A systematic review of the Trier Social Stress Test methodology: Issues in promoting study comparison and replicable research.

Since its development in 1993, the Trier Social Stress Test (TSST) has been used widely as a psychosocial stress paradigm to activate the sympathetic nervous system and hypothalamic-pituitary-adrenal axis (HPAA) stress systems, stimulating physiological functions (e.g. heart rate) and cortisol secretion. Several methodological variations introduced over the years have led the scientific community to question replication between studies. In this systematic review, we used the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) to synthesize procedure-related data available about the TSST protocol to highlight commonalities and differences across studies. We noted significant discrepancies across studies in how researchers applied the TSST protocol. In particular, we highlight variations in testing procedures (e.g., number of judges, initial number in the arithmetic task, time of the collected saliva samples for cortisol) and discuss possible misinterpretation in comparing findings from studies failing to control for variables or using a modified version from the original protocol. Further, we recommend that researchers use a standardized background questionnaire when using the TSST to identify factors that may influence physiological measurements in tandem with a summary of this review as a protocol guide. More systematic implementation and detailed reporting of TSST methodology will promote study replication, optimize comparison of findings, and foster an informed understanding of factors affecting responses to social stressors in healthy people and those with pathological conditions.

Fetus in fetu or not?

A case of sacrococcygeal teratoma is presented with characteristics of fetus in fetu. The clinical implications of teratomatous tissue in an inguinal node are presented.

Cat-scratch disease: an unusual presentation.

A 2-year-old child was found to have mesenteric lymphoadenopathy during investigation of a fever of unknown origin. The lymphadenopathy persisted at follow-up 2 months later. Workup for an infectious etiology was negative. A laparotomy and excisional biopsy was performed to eliminate lymphoma. Pathology showed enlarged lymph nodes containing granulomas with giant cells and central caseating necrosis. Warthin-Starry staining showed cat-scratch bacilli within the necrotic material. Cat-scratch disease is a well-recognized cause of regional adenopathy in children and usually resolves without treatment. Intraabdominal involvement, consisting of hepatic and splenic lesions, often associated with retroperitoneal adenopathy, has been reported. Isolated mesenteric adenopathy is an unusual presentation of this disease but should be included in the differential diagnosis of intraabdominal lymphadenopathy.

Total anomalous pulmonary venous return complicating portoenterostomy for biliary atresia.

Cardiovascular anomalies such as absent inferior vena cava and preduodenal portal vein are reported in cases of biliary atresia and make hepatic portoenterostomy a technical challenge. The authors present the case of a severe cardiac anomaly that significantly altered the functional outcome of a Kasai procedure. Baby M., an 8-week-old boy born with total anomalous pulmonary venous return (TAPVR), underwent hepatic portoenterostomy for biliary atresia. Over the next 3 months he remained icteric and febrile, and failed to gain weight. After multiple antibiotic treatments for suspected cholangitis, he underwent reexploration of the portoenterostomy, with no improvement in his overall condition. His prognosis was considered dismal because correction of the cardiac anomaly is associated with a high mortality rate (> 90%). The cardiac surgeon agreed to attempt a cure of the TAPVR, provided liver transplantation is contemplated if the patient survived. Within 48 hours postoperatively, his hepatic function had improved drastically. He became afebrile, had an improved appetite and weight gain, and was finally discharged 203 days after admission. One year later, he is thriving and remains anicteric. The exact reason for this drastic improvement is not well understood, but the right-sided cardiac failure caused by the TAPVR had a significant effect on the functional outcome of the portoenterostomy.

Partial splenectomy for benign cystic lesions of the spleen.

Cystic lesions of the spleen are uncommon, about 600 cases being reported in the world literature. This report concerns three pediatric patients treated by partial splenectomy for benign cyst. In the world literature most of the cystic lesions of the spleen are treated by splenectomy and more recently by partial splenectomy. The infected lesions are treated by splenectomy or by incision and drainage only. Partial splenectomy has evident advantage over splenectomy. Although in the world literature we have not found a single case of infected splenic benign cyst treated by partial splenectomy, we believe that this procedure also has an advantage over drainage as the infected and necrotic part of the cyst is removed, thereby reducing morbidity and further possible complications.

Blunt pancreatic injuries in children: the role of percutaneous external drainage in the treatment of pancreatic pseudocysts.

During the past 10 years, 26 cases of blunt pancreatic trauma were diagnosed in our institution. In 42.3% (11/26) the accident was bicycle-related. Seventy-three percent of patients were seen within 48 hours of injury. The most frequent clinical presentations included abdominal pain, tenderness and vomiting. Diagnosis of pancreatic injury was suggested by hypermylasemia in most cases. Associated trauma was seen in seven patients (26.9%) and it was intraabdominal in four (15.3%). Computerized tomography (CT) scan is the single most useful radiologic investigation in evaluating pancreatic trauma. Ultrasound, although less accurate than CT scan in determining the severity of the initial injury, is useful in the evaluation and treatment of pancreatic pseudocysts. Pancreatic pseudocysts developed in ten patients. Spontaneous resolution occurred in five (50%). In three patients, percutaneous external drainage (PED) was successful in treating pancreatic pseudocysts without complications or recurrence at 11, 19, and 31 months. PED is a suitable form of treatment in selected cases of pancreatic pseudocysts. Results in children are better than in the adult population, probably due to the absence of primary pancreatic pathology. We believe that PED should be considered the primary therapeutic procedure for traumatic pancreatic collections prior to more invasive surgical treatment, when there is no evidence of pancreatic duct transection on CT scan.

Intestinal vascular anomalies in children.

Vascular anomalies are an uncommon cause of gastrointestinal bleeding in childhood. Confusing nomenclature has made objective comparisons of published cases difficult and has interfered with an established consensus regarding diagnosis and therapeutic modalities. The purpose of this study was to clarify the situation by reviewing the records of all children who had intestinal vascular anomalies who were referred to our institution from 1975 to 1995. Thirteen lesions were identified in nine children (five boys and four girls). The median age at clinical onset was 8 years. Only two patients presented with a complex syndrome (Klippel-Trenaunay, 1; Osler-Rendu-Weber, 1). Diagnosis, location, and extension of these anomalies was only possible by angiography, which indicated that seven patients had isolated venous malformations and two had arteriovenous malformations. Because the lesions did not involve the serosa, intraoperative localization was a major problem. The main findings were a few slightly dilated mesenteric veins. Treatment was conservative in four children and surgical in five. Pathological findings on resected bowel demonstrated dilated and abnormal veins in the mucosa and submucosa. Selective angiography should not be delayed in patients with gastrointestinal bleeding if results of all other investigations are negative. Because these lesions are rarely recognizable on operative inspection, precise preoperative angiographic localization of intestinal vascular anomalies is essential to allow for a safe and limited resection of the involved bowel segment. Based on a better understanding of the natural history of these lesions, a classification of vascular anomalies of intestines in children is proposed.

Evaluation of the Effect of Seed Treatments, Bactericides, and Cultivars on Bacterial Leaf Spot of Lettuce Caused by Xanthomonas campestris pv. vitians.

As a part of a broader program for management of bacterial leaf spot, the effects of lettuce-seed treatments, greenhouse application of bactericides, and cultivars were evaluated. Seed artificially inoculated with Xanthomonas campestris pv. vitians was treated with bactericides or heat treated and evaluated for the incidence of contaminated seed and seed germination. Seed soaked in 1% sodium hypochlorite for 5 and 20 min had an incidence of contaminated seed of less than 10%. Dry-heat (1 h), hot-water (50°C, 2 h), and organic-acid treatments significantly reduced seed germination. Considering both the effects on incidence of contaminated seed and seed germination, the best treatments were soaking the seeds in 1% sodium hypochlorite for 5 or 20 min. Copper sulfate, alone or mixed with Zineb or Dithane, failed to control the disease and caused phytotoxicity. All of the other bactericides significantly reduced the severity of bacterial leaf spot. However, the differences among bactericide efficacy were too small to allow comparison between the different forms of copper used, as well as the effect of adding manganese and zinc (Dithane) or zinc alone (Zineb) to the copper product. Nevertheless, copper hydroxide alone, mixed with Zineb or mixed with Dithane, and basic copper sulfate reduced disease severity by 86.89, 78.67, 80.42, and 81.82%, respectively, without causing phytotoxicity. For the two years of cultivar evaluation, no significant difference in mean disease severity was observed among the cultivars. Based on disease incidence, the most susceptible cultivar was Bellagreen. Cvs. Ideal cos, Grand Teton, Great Lakes, Paris Island, Ithaca, and Optima showed intermediate susceptibility, and the least-susceptible cultivars were Waldmann's and Grand Rapids, both green-leaf type. There was no significant difference between the three romaine (cos) cultivars and between the two crisphead cultivars, but a significant difference was observed between the two butterhead types, Bellagreen and Optima, which had 80.04 and 48.01%, respectively, of their leaves diseased at the time of harvest.

[An isolated intestinal form of infantile myofibromatosis]. / La forme intestinale isolée des myofibromatoses infantiles.

Infantile myofibromatosis is the most common form of fibromatosis in children. It can be solitary, mainly affecting the bone or soft tissues, or multicentric with the possibility of visceral involvement. Solitary forms of visceral localization are exceedingly rare. The authors report the observation of a newborn female infant, with solitary jejunal infantile myofibromatosis which after reviewing relevant litterature on the subject appears to be the sixth case of its kind. This form must be considered in the differential diagnosis of the neonatal intestinal obstruction.

Acute appendicitis in children: evaluation with US.

During a 4-month period, high-resolution ultrasonography (US) was used to prospectively evaluate 70 children with clinically suspected acute appendicitis. Thirty-five US scans showed a noncompressible appendix with maximal outer diameters greater than 6 mm. This finding was considered positive for the diagnosis of acute appendicitis. Thirty-one of these 35 patients had acute appendicitis documented by surgical and pathologic findings. The remaining four patients were observed, and their symptoms resolved. Thirty-five patients had US scans considered negative for appendicitis. Seventeen of these patients had US findings positive for other conditions including mesenteric adenitis, ileitis, intussusception, Crohn disease, and Burkitt lymphoma. In this series US enabled diagnosis of acute appendicitis with a sensitivity of 94%, a specificity of 89%, and a predictive accuracy of 91%. Diagnosis of acute appendicitis can be made with US with the same accuracy in children as has been previously reported in series of adult patients. The use of US in clinically ambiguous cases may allow earlier diagnosis, prevention of perforation, and decreased complications in the pediatric patient with acute appendicitis.

[End to side porto-caval shunt in familial type II homozygote hypercholesterolemia (author's transl)]. / L'anastomose porto-cave termino-latérale dans l'hypercholestérolémie familiae de type II homozygote.

Two patients with homozygous type II familial hypercholemia have had significant improvement by end to side porta-caval shunt. Follow-up is respectively 1 and 4 years. When all the other treatment have failed in lowering blood cholesterol and L.D.L. levels, a portal diversion may help to prevent cardio-vascular atherosclerotic complications in the pediatric age.

Diaphragmatic injury in children.

Injury to the diaphragm is rare in children. From 1972 to 1990, 13 children were treated for diaphragmatic injury at Ste-Justine and Montreal Children's hospitals. There were seven boys and six girls, ranging in age from 1 to 15 years (average, 7.5 years). Eight patients sustained penetrating trauma and five patients sustained blunt trauma. Nine patients had associated injuries, most commonly involving the liver. All thirteen patients underwent exploratory laparotomy with repair of the diaphragm. There were two deaths, both unrelated to the diaphragmatic trauma. All surviving patients recovered without sequelae. One patient underwent cosmetic repair of a chest wall deformity 9 years after injury. Diaphragmatic injury must be considered in any child suffering blunt or penetrating thoracoabdominal trauma. Because of the increased compliance of the thoracic cage in children, rupture of the diaphragm can occur without signs of external injury. Morbidity and mortality can be minimized by a high index of suspicion, prompt recognition, and surgical repair of even the smallest diaphragmatic injury.

Appendicitis in children and young adults: Doppler sonographic-pathologic correlation.

OBJECTIVE: The purpose of this study was to determine the following: whether the arterial supply of a normal appendix is visible with Doppler sonography; whether the physiologic vasodilatation that accompanies childhood appendicitis is visible; what Doppler patterns appear once necrosis of the appendix has occurred; what Doppler shifts are visible with chronic, recurrent appendicitis; and whether other conditions in the right lower quadrant can mimic the Doppler sonographic patterns of appendicitis. MATERIALS AND METHODS: Twenty-five fasting patients without abdominal pain or intestinal disease and 45 patients (1-25 years old; mean, 8 years old) with right lower quadrant pain and suspected appendicitis were examined sonographically, using 5- and 7-MHz linear, color, and pulsed Doppler transducers. Arterial signals were sought within the appendix and neighboring tissues, counted, and classified as sparse (1-2), moderate (3-4), or abundant (>4). The resistive index (RI) was measured. Thirty patients who underwent surgery were retained for surgical and pathologic correlation, and only they formed the appendicitis study. RESULTS: A normal appendix was found in 10 patients. Doppler shifts were sparse, and diastolic flow was low or absent (RI, 0.85-1). Acute uncomplicated appendicitis was found in 13 patients, who had abundant color Doppler signals throughout most of the appendix, with high diastolic flow (RI, 0.40-0.77; mean, 0.54). Acute necrotic appendicitis with perforation was found in 11 children, eight of whom showed no signals in the necrotic area at the tip. Few or no signals were seen in the remainder of the appendix (RI, 0.33-0.90; mean, 0.54). In two patients, signals were abundant in the tissues surrounding the appendix. Recurrent or chronic appendicitis was found in three patients, previously diagnosed as having Crohn's disease, psychosomatic illness, or nonspecific abdominal pain. The appendix had Doppler signals confined to the tip (RI, 0.63-0.83; mean, 0.75). Other diagnoses were found in three patients, in whom the appendix was not seen. There were abundant color signals in the intestinal wall and adjacent tissues in the right lower quadrant. Two patients had Crohn's disease, and the third had an unsuspected early pregnancy. The appendix was normal in all. CONCLUSION: Acute appendicitis is accompanied by inflammatory hypervascularity reflected as an increased number of color signals and higher diastolic Doppler shifts as compared with those found in normal persons. No Doppler shifts are identified in areas of appendiceal ischemia. Other acute inflammation in the right lower quadrant also produces numerous Doppler shifts with high diastolic flow, as does ovulation. Care must be taken to identify the source of these Doppler signals. The changing vascularity of healing, recurrent, and chronic appendicitis promises to further our understanding of the pathogenesis and evolution of this disease.

Blunt abdominal trauma in children: the practical value of ultrasonography.

The occult nature of blunt abdominal trauma justifies the need for reliable diagnostic adjuncts to physical examination. From June 1988 to June 1991, 259 children admitted to the general surgery/trauma service underwent abdominal ultrasonographic scanning (US). A total of 116 abdominal lesions were found in 81 patients. Ultrasonography alone had a sensitivity of 89%, a specificity of 96%, and an overall accuracy of 94%, as determined against the overall diagnostic workup and clinical course (mean follow-up, 17.4 weeks). In 44% of the patients, US was used alone; in 49% one or two additional tests were performed, and in only 7% were three or more tests required. Compared with computed tomography, US is more versatile, easier to perform in children, and more cost effective, even with the addition of a functional imaging modality. Although not demonstrated by this preliminary, retrospective study, Doppler US appears to be the logical complement to abdominal ultrasonography in the evaluation of children with blunt abdominal trauma.