia and perception of illness in patients with cancer.

This study aimed to determine how alexithymia affects the perception of illness in patients with cancer. This was a descriptive study conducted at the Atatürk University Health, Research and Practice Hospital and the Erzurum Regional Training and Research Hospital's Medical Oncology Clinic and Chemotherapy Unit. The study data were collected between July 2013 and January 2014. In total, data were collected from 283 patients with cancer. The data were collected using questionnaires enquiring about demographic and medical information: the IPQ and TAS-20. The study concluded that 50.5% of the participating patients had alexithymia. It was found that the alexithymic patients with cancer perceived the negative outcomes of their illness more strongly, and their negative feelings about the illness were more intense. This study suggests that further research should be carried out on alexithymia in patients with cancer and that their positive beliefs about the illness could be enhanced using psychosocial interventions.

Suitability of foramen magnum measurements in sex determination and their clinical significance.

BACKGROUND: The foramen magnum provides a transition between fossa cranii posterior and canalis vertebralis. Medulla oblongata, arteria vertebralis and nervus accessorius spinal part pass through the foramen magnum. In this study, we aimed to make the morphometric measurements of the foramen magnum on computed tomography (CT) and to determine the feasibility of sex determination based on these measurements. Besides sex determination, from a clinical aspect, it is important to know the measurements of the foramen magnum in the normal population in terms of diseases characterised by displacement of the posterior fossa structures through foramen magnum to upper cervical spinal canal such as Chiari malformations and syringomyelia. MATERIALS AND METHODS: All the data for our study was obtained retrospectively from 100 patients (50 males, 50 females) who had a CT scan of the head and neck region in Adnan Menderes University Hospital, Department of Radiology. To examine the foramen magnum in each and every occipital bone, we measured the foramen magnum's anteroposterior diameter, transverse diameter, the area of the foramen magnum and its circumference. RESULTS: We found that men have a higher average value than women in our study. According to Student's t-test results; in all measured parameters, there is significant difference between the genders (p < 0.05). When multivariate discriminant function test is performed for all four measurements, the discrimination rate is 64% for all women, 70% for all men and 67% for both genders. CONCLUSIONS: As a result of our study, the metric data we obtained will be useful in cases where the skeletons' sex could not be determined by any other methods. We believe that, our study may be useful for other studies in determining of sex from foramen magnum. Our measurements could give some information of the normal ranges of the foramen magnum in normal population, so that this can contribute to the diagnosis process of some diseases by imaging. (Folia Morphol 2018; 77, 1: 99-104).

Colossal pilomatrixoma.

We describe the largest reported case of pilomatrixoma in the literature. While pilomatrixomas typically present as small soft-tissue nodules of the head, neck and upper extremities, they can also present as much larger masses in atypical locations. When they present in their usual size, pilomatrixomas have typical imaging features and can be correctly diagnosed with imaging studies before histological confirmation. Their clinical and imaging diagnosis become challenging when they are very large, as in our case. A giant pilomatrixoma should also be considered for paediatric patients presenting with a large subcutaneous soft-tissue mass.

Pregnancy After Liver Transplantation: Risks and Outcomes.

OBJECTIVE: The aim of this study was to evaluate the outcomes of liver transplant recipients who became pregnant after transplantation. METHODS: The clinical data of all patients who underwent liver transplantation between January 2007 and December 2016 in our liver transplantation institute were reviewed. The following data were analyzed: indications for transplantation, recipient age at the beginning of pregnancy, the interval between transplantation and pregnancy, maternal and fetal complications, type of delivery, the health condition of neonates, and modifications in immunosuppressive therapy. RESULTS: During the study period, 1890 patients underwent liver transplantation. There were 185 women (9.8%) in childbearing age (15-45 years old), and 18 (9.7%) of them became pregnant during the study period. There were a total of 26 pregnancies. The mean age of patients at the time of operation was 25.3 ± 5.2 years, and the mean interval between operation and conception was 32.7 ± 15.3 months. Seventeen pregnancies (65.4%) ended in a live birth in the study. Six pregnancies (23%) resulted with no maternal or fetal complications. The most frequent maternal complication during pregnancy was pregnancy-induced hypertension (n = 3; 16.6%). CONCLUSIONS: Despite advances in immunosuppressive therapy and increasing experience in the management of these patients, pregnancies in liver transplant recipients are still more risky than in the general population for both the mother and the fetus. Thus, the issues related to fertility should be comprehensively discussed with the patients and their partners, preferably before transplantation, and pregnancies in liver transplant recipients should be followed up more carefully by a multidisciplinary team.

Telescopic Biliary Reconstruction in Patients Undergoing Liver Transplantation With 1-Year Follow-up.

BACKGROUND: Biliary complications are important during liver transplantation because of their effect on recipient and graft survival, incidence, and the long treatment period. These complications are associated with 50% morbidity and 30% mortality rates in recent studies. One of the most important reasons for biliary anastomosis complications is arterial ischemia. We present the results of our telescopic biliary anastomosis technique performed on the mucosa of the main biliary duct. PATIENTS AND METHODS: Fifty-six cases of telescopic biliary reconstruction were performed in 203 patients during 2015. Fifty cases and 52 patients who underwent standard reconstruction were chosen and compared. All patients had been scanned retrospectively. Statistical analyses were conducted with χ2 and Mann-Whitney U tests for the complications that occurred during the first 3 months. A P value <.05 was considered significant. RESULTS: No clinical or demographic differences were detected between the groups. About 90% of both groups were living donor liver transplantation cases. Five (10%) anastomotic leaks occurred in telescopic reconstruction group (n = 50), and 13 (25%) occurred in the standard reconstruction group (n = 52; P < .05). CONCLUSION: The arterial blood supply is better if the biliary anastomosis is made on the mucosal side of the main biliary duct. Early period anastomotic leaks may decrease significantly.

Can Patients Who Develop Cerebral Death in Fulminant Liver Failure Despite Liver Transplantation Be Previously Forseen?

BACKGROUND: The outcome of medical treatment is worse in fulminant liver failure (FLF) developing on acute or chronic ground. Recently, liver transplantations with the use of living and cadaveric donors have been performed in these diseases and good results obtained. In this study, we aimed to present the factors affecting the recovery of cerebral functions after liver transplantation in hepatic encephalopathy (HE) developing in FLF, to identify irreversible patient groups and to prevent unnecessary liver transplantation. METHODS: In Inonu University's Liver Transplant Institute, 69 patients who made an emergency notice to the National Coordination Center for liver transplantation owing to FLF from January 2012 to December 2015 were included in the study. Patients were divided into 2 groups. Group 1 consisted of 52 patients who underwent liver transplantation and recovered normal brain function, and group 2 had 17 patients who underwent liver transplantation and did not recover normal brain function and had cerebral death. All patients were evaluated before surgery for clinical encephalopathy stage, light reflex, and convulsions. Groups were compared and assessed according to age (>40, 10-40 and <10 years), body mass index, etiologic factor, preoperative laboratory values, transplantation type, mortality, and encephalopathy level. Multivariate analysis was done for specific parameters. RESULTS: Prothrombin time (PT), international normalized ratio (INR), and total bilirubin values were significantly different between the groups. There was no significant difference between the groups regarding ammonia and lactate levels. There was a statistically significant difference between the groups regarding sodium and potassium levels from serum electrolytes. However, the averages of both groups were within normal limits. pH and total bilirubin levels were meaningful for multivariate analysis. CONCLUSIONS: HE reversibility, mortality, and morbidity are important in patients with HE who undergo liver transplantation. Therefore, West Haven clinical staging and serum INR, PT, and total bilirubin level may be helpful in predicting the reversibility of FLF patients with HE before liver transplantation. It was determined that West Haven encephalopathy grading is important in determining the reversibility of HE after transplantation in FLF; especially the probability of reversibility of stage 4 HE decreases significantly. High PT and INR levels, hyperbilirubinemia, and serum sodium and potassium concentrations were risk factors for the reversibility of HE in this study.

Surgical Treatment of Portal Vein Thrombosis With the Use of Cadaveric Venous Patch After Donor Hepatectomy: A Case Report.

Live donors should be the priority of transplant professionals to prevent surgery-related morbidity and mortality during living-donor liver transplantation. Portal vein thrombosis after donor hepatectomy is an important complication which can be prevented by careful preoperative as well as perioperative evaluation. If portal vein thrombus occurs after donor hepatectomy, anticoagulation and surgical thrombectomy and even portal vein reconstruction should be kept in mind. Cadaveric venous patches can be used for the reconstruction of narrowed and angulated portal veins. Here we report the surgical treatment of a donor with a cadaveric venous patch who developed portal vein thrombosis after donor hepatectomy.