Ten-year follow-up of cavoportal hemitransposition in pediatric liver transplantation for complete portomesenteric venous thrombosis: A case report and literature review.

BACKGROUND: Portal vein thrombosis is a potentially devastating complication following pediatric liver transplantation. In rare instances of complete portomesenteric thrombosis, cavoportal hemitransposition may provide graft inflow. Here we describe long-term results following a case of pediatric cavoportal hemitransposition during liver transplantation and review the current pediatric literature. METHODS: A 9-month-old female with a history of biliary atresia and failed Kasai portoenterostomy underwent living donor liver transplantation, which was complicated by portomesenteric venous thrombosis. The patient underwent retransplantation with cavoportal hemitransposition on postoperative day 12. OUTCOME: The patient recovered without further complication, and 10 years later, she continues to do well, with normal graft function and no clinical sequelae of portal hypertension. CT scan with 3-D vascular reconstruction demonstrated recanalization of the splanchnic system, with systemic drainage to the inferior vena cava via an inferior mesenteric vein shunt. The cavoportal anastomosis remains patent with hepatopetal flow. Of the 12 previously reported cases of pediatric cavoportal hemitransposition as portal inflow in liver transplantation, this is the longest-known follow-up with a viable allograft. Notably, sequelae of portal hypertension were also rare in the 12 previously reported cases, with no cases of long-term renal dysfunction, lower extremity edema, or ascites. CONCLUSIONS: Long-term survival beyond 10 years with normal graft function is feasible following pediatric cavoportal hemitransposition. Complications related to portal hypertension were generally short-lived, likely due to the development of robust collateral circulation. Additional reports of long-term outcomes are necessary to facilitate informed decision making when considering pediatric cavoportal hemitransposition for liver graft inflow.

Successful management of severe Kell alloimmunization in pregnancy with intravenous immune globulin.

Hemolytic Disease of the Fetus and Newborn (HDFN) is a condition that affects 1 to 2 out of 1000 patients during pregnancy (1). When an alloantibody is present, it is essential to identify its nature in order to organize appropriate follow-up. Kell-mediated HDFN is rare; it occurs in about 5% of Kell alloimmunized pregnant women. It is important to note that in case of anti-Kell immunization, the severity of HDFN is not correlated with maternal antibody titers, and anemia tends to occur earlier and more severely. Therefore, early diagnosing and management of this condition is crucial. In the management of severe fetal anemia due to Kell immunization, available treatments include in utero transfusion (IUT), immunoglobulin therapy. Other alternative treatments exist, such as plasmapheresis. Intravenous immunoglobulin (IVIG), a noninvasive therapeutic approach, acts through multiple mechanisms. IVIG has been evaluated in cases of RhD immunization with high maternal antibody titers and a history of pregnancies involving early hydrops or intrauterine death. Regarding the potential benefits of intravenous IgG therapy, it may delay the need for early IUT, reduce the overall reliance on IUT, and have a positive impact on obstetric outcomes. This case of IV IgG therapy of anti-Kell immunization offers a thought-provoking avenue for future exploration.

Obstructing Sigmoid Volvulus: An Unusual Complication in a Pediatric Patient With Ulcerative Colitis.

Acute colonic dilation in pediatric patients with ulcerative colitis (UC) raises a concern for toxic megacolon, but other rare conditions such as sigmoid volvulus may present in a similar manner. We report a rare case of a teenager with UC without prior surgery who developed an obstructing sigmoid volvulus managed with endoscopic detorsion and decompression. Colonic inflammation in patients with UC may result in a volvulus in the absence of other predisposing factors and should be considered in the differential diagnosis of patients with UC who present with obstructive symptoms with an atypical presentation.

Hepatitis C: Current State of Treatment in Children.

Hepatitis C in children is on the rise due to perinatal transmission from infected mothers, and high-risk practices in adolescents and young adults. Prevalence remains underestimated because children at high risk are often not screened. Treatment has evolved over the past decade with the advent of new drugs, and global elimination is now possible. Direct-acting antiviral combinations are safe and effective, with sustained viral suppression rate >90%, and Food and Drug Administration-approved for children ≥3 years old. Although challenging, efficient screening and treatment of chronic hepatitis C virus early is cost-effective and reduces burden of disease and its complications.

Emergency Management of the Ingested Magnet: An Algorithmic Approach.

INTRODUCTION: Accidental ingestion of foreign bodies is an increasing problem in the pediatric population. Symptoms are often nonspecific and may lead to a missed diagnosis because the ingestion event often goes unwitnessed. CASE: We present a case of a missed diagnosis of a multiple magnet ingestion event in a pediatric patient leading to operative management. A 2-year-old boy with a 4-week history of nonspecific abdominal pain presented to the emergency department (ED) with vomiting and worsening abdominal pain. He was recently seen in the ED for nonspecific abdominal pain diagnosed as acute otitis media. In this second ED visit, the child was found to be febrile and tachycardic and had signs of peritonitis. Radiographs revealed a foreign body in the right lower quadrant. The child was taken to the operating room where multiple intestinal perforations were identified and repaired. The child had an uneventful postoperative course and was discharged 7 days later. DISCUSSION: There are increasing awareness and growing concern over complications from pediatric magnet ingestion. Complications from neodymium magnet ingestion may include bowel obstruction, perforation, and fistula formation. The risk of complications is especially high with multiple-magnet ingestion. Pediatric foreign-body magnet ingestion may be a diagnostic challenge because the associated symptoms are nonspecific, and the ingestion is often unwitnessed. CONCLUSIONS: Our case represents the missed diagnosis of 4 magnets ingested separately over time. Emergency department providers may benefit from a clinical algorithm guiding the management of these increasingly prevalent patient presentations to prevent delayed diagnoses and to decrease morbidity.

Presence of Cytomegalovirus in urine and blood of pregnant women with primary infection might be associated with fetal infection.

BACKGROUND: Cytomegalovirus (CMV) congenital infection can result from primary infection, reinfection or reactivation among pregnant women. The risk of vertical transmission is much higher in case of primary infection, and the transmission rate increases with gestational age. However there are still many questions about maternal markers that can predict whether the virus will be transmitted to the fetus. OBJECTIVES: To investigate the relationship between the presence and the quantity of CMV in urine and blood of women presenting a primary CMV infection during pregnancy and the presence of congenital infection in their offspring. STUDY DESIGN: Detection and quantification of CMV DNA was performed on 150 urine samples and 114 blood samples from 150 pregnant women with proven CMV primary infection. RESULTS: Transmission rate was 36.7% (55/150). A statistically significant association was found between the presence of CMV in maternal urine and newborn infection (OR 2.03 95%CI 1.03-3.99). A clearly significant association was found between the presence of CMV in maternal blood and newborn infection (OR 3.14 95% CI 1.38-7.16). Taking into consideration those samples that are positive for CMV in maternal urine, the median value of viral load was significantly higher in those patients who transmitted to offspring (P=0.015). No significant association between viral load in maternal blood and newborn infection was observed. CONCLUSION: The presence of CMV in maternal urine and maternal blood correlated to the transmission of CMV to offspring in our cohort. The median viral load in urine is higher in women who transmitted. These markers may help to identify pregnant women at risk to transmit to the fetus.

Preoperative 3-T diffusion-weighted MRI for the qualitative and quantitative assessment of extracapsular extension in patients with intermediate- or high-risk prostate cancer.

OBJECTIVE: The purpose of this study was to prospectively evaluate the value of diffusion-weighted MRI (DWI) for the assessment of extracapsular extension (ECE) in patients with prostate cancer. SUBJECTS AND METHODS: Between November 2010 and April 2012, 40 patients with intermediate- to high-risk prostate cancer were prospectively recruited. MR images were obtained at 3 T with a phased-array coil. Two independent readers scored the T2-weighted images alone and then in combination with DW images. ROIs were drawn on the apparent diffusion coefficient (ADC) maps, and histogram-derived values were calculated. Whole-mount histopathologic examination was the standard of reference. Reader performance was analyzed, and differences in patient characteristics and histogram-based ADC values, according to ECE status, were evaluated. RESULTS: ECE was present in 23 of 40 (58%) patients and 23 of 43 (53%) tumors. The sensitivity for side-specific ECE detection significantly increased, from 0.22 to 0.44 for reader 1 and 0.33 to 0.82 for reader 2 (both p < 0.05) without a significant change in specificity for either reader with the addition of DWI and ADC mapping. The positive and negative predictive values for both readers also increased. The ADC parameters of median and 10th and 25th centiles showed a statistically significant difference between tumors with and those without ECE (p < 0.05). CONCLUSION: The addition of DWI and ADC mapping to T2-weighted MRI improved the accuracy of preoperative detection of ECE. Median and 10th and 25th centile ADC values were significantly associated with the presence of ECE and may be useful in the pretreatment assessment of patients with prostate cancer.

HIV type 1 zidovudine (ZDV) resistance in blood and uterine cervical secretions of pregnant women.

To determine if HIV-1 resistance testing of the blood predicts mutants in the genital secretions of ZDV-treated pregnant women, ZDV resistance mutations were assessed by an oligonucleotide ligation assay. ZDV resistance was detected in viral sequences from blood (16/48; 33%) and cervical secretions (6/24; 25%) collected during 57 pregnancies. The genotype of 11/69 (16%) resistance codons was discordant between blood and cervical virus of pregnant women near term. However, in only 1 (1.8%) of 57 pregnancies evaluated was resistant virus limited to the cervical secretions. ZDV-resistant virus is rarely limited to the female genital tract.