Operationalizing a fisheries social-ecological system through a Bayesian belief network reveals hotspots for its adaptive capacity in the southern North sea

Fisheries social-ecological systems (SES) in the North Sea region confront multifaceted challenges stemming from environmental changes, offshore wind farm expansion, and marine protected area establishment. In this paper, we demonstrate the utility of a Bayesian Belief Network (BN) approach in comprehensively capturing and assessing the intricate spatial dynamics within the German plaice-related fisheries SES. The BN integrates ecological, economic, and socio-cultural factors to generate high-resolution maps of profitability and adaptive capacity potential (ACP) as prospective management targets. Our analysis of future scenarios, delineating changes in spatial constraints, economics, and socio-cultural aspects, identifies factors that will exert significant influence on this fisheries SES in the near future. These include the loss of fishing grounds due to the installation of offshore wind farms and marine protected areas, as well as reduced plaice landings due to climate change. The identified ACP hotspots hold the potential to guide the development of localized management strategies and sustainable planning efforts by highlighting the consequences of management decisions. Our findings emphasize the need to consider detailed spatial dynamics of fisheries SES within marine spatial planning (MSP) and illustrate how this information may assist decision-makers and practitioners in area prioritization. We, therefore, propose adopting the concept of fisheries SES within broader integrated management approaches to foster sustainable development of inherently dynamic SES in a rapidly evolving marine environment.

Pathophysiologie des Myokardinfarktes

Der Myokardinfarkt wird durch den thrombotischen Verschluß einer Koronararterie erzeugt, wobei sich der verschließende Thrombus auf (oder aus) dem »Beet« eines früheren, nichtverschließenden muralen Thrombus entwickelt hat. Das histologische Substrat der verschließenden Koronarthrombose unterscheidet sich wesentlich von dem der Fütterungsatheromatose, die sich durch den diffusen Befall (im Gegensatz zum fokalen bei der menschlichen Athero-sklerose) auszeichnet und durch die große Regenerationsfähigkeit der Arterienwand.

Das von dem Koronarverschluß betroffene Myokard kann eine unterschiedliche Ischämietoleranz haben, wofür die Existenz (oder Aktivierung) von trophischen Substanzen verantwortlich sein kann.

Paraneoplastic limbic encephalitis with SOX1 and PCA2 antibodies and relapsing neurological symptoms in an adolescent with Hodgkin lymphoma

BACKGROUND

Immune cross-reactivity between malignant and normal tissues causes the rare, so called paraneoplastic syndrome (PS). In approximately 60% of the patients, various onconeural antibodies are detectable in the cerebrospinal fluid (CSF) and are associated with typical tumour entities.

METHODS

We report an unusual case of paraneoplastic limbic encephalitis (PLE) in a 17-year-old adolescent with classical Hodgkin lymphoma.

RESULTS

He presented with a variety of neurologic and neuropsychiatric symptoms, profound B-symptoms and typical MRI findings including hyperintense lesions with contrast enhancement in the medial temporal lobe and limbic system. Under immunosuppressive therapy and subsequently chemotherapy the neurological situation only temporarily improved and worsened again after interruption of immunosuppression several times. Thus, multiple courses of multidrug immunosuppressive therapy were administered. To date, five years after initial presentation, the young man is able to walk with walking aids and orthoses and is still on oral prednisolone therapy. Analyses of the CSF and serum revealed anti SOX-1 antibodies at initial presentation but PCA-2 antibodies seven months after diagnosis.

CONCLUSION

Neurologic and/or neuropsychiatric symptoms combined with typical MRI findings should raise the suspicion of PS and lead to further diagnostics for an underlying tumour even in children.

Structural white matter changes in adolescents and young adults with maple syrup urine disease

OBJECTIVE

To get insight into the nature of magnetic resonance (MR) white matter abnormalities of patients with classic maple syrup urine disease (MSUD) under diet control.

METHODS

Ten patients with classic MSUD and one with a severe MSUD variant (mean age 21.5 ± 5.1 years) on diet and 11 age and sex-matched healthy subjects were enrolled. Apart from standard MR sequences, diffusion weighted images (DWI), diffusion tensor images (DTI), and magnetization transfer images (MT) were obtained and comparatively analyzed for apparent diffusion coefficient (ADC), tensor fractional anisotropy (FA) and MT maps in 11 regions of interest (ROI) within the white matter.

RESULTS

In MSUD patients DWI, DTI and FA showed distinct signal changes in the cerebral hemispheres, the dorsal limb of internal capsule, the brain stem and the central cerebellum. Signal intensity was increased in DWI with a reduced ADC and decreased values for FA. MT did not reveal differences between patients and control subjects.

CONCLUSION

Signal abnormalities in the white matter of adolescents and young adults under diet control may be interpreted as consequence of structural alterations like dysmyelination. The reduced ADC and FA in the white matter with preserved MT indicate a reduction in fiber tracks.

Aicardi-Goutières syndrome with emphasis on sonographic features in infancy

BACKGROUND

Aicardi-Goutières syndrome (AGS) is a severe familial, mostly autosomal recessive encephalopathy, first described in 1984. The clinical picture and genetic abnormalities are heterogeneous. US findings in AGS have thus far not been systematically described.

OBJECTIVE

The purpose of this study was to analyse sonographic features in AGS and to compare them to CT/MRI.

MATERIALS AND METHODS

Four male infants with AGS, two brothers, underwent imaging between the ages of 4 weeks and 6 months.

RESULTS

Sonographically isolated mineralization of lenticulostriate vessels, dilatation of the lateral ventricles, subependymal cysts, and diffuse and focal hyperechogenicity of the periventricular white matter and basal ganglia, respectively, were the abnormal findings, that may be present even before the development of major neurological symptoms.

CONCLUSION

Early cranial US is able to visualize the whole spectrum of cerebral anomalies in AGS: calcifying microangiopathy, white matter disease and unusual subependymal cysts. The imaging pattern is similar to that of congenital viral infection of the central nervous system, which may mislead the genetic counseling.

Cat scratch disease--heterogeneous in clinical presentation: five unusual cases of an infection caused by Bartonella henselae

BACKGROUND

Cat-scratch disease (CSD) is common in children, however the wide spectrum of the clinical presentation of CSD may lead to delayed diagnosis. An atypical presentation of CSD includes in its differential diagnosis diseases such as tuberculosis, other mycobacterioses, Epstein-Barr-Virus infection (EBV) or malignant disease. Since, in a small number of cases, these diseases may be present concurrently with an active CSD, it is important to consider CSD early in the differential diagnosis and order the appropriate tests. These tests include serology and, where possible, histology including molecular diagnostic methods on tissue specimens.

PATIENTS AND METHOD

We performed a case series of five patients treated in our hospital with a clinical diagnosis of cat-scratch disease, confirmed by serology. An analysis of the history and clinical symptoms associated specifically with an atypical presentation of CSD was performed.

RESULTS

The clinical presentation of CSD no longer encompasses the original typical description from 1950, but rather presents with a wide spectrum of signs and symptoms, including the absence of a documented cat scratch, fever, primary lesions or peripheral lymphadenopathy. Low density lesions in spleen, liver and lymph nodes are typical findings in ultrasound, MRI, or CT. Ignoring CSD as a possibility in investigating possible malignancy or tuberculosis could lead to unnecessary hospitalisation and delay in the proper treatment.

CONCLUSION

CSD should also be considered in differential diagnosis of any patient with intraabdominal lymphadenopathy, abdominal pain and fever of unknown origin. A careful history is important, however, often patients with CSD have no history of contact with cats. Therefore in atypical cases of CSD the finding of other clinical symptoms and performance of specific diagnostic tests is important. Our experience suggests that early serological testing for Bartonella henselae should be performed and may avoid invasive diagnostic procedures.

Impulse conduction and gap junctional remodelling by endothelin-1 in cultured neonatal rat ventricular myocytes

Endothelin-1 (ET-1) is an important contributor to ventricular hypertrophy and failure, which are associated with arrhythmogenesis and sudden death. To elucidate the mechanism(s) underlying the arrhythmogenic effects of ET-1 we tested the hypothesis that long-term (24 hrs) exposure to ET-1 impairs impulse conduction in cultures of neonatal rat ventricular myocytes (NRVM). NRVM were seeded on micro-electrode-arrays (MEAs, Multi Channel Systems, Reutlingen, Germany) and exposed to 50 nM ET-1 for 24 hrs. Hypertrophy was assessed by morphological and molecular methods. Consecutive recordings of paced activation times from the same cultures were conducted at baseline and after 3, 6 and 24 hrs, and activation maps for each time period constructed. Gap junctional Cx43 expression was assessed using Western blot and confocal microscopy of immunofluorescence staining using anti-Cx43 antibodies. ET-1 caused hypertrophy as indicated by a 70% increase in mRNA for atrial natriuretic peptide (P < 0.05), and increased cell areas (P < 0.05) compared to control. ET-1 also caused a time-dependent decrease in conduction velocity that was evident after 3 hrs of exposure to ET-1, and was augmented at 24 hrs, compared to controls (P < 0.01). ET-1 increased total Cx43 protein by approximately 40% (P < 0.05) without affecting non- phosphorylated Cx43 (NP-Cx43) protein expression. Quantitative confocal microscopy showed a approximately 30% decrease in the Cx43 immunofluorescence per field in the ET-1 group (P < 0.05) and a reduced field stain intensity (P < 0.05), compared to controls. ET-1-induced hypertrophy was accompanied by reduction in conduction velocity and gap junctional remodelling. The reduction in conduction velocity may play a role in ET-1 induced susceptibility to arrhythmogenesis.

Mechanical load induced by glass microspheres releases angiogenic factors from neonatal rat ventricular myocytes cultures and causes arrhythmias

In the present study, we tested the hypothesis that similar to other mechanical loads, notably cyclic stretch (simulating pre-load), glass microspheres simulating afterload will stimulate the secretion of angiogenic factors. Hence, we employed glass microspheres (average diameter 15.7 μm, average mass 5.2 ng) as a new method for imposing mechanical load on neonatal rat ventricular myocytes (NRVM) in culture. The collagen-coated microspheres were spread over the cultures at an estimated density of 3000 microspheres/mm², they adhered strongly to the myocytes, and acted as small weights carried by the cells during their contraction. NRVM were exposed to either glass microspheres or to cyclic stretch, and several key angiogenic factors were measured by RT-PCR. The major findings were: (1) In contrast to other mechanical loads, such as cyclic stretch, microspheres (at 24 hrs) did not cause hypertrophy. (2) Further, in contrast to cyclic stretch, glass microspheres did not affect Cx43 expression, or the conduction velocity measured by means of the Micro-Electrode-Array system. (3) At 24 hrs, glass microspheres caused arrhythmias, probably resulting from early afterdepolarizations. (4) Glass microspheres caused the release of angiogenic factors as indicated by an increase in mRNA levels of vascular endothelial growth factor (80%), angiopoietin-2 (60%), transforming growth factor-β (40%) and basic fibroblast growth factor (15%); these effects were comparable to those of cyclic stretch. (5) As compared with control cultures, conditioned media from cultures exposed to microspheres increased endothelial cell migration by 15% (P<0.05) and endothelial cell tube formation by 120% (P<0.05), both common assays for angiogenesis. In conclusion, based on these findings we propose that loading cardiomyocytes with glass microspheres may serve as a new in vitro model for investigating the role of mechanical forces in angiogenesis and arrhythmias.

Fetal MRI of the central nervous system: clinical relevance

OBJECTIVE

Specific conditions of the mother sometimes reduce the quality of ultrasound. In these cases, fetal magnetic resonance imaging (MRI) can be performed after gestational week (GW) 18. Interpretation of subtle disorders or malformations becomes safe not before GW 23. Clinical development of children with central nervous system (CNS) disorders is not predictable with imaging alone. Statistical evidence and personal experience of the medical team are essential in counseling, but optimized imaging is helpful in being more precise. The value of fetal MRI (fMRI) is evaluated.

MATERIALS AND METHODS

Twenty-five pregnant women (30.5 +/- 4.5 years) were investigated by additional fMRI.

TECHNIQUE

Breath-hold technique with T2 half-Fourier acquisition single-shot turbo spin-echo and T1 FLASH-2D images in three dimensions with field of view of 350 x 400 mm. All cases have been correlated with postnatal MRI, ultrasound, and clinical follow-up.

RESULTS

In all fetuses, diagnostic MRI was performed 3-10 days after ultrasound between GW 22 and 34 (GW 26.1 +/- 3.6). Sedation was not necessary. In eight cases of suspicious ultrasound, fMRI confirmed ultrasound findings. In 13 cases, additional diagnoses or exclusions of suspected findings could be established. Complete revision of diagnosis was realized in four cases. Findings could be confirmed by postnatal MRI in 11 patients. The clinical course was not predictable in cases with ambivalent prognosis.

CONCLUSIONS

Prenatal diagnosis of CNS pathologies should result in parental counseling. Sufficient diagnostic information, statistical data, and experience of the involved professionals are essential. These results show that in detecting congenital CNS abnormalities fMRI is superior to ultrasound and should be considered in difficult cases.

A novel element in the management of chronic granulomatous disease (CGD)? - treatment of osteomyelitis with additional hyperbaric oxygen therapy (HBO)

Chronic granulomatous disease (CGD) is caused by malfunctioning of the phagocyte NADPH oxidase responsible for the generation of microbicidal reactive oxygen species. It is characterized by severe recurrent infections with catalase positive bacteria. Bacterial or fungal osteomyelitis is a common complication which often does not respond sufficiently to intravenous antibiotic treatment. We report the case of a four year old boy with CGD and osteomyelitis of the mandible refractory to intravenous antibiotic therapy. Introduction of hyperbaric oxygen therapy (HBO) was well tolerated and led to resolution of the osteomyelitis.

Hyperthermia associated osteonecrosis in young patients with pelvic malignancies

INTRODUCTION

Progressive and non-juvenile avascular osteonecrosis (AVN) is a rare condition in children. During the last decade, some data indicate that regional deep hyperthermia therapy (RHT) combined with either chemo- and / or radiotherapy in malignancies is associated with AVN in young patients. In this study, we present our data on AVN following RHT in children with intra-pelvic malignancies.

MATERIAL AND METHODS

Localization, extent of AVN, and associated joint effusions were evaluated via MRI and X-ray findings in 37 patients treated with RHT and chemotherapy +/- additional radiotherapy for intra-pelvic malignancies in our study. AVN was classified in accordance to the Association Research Circulation Osseus (ARCO). In addition, the recurrence of sarcoma after RHT, the number of total joint replacements, and level of activity including sport activities were recorded in all patients. The mean follow-up was 6.2 years (SD: 4.1, range: 1-12 years).

RESULTS

Eight out of 37 pediatric patients treated with RHT and chemotherapy +/- additional radiotherapy showed AVN of the femoral head within our follow-up period. Five out of the eight children developed bone marrow edema within 6 months after RHT procedure and three additional patients within the first year. All patients except one showed a rapid progression of AVN from ARCO stage 0 to the post-collapse-stages III and IV in our study. Seven out of eight AVN patients survived without evidence of further malignancy. Although advanced stages of AVN were observed in our patient group, they were able to still maintain a high quality of life. No patients in our group have undergone total hip replacement thus far.

CONCLUSION

Based on our findings, we hypothesize a high risk of AVN in young children who receive RHT for pelvic sarcoma. However, further clinical investigation needs to be done to prove our hypothesis.

Fetales MRT

Ultrasonography is the method of choice for prenatal malformation screening, but it does not always provide sufficient information for correct diagnosis or adequate abnormality evaluation. Fetal MRI is increasingly being used to complete sonographic findings. It was initially used for evaluation of cerebral abnormalities but is increasingly being applied to other fetal areas. In vivo investigation of fetal brain maturation has been enhanced by MRI. An adequate analysis of fetal chest and abdomen can be achieved with fast T2-, T1-weighted and diffusion-weighted imaging (DWI). The advantages include the great field of view and the excellent soft tissue contrast. This allows correct diagnosis of congenital diaphragmatic hernia and evaluation of the consequences on pulmonary growth. Other pulmonary malformations, such as cystic adenomatoid malformation, sequestration and bronchogenic cysts, can also be easily identified. Renal position can be quickly determined using DWI sequences and renal agenesia can be easily diagnosed with only one sequence. Prenatal MRI is virtually as effective as postnatal examination, dispenses with transport of a potentially very ill newborn, and provides logistic advantages. Therefore, prenatal MRI is useful for adequate postnatal treatment of newborns with malformations.

[Effects of self-adapting G-DRG system 2004 to 2006 on in-patient services payment in pediatric hematology and oncology patients of a university hospital]

BACKGROUND

Reimbursement of inpatient treatment by daily constant charges is replaced by diagnosis- and procedure-related group system (G-DRG) in German acute care hospitals excerpt for psychiatry since 2004. Re-designs of G-DRG system were undertaken in 2005 and 2006. Parallel to implementation requirement- and resource-based self-adjustment of this new reimbursement system has been established by law. Adjustments performed in 2005 and 2006 are examined with respect to their effect on reimbursements in treatments of children with oncological, hematological, and immunological diseases.

PATIENTS AND METHODS

An unchanged population of 349 patients associated with 1,731 inpatient stays of a Clinic of Pediatric Oncology, Hematology, and Immunology in 2004 was analyzed by methods and means of G-DRG systems 2004, 2005, and 2006. DRGs and additional payments for drugs and procedures eligible for all and/or individual hospitals were calculated.

RESULTS

G-DRG system 2005 resulted in overall reimbursement loss of 3.77 % compared to G-DRG 2004. G-DRG 2006 leads to slightly improved overall reimbursements compared to G-DRG 2005 by increasing DRG-based revenues. G-DRG 2006 effects 2.40 % reduction in overall reimbursement compared to G-DRG 2004. This loss includes ameliorating effects of additional payments for drugs and blood products already. Despite introduction of additional payments especially designed for children and teenagers in 2006, additional payment volume is decreased by 21.71 % from 2005 to 2006. G-DRG 2006 yields over-all reimbursement losses of 1.45 % in comparison to G-DRG 2004. Overall reimbursements include introduced additional payments for drugs and blood products. (Reimbursements resulting out of DRG payment alone drop by 14.73 % from 2004 to 2005, and increase by 3.26 % from 2005 to 2006 (2004 vs. 2006 11.95 %). Introduction of additional payments for drugs and blood products on a Germany-wide basis introduced in 2005 dampens DRG-based reimbursement losses. Despite introduction of dosage intervals specifically designed for children and adolescents in 2006, reimbursement of additional payments for drugs and blood products decrease by 21.71 % from 2005 to 2006. An important revenue-balancing function is attributed to additional charges individual for each hospital according to Par. 6 Section 2 (New diagnostic and therapeutic methods) and Section 2 a KHEntgG (German Hospital Reimbursement Law) with respect to financing tertiary care focusses. If possible to attain, those charges may partially equalize losses. Including these additional charges per individual hospital balance of summarized additional charges is -3.89 % from 2005 to 2006. However, fraction of additional payments on total reimbursements increases from 0.64 % in 2004 to 11.98 % in 2005, and 11.24 % in 2006, respectively.

CONCLUSIONS

The G-DRG system in its versions 2005 and 2006 results in lowering overall reimbursements of a pediatric hematology, oncology, and immunology department compared to initial status in 2004. The growing chargeability of additional payments ameliorate this effect.

Avascular osteonecrosis after hyperthermia in children and adolescents with pelvic malignancies: a retrospective analysis of potential risk factors

PURPOSE

In children with locally advanced or recurrent malignant tumours, prognosis can be improved by regional deep hyperthermia (RHT) in combination with platin-based chemotherapy. However, because of the increasing number of patients that achieve long-time remission with this therapy, it is necessary to evaluate long-term sequelae of thermochemotherapy. During the years 1993-2004 one has observed avascular osteonecrosis (AON) of the femoral head after RHT in seven children with pelvic germ cell tumours or rhabdomyosarcomas.

METHODS

Although AON may develop in patients with malignancies treated with chemo- or radiotherapy alone, RHT might nevertheless contribute to the occurrence of AON. In order to determine potential risk factors for AON after RHT, this study analysed the relationship of AON to the patient's age, medical history and treatment parameters such as thermal dose equivalent and power output.

RESULTS AND CONCLUSIONS

In the present study AON was associated with young age as well as intensity of hyperthermia indicated by high power levels that exceed 20 W per kg body weight and/or application of eight or more heat sessions as well as additional radiotherapy. Based on this observation, it was assumed that an optimized three dimensional thermal field modelling may be helpful to avoid hazardous temperatures in the femoral heads during RHT treatment and to reduce AON of the femoral heads.

[Pre- and postnatal MRI of the fetus with complex intracranial vascular malformation]

Intracranial vascular malformations (IVM) on the whole occur in neonates very rarely. In such cases of IVM two different kinds can and must be discerned: (1) dural arteriovenous shunts (DAVS) and (2) vein of Galen aneurysmal malformations (VGAM). The latter seem to represent the majority of IVM of newborns. Several classifications are known for both types. Mortality of neonates and babies due to DAVS exceeds the average mortality from DAVS in adults. VGAM and DAVS can be diagnosed by prenatal ultrasonography only when the vessels behind the shunt are vasodilated because of the increasing flow stress. For that reason VGAM and DAVS are generally not recognized before the last trimenon or even postnatally. The prognosis of an IVM is influenced by the shunt capacity and its resulting cardiac stress as well as by the child's age. To plan the mostly interventional therapy, postnatal angiography (DSA) and MRI are employed and to an increasing extent also prenatal MRI examinations. We describe the case of a very complex IVM, the full dimensions of which could only be discerned by using pre- and postnatal MRI supplementary to the ultrasonography. Besides DAVS, flows from the pericallosal arteries as well as from the thalamic branches had to be considered. As a consequence DAVS and in addition VGAM existed in parallel.

Clinical findings and a therapeutic trial in the first patient with beta-ureidopropionase deficiency

The clinical, neurophysiological and neuroradiological work-up as well as the results of a specific treatment trial are presented of the first patient diagnosed with beta-ureidopropionase deficiency (E.C. 3.5.1.6, McKusick 606673). The patient presented with an early-onset dystonic movement disorder, severe developmental delay with marked impairment of visual responsiveness in combination with severely delayed myelination in magnetic resonance imaging studies. In addition, there were partial optic atrophy, pigmentary retinopathy and mild cerebellar hypoplasia. The enzyme defect was expected to lead to intracerebral deficiency of beta-alanine which seems to be a neuromodulator at inhibitory synapses. Therefore, a therapeutic trial with supplementation of beta-alanine was undertaken over 1.5 years with no convincing clinical improvement.

The cytoskeleton and related proteins in the human failing heart

In addition to functional alterations, heart failure has a structural basis as well. This concerns all components of the cardiac myocytes as well as the extracellular space. Proteins of the cardiomyocyte can be subdivided in 5 different categories: 1) Contractile proteins including myosin, actin, tropomyosin and the troponins. 2) Sarcomeric skeleton: titin, myosin binding protein C, alpha-actinin, myomesin, and M-protein. 3) True 'cytoskeletal' proteins: tubulin, desmin and actin. 4) Membrane-associated proteins: dystrophin, spectrin, talin, vinculin, ankyrin and others. 5) Proteins of the intercalated disc: desmosomes consisting of desmoplakin, desmocollin, desmoglein and desmin; adherens junctions with N-cadherin, the catenins and vinculin, and gap junctions with connexin. Failing myocardium obtained from patients undergoing cardiac transplantation exhibits ultrastuctural degeneration and an altered nucleus/cytoplasm relationship. The contractile proteins and those of the sarcomeric skeleton, especially titin, are downregulated, the cytoskeletal proteins desmin and tubulin and membrane-associated proteins such as vinculin and dystrophin are upregulated and those of the intercalated disc are irregularly arranged. Elevation of cytoskeletal proteins correlates well with diastolic and contractile dysfunction in these patients. The enlarged interstitial space contains fibrosis, i.e. accumulations of fibroblasts and extracellular matrix components, in addition to macrophages and microvascular elements. Loss of the contractile machinery and related proteins such as titin and alpha-actinin may be the first and decisive event initiating an adaptive increase in cytoskeleton and membrane associated components. Fibrosis may be stimulated by subcellular degeneration. The hypothesis is put forward that all proteins of the different myocardial compartments contribute to the deterioration of cardiac function in heart failure.

Aplasia cutis congenita of the scalp: how much therapy is necessary in large defects?

AIM

To show that local antibiotic management and a regular inspection of aplasia cutis congenita of the skull can give an excellent result.

METHOD

This case reports a girl born with aplasia cutis congenita of the skull presenting with a large aplasia of the epidermis, dermis, subcutaneous tissue and galea, including a bone defect without any additional risk factor, e.g. early eschar formation, cerebrospinal fluid leakage or uncommon dural blood vessels.

RESULTS

A primarily conservative treatment with local wet and antibiotic dressings together with a systemic antibiotic treatment for the first 2 wk led to an excellent result and thus prevented untimely operative and peri-operative procedures.

CONCLUSIONS

Here we have shown that conservative treatment might be an option, even if the wound diameter is greater than 1 cm(2), to prevent infants from any untimely operative procedure with an elevated operative risk if any additional risk factors are excluded.