Static Plantar Pressure under Different Conditions in Children with Surgically Treated Unilateral Slipped Capital Femoral Epiphysis.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is the most common hip disease during infancy and adolescence. Our study aimed to analyze static plantar pressure in children with surgically treated unilateral SCFE. METHODS: Twenty-two children with right SCFE with in situ fixation with one percutaneous screw were assessed by PoData plantar pressure analysis under three different conditions (open eyes, eyes closed, and head retroflexed). RESULTS: The total foot loading was significantly higher on the unaffected limb compared with the affected one for all the three testing conditions (p < 0.05). When assessing the differences between testing conditions, there were no significant differences for the right and left foot loadings, or for the three sites of weight distribution, except for the right fifth metatarsal head (lower loading in eyes-closed condition in comparison to eyes open, p = 0.0068), left fifth metatarsal head (increased loading in head-retroflexed condition in comparison to eyes open, p = 0.0209), and left heel (lower loading in head-retroflexed condition in comparison to eyes open, p = 0.0293). CONCLUSION: Even after a successful surgical procedure, differences in foot loading can impact the postural static activities in different conditions (natural eyes-open, eyes-closed, or head-retroflexed posture).

Artificial Intelligence (AI) Based Analysis of In Vivo Polymers and Collagen Scaffolds Inducing Vascularization.

BACKGROUND/AIM: Biomaterials are essential in modern medicine, both for patients and research. Their ability to acquire and maintain functional vascularization is currently debated. The aim of this study was to evaluate the vascularization induced by two collagen-based scaffolds (with 2D and 3D structures) and one non-collagen scaffold implanted on the chick embryo chorioallantoic membrane (CAM). MATERIALS AND METHODS: Classical stereomicroscopic image vascular assessment was enhanced with the IKOSA software by using two applications: the CAM assay and the Network Formation Assay, evaluating the vessel branching potential, vascular area, as well as tube length and thickness. RESULTS: Both collagen-based scaffolds induced non-inflammatory angiogenesis, but the non-collagen scaffold induced a massive inflammation followed by inflammatory-related angiogenesis. Vessels branching points/Region of Interest (Px^2) and Vessel branching points/Vessel total area (Px^2), increased exponentially until day 5 of the experiment certifying a sustained and continuous angiogenic process induced by 3D collagen scaffolds. CONCLUSION: Collagen-based scaffolds may be more suitable for neovascularization compared to non-collagen scaffolds. The present study demonstrates the potential of the CAM model in combination with AI-based software for the evaluation of vascularization in biomaterials. This approach could help to reduce and replace animal experimentation in the pre-screening of biomaterials.

Cystic Echinococcosis in Hospitalized Children from Western Romania: A 25-Year Retrospective Study.

Cystic echinococcosis (CE) is a cosmopolitan parasitic disease caused by Echinococcus granulosus. We aimed to assess the epidemiological aspects of the disease in hospitalized children from Western Romania, a well-known endemic area for CE. We retrospectively investigated the medical records of children hospitalized between 1998 and 2022. A total of 144 patients were included, and 58.3% were from rural areas. The number of cases increased with age, from 9% in the age group 3-5 years to 59.7% in the age group 11-17 years. The liver was more frequently affected (65.3%), and a significant association between gender and the affected organ was noted; liver cysts were more frequently diagnosed in girls, while lung cysts were recorded mostly in boys. Complications were more frequently reported in patients with pulmonary CE compared to hepatic CE (p = 0.04). Boys had more complications (16/23, 69.6%) compared to girls (7/23, 30.4%) (p = 0.03). A third of the children were hospitalized for more than 14 days, and multiple hospitalizations were recorded in 31.3% of the patients. This paper provides new insights into the epidemiologic features of cystic echinococcosis in children from Western Romania. Our findings indicate that exposure to the parasite starts in childhood, and the rate of hospitalization increases with age. Public health strategies should be implemented and permanently improved in order to lower the prevalence of CE in children.

Case Report of a Unique Intra-Operative Finding in a Pediatric Distal Radius Non-Union: Does This Shed Light on Other Non-Unions or Malunions in Children?

Non-unions are quite rare in closed fractures in children. Most distal radius fractures require orthopedic reduction and conservative treatment with very good radiological and clinical/functional results. In case of unsatisfactory reduction, surgical treatment is necessary to correct significant displacement. Surgical treatment consists of closed reduction and percutaneous fixation using K-wires. If closed reduction is not possible, open reduction and fixation is mandatory. Generally, fixation is obtained using K-wires, in most cases, even if open reduction is necessary, rarely locking plates, especially in adolescents. The present paper presents a case of non-union that eventually required open reduction and plating. During surgery, however, it became evident that the cause for non-union was the traumatic transposition of the long extensor radialis tendon, through the fracture site to the volar side of the distal forearm. The movement of the carpus translated to constant mobility in the fracture site, leading to non-union and a continuous tendency towards anterior angulation of the distal fragment. The tendon was reduced to its anatomical position, the fracture was reduced, and fixed using a locking plate, and union was achieved with no complications. Traumatic transpositions of tendons should be considered in pediatric non-unions, and restoring anatomy is essential.

Pain Management in Pediatric Burns: A Review of the Science behind It.

Pediatric burns are a significant medical issue that can have long-term effects on various aspects of a child's health and well-being. Pain management in pediatric burns is a crucial aspect of treatment to ensure the comfort and well-being of young patients. The causes and risk factors for pediatric burns vary depending on various factors, such as geographical location, socioeconomic status, and cultural practices. Assessing pain in pediatric patients, especially during burn injury treatment, poses several challenges. These challenges stem from various factors, including the age and developmental stage of the child, the nature of burn injuries, and the limitations of pain assessment tools. In pediatric pain management, various pain assessment tools and scales are used to evaluate and measure pain in children. These tools are designed to account for the unique challenges of assessing pain in pediatric patients, including their age, developmental stage, and ability to communicate effectively. Pain can have significant physical, emotional, and psychological consequences for pediatric patients. It can interfere with their ability to engage in daily activities, disrupt sleep patterns, and negatively affect their mood and behavior. Untreated pain can also lead to increased stress, anxiety, and fear, which can further exacerbate the pain experience. Acute pain, which is short-term and typically associated with injury or illness, can disrupt a child's ability to engage in physical activities and impede their overall recovery process. On the other hand, chronic pain, which persists for an extended period, can have long-lasting effects on physical functioning and quality of life in children. The psychological consequences of burns can persist long after the physical wounds have healed, leading to ongoing emotional distress and impaired functioning. Multimodal pain management, which involves the use of multiple interventions or medications targeting different aspects of the pain pathway, has gained recognition as an effective approach for managing pain in both children and adults. However, it is important to consider the specific needs and considerations of pediatric patients when developing evidence-based guidelines for multimodal pain management in this population. Over the years, there have been significant advances in pediatric pain research and technology, leading to a better understanding of pain mechanisms and the development of innovative approaches to assess and treat pain in children. Overall, pain management in pediatric burns requires a multidisciplinary approach that combines pharmacologic and nonpharmacologic interventions.

Comparison of Type I and Type III Collagen Concentration between Oreochromis mossambicus and Oreochromis niloticus in Relation to Skin Scaffolding.

Background and Objectives: Skin scaffolding can be done using allografts and autografts. As a biological allograft, the skin of Oreochromis niloticus (ON) has been used due to its high type I and III collagen content. Oreochromis mossambicus (OM) is also a member of the Oreochromis family, but not much is known regarding its collagen content. As such, this study aimed to assess and compare the collagen content of the two fish species. Materials and Methods: This is a crossover study comparing the skin collagen contents of the two fish. Young fish were chosen, as they tend to have higher collagen concentrations. The skin samples were sterilized in chlorhexidine and increasing glycerol solutions and analyzed histochemically with Sirius red picrate under polarized light microscopy. Results: 6 young ON and 4 OM specimens were used. Baseline type I collagen was higher for OM, but at maximum sterilization it was higher for ON, with no differences in between Type III collagen was higher for OM across all comparisons with the exception of the last stage of sterilization. Generally, collagen concentrations were higher in highly sterilized samples. Conclusions: OM skin harvested from young fish, with its greater collagen III content may be a better candidate for use as a biological skin scaffold in the treatment of burn wounds, compared to ON.

Peritoneal Dialysis Catheter Placement in Children: Initial Experience with a "2+1"-Port Laparoscopic-Assisted Technique.

The placement of a peritoneal dialysis catheter (PDC) is currently a common procedure in pediatric surgeon practice, and the search for the ultimate technique never stops. The purpose of this study is to evaluate our experience with the laparoscopic PDC placement approach, performing a "2+1" ("two plus one") technique, where the "+1" trocar is placed in an oblique manner, pointing toward the Douglas pouch when passing through the abdominal wall. This tunnel is further used to place and maintain the proper position of the PDC. MATERIALS AND METHODS: We assessed a cohort of five children who underwent laparoscopic-assisted PDC placement between 2018 and 2022. RESULTS: This procedure is a simple, relatively quick, and safe technique for PDC placement. Furthermore, in our experience, concomitant omentectomy is necessary to reduce the risk of catheter obstruction and migration due to omental wrapping. CONCLUSIONS: The laparoscopic approach allows for improved visualization and more accurate placement of a catheter inside the abdominal cavity. Concomitant omental excision is necessary to prevent PDC malfunction and migration.

"Face(s)" of a PHACE(S) Syndrome Patient before and after Therapy: Particular Case Report and Review of Literature.

A rare, uncommon disorder called PHACE(S) (P-posterior fossa anomalies, H-hemangioma, A-arterial anomalies, C-cardiac anomalies, E-eye anomalies, and S-sternal cleft) of unknown etiology was rarely reported. Children are susceptible to developing PHACE(S) syndrome from the moment they are born. It may be challenging for a physician to appropriately diagnose and treat children with PHACE due to the multifaceted nature of the disease and the extensive range of consequences that may be associated with it. A one-month-old newborn girl was admitted to hospital with extensive, multiple facial infantile hemangiomas, ulceration of the lower lip hemangioma-like lesion, cardiovascular, sternal, and neurological concomitant malformations. Five days following the initial application of the medication, systemic treatment with propranolol and topical treatment with silver sulfadiazine produced their first noticeable benefits. The lip ulceration was mostly healed and facial hemangioma started to regress. The regression continued under therapy and this effect persists for 6 months since Propranolol therapy ended. No cardiovascular or neurological clinical events have been registered during follow-up. The present case has three peculiarities: (1) high number of facial hemangiomas; (2) presence of subependymal cyst not yet reported in the literature associated with PHACE syndrome; and (3) lack of cardiovascular events during therapy knowing that these events frequently appear in PHACE syndrome patients.

Costal cartilage overgrowth does not induce pectus-like deformation in the chest wall of a rat model.

Overgrowth of the costal cartilages has been frequently reported to be an etiological factor of chest wall deformities in children. The present study aimed to investigate if induced overgrowth of the costal cartilages could lead to deformation of the chest wall in a rat model. An insulin-like growth factor 1 (IGF1) solution was directly injected under the perichondrium of the last three costal cartilages of 2-week-old rat pups. Two different concentrations, 50 µg/ml (E50) and 100 µg/ml (E100), were applied. This procedure was repeated once per week for 5 consecutive weeks. Subsequently, 14 days after the last injection, all animals were euthanized before the shape of the thoracic cage was assessed, and the diameter was measured. In addition, the last three costal cartilages were dissected before the samples were prepared and examined by light microscopy. Rats that received E100 exhibited larger sagittal and coronal rib cage diameters compared with those in the E50 and control groups. However, no deformation could be observed in the chest wall. Microscopic examinations revealed an anabolic pattern in the E100 group. The present findings suggested that locally administered IGF1 stimulated cell proliferation and tissue growth in coastal cartilages in a dose-dependent manner in vivo. However, this induced overgrowth of the costal cartilages did not result in the deformation of the chest wall.

Expression of ß1 adrenergic receptor in vascular anomalies in children.

OBJECTIVE: Controversial, heterogeneous, and inconsistent responses to beta-blockers have been reported in some cases of infantile proliferative hemangiomas. On the basis of these clinical observations, we aimed to examine the ß1 adrenergic receptor (ß1-AR) protein expression distribution among different types of pediatric vascular anomalies. METHODS: Immunohistochemistry (IHC) was performed for ß1-AR on 43 surgical specimens. RESULTS: We found positive ß1-AR IHC staining in all intramuscular hemangiomas, capillary-lymphatic, lymphatic, venous, and combined malformations, and Masson's tumor cases, as well as in 7 of 10 cases of proliferative infantile hemangiomas. CONCLUSIONS: Our research demonstrates, for the first time, the degree of heterogeneous expression of ß1-AR among pediatric vascular malformations. Our results support the need for ß1-AR assessment in pediatric vascular anomalies to select cases with a robust response to ß1-selective blockers. ß1-AR assessment may have a strong impact on therapeutic refinement for pediatric vascular anomalies by selecting cases with a stronger response to beta-blockers.

Combined Staged Surgery and Negative-Pressure Wound Therapy for Closure of a Giant Omphalocele.

The management of giant omphaloceles had always been a point of interest for the pediatric surgeons. Many surgical techniques were proposed, but none of them succeeded to become the standard procedure in closing the congenital abdominal defect. We present a case of giant omphalocele in which we used staged surgical closure combined with a prosthetic patch, with negative-pressure therapy and, finally, definitive surgical closure. Even though a major complication occurred during the treatment, we were able to close the defect without any prosthetic material left in place.

Upper Extremity Fractures in Children-Comparison between Worldwide, Romanian and Western Romanian Region Incidence.

(1) Background: Fractures represent a significant part of all pediatric injuries, with distal forearm fracture being the most common fracture type in children. (2) Methods: In this comparative, epidemiological study we collected fracture incidence data from the scientific literature and compared it to real-world data extracted from the Romanian national and regional hospital database. In order to collect information on the epidemiology of upper extremity fractures in children, we conducted a systematic literature review on Medline, via PubMed. Extracted incidence data were stratified by fracture location, age or age interval and gender. Nationwide and Western Region incidence values were calculated for different fracture locations of the upper extremity using data extracted from a centralized hospital database. Incidence values were calculated using the mid-2018 census data. The search was restricted to the pediatric population. (3) Results: Incidence values for upper arm fractures nationwide and for Western Region were 54.83/100,000 person-years and 64.79/100,000 person-years, respectively. Forearm fractures had an incidence of 139.77/100,000 person-years and 139.56/100,000 person-years, respectively. The overall incidence of upper extremity fractures nationwide and for the Romanian Western Region were 206.02/100,000 person-years and 220.14/100,000 person-years, respectively. (4) Conclusions: Incidence of upper extremity fractures in the pediatric population varies according to the analyzed data. The calculated incidence depends on the site of fractures, assessed population (worldwide, Romanian population or regional-Western part of Romania) or patients' age.

Rat Animal Model of Pectus Excavatum.

BACKGROUND: pectus excavatum (PE) is the most common congenital deformity of the thoracic wall. Lately, significant achievements have been made in finding new, less invasive treatment methods for PE. However, most of the experimental work was carried out without the help of an animal model. In this report we describe a method to create an animal model for PE in Sprague-Dawley rats. METHODS: We selected 15 Sprague-Dawley rat pups and divided them into two groups: 10 for the experimental group (EG) and 5 for the control group (CG). We surgically resected the last four pairs of costal cartilages in rats from the EG. The animals were assessed by CT-scan prior to surgery and weekly for four consecutive weeks. After four weeks, the animals were euthanized and the thoracic cage was dissected from the surrounding tissue. RESULTS: On the first postoperative CT, seven days after surgery, we observed a marked depression of the lower sternum in all animals from the EG. This deformity was present at every CT-scan after surgery and at the post-euthanasia assessment. CONCLUSIONS: By decreasing the structural strength of the lower costal cartilages, we produced a PE animal model in Sprague-Dawley rats.

Cost-Effectiveness of Titanium Elastic Nail (TEN) in the Treatment of Forearm Fractures in Children.

Background and objectives: There are various methods in the management of forearm fractures in children. Elastic stable intramedullary nailing using Titanium Elastic Nail (TEN) is nowadays employed in diaphysis fractures of children, with clear benefits over other treatment options. However, in the case of TEN versus other treatment methods of forearm fractures in children, cost is an important issue. This report will focus on the cost assessment of using TEN versus other therapeutic means in the treatment of forearm fractures in children. Materials and Methods: We performed a retrospective longitudinal study of 173 consecutive patients with forearm fractures treated in a single institution during 2017. We calculated the cost for each patient by summing up direct costs plus indirect costs, calculated at an aggregate level. Hospital income data were extracted from the Diagnosis Related Groups database. Results: A total of 173 patients with forearm fractures were treated, 44 using TEN, 86 using K-wire, and 46 using closed reduction and cast. There were 66 radius fractures, 1 ulna fracture, and 106 that were both radius and ulna fractures. Mean treatment cost were $632.76 for TEN, $499.50 for K-wire, and $451.30 for closed reduction and cast. Costs for TEN were higher than for K-wire insertion (p = 0.00) and higher than closed reduction and cast ($182.42; p = 0.00). Reimbursement per patient was higher with TEN versus K-wire patients; $497.88 vs. $364.64 /patient (p = 0.00), and higher than for patients treated with closed reduction and cast (p = 0.00). Conclusions: The treatment of upper extremity fractures using TEN was more expensive than the other methods. In Romania, because the reimbursement for TEN is higher as well, there are no differences in the financial burden when treating forearm fractures with TEN versus K-wire. Non-surgical treatment has the lowest cost but also the lowest reimbursement.

The Financial Burden of Setting up a Pediatric Robotic Surgery Program.

Background and Objectives: Robotic surgery is currently at the forefront of both adult and pediatric treatment. The main limit in the wide adoption of this technology is the high cost of purchasing and running the robotic system. This report will focus on the costs assessment of running a robotic program in a pediatric surgery center in Romania. Materials and Methods: In 12 months we performed 40 robot-assisted procedures in children. We recorded and analyzed data regarding their age, gender, pathological condition and comorbidities, surgical procedure, time of surgery, complications, hospital stay and related costs, medication, robotic instruments and consumables, additional cost, and income per case received from the National Insurance Company (NIC). Results: Mean cost per case was €3260.63 (€1880.07 to €9851.78) and was influenced by type of the procedure, intraoperative incidents, postoperative complication, and non-scheduled reinterventions (p < 0.05). The direct costs for operating the surgical robot were relatively constant, regardless of the surgical procedure (mean €1579.81). The reimbursement from the NIC ranged from 5% to 56% (mean 16.9%) of the total cost per case. Conclusion: In Romania, a pediatric surgery robotic program is not cost-efficient and cannot operate relying solely onto the health insurance system.

Role of imagistic techniques in diagnosing soft-tissue vascular anomalies in pediatric population - a 5-year experience.

Soft-tissue vascular anomalies have a worldwide estimated prevalence of 4.5% in the pediatric population. From January 1, 2014 until December 31, 2018, imagistic and histological evaluations were performed in 214 patients aged between one day and 18 years old, who were diagnosed with different soft-tissue vascular anomalies in our Center. From the 214 patients included in the study, 36.45% (n=78) were males, 63.55% (n=136) were females and 37.38% (n=80) of the patients were less than one year of age at time of admission. Infantile hemangioma was the most frequent type of soft-tissue vascular anomaly (35.51%) and the face was the most frequent affected region (25.7%). Ultrasound (US) examination is the most used imaging technique due to its wide accessibility and for providing valuable information about the anatomical localization of the lesions, the type of vessels involved, distribution and density of vascularization. Magnetic resonance imaging (MRI) can be used for assessing the extent of deep or large lesions, but it usually requires anesthesia. Computed tomography (CT) is useful when patients present contraindications to anesthesia and it has the advantage of a shorter image acquisition time. Histological studies have an important role in establishing the diagnosis even for the atypical cases of soft-tissue vascular anomalies. Furthermore, the prognosis depends on the histological type. In conclusion, there is a need for collaboration between the clinician, radiologist, pathologist and surgeon in order to establish a precise diagnosis and therapeutic strategy for each patient.

Acute limb ischemia in neonates: etiology and morphological findings - short literature review.

The acute limb ischemia (ALI) in neonates is a rare phenomenon, but with serious consequences if undiagnosed or untreated. The purpose of this review is to briefly present the etiology of ALI and morphological findings in correlation with specific causes. Etiology can be classified into two main groups: prenatal (in utero compression, thrombosis and embolism) and postnatal (iatrogenic, thromboembolism and vascular malformations). The most common cause of ALI is catheter-related thrombosis (almost 90% of thrombosis cases are associated with catheter use), but other rare causes like vascular malformations should not be overlooked. Ultrasound represents a non-invasive, inexpensive and widely available imaging technique, which provides sufficient information to evaluate the situation and establish proper therapeutic strategies. Morphological tests do not represent the standard diagnostic procedure in ALI, but they can provide useful information. The findings depend on the etiology: intraluminal thrombi, vascular changes, placental pathological modifications. Every morphological result must be correlated with the clinical picture and imagistic findings. In conclusion, ALI in neonates is a rare condition, usually associated with catheter use in intensive care unit setting, with multiple risk factors and conditions that increase the risk of occurrence.

Verner-Morrison syndrome. Literature review.

Chronic diarrhea in infants is a common condition for addressability to pediatric gastroenterologists. The causes are multiple and the delay in reaching the final diagnosis can lead to complications in the general condition of the child. The purpose of this review is to present the bio-clinical and histogenetic particularities of a rare clinical entity, characterized by tumoral causes of chronic diarrhea. VIPomas are neuroendocrine tumors that autonomously secrete vasoactive intestinal peptide (VIP). Watery diarrhea, hypokalemia and achlorhydria (WDHA) syndrome caused by VIP-producing tumors only rarely occurs in adult patients with non-pancreatic disease. In pediatric patients, it is extremely rare for a VIPoma to originate in the pancreas; instead, WDHA syndrome is usually associated with VIP-secreting neurogenic tumors involving the retroperitoneum or mediastinum. The majority of VIP secreting tumors in pediatric patients are represented by ganglioneuroblastomas or ganglioneuromas originating in the adrenal medulla or sympathetic neural crest. This syndrome of watery diarrhea associated with hypokalemia and achlorhydria was first described by Verner and Morrison, in 1958, and has been assumed to be due to hypersecretion of VIP. In children, as well as in adult patients, the most likely explanation for persistent secretory diarrhea may be an occult VIPoma. In conclusion, the physicians should be aware that there are some rare tumoral causes of chronic diarrhea, often under-diagnosed. If the diagnosis is not considered, extensive gastrointestinal investigations will be undertaken, delaying the diagnosis and avoidable morbidity will occur.

Mesenchymal hamartoma of the left liver lobe in an 18-month-old female patient.

Mesenchymal hamartoma of the liver (MHL) is a benign and rare hepatic lesion, with an uncertain etiology and a potential for developing into an undifferentiated distant embryonal sarcoma after an incomplete resection. It mainly presents as progressive abdominal distension with normal blood works. Most cases are diagnosed in the first two years of life, with a higher frequency in boys and on the right liver. We report the case of a mesenchymal hamartoma of the left liver in an 18-month-old girl, with a rough evolution and a literature review. There were performed an abdominal computed tomography (CT) scan and resection of the lesion. The macroscopic and histological examination described a 16.5×17.9×10.5 cm multicystic mass as a MHL lesion. MHLs may have a malignant potential and in the clinical presence of a "neoplastic" syndrome there requires a good diagnosis and drastic surgical treatment.