Major bronchial trauma in the pediatric age group.

Tracheobronchial injuries are rare among all age groups and are extremely rare among the pediatric age group. Yet, the incidence has seemed to increase. Most of these patients die before reaching the hospital from severe associated injuries. Isolated bronchial injury is even more rare than tracheal injury, and it is the focus of the present study. A retrospective national survey was conducted among all tertiary referral and trauma centers in Israel regarding the period between the years 1983 and 1998. Only six cases (3 males and 3 females) of isolated bronchial rupture were found the throughout the country. Ages of the patients ranged from 2 to 14 years; all were involved in motor vehicle accidents, four of them as pedestrians. Ruptures occurred in the bronchus intermedicus (2 cases), left and right main bronchus (2 cases each). All but one patient went through primary repair. We give a full description of the procedure and discuss the literature regarding incidence, diagnosis, treatment, and outcome.

Rectal flap advancement--a simple and effective approach for the treatment of rectourethral fistula.

OBJECTIVE: Rectourethral fistula is a rare complication of prostatic surgery and other pelvic procedures. We report our experience of surgical repair of using a rectal advancement flap. PATIENTS: Three patients with rectourethral fistula following prostatic surgery were treated. Two patients had an anterior partial thickness of rectal flap advancement via a trans-anal approach without urinary or faecal diversion. In one patient a rectal flap repair was performed through a posterior transsphincteric approach following urinary and faecal diversion. RESULTS: No significant postoperative complications occurred. Healing was successful in each patient and faecal and urinary continence was normal. CONCLUSION: Transanal rectal advancement flap is a simple and effective technique for the treatment of a rectourethral fistula with no need for urinary or faecal diversion.

Hepatitis B vaccination: long-term follow-up of the immune response of preterm infants and comparison of two vaccination protocols.

BACKGROUND: We conducted a 3-year follow-up study of long-term antibody persistence following vaccination of low-risk preterm infants with recombinant hepatitis B vaccine (HBV). Two three-dose protocols were compared: vaccination beginning within 24 h of birth to initial vaccination delayed until a weight of 2,000 g was reached. SUBJECTS AND METHODS: The study population included 136 children, divided into three groups: children born prematurely (< or = 35 weeks, n = 57), children born at term (> or = 37 weeks, n = 39), both groups receiving the first dose of HBV within 24 h of birth, and children born prematurely (< or = 35 weeks, n = 40), who received the first dose of HBV when a weight of 2,000 g was reached. All infants received the second hepatitis vaccination 1 month after the first, and the third dose 6 months after the first. Hepatitis B surface antibody (AntiHBs) was measured at an age of 3-3.5 years (at least 2.5 years after completion of the three-dose HBV series). An AntiHBs level of > or = 10 IU/l was considered positive. RESULTS: At 3-3.5 years of age, a higher percentage of the premature-delayed vaccination group had a positive AntiHBs level (92.5%) compared to both the premature (54.4%, p < 0.001) and full-term groups (71.8%, p < 0.05) vaccinated soon after birth. The premature-delayed vaccination group also had a significantly higher geometric mean concentration (GMC) (119 vs 14.2 IU/l, p < 0.001 and 119 vs 32.7 IU/l, p < 0.005, respectively). CONCLUSION: Delaying vaccination of premature infants against hepatitis B until a weight of 2,000 g was reached resulted in both a significantly higher percentage of children with positive antibody levels and a significantly higher GMC at 3-3.5 years of age as compared to early-vaccinated preterm and full-term infants. The known short-term advantage of delayed vaccination of preterm infants was shown to persist for at least the first 3 years of life.

Deposition of whole blood platelets on extracellular matrix under flow conditions in preterm infants.

BACKGROUND: A previous study showed greater adhesion by platelets of healthy full term infants to subendothelial extracellular matrix (ECM) under flow conditions compared with healthy adult platelets. AIM: To investigate the adhesion and aggregation of platelets from preterm infants on ECM under defined shear conditions. METHODS: In vitro platelet function was investigated in 106 preterm infants, 74 full term infants, and 26 healthy adults. Blood samples were obtained from all infants within 24 hours of birth, and weekly until discharge from preterm infants only. Citrated whole blood was placed in ECM precoated tissue culture plates and subjected to shear stress (1300 s-1) for two minutes using a rotating Teflon cone. Platelet adhesion (surface coverage) and aggregation (average size) to ECM were assayed using an image analyser. Assays for von Willebrand factor (vWF) antigen, ristocetin cofactor, and vWF collagen-binding activity were performed on samples from an additional 70 preterm infants, 23 healthy full term infants, and 24 healthy adults. Preterm infants with hyaline membrane disease (HMD) were analysed separately in both cohorts. RESULTS: Platelets from preterm infants displayed significantly less platelet adhesion than those from full term infants but similar aggregation and levels of vWF antigen, ristocetin cofactor, and collagen binding activity. Mean surface coverage was 22.0 (8.4)% for preterm infants with HMD, 28.7 (8.0)% for healthy preterm infants, and 35.7 (7.9)% for full term infants. Surface coverage in the preterm infants correlated with gestational age during the first 24 hours only, and did not reach full term levels during 10 weeks of follow up. CONCLUSION: Platelet adhesion to ECM is significantly poorer in preterm than in full term infants, and poorer in preterm infants with HMD than in healthy preterm infants. Intrinsic platelet properties rather than the concentration or activity of vWF may be responsible for this difference.

Optic pathway glioma: correlation of imaging findings with the presence of neurofibromatosis.

BACKGROUND AND PURPOSE: Despite the benign histology of optic pathway glioma (OPG) (low-grade astrocytoma), its biological behavior is unpredictable, and it is unclear whether specific morphologic or anatomic patterns may be predictive of prognosis. It is also unclear whether OPG associated with neurofibromatosis (NF) is a distinct entity from non-NF-OPG. Our purpose was to describe the MR imaging features of OPG, compare the findings between patients with and those without NF, and identify prognostic imaging signs. METHODS: MR examinations of 91 patients with OPG (47 with NF and 44 without) were reviewed at presentation and during follow-up. The images were evaluated for size and extension of tumor, and imaging parameters. Statistical bivariate analysis was used to compare the patients with and those without NF, and Pearson correlation was used to evaluate the correlation between the different imaging parameters and prognosis. Kappa values were calculated to determine intraobserver and interobserver variability. RESULTS: The most common site of involvement in the NF group was the orbital nerve (66%), followed by the chiasm (62%). In the non-NF group, the chiasm was the most common site of involvement (91%); the orbital nerves were involved in only 32%. Extension beyond the optic pathway at diagnosis was uncommon in the NF group (2%) but frequent in the non-NF group (68%). In the NF group, the tumor was smaller and the original shape of the optic pathways was preserved (91% vs. 27% in the non-NF group). The presence of cystic components was significantly more common in the non-NF patients (66% vs. 9% in the NF group). During follow-up, half the NF patients remained stable, in contrast to 5% of the non-NF group. No statistical correlation was found between imaging features and biological behavior of the tumor. CONCLUSION: NF-OPG is a separate entity from non-NF-OPG, with different imaging features and prognosis, thereby warranting a specific diagnostic, clinical, and therapeutic approach.

[Local necrosis of finger following stab with needle used to pump terbutaline sulfate (Bricalin)].

Terbutaline sulfate (Bricalin) is a widely used medication for asthma. It works mostly, but not only, on beta-adrenergic receptors. In this case study we describe a 50-year-old nurse referred to the emergency department after she was stabbed by needle that was used to draw bricalin for inhalation. She arrived at the emergency room with an inflamed necrotic area at the point of the stab. Later, she developed acute infection that was treated with antibiotics. Following the acute phase there was still a necrotic area, that required surgical debridement. It seems that this is the result of the vasoconstrictive influence of terbutaline sulfate via alpha adrenergic receptors. In the medical literature there is scarce data regarding this side effect.

Rectal prolapse: a possibly underrecognized complication of anorexia nervosa amenable to surgical correction.

OBJECTIVE: Rectal prolapse is a complication of anorexia nervosa (AN) that may be more common than previously recorded experience would suggest. METHOD: In this report we document, for the first time, the association of (AN) and rectal prolapse in a series of three patients seen in the past three years. An extensive review of the literature using Medline over the period from 1966 to Jan 2000 failed to reveal any previous example of this association. RESULTS AND CONCLUSION: The finding could have significant health care implications if confirmed. It would suggest that patients with either the psychiatric or surgical problem may not be receiving the appropriate complementary referrals: psychiatrist to surgeon and vice versa. The importance of recognition of this association in anorectic patients is the availability of effective surgical therapy.

The diagnostic aid of routine EEG findings in patients presenting with a presumed first-ever unprovoked seizure.

Data are available on the yield of a single EEG recording in patients with epilepsy but there is little information on EEG findings as an aid in supporting the diagnosis of an epileptic event in patients presenting with a first-ever event suspected of being an unprovoked seizure. We retrieved files of patients above the age of 15 years admitted through the emergency room during 1991-1995 with presumed first-ever unprovoked seizure. There were 91 patients (age 50+/-24; 52 males), of whom 66% had a presumed seizure of unknown origin and 34% had presumed remote symptomatic seizures. About 80% had generalized seizures (primarily or secondarily). In all the patients an EEG had been performed within 48 h of the event. Abnormal EEGs were obtained in 69%, with epileptiform activity in 21% (10% focal, 9% generalized and 2% focal and generalized), slowing in 58% (21% focal, 31% generalized and 7% focal and generalized), and both epileptiform activity and slowing in 10%. Epileptiform activity was most common in younger patients with seizures of unknown origin, compared with older individuals with symptomatic seizures (34, 38 vs. 27%, 7%, P=0.001). We conclude that following a single unprovoked presumed seizure, adults commonly exhibit abnormalities in an EEG recorded close in time to the event. The EEG is particularly helpful in supporting the epileptic nature of the event in younger patients and in those with seizures of unknown origin.

Effect of cefotaxime on cytokine production in newborns and adults in vitro.

The in vitro effect of cefotaxime on the production of interleukin (IL)-1beta, IL-2, IL-6 and tumor necrosis factor alpha (TNFalpha) was studied in term neonates and was compared with that of adults. The addition of cefotaxime caused a significant enhancement of IL-2 production by cells of both adults and neonates, and increased the secretion of TNFalpha by peripheral blood mononuclear cells (PBMC) of adults, whereas the synthesis of this cytokine by cord blood mononuclear cells (CBMC) of the newborns was not affected. In contrast with the described stimulatory effects of cefotaxime, this drug induced dose-dependent inhibition of the spontaneous and lipopolysaccharide (LPS)-induced IL-1beta production by cells of the two groups, but had no effect on the in vitro production of IL-6. These data suggest that cefotaxime, apart from its known antimicrobial activity, may modify the host immune response of both newborns and adults, via the alteration of cytokine production.

Constrictive pericarditis. Early experience in 12 patients in light of modern cardiology.

The last several decades have witnessed major advances in the understanding and management of constrictive pericarditis. The aim of the present study was to compare the diagnosis, treatment and outcome of constrictive pericarditis of 40 years ago to today. The study population consisted of 12 patients with a diagnosis of constrictive pericarditis who presented at the Institute of Cardiology of Beilinson Hospital, from 1961 to 1970. Their main physical findings, electrocardiographic and chest X-ray changes, and hemodynamic study results are discussed in relation to the surgical outcome of patients with constrictive pericarditis today. New noninvasive imaging modalities, such as M mode, two-dimensional and Doppler echocardiography, computed tomography and magnetic resonance imaging are presented, and their advantages and disadvantages in the diagnosis of constrictive pericarditis and its differentiation from restrictive cardiomyopathy are explained.

Maternal infectious morbidity following multiple courses of betamethasone.

OBJECTIVE: the beneficial effects of antepartum corticosteroids on the reduction of morbidity and mortality in the premature neonate have been amply demonstrated. The NIH consensus statement has, therefore, endorsed their use in women at risk from pre-term delivery between 24 and 34 weeks gestation. Patients at persistent risk of pre-term delivery nay receive multiple weekly courses. However, increased susceptibility to infection is a well-recognized complication of prolonged high-dose steroid therapy. We examined infectious morbidity among women exposed to three or more courses of betamethasone. METHODS AND OUTCOMES MEASURES: thirty-seven patients at risk of pre-term delivery who received three or more courses of betamethasone (median = 6: range 3-10) and 74 normal controls, matched for maternal age, route of delivery, and year of delivery were included in the study. Data on medical care provided to study and control patients between 24 weeks gestation and 6 weeks postpartum were retrieved from centralized medical records. Incidences and types of infections were compared by Chi-square and Fisher's exact test, as appropriate. Only infections diagnosed at least 1 week after betamethasone therapy was initiated were included. Patients with pre-existing conditions predisposing to infectious morbidity were excluded. RESULTS: twenty-four of 37 patients (64.8%) exposed to betamethasone vs. 13 of 74 (17.5%) controls developed infectious diseases (P < 0.001). Symptomatic lower urinary tract infections occurred in 13 of 37 (35.1%) and two of 74 (2.7%) in the study and control groups, respectively (P < 0.001). Serious bacterial infections were found in nine of 37 (24.3%) vs. none of 74 (0%) patients, respectively (P < 0.001). These included sepsis (n=2), pneumonia (n=4), pyelonephritis (n=2), and cholangitis (n=1). Eight of nine serious infections occurred in patients exposed to five or more weekly courses of betamethasone. Postpartum endometritis related to Caesarean delivery was found in five of 37 patients (13.5%) vs. seven of 74 (9.4%), respectively (P=NS). CONCLUSIONS: Three or more courses of antepartum betamethasone in women at risk of pre-term delivery are associated with substantial infectious maternal morbidity. The excess morbidity consisted mainly of bacterial infections, some of which were associated with systemic and potentially life-threatening infections.

The effect of betamethasone and dexamethasone on fetal heart rate patterns and biophysical activities. A prospective randomized trial.

UNLABELLED: BACKGROUND; Contradictory findings on the effect of betamethasone versus dexamethasone on antenatal tests of fetal well-being have been reported. The purpose of this study was to compare the effects of these steroid compounds on fetal heart rate patterns and biophysical activities in a prospective. randomized trial. STUDY DESIGN: Forty-six pregnant women (gestational age range 27-34 weeks) at risk for preterm delivery were randomized to receive betamethasone or dexamethasone for enhancement of fetal lung maturity. Fetal heart rate was recorded for 60 minutes and analyzed with the Sonicaid System 8000 before (0 hours), and 48 hours and 96 hours after steroid administration. Subsequently, fetal limb, body and breathing movements were sonographically observed and quantified for 30 minutes. To account for fetal circadian rhythms, all examinations were performed between 1 p.m. and 5 p.m., at least one hour after maternal meals. RESULTS: Fetal heart rate accelerations (p<0.001; p<0.01), short-term variation (p<0.0001; p<0.05), long-term variation (p<0.01; p=NS), duration of high episodes (p<0.001; p<0.05), total movement count (p<0.001; p<0.05), and duration of breathing time (p<0.0001; p<0.0001) were substantially reduced 48 h after betamethasone and dexamethasone administration, respectively, with percent reduction being larger for the betamethasone group, except for breathing movements (p<0.05; p<0.001; p<0.001; p<0.005; p<0.05; p=NS; respectively). In 68.2%( and 45.5% of fetuses, less than 30 seconds of continuous breathing movements were found in the betamethasone and dexamethasone groups, respectively. In 71.8% and 12.5%, of fetuses, respectively, less than 2 body/limb movements were observed. Therefore five and two fetuses in the betamethasone and dexamethasone study group, respectively, had both nonreactive fetal heart rate monitors for 60 minutes and biophysical profiles of < or =4/10. All parameters returned to baseline values at 96 h. Baseline fetal heart rate and numbers of decelerations remained unchanged (p=NS). CONCLUSIONS: Both betamethasone and dexamethasone induce a profound, albeit transient, suppression of fetal heart rate characteristics and biophysical activities in the preterm fetus. However, the effect of betamethasone is more pronounced. Awareness of these phenomena might prevent unwarranted iatrogenic delivery of preterm fetuses.

Phase II study of carboplatin and etoposide as salvage treatment for patients with metastatic breast cancer.

A phase II study of carboplatin and etoposide as salvage polychemotherapy in metastatic, infiltrating breast carcinoma was carried out with 25 multiply pretreated patients. Six of 25 patients (24%) had a partial response that lasted an average of 3.5 months; of the six responders, four had undergone either four or five previous chemotherapeutic treatments. Eight of 25 patients (32%) had stable disease, and 11 (44%) manifested disease progression. The median survival from time of entry to the salvage protocol was 8 months. There were treatment responses in lung, chest wall, liver, and skeleton. The most common side effects were leukopenia (68% of 25 patients), thrombocytopenia (56%), anemia (40%), fever (28%), and weakness (16%). Carboplatin combined with etoposide may be an effective and tolerable salvage regimen in advanced breast cancer.

Midtrimester maternal serum screening after multifetal pregnancy reduction in pregnancies conceived by in vitro fertilization.

PURPOSE: Data about the effect of multifetal pregnancy reduction on midtrimester maternal serum levels of alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and unconjugated estriol (uE3) are scarce and contradictory. Differing gestational ages at fetal reduction, transvaginal versus transabdominal needle insertion, and injection of different feticidal agents compound the analysis of published data. METHODS: We examined clinical and laboratory data about 27 high-order gestations that were reduced to twins in the first trimester. Fetal reductions were performed transabdominally at 11.41 +/- 1.15 weeks' gestation by fetal intrathoracic injection of KCl, and maternal blood sampling was performed at 16.48 +/- 1.05 weeks. "Pseudo-risks" for singleton pregnancies were calculated by correcting serum analyte levels for twins. RESULTS: Twenty-four (88.9%) of 27 patients had maternal serum AFP levels above 2.0 MoM (mean, 4.60 +/- 3.48 MoM; range, 1.49-14.85 MoM), however, none of the newborns had structural anomalies. AFP serum levels did not correlate with the number of reduced fetuses or with adverse obstetric outcome. The mean hCG levels were 1.22 +/- 0.49 MoM (range, 0.14-2.47), and the mean uE3 levels were 1.15 +/- 0.31 MoM (range, 0.56-1.84). Based on maternal age alone, seven patients (25.9%) would have been offered amniocentesis for a term Down syndrome risk greater than 1:384, whereas combined risk calculations with hCG and uE3 levels resulted in 1 (3.7%) screen-positive case (P < 0.01).

Strontium-89 (89Sr) analgesia for rare thymic carcinoid tumor with bony metastases.

The authors report the cases of two patients in whom strontium-89 (89Sr) was used to relieve diffuse metastatic bone pain. The type of cancer involved, thymic carcinoid tumor, is itself rare and the risk of its metastasizing to the bone is very low. Both patients showed a measure of response to treatment, suggesting that this analgesic method has value for some patients. The marked benefit of one patient for a total of 9 months was attributable to two 89Sr injections, whereas the other patient improved for only 5 weeks after one injection.