Dismal prognosis of Pneumocystis jirovecii pneumonia in patients with multiple myeloma.

Patients with multiple myeloma (MM) are at high risk for infections, including opportunistic infections such as Pneumocystis jirovecii pneumonia (PJP). We conducted a retrospective analysis of patients with MM developing PJP over a 6-year period between January 2016 and December 2021 at the University Hospital of Würzburg by screening cases of microbiologically documented PJP. A total of 201 positive results for P. jirovecii in respiratory specimens were retrospectively retrieved through our microbiology database. Of these cases, 13 patients with MM fulfilled the definition of probable PJP according to EORTC fungal disease definitions. We observed two peaks in PJP incidence, one after stem cell transplantation during first-line treatment (n = 5) and the other in heavily pretreated patients with six or more prior lines of therapy (n = 6). There was high morbidity with nine (69%) patients admitted to the ICU, seven of whom (78%) required mechanical ventilation, and high mortality (62%, n = 8). Notably, only two of the 13 patients (15%) had received PJP prophylaxis. The main reason for discontinuation of prophylaxis with trimethoprim-sulfamethoxazole was grade IV neutropenia. The observed morbidity and mortality of PJP in MM patients are significant and even higher than reported for patients with other hematologic malignancies. According to most current guidelines, the use of prophylaxis would have been clearly recommended in no more than three (23%) of the 13 patients. This illustrates the need to critically reconsider the indications for PJP prophylaxis, which remain incompletely defined.

Magnetic resonance imaging of osteoarthritis.

Considering the plethora of imaging protocols, joint-specific orientations, and potential artifacts, the design and interpretation of MR imaging examination is difficult. Like a physical examination, these considerations must be tailored to the specific tissue, joint, and clinical question under consideration. Shortcomings of MR imaging include the lack of consensus among radiologists with respect to which protocols best image articular joints. To date, few prospective studies have been undertaken to assess osteoarthritis by MR imaging. Diagnostic imaging is central to staging the severity of osteoarthritis and assessing the efficacy of therapeutic osteoarthritis. Plain film radiography is insensitive for identifying early changes of osteoarthritis. Tailored MR imaging, producing high spatial and or contrast resolution images, is proving to be an important tool in the early detection and surveillance of osteoarthritis progression. Future therapeutic techniques, such as chondrocyte transplantation, use of growth factors, or cartilage protease inhibitors requires high resolution and volumetric MR imaging studies for accurate identification of focal articular cartilage defects and generalized cartilage loss. Creation of cartilage models by three-dimensional MR image rendering may be helpful for preoperative planning of orthopedic surgical procedures in advanced cases of osteoarthritis. More work needs to be done in high resolution and volumetric MR imaging of articular cartilage. Given the availability of new disease-modifying treatments designed to prevent, delay the progression of, or reverse osteoarthritis, additional prospective MR imaging studies need to be undertaken to improve the reproducibility of MR imaging as a primary outcome measure in the evaluation of osteoarthritis. Interinstitutional standardization of specific MR imaging magnet strengths, surface coils, joint orientations, sequences used, scoring systems and quality assurance methodologies are needed to establish the reproducibility of MR imaging and interpretation for assessment of patients with osteoarthritis.

[Percutaneous removal of a brachiocephalic vein anchored venous catheter with wire loop and mini-laparoscopy scissors]. / Perkutane Entfernung eines in der Vena brachiocephalica festgenähten Venenkatheters mittels Drahtschlinge und Mini-Laparoskopieschere.

PURPOSE: The use of mini-laparoscopy scissors to remove a central venous catheter inadvertently fixed to the wall of the brachiocephalic vein is described. PATIENT AND METHODS: During a rethoracotomy in a 15-year-old female patient, a central venous catheter preoperatively introduced in the left subclavian vein was inadvertently trapped by a suture and fixed to the wall of the left brachiocephalic vein. The foreign body was removed by use of a transjugularly introduced venous sheath, a catheter wire snare, and mini-laparoscopy scissors. RESULTS: The fixed catheter was freed from the wall of the vein under fluoroscopic control with the help of a mini-laparoscopy scissors. Since the intravasal end of the catheter had already been grasped during mobilization with the wire snare it could be completely removed subsequently without any problem. CONCLUSIONS: The percutaneous, intravascular use of mini-laparoscopy instruments may be considered for foreign body removal in special cases.

Congenital cystic adenomatoid malformation of the lung and fetal hydrops--a case with favourable outcome.

We present a case of congenital cystic adenomatoid malformation of the lung (CCAM) diagnosed at 23 weeks of gestation with concomitant fetal hydrops. The sonographical picture of CCAM disappeared in the third trimester of pregnancy and fetal hydrops resolved under medication with digitalis to the mother. The neonate showed mild dyspnea; the prenatal diagnosis of CCAM was confirmed by chest X-ray and computed tomography. The affected lung segments were dissected at 5 days of age. The diagnosis of CCAM type III was confirmed histologically.

Thoracoscopy in children.

Pediatric surgical experience with video-assisted thoracoscopy is limited. The authors report their experience with 27 thoracoscopies in 22 children. The median age was 6.1 years (range, 1 day to 16 years). The two primary indications for thoracoscopy were management of pneumothorax and mediastinal cysts. Fifteen thoracoscopies accomplished their purpose without complications. Intraoperative complications required conversion to an open operation in three patients. One bronchogenic cyst and four pneumothoraces recurred. The main complications were poor visualization, bleeding from an intercostal artery, and difficulty with suturing. Compared with open thoracotomy, anesthesia time did not differ significantly, and less pain medication was required postoperatively.

Microlymphography of spontaneous lymph vessel anastomosis in small bowel transplantation in the rat.

Following small bowel transplantation, new lymph vessel anastomoses form spontaneously. Surgical anastomoses of the lymphatic vessels are unnecessary. The formation occurs in three stages. To the second postoperative day, lymph stays within the lymphatic vessels of the transplant. Following the fourth postoperative day, lymph flows within preexistent adventitial lymphatic vessels along the transplanted mesenteric artery to the arterial anastomosis at the aorta and stops there. From the sixth postoperative day on, lymph crosses the arterial anastomosis for the first time and flows along the recipient's aorta. To the eighth postoperative day a new lymph anastomosis is formed between the adventitia of the aorta and the neighbouring major lymphatic vessels. In the experiments presented here, these are represented by the vasa lymphatica testicularia sinistra of the recipient. Thus, the new anastomosis between lymphatic vessels is complete on the eight postoperative day. These new vessels gradually dilate with time.

Endoscopic laser resection of a duodenal membrane.

This report documents the first resection of a duodenal membrane by laser. Subsequently, however, a laparotomy was required because of an annular pancreas. Nevertheless, it demonstrates that the laser endoscopical resection of a duodenal membrane is technically feasible.

Multisystem organ failure and capillary leak syndrome in severe necrotizing enterocolitis of very low birth weight infants.

BACKGROUND: Classification systems for necrotizing enterocolitis (NEC) in preterm infants have been developed to define severity grades relevant for treatment and prognosis. Multisystem organ failure (MSOF) and capillary leak syndrome (CLS) also have prognostic value in these patients. The aim of this retrospective study was to investigate the incidence and predictive value of MSOF and CLS according to the classification criteria. METHODS: The records of 1,022 very low birth weight infants admitted from 1982 to 1996 were reviewed for diagnosis of NEC stage IIA or higher (classification of Walsh and Kliegman). Among those patients (n = 50) the incidence of MSOF and CLS was determined, separately for surgical or conservative treatment. RESULTS: Twelve patients were assigned to stage II, 22 to stage IIIa, and 16 to stage IIIb; 31 infants underwent operation. Mortality rate was not influenced by the grade. In eight patients only gastrointestinal symptoms were found, whereas in 23 patients, up to three organ systems and in 19 patients, four or more organ systems were affected. Mortality depended on the number of involved organ systems. CLS occurred postoperatively in 10 of the 31 infants; eight of them died. CONCLUSION: The prognostic values of MSOF and CLS are higher than that of classification criteria in NEC of VLBW infants.

Pulmonary embolism and myocardial hypoxia during extracorporeal membrane oxygenation.

The treatment of a newborn with severe meconium aspiration by venoarterial extracorporeal membrane oxygenation (ECMO) was complicated by myocardial hypoxia with a marked decrease of myocardial contractility. The onset of the cardiac hypoxia was related to a pulmonary artery embolus. The origin of the embolus was a deep femoral vein thrombosis, caused by a central vein catheter, which was inserted 1 day before ECMO by venous cutdown. The possible pathophysiology of myocardial hypoxia in this patient is discussed, especially with regard to myocardial perfusion, supporting the hypothesis of coronary perfusion occuring with blood from the left ventricle and not from the arterial cannula in the aorta.

The influence of lung injury due to mechanical ventilation on the initiation of ECMO.

Before the entry criteria for extracorporeal membrane oxygenation (ECMO) are met, newborns may require aggressive mechanical ventilation which may result in lung injury. The question arises whether the presence of a pneumothorax in these infants plays a role in the prognosis. Of the 21 newborns transferred to our hospital for ECMO, 8 were treated with ECMO. 9 of the 21 newborns developed a pneumothorax with conventional ventilation and 6 of these 9 newborns subsequently required ECMO. Infants who developed a pneumothorax but did not meet ECMO criteria and remained in the oxygenation index (OI) range between 25 and 40 for more than 2 days had a poorer prognosis. If adequate oxygenation cannot be attained with acceptable mechanical ventilation and a more aggressive ventilation results in a pneumothorax, ECMO should be considered even if the oxygenation index is below 40.

Surgical correction of abdominal testes after Fowler-Stephens using the neodymium: YAG laser for preliminary vessel dissection.

Two boys with high undescended testes were submitted to laparoscopic laser transsection of the internal spermatic vessels. Subsequently strong collaterals developed. Definitive scrotal transfer was performed six weeks later through an inguinal incision. Two and a half years later, the testes had recovered very well. Their volume had increased markedly, and further development was normal.

Laparoscopic fundoplication in a child.

A case of laparoscopic fundoplication is described in a child weighing 25 kg. The patient had severe skeletal deformities. Five trocars were used. The view was excellent. A complete posterior wrap was achieved without transsecting the short gastric vessels. Operating time and expenses were greater than with the conventional technique. No complications occurred. The cosmetic result was good.

Laparoscopic surgery in neonates and infants.

Between 1978 and 1991 a total of 136 operations with the laparoscope have been performed. 79 additional laparoscopies were carried out for diagnostic purposes. The most frequent indications for operative laparoscopy were: adhesions, abdominal cysts, tumors, gonadectomy, appendectomy and cholecystectomy. Diagnostic laparoscopies were performed for the differential diagnosis of cholestasis, chronic abdominal pain, intersex and cryptorchidism. The only complication was a scar hernia in a 1,400 gram preterm baby. We recommend laparoscopy because of its smaller trauma and the reduced postoperative complication rate. Furthermore, an advantage is the magnification by the lupes and video, the excellent illumination and exposure.

Laparoscopic Swenson's procedure in children.

The technique is described, and the experience gained with 7 laparoscopic sigmoid resections is reported. The approach resembles Swenson's technique with only the preparatory part performed laparoscopically. With the most recent procedures, the anaesthesia time of the laparoscopic procedure did not exceed that of the open technique. There were no serious complications or blood losses.

Laparoscopic removal of Meckel's diverticula in children.

We report on 4 children where Meckel's diverticula (MD) were excised laparoscopically. In two of the children the finding of an MD was incidental and in two it was suspected preoperatively. In three of the patients the MD was ligated by means of an "endoloop" and could be removed in a similar manner to an appendix. In one patient the MD was resected by means of a stapler. No complications occurred. Subsequent histology confirmed the complete excision of the MD. Allowing for the size and shape of an MD, we prefer to excise it by means of an endoloop. An endoloop has the advantage that it can be used through a 5 mm trocar while a stapler has the disadvantage that it requires a larger 12 mm trocar and it leaves a foreign body, i.e. metal clips behind.

Dura covered with fibrin glue reduces adhesions in abdominal wall defects.

Dura can greatly facilitate the closure of abdominal wall defects. However, a main disadvantage of its use are the adhesions which develop between omentum, bowel and dura and may lead to bowel obstructions. In this study various groups of rats had either the anterior wall replaced by untreated dura or by dura covered with fibrin glue prior to implantation. Adhesions were found in 75% of sham operated rats, 100% after untreated dura implantation and 50% after the implantation of fibrin glue treated dura.

The use of the laser in the treatment of arterio-venous malformations and vascular tumours of the liver.

Vascular tumours of the liver present variously in the paediatric age group. Their clinical course depends on tumour size, its growth characteristics, localization and complications. The most feared complications are cardiac failure and the Kasabach-Merritt syndrome which may occur in up to 50% of affected children. In haemangioendotheliomata and capillary haemangiomata spontaneous regression can be expected. Regression may be stimulated by x-ray radiation therapy, corticosteroids, Endoxane or alpha Interferon. Emergency percutaneous catheter embolization or operation must be carried out in the event of such complications. The Nd:YAG laser is particularly well suited for these cases. In all events, careful interdisciplinary cooperation among paediatricians, radiologists, cardiologists, oncologists and paediatric surgeons is required owing to threatening complications which mostly occur in neonates and infants.

Carcinoid tumors of the appendix in children--epidemiology, clinical aspects and procedure.

INTRODUCTION: Incidental detection of a carcinoid tumor of the appendix after appendectomy is often accompanied by uncertainty about the further procedure. The tumor frequency in our own patient population, the further course in these children and a practicable follow-up protocol have to be determined. PATIENTS AND METHODS: All appendectomies performed between January 1, 1982, and December 31, 1996, were retrospectively evaluated with regard to carcinoids, monitoring the clinical course, and follow-up of the patients involved. RESULTS: A total of 4747 appendectomies were performed, 8 children had a histologically manifest carcinoid (0.169%). All patients were symptom-free in the further course, no metastases or signs of a carcinoid were documented during a mean follow-up period of 6.6 years. CONCLUSION: The youngest patient with a metastasizing carcinoid tumor of the appendix reported in the literature was 19 years old. Nevertheless, all younger patients should undergo regular follow-ups; this is done in our department by serum serotonin and chromogranin A determination.

Spheric duodenal duplication in a 13-year-old child.

Duodenal duplications are rare. Modern imaging procedures demonstrate the relation of the duplication to the duodenum and the adjacent organs. Thus the surgical procedure can be selected preoperatively. Endoscopic ultrasound is an excellent technique for visualizing a duodenal duplication. A cystic duodenal duplication measuring 6 cm in diameter was resected in a 13-year-old boy.

Biliary atresia--bile acids and prostaglandin E2 in cell cultures of bile duct epithelia.

In a cell culture model of bile duct epithelial cells, the effect of prostaglandin E2, lithocholic acid and deoxycholic acid was studied. Bile acids and prostaglandin are administered postoperatively in biliary atresia empirically as choleretics. Prostaglandin E2 and the bile acids all had inhibitory effects on bile duct epithelial cells in culture. There is no clinical study proving the efficacy of either bile acids or prostaglandin E2 in biliary atresia. The negative results with these substances in cell cultures warrants reserve in their routine clinical use in biliary atresia.