Congenital lung malformations: a nationwide survey on management aspects by the Italian Society of Pediatric Surgery

INTRODUCTION

Over the years, congenital lung malformations (CLM) management remains a controversial topic in pediatric thoracic surgery. The Italian Society of Pediatric Surgery performed a national survey to study the current management variability among centers, trying to define national guidelines and a standardized approach of children with congenital lung malformations.

METHODS

Following a National Society approval, an electronic survey including 35 items on post-natal management was designed, focusing on surgical, anesthesiology, radiology and pneumology aspects. The survey was conducted contacting all pediatric surgical units performing thoracic surgery.

RESULTS

39 pediatric surgery units (97.5%) participated in the study. 13 centers (33.3%) were classified as high-volume (Group A), while 26 centers (66.7%) were low volume (Group B). Variances in diagnostic imaging protocols were observed, with Group A performing fewer CT scans compared to Group B (p = 0.012). Surgical indications favored operative approaches for asymptomatic CLM and pulmonary sequestrations in both groups, while a wait-and-see approach was common for congenital lobar emphysema. Surgical timing for asymptomatic CLM differed significantly, with most high-volume centers operating on patients younger than 12 months (p = 0.02). Thoracoscopy was the preferred approach for asymptomatic CLM in most of centers, while postoperative long-term follow-up was not performed in most of the centers.

CONCLUSION

Thoracoscopic approach seems uniform in asymptomatic CLM patients and variable in symptomatic children. Lack of uniformity in surgical timing and preoperative imaging assessment has been identified as key areas to establish a common national pattern of care for CLM.

A Rare Case of Mesenteric Chylous Cyst in Infant: Case Report and Review of Literature

The occurrence of a mesenteric cyst (MC) is common in adults while in children and in infants is rare. In adults mesenteric cysts are often asymptomatic and discovered incidentally; however, in children they commonly present with symptoms of abdominal pain or distension with fever and leucocytosis. We report on a rare case, in our experience, of Mesenteric Chylous cyst (MCC) in an infant with signs and symptoms of intestinal obstruction. Discussion of literature is also reported.

Bedside surgery in the newborn infants: survey of the Italian society of pediatric surgery

Introduction

This is the report of the first official survey from the Italian Society of Pediatric Surgery (ISPS) to appraise the distribution and organization of bedside surgery in the neonatal intensive care units (NICU) in Italy.

Methods

A questionnaire requesting general data, staff data and workload data of the centers was developed and sent by means of an online cloud-based software instrument to all Italian pediatric surgery Units.

Results

The survey was answered by 34 (65%) out of 52 centers. NICU bedside surgery is reported in 81.8% of the pediatric surgery centers. A lower prevalence of bedside surgical practice in the NICU was reported for Southern Italy and the islands than for Northern Italy and Central Italy (Southern <Northern<Central, p < 0.03). The most frequent clinical characteristics of neonates was preterm neonates with birthweight < 1200 g, with cardiorespiratory instability and/or ventilatory dependence. The most frequently selected indications to surgery were pneumothorax, pleural effusion, pericardial effusion, central venous catheter (CVC) positioning, intestinal perforation, patent ductus arteriosus ligation and congenital diaphragmatic hernia. More than 60% of respondents report no institutional recommendations and dedicated informed consent on bedside surgical procedures. The lack of dedicated areas and infrastructures is considered a relative contraindication to the performance of bedside surgery.

Conclusion

Bedside surgery is performed in the majority of the Italian pediatric surgery centers included in this census. The introduction of a national set of surgery guidelines would be widely welcomed.

Comment on "Brownian diffusion of a particle at an air/liquid interface: elastic (not viscous) response of the surface"

In a recent article Toro-Mendoza et al. considered an elastic response of an interface in order to explain the enhanced lateral drag of solid particles straddling fluid interfaces we recently measured.

A cross-sectional nationwide survey on esophageal atresia and tracheoesophageal fistula

BACKGROUND

Our study aims at disclosing epidemiology and most relevant clinical features of esophageal atresia (EA) pointing to a model of multicentre collaboration.

METHODS

A detailed questionnaire was sent to all Italian Units of pediatric surgery in order to collect data of patients born with EA between January and December 2012. The results were crosschecked by matching date and place of birth of the patients with those of diagnosis-related group provided by the Italian Ministry of Health (MOH).

RESULTS

A total of 146 questionnaires were returned plus a further 32 patients reported in the MOH database. Basing on a total of 178 patients with EA born in Italy in 2012, the incidence of EA was calculated in 3.33 per 10,000 live births. Antenatal diagnosis was suspected in 29.5% patients. 55.5% showed associated anomalies. The most common type of EA was Gross type C (89%). Postoperative complications occurred in 37% of type C EA and 100% of type A EA. A 9.5% mortality rate was reported.

CONCLUSIONS

This is the first Italian cross-sectional nationwide survey on EA. We can now develop shared guidelines and provide more reliable prognostic expectations for our patients.

Liquid crystal quenched orientational disorder at an AFM-scribed alignment surface

A polyimide substrate was scribed using the stylus of an atomic force microscope, then covered with a nematic liquid crystal. The fiber from a near field scanning optical microscope was immersed into the liquid crystal and rastered approximately 80 nm above the surface, thereby obviating smearing effects that occur in thicker samples. By appropriate averaging of multiple data sets, a histogram of the "frozen-in" director deviation Δφ from the average easy axis was obtained, having a full-width-half-maximum of ∼0.02 rad. Additionally, the spatial autocorrelation function of Δφ was extracted, where the primary correlation length was found to be comparable to, but larger than, the liquid crystal's extrapolation length. A secondary characteristic length scale of a few μm was observed, and is thought to be an artifact due to material ejection during the scribing process. Our results demonstrate the utility of nanoscale imaging of the interface behavior inside the liquid crystal.

Possible model of an antiferroelectric twist grain boundary phase

Using x-ray and optical methods we have probed the structural organization of an antiferroelectric twist grain boundary phase (TGBC(a)) lying between the regular antiferroelectric smectic-C (SmC(a)* and the smectic-Q (SmQ) or isotropic phase. We find that the twist axis is everywhere perpendicular to the local smectic layer normal and that the helical superstructure is incommensurate with the smectic layer structure. The twist grain boundaries consist of a periodic lattice of alternating +1/2 and -1/2 dispirations, i.e., unit screw dislocations in combination with half unit disclinations. The molecular tilt plane is alternatingly parallel and perpendicular to the twist axis. We find that the optically measured tilt angle in the SmC(a)* phase is smaller than that measured by x rays, which is the opposite to what is found in the SmC* phase. This means that the core part tilts less than the end chains in the SmC(a)* phase, while it tilts more in the SmC* phase. On entering the TGB phase a clear decrease is measured in the tilt angle. This is explained by the elastic influence from the disclinations, which appear in this phase.

Two fluid-structure approaches for 3D simulation of St. Jude Medical bileaflet valve opening

This paper deals with the three-dimensional (3D) numerical simulation of the opening transient for a bileaflet mechanical heart valve (St. Jude Medical Hemodynamic Plus, 27 mm characteristic size). The discussion concerns two different types of ""partitioned"" fluid-structure models, with weak and strong coupling. Both approaches are based on a moving deforming mesh method as implemented in the CFD commercial software Fluent (Fluent Inc., USA), and both yielded dynamically consistent results from a quantitative viewpoint. There is a slight improvement (peak relative difference <1%) of the numerical solution (angles vs. time) when using the strong instead of the weak coupling model. This is of utmost importance when the considerable reduction of the computational costs for the weak scheme (about 60% less) is taken into account. However, the strong coupling model provides a more consistent physical description of the interaction when looking at small-scale features like stress close to geometrical singularities. In the experiments, the differences both in terms of time-to-peak delay (15% of the opening time) and in terms of underestimation of the peak velocity (8%) seemed due to defects in the fluid inertia assessment, which depends on initial and boundary data.

Brownian motion of an ellipsoid

We studied the Brownian motion of isolated ellipsoidal particles in water confined to two dimensions and elucidated the effects of coupling between rotational and translational motion. By using digital video microscopy, we quantified the crossover from short-time anisotropic to long-time isotropic diffusion and directly measured probability distributions functions for displacements. We confirmed and interpreted our measurements by using Langevin theory and numerical simulations. Our theory and observations provide insights into fundamental diffusive processes, which are potentially useful for understanding transport in membranes and for understanding the motions of anisotropic macromolecules.

A 2D spring model for the simulation of ultrasonic wave propagation in nonlinear hysteretic media

A two-dimensional (2D) approach to the simulation of ultrasonic wave propagation in nonclassical nonlinear (NCNL) media is presented. The approach represents the extension to 2D of a previously proposed one dimensional (1D) Spring Model, with the inclusion of a PM space treatment of the intersticial regions between grains. The extension to 2D is of great practical relevance for its potential applications in the field of quantitative nondestructive evaluation and material characterization, but it is also useful, from a theoretical point of view, to gain a better insight of the interaction mechanisms involved. The model is tested by means of virtual 2D experiments. The expected NCNL behaviors are qualitatively well reproduced.

Cracks and topological defects in lyotropic nematic gels

We report on the effects of the coupling of nematic order and elasticity in anisotropic lyotropic gels consisting of large nematic domains of surfactant coated single wall carbon nanotubes embedded in a cross-linked N-isopropyl acrylamide polymer matrix. We observe the following striking features: (i) undulations and then cusping of the gel sidewalls, (ii) a nematic director field that evolves as the gel sidewalls deform, (iii) networks of surface cracks that are orthogonal to the nematic director field, and (iv) fissures at the sidewall cusps and associated topological defects that would not form in liquid nematics.

Dynamics of nematic liquid crystal disclinations: the role of the backflow

We measure the electric-field-driven annihilation of nematic disclination pairs with strength +/- 1/2 in the 4-cyano-4'-n-pentylbiphenyl (5CB) liquid crystal. The use of a very weak azimuthal anchoring ensures a two-dimensional director field. The relaxation is governed by the formation of a pi wall connecting the two opposite charge defects. The +1/2 disclinations move almost twice as fast as the -1/2 disclinations. The simple used geometry allows a quantitative comparison with numerical studies based on the hydrodynamics of the tensorial order parameter. The simulations show that in the pi wall regime the symmetry breaking is due to the backflow and not to the elastic anisotropy.

[Uncommon etiology of acute abdomen in pediatric age: the torsion of spleen]

The torsion of spleen on its vascular shank represents an uncommon problem, responsible of acute and chronic pain. The mobile spleen is fixed only through hilus vessels the gastrosplenic ligament. The incidence is unknow, greater in the male with an M:F ratio 6.1 in the first ten years of life, even if an episode of intrauterine torsion has been reported. The diagnosis can be performed with ultrasonography, angiography, scintigraphy and CT scan. There are reported two cases: male of 2.5 years female of 14 years who presented with recurrent pain to the left side, vomit diarrhoea and fever. Objectively a palpable mass was present. Ultrasonography and angio-CT scan of abdomen revealed splenomegaly, ptosis of the spleen and malrotation with signs of obstruction of the vessels. The treatment in both cases was splenectomy. The spleen appeared rotated on its shank and increased of volume, deprived of anatomical structures of fixation. The histological report confirmed the haemorrhagic infarction. The excessive mobility of the spleen, from insufficiency or absence of the ligamentous attachments is case of abdominal pain or acute abdomen, that can complicate with the infarction of the spleen. Angio-CT scan, in the cases here reported, has shown to greater sensibility in comparison to the ultrasonography. The Authors believe that the video-laparoscopic splenopexy, when the diagnosis is made of "wandering spleen" with painful repeated episodes, can be finalized, to the preservation of organ.

Progesterone supplement in pregnancy: an immunologic therapy?

One of the most interesting functions of the placenta is the regulation of the maternal immune response such that the fetal semi-allograft is tolerated during pregnancy. Trophoblasts are presumed to be essential to this phenomenon because they lie at the maternal-fetal interface, where they are in direct contact with cells of the maternal immune system. Trophoblasts do not express classic major histocompatibility complex (MHC) class II molecules. Surprisingly, cytotrophoblasts express more HLA-G, a MHC class Ib molecule, as they invade the uterus. Progesterone plays an important role in postovulatory regulation of the menstrual cycle. If fertilization occurs, progesterone supports implantation of the ovum and maintains the pregnancy. Progesterone has been named the 'hormone of pregnancy', because in preparing the endometrium for embryo implantation and facilitating endometrial development, it is critical to the very survival of a pregnancy. In addition, this key hormone inhibits the rejection of T cell-mediated tissue and also decreases myometrial activity and sensitivity throughout pregnancy. The cellular actions of progesterone are mediated through intracellular progesterone receptors (PRs), which are well studied gene regulators, not express classic major histocompatibility complex. The more used paradigm is relative to the alteration of relationship TH1/TH2, but the complexity of the respective distributions of cytokines at the materno-fetal interface, strongly suggest that, as useful as it certainly was for a while, the Th1/Th2 paradigm must now be considered as an oversimplification. Rather, the existing data point to sequential windows and are suggestive of a system where an extreme complexity is allied to very precise timing and tuning. They also suggest that the materno-fetal relationship is not simply maternal tolerance of a foreign tissue, but a series of intricate mutual cytokine interactions governing selective immune regulation and also control of the adhesion and vascularization processes during this dialogue. However, as shifting the immune response toward the Th2 pattern (IL-4, IL-5, IL-6) may benefit the fetus, whereas development of proinflammatory Th1 cells (secreting IL-2, IFN g, TNF a) may be harmful. Now we are working to open comprise the precise behaviour of NK populations, with the hope of obtaining a diagnostic test of the condition of abortion from 'immunological causes'.

Azimuthal anchoring energy at the interface between a nematic liquid crystal and a PTFE substrate

The azimuthal anchoring energy of the nematic liquid crystal 4-pentyl-4'-cyanobiphenil (5CB) on a poly(tetrafluoroethylene) (teflon, PTFE) film is measured for the first time. The PTFE film is deposed using the Wittmann and Smith technique which consists on rubbing a bar of this polymer against a glass substrate at a controlled temperature and pressure. Measurements of the azimuthal anchoring energy are made with a reflectometric technique which provides high accuracy and sensitivity. The dependence of the azimuthal anchoring energy on temperature and on the rubbing pressure is investigated. The extrapolation length remains virtually constant in the whole temperature range of the nematic phase except for an increase of 25% close to the clearing temperature. The azimuthal anchoring energy is somewhat strong and increases with increasing the deposition pressure of PTFE. The observation of a relevant pre-transitional anisotropy of the reflection coefficients in the isotropic phase proves that the surface interactions favor an excess of orientational order. Ageing of the anchoring energy and gliding of the easy axis are experimentally observed. Both these phenomena suggest the presence of an anisotropic adsorbed layer of nematic molecules on the PTFE film.

Anchoring screening of defects interaction in a nematic liquid crystal

The relaxation dynamic of a dipole of +1/2 and -1/2 parallel disclination lines in a confined geometry is measured. The confinement and the planar anchoring conditions force the disclinations to be normal to the glass plates. In a first asymptotic regime, the direct elastic interaction between disclination is completely screened out by the anchoring energy. In a second regime, corresponding to the final annihilation steps, the dynamic follows the square-root law predicted by de Gennes for two isolated and parallel disclinations. The annihilation dynamic, in the asymptotic regime, is in good agreement with an elastic model based on an electrostatic analogy.

[Esophageal atresia and tracheoesophageal fistula: personal contribution]

From January 1988 to December 1999, 21 new born babies, 13 boys and 8 girls, with esophageal atresia (EA) and tracheosophageal fistula (TEF) were treated at Division of Pediatric Surgery in Foggia (Italy). At birth their weight ranged from 1.600 to 3.000 g, the gestional age ranged from 36 to 41 weeks. Five (23%) of them were premature, seven (58%) SGA, seventeen (80%) associated congenital anomalies. Complete surgical correction was performed in all patients. In three AE cases with wide-gap an azygos vein flap was used to strengthen the anastomosis under excessive tension. The pathogenetic factors involved in these complications such as leak, stricture (stenosis), recurrent TEF and gastro-esophageal reflux are (are taken into account) and analysed. No baby died owing to anastomatic complication. Survival rate was 100% in Montreal I and 83% in Montreal II. A new born baby died but his death was due to major associated conenital anomalies and not to surgical complications. The Authors believe that the azygos vein flap is a useful technique in the treatment of esophageal atresia wide-gap.

Nanostructured Silica-Based Organic-Inorganic Hybrid Materials-Evidence for Self-Organization of a Xerogel Prepared by Sol-Gel Polymerization

A hydrolytic polycondensation reaction of a rigid, rodlike nonmesomorphous precursor leads to an isotropic sol and then an anisotropic birefringent xerogel (see scheme). Optical and X-ray structural analyses demonstrate a short-range order and the possibility of a crystalline order.

[Meckel's diverticulum in childhood. The authors' own experience]

Meckel's diverticulum occurs in approximately 2 percent of the population and may present at any age. Although Meckel's diverticulum may produce an intestinal obstruction or perforation, simulating an appendicitis, hemorrhage is its most important clinical presentation. From 1989 to 1994, Meckel's diverticulum was discovered in ten children at laparotomy. Three cases were asymptomatic, representing an incidental finding at laparotomy. Of the seven symptomatic patients, four presented with bowel obstruction (intussusception), three had rectal bleeding one of whom had diverticulitis. Contrast studies--in gastrointestinal hemorrhage--were not helpful in establishing the diagnosis; colonoscopy and gastroscopy ruled out other causes of bleeding. Five of seven symptomatic patients had an intestinal resection while two a diverticulectomy after assessment that the ulcer did not require resection. No postoperative morbidity and mortality is reported in either groups. A Meckel's diverticulum found incidentally at laparotomy should be always resected as the risk of complication is high and that of resection low.

[Intestinal invagination in childhood: our experience]

The Authors report their experience in the treatment of twenty-one patients with intussusception operated in the Paediatric Surgery Division ASL FG/3 between January 1988 and December 1994. Eighty-nine percent of the patients were between 2 and 12 months of age, with a peak between 2 and 6 months (60%). Ultrasound allowed to identify the pathological picture in forty-two percent of the cases and diagnosis was confirmed by barium enema. In 8 patients a pathology more or less responsible of the intussusception or associated with it was detected. The time between the onset of symptoms and admission as well as the relation between intestinal resection and duration of symptomatology were analyzed. The resection rate was maximal (55%) in those patients presenting symptoms beyond 25 hours. Intestinal resection was performed in 9 patients (47%): 6 ileo-colic; 1 ileo-colic resection extended to the splenic flexure; and 2 ileo-ileal ones. In this series no postoperative complications or recurrences or deaths were registered. Long term results proved that ileo-colic resection, even in few-months old infants, is well tolerated.

[Detoxification from opiates through hospitalization: the long-term results. A longitudinal study of 104 admissions in 1982-1986]

One hundred and four drug addicts admitted to hospital during the period 1982-1986 were studied in order to evaluate whether detoxification from opiates in a protected environment had positive long-term results, namely a definitive rejection of the world of drugs. A follow-up of this population was carried out at the start of the current year and approximately 20% were found to be drug-free. Accumulated experience leads to the conclusion that hospitalisation may have a positive long-term outcome if a subject with proven motivation to "give up" is carefully selected, and if the subject is then inserted in a broader social health project.

[5 patients in irreversible coma in which it was not possible to remove the organs for therapeutic transplant]

The special committee consisting of a neurologist, an anaesthesist and a forensic doctor, refused transplantation permission since spinal reflexes were present. These reflexes persisted until cardiac death occurred. Brain death was diagnosed by instrumental techniques and was confirmed by necropsies.

[Changes induced by carbamazepine in the action of ADH (antidiuretic hormone) in neurologic patients]

We report the result of a study performed in 27 patients taking carbamazepine because of epilepsy or neuralgia, in order to point out subclinical water abnormal retention. We tested serum sodium and potassium levels, plasma and urine osmolarity, free water clearance. The carbamazepine serum level is also reported. We didn't find abnormal values. So in our experience there is not any complication concerning water retention during oral carbamazepine treatment.

[Computerized electroencephalography in acute cerebral ischaemia (author's transl)]

Physiopathological, clinical and therapeutical problems of acute cerebral ischaemia and brain infarction are briefly discussed. In the opinion of the Authors, a first valuable approach to the diagnosis and treatment of these conditions is afforded by the computerized electroencephalography (Berg Fourier Analysis). This investigations proved to be a safe, easy and reliable tool for testing and monitoring the effectiveness of individually selected drugs in early phases of cerebral ischaemia.

Catatonia with high CSF lactate in a case of diabetes with associated conditions

A case of reversible catatonia in a well controlled insulin-dependent diabetic is described. The course of catatonia was characterized by very high CSF lactate values (serial semiautomatic determinations) during more than one month, beyond the clinical recovery. The CSF lactate elevations seem to reflect cerebral hypoxia. The uncommon coincidence of diabetes with cerebral atrophy, mental weakness, and perceptive deafness migh suggest the classification of this case of diabetes in the group 'associated with certain conditions and syndromes'.

[Cerebral thrombophlebitis as the expression of disseminated intravasal coagulopathy in pregnancy. Presentation of a clinical case]

A case of cerebral thrombophlebitis that arose during pregnancy is presented. The aetiology of this form is discussed and its relation to placental pathology and disseminated intravasal coagulopathy.

[Peduncular hallucinosis in a young woman with vertebrobasilar insufficiency based on severe hypoplasia of a vertebral artery, demonstrated angiographically]

A clinical case of peduncular hallucinosis due to circulatory insufficiency of the cerebral trunk is reported. Angiography revealed marked hypoplasia of a vertebral artery. The patient presented changes to sleep-arousal rhythms and neurological signs with focus involving the cerebral trunk. The patient took an emotional part in her visual hallucinations even though she was aware that they were only hallucinations. A review of the literature on the subject follows.

[Vertebrobasilar insufficiency sustaining grave hypoplasia of the vertebral artery. Report of a clinical case resembling disseminated sclerosis]

The case of a young woman affected by at first paroxysmal and then stabilized disturbances of the pyramidal system and of certain cranial nerves is reported. The case had been diagnosed on several previous occasions as ascribable to demyelinizing disease. Careful study of the vertebrobasilar circulation and of the origin of the large trunks of the aortic arch, highlighted hypoplasia of a vertebral artery. The need to study further the arterial circulation (aortic arch and vertebrobasilar district) in those young patients whose symptoms too obviously point to disseminated sclerosis is pointed out.

[Dyskinetic-athetosic syndrome in a patient with prior radiculo-myelo-encephalopathy of probable viral origin. Therapeutic guidelines with levodopa and preliminary results]

The regulation of skeletal muscle tone and of the automatic and half-automatic movements by the extrapyramidal system in briefly discussed. The essential importance to keep separated the akinetic-hypertonic syndromes from the hypotonic-hyperkinetic ones is further confirmed. In fact two different chemical mediating agents work separately in these two cases: the Dopamine for the Nigro-Striatal system and the Ach for other tracts whose anatomy is still not well known, but which surely belong to the extrapyramidal system. Further more a clinical case of dyskinetic-athetosic post-infective syndrome, successfully treated with L.D., is discussed. The effectiveness of neuroleptic drugs in these hypotonic-hyperkinetic syndrome is stressed while they cause and worsen extra-pyramidal symptoms such as hypertonia and akynesia (hypertonic akinetic s.).

[Long-term levodopa syndrome. Report of a clinical case]

Since it is was first described by James Parkinson in 1817 much has been learnt about Parkinson's disease. The complete picture is not clear, however, and a new impulse has been given to the study of the physiopathology of the basal ganglia by the therapeutic employment of L-Dopa with a peripheral inhibitor of the decarboxylase. This treatment is the best available particularly for akinetic-hypertonic forms. In certain cases, however, patients developed a dyskinetic long-term L-Dopa syndrome, depending on the amount of L-Dopa given and individual sensitivity. The syndrome occurs in Parkinsonism only and can be prevented by thalamolysis. It would appear to be a specific expression of the effect of L-Dopa on the striatonigral system rather than of generic hypersensitivity due to denervation. A personal case is presented.