Ninety Sixth-Hour Impact of Scalding Burns on End Organ Damage, Systemic Oxidative Stress, and Wound Healing in Rats Treated With Three Different Types of Dressings

In this study, we investigated the effects of 3 different burn dressing treatments, including experimental, silver, and modern dressing materials, on systemic oxidative stress in rats with severe scald burns within the first 96 h. The rats were divided into five groups: a burn group (n = 10), a polylactic membrane group (n = 10), a silver sulfadiazine group (n = 10), a curcumin group (n = 10), and a control group (n = 10), consisting of equal numbers of female and male rats. In the first 4 groups, 30% of the rats' total body surface area was scalded at 95°C. The burn group was not treated. Each group was treated with group-name dressing material. The control group was neither treated nor burned. The rats were sacrificed, and blood and tissue samples were obtained at the 96th hour when severe effects of oxidative stress developed postburns. Systemic inflammatory biomarkers and oxidative stress parameters were examined. In addition, apoptosis and organ damage in liver, kidney, lung, and skin tissues were evaluated biochemically and histopathologically. When the parameters were statistically analyzed, we found that the systemic levels of oxidative stress and inflammatory damage to liver, kidney, and lung tissues were lower in the 3 treated groups than in the burn group. We believe that the dressing material's efficacy in the treatment of severe burns may be dependent on its ability to combat oxidative stress and inflammation.

Investigation of Serum Interleukin 6, High-Sensitivity C-Reactive Protein and White Blood Cell Levels during the Diagnosis and Treatment of Paediatric Appendicitis Patients Before and during the COVID-19 Pandemic

Introduction

In this study, we prospectively investigated changes in serum interleukin-6 (IL-6), high-sensitivity C-reactive protein (hsCRP) and full white blood cell (WBC) counts during the diagnosis and treatment of paediatric patients with appendicitis. We also investigated the effects of the COVID-19 pandemic on the diagnosis and treatment processes of paediatric appendicitis patients.

Materials and Methods

A non-perforated appendicitis group (n = 110), a perforated appendicitis group (n = 35) and an appendicitis + COVID-19 group (n = 8) were formed. Blood samples were taken upon admission and every day until the three studied parameters returned to normal values. To investigate the effects of the COVID-19 pandemic on paediatric appendicitis patients, the perforated appendicitis rates and the times from the onset of the first symptoms to the operation before and during the pandemic were compared.

Results

WBC, IL-6, and hsCRP dropped below the upper limits on the second postoperative day in the non-perforated appendicitis group, four to six days postoperatively in the perforated appendicitis group, and three to six days postoperatively in the appendicitis + COVID-19 group. These parameters were not within normal range in patients who developed complications during follow-up. The time from the onset of abdominal pain to the surgery was significantly longer during than before the pandemic in both the non-perforated appendicitis group and the perforated appendicitis group.

Conclusions

Our results show that WBC, IL-6, and hsCRP are useful laboratory parameters that can complete clinical examinations in the diagnosis of appendicitis in paediatric patients and the identification of complications that may develop postoperatively.

Ultra-structural and histopathological features of liver biopsy taken during laparotomy to confirm the diagnosis of biliary atresia

BACKGROUND

Neonatal cholestasis is caused by a group of diseases that cause jaundice, which can be encountered in the neonatal period. Biliary atresia (BA) and idiopathic neonatal hepatitis (INH) are among neonatal cholestasis diseases.

AIMS

The aim of this study was to perform histopathological and ultra-structural examinations of liver biopsy tissue samples from BA and INH patients with liver biopsies taken during laparotomy to confirm the diagnosis of biliary atresia.

SETTINGS AND DESIGN

A total of patients undergoing Kasai surgery before the age of 60 days were included in an "early" group (n = 7), whereas patients undergoing surgery after the age of 60 days were included in a "late" group (n = 11). The control group (n = 11) included INH patients.

MATERIALS AND METHODS

For histopathological examinations, liver tissue samples obtained intra-operatively were subjected to routine histopathological procedures after being stained with caspase-3 and cytokeratin-7 antibodies. Ultra-structural evaluations were also performed. Statistical analysis used: For comparisons between the groups, a one-way analysis of variance (ANOVA) test and the Mann-Whitney U test were used for continuous variables.

RESULTS

Histopathological findings reflected the specific liver pathologic findings seen in biliary atresia. Although there was no significant difference between the BA groups, these parameters were not detected in the control group. The histopathological evaluations revealed no significant differences in the findings of liver parenchyma damage between the early, late, and control groups. Electron microscopic examinations showed that the patients in the late group had more severe signs of intra-cellular damage to the liver.

CONCLUSIONS

Although the histopathological examination revealed no significant differences in liver damage between the three groups, in ultra-structural evaluation, intra-cellular damage was found to be less in groups with better prognosis. Electron microscopy evaluations of intra-cellular damage may be more useful in this respect.

Global gene expression profiling in congenital diaphragmatic hernia (CDH) patients

Congenital diaphragmatic hernia (CDH) is an anomaly characterized by a defect in the diaphragm, leading to the passage of intra-abdominal organs into the thoracic cavity. Herein, the presented work analyzes the global gene expression profiles in nine CDH and one healthy newborn. All of the patients had left posterolateral (Bochdalek) diaphragmatic hernia, operated via an abdominal approach, and stomach and bowels in the thorax cavity. Some patients also had additional anomalies. A total of 560 differentially regulated genes were measured. Among them, 11 genes showed significant changes in expression associated with lung tissue, vascular structure development, and vitamin A metabolism, which are typical ontologies related to CDH etiology. Among them, SLC25A24 and RAB3IL1 are involved in angiogenesis, HIF1A and FOXC2-AS1 are related with the alveolus, MAGI2-AS3 is associated with the diaphragm, LHX4 and DHH are linked with the lung, and BRINP1, FZD9, WNT4, and BLOC1S1-RDH5 are involved in retinol. Besides, the expression levels of some previously claimed genes with CDH etiology also showed diverse expression patterns in different patients. All these indicated that CDH is a complex, multigenic anomaly, requiring holistic approaches for its elucidation.

Histopathological examination of acute appendicitis tissue in children during the COVID-19 pandemic

In this study, we prospectively investigated the histopathological features of the removed appendix tissue in pediatric patients who were operated on with the preliminary diagnosis of appendicitis. A catarrhal appendicitis group (n=43), a phlegmonous appendicitis group (n=28), a gangrenous appendicitis group (n=19), a perforated appendicitis group (n=35), and an appendicitis +COVID-19 group (n=7) were formed. The control group consisted of 21 children. A section of each patient's appendix tissue from the part with the highest diameter was taken for histopathological examination. The sections were routinely stained with hematoxylin and eosin (H&E). The two pathologists evaluated all H&E sections in a light microscope. The evaluation results were analyzed statistically. No significant differences in age and gender were found between all groups. The results of neutrophil and lymphocyte counts in all tissue layers of all groups were significantly different. Neutrophil count in the mucosa and muscularis propria in the appendix tissues of the control group were found to be zero. Among all groups, the highest number of neutrophil counts in the mucosa and muscularis propria were found in the perforated group. Among all groups, the highest number of lymphocyte counts in mucosa and muscularis propria were found in the Covid-19 group. The mucosal erosion, intraluminal neutrophils, and reactive lymphoid hyperplasia were negative in all samples in the control group. Neutrophil accumulation in the mucosa and muscularis propria layers in appendix tissue together with other inflammation findings are important in the histopathological diagnosis of appendicitis. In patients with Covid-19 infection, appendicitis may occur, in which case, severe accumulation of lymphocytes appears in the mucosal layer in addition.

Oxygen, pH, Lactate, and Metabolism-How Old Knowledge and New Insights Might Be Combined for New Wound Treatment

Over time, we have come to recognize a very complex network of physiological changes enabling wound healing. An immunological process enables the body to distinguish damaged cells and begin a cleaning mechanism by separating damaged proteins and cells with matrix metalloproteinases, a complement reaction, and free radicals. A wide variety of cell functions help to rebuild new tissue, dependent on energy provision and oxygen supply. Like in an optimized “bio-reactor,” disturbance can lead to prolonged healing. One of the earliest investigated local factors is the pH of wounds, studied in close relation to the local perfusion, oxygen tension, and lactate concentration. Granulation tissue with the wrong pH can hinder fibroblast and keratinocyte division and proliferation, as well as skin graft takes. Methods for influencing the pH have been tested, such as occlusion and acidification by the topical application of acidic media. In most trials, this has not changed the wound’s pH to an acidic one, but it has reduced the strong alkalinity of deeper or chronic wounds. Energy provision is essential for all repair processes. New insights into the metabolism of cells have changed the definition of lactate from a waste product to an indispensable energy provider in normoxic and hypoxic conditions. Neovascularization depends on oxygen provision and lactate, signaling hypoxic conditions even under normoxic conditions. An appropriate pH is necessary for successful skin grafting; hypoxia can change the pH of wounds. This review describes the close interconnections between the local lactate levels, metabolism, healing mechanisms, and pH. Furthermore, it analyzes and evaluates the different possible ways to support metabolism, such as lactate enhancement and pH adjustment. The aim of wound treatment must be the optimization of all these components. Therefore, the role of lactate and its influence on wound healing in acute and chronic wounds will be assessed.

Glial Cell Line-Derived Neurotrophic Factor, S-100 Protein and Synaptophysin Expression in Biliary Atresia Gallbladder Tissue

PURPOSE

Biliary atresia (BA) is a disease that manifests as jaundice after birth and leads to progressive destruction of the ductal system in the liver. The aim of this study was to investigate histopathological changes and immunohistochemically examine the expression of glial cell line-derived neurotrophic factor (GDNF), synaptophysin, and S-100 protein in the gallbladder of BA patients.

METHODS

The study included a BA group of 29 patients and a control group of 41 children with cholecystectomy. Gallbladder tissue removed during surgery was obtained and examined immunohistochemically and histopathologically. Tissue samples of both groups were immunohistochemically assessed in terms of GDNF, S-100 protein, and synaptophysin expression. Expression was classified as present or absent. Inflammatory activity assessment with hematoxylin and eosin staining and fibrosis assessment with Masson's trichrome staining were performed for tissue sample sections of both groups.

RESULTS

Ganglion cells were not present in gallbladder tissue samples of the BA group. Immunohistochemically, GDNF, synaptophysin, and S-100 expression was not detected in the BA group. Histopathological examination revealed more frequent fibrosis and slightly higher inflammatory activity in the BA than in the control group.

CONCLUSION

We speculate that GDNF expression will no longer continue in this region, when the damage caused by inflammation of the extrahepatic bile ducts reaches a critical threshold. The study's findings may represent a missing link in the chain of events forming the etiology of BA and may be helpful in its diagnosis.

The Effects of Two Different Burn Dressings on Serum Oxidative Stress Indicators in Children with Partial Burn

In this study, we evaluated and compared the effect of treatment with a hydrofiber dressing with silver (HFAg) and a polylactic membrane (PLM) on systemic oxidative stress in systemic inflammatory reaction in thermal burn injuries in children. A prospective randomized and matched pairing study of 20 to 50% of TBSA was performed from children equal to both sexes affected by thermal injuries. The control group was included in normal children of both sexes. Serum malondialdehyde (MDA), total antioxidant capacity (TAC), total oxidant capacity (TOC), and glutathione (GSH) levels were analyzed and the results were analyzed statistically. In this study, it was found that PLM treatment increased TAC and GSH levels in burn patients significantly more than the other group. With the use of PLM, TOC decreased to normal level from day 3. In the HFAg group, TAC and GSH levels began to increase on the seventh day. On the first day of the burn, the TOC level started to increase. This increase continued on days 7 and 14. The TOC level began to fall on the 21st day. The increase in TAC was higher in the PLM group. In the PLM group, TOC fell faster. As a result, we think that different burn dressings can have different systemic effects. We can speculate that PLM has an antioxidant effect in the burn tissue due to high lactate content. Therefore, PLM may have decreased serum oxidative stress indicators more effectively than HFAg.

The Effects of Different Burn Dressings on Length of Telomere and Expression of Telomerase in Children With Thermal Burns

BACKGROUND

Burns are a common traumatic injury triggered by local tissue damage and a systemic response. In this study, we evaluated the effects of different burn dressings on telomere kinetics in children with thermal burn injury.

METHODS

Sixty children with thermal burn were included in this prospective study. The burn area of the patients included 20 to 50% total body surface area. Three different dressings (hydrofiber with silver [HFAg], poylactic membrane [PLM], and silver sulfadiazine [SSD]) and control groups were created. Telomere length in nucleated blood cells and telomerase expression in the skin tissue were evaluated in control and burn groups.

RESULTS

In the whole burn groups, telomere length in blood cells increased. The length of telomeres increased the most in the SSD group. The PLM group is the treatment that increases the number of squamous cell counts in the basal layer and telomerase expression in the skin. In HFAg and SSD groups, the expression of telomerase in the skin is decreased. In the HFAg group, the basal layer in the skin was also reduced in squamous cells.

CONCLUSION

In all burn groups, the telomere length of nucleated cells in the blood was higher than in the control group. SSD dressing along with autografting is the treatment method that maximizes telomere length in blood cells. The PLM has the most increased telomerase expression in the skin of burned patients. The PLM application increases the number of cells on both burned and normal skin.

The Efficacy of Five Different Wound Dressings on Some Histological Parameters in Children With Partial-Thickness Burns

An ideal dressing should ensure that the wound remains moist with exudates but not macerated. Currently, there is no dressing available to suit all wounds, at all stages of the healing process. Although silver-containing dressings are the gold standard for burn wound care, few high-level trials have been completed comparing the clinical utilities of these dressings. In our study, five different types of wound dressings: carboxymethyl cellulose hydrofiber dressing with ionized silver (CMCH-Ag), polyethylene-polyethylene terephthalate aqua fiber dressing with elementary silver (PPAF-Ag), calcium alginate (CA), calcium + zinc alginate (CZA), and 0.2% nitrofurazone-embedded (NF) gauze dressings were compared in regard to histopathological parameters. Children aged between 0 and 18 years with small or middle-sized partial-thickness burns that affected less than 30% of the total body surface area were included in this study. The study groups (CMCH-Ag, PPAF-Ag, CA, and CZA) and the control group (NF) were randomly attained. Wound healing was evaluated by punch biopsies on the 21st day. The thickness of the stratum corneum and the epithelium, the number of papillae, and the papillary length were calculated and compared. The histological parameters of healing, except the stratum corneum thickness, did not show any statistical significance among the groups (P > .05). The dressings that included silver, calcium, or zinc showed useful and similar effects in noninfective burn wounds when compared with nitrofurazone-only dressings. Thus, it may be concluded that silver-containing wound dressings should not be considered as the gold standard in noninfective partial-thickness burn wounds in children.

Investigation of the cardiotoxic effects of parenteral nutrition in rabbits

INTRODUCTION

Parenteral nutrition (PN) is used for the intravenous delivery of nutrients to patients who cannot take food orally. However, it is not clear whether PN also negatively impacts cardiac tissue. The present empirical study investigated the cardiac effects of PN in rabbits.

METHODS

The effects of PN were examined in three groups of rabbits: animals in the PN + fasting group (n = 14) had been fully fasted before receiving a full PN dose via an intravenous central catheter; the PN + oral feeding group (n = 14) received half of the daily calorie requirement as a half dose of PN via an intravenous central catheter; the third group consisted of controls (n = 14) with full enteral feeding and full enteral fluid intake with no PN and no central venous catheter. At the end of the 10-day study period, the rabbits were subjected to echocardiographic examination and euthanized. Blood and tissue samples were obtained from all groups. DNA was isolated from nucleated blood cells. Tissue samples were examined by both light and electron microscopy, relative telomere length was determined from DNA, and blood samples were analyzed biochemically.

RESULTS

At the end of the study, there were no statistically significant differences in weight change between the three groups. Echocardiography revealed minimally impaired diastolic function in the PN + fasting group compared to the other groups. Biochemical and histopathological analyses, relative telomere length determination, and electron micrographs showed significant cardiac damage in the PN + fasting group but not in the PN + oral feeding group or the control group. The blood biochemical analyses showed hyperglycemia and a low insulin level in the PN + fasting group but not in the other two groups.

CONCLUSIONS

A combination of PN and fasting may damage the cardiac muscle cells of rabbits via a mechanism involving hyperglycemia and oxidative stress. Additional enteral feeding may protect against the destructive effects of PN on cardiac tissue.

Advantages of early intervention with arterial embolization for intra-abdominal solid organ injuries in children

PURPOSE

Active bleeding due to abdominal trauma is an important cause of mortality in childhood. The aim of this study is to demonstrate the advantages of early percutaneous transcatheter arterial embolization (PTAE) procedures in children with intra-abdominal hemorrhage due to blunt trauma.

METHODS

Children with blunt abdominal trauma were retrospectively included. Two groups were identified for inclusion: patients with early embolization (EE group, n=10) and patients with late embolization (LE group, n=11). Both groups were investigated retrospectively and statistically analyzed with regard to lengths of stay in the intensive care unit and in the hospital, first enteral feeding after trauma, blood transfusion requirements, and cost.

RESULTS

The duration of stay in the intensive care unit was greater in the LE group than in the EE group (4 days vs. 2 days, respectively). The duration of hospital stay was greater in the LE group than in the EE group (14 days vs. 6 days, respectively). Blood transfusion requirements (15 cc/kg of RBC packs) were greater in the LE group than in the EE group (3 vs. 1, respectively). The total hospital cost was higher in the LE group than in the EE group (4502 USD vs. 1371.5 USD, respectively). The time before starting enteral feeding after first admission was higher in the LE group than in the EE group (4 days vs. 1 day, respectively).

CONCLUSION

Early embolization with PTAE results in shorter intensive care and hospitalization stays, earlier enteral feeding, and lower hospital costs for pediatric patients with intra-abdominal hemorrhage due to blunt trauma.

Use of angiographic embolization in trauma-induced pediatric abdominal solid organ injuries

BACKGROUND

Knowledge of the utility of angiographic embolization (AE) in pediatric cases of blunt abdominal solid organ trauma injuries is limited. The current study is an examination of AE as an effective and reliable method to control bleeding in patients with persistent bleeding due to blunt trauma-induced abdominal solid organ injury.

METHODS

This was a retrospective examination of patients <17 years of age who had experienced blunt abdominal solid organ injury and who presented at a single institution within 4 years. A statistical analysis of the data was performed.

RESULTS

The mean length of intensive care unit stay was 4 days for those who underwent embolization (n=11), and the mean length of hospital stay was 12 days. The average pre-AE blood loss, as measured by the decrease in hematocrit (%) from admission to embolization, was -7.33+-5.3% (p<0.001). The average post-AE blood loss, as measured by the change in hematocrit 72 hours post AE, was 2+-0.97% (p>0.05). All of the patients were discharged with a full recovery.

CONCLUSION

AE was a safe and effective method to control solid organ hemorrhage in pediatric patients with blunt abdominal injuries.

Preliminary results in single-step wound closure procedure of full-thickness facial burns in children by using the collagen-elastin matrix and review of pediatric facial burns

BACKGROUND

Management of full-thickness facial burns remains one of the greatest challenges. Controversy exists among surgeons regarding the use of early excision for facial burns. Unfortunately, delayed excision of deeper burns often results in more scarring and subsequent reconstruction becomes more difficult. A collagen-elastin matrix is used to improve the quality of the reconstructed skin, to reduce scarring and to prevent wound contraction. It serves as a foundation for split thickness skin graft and enhances short and long-term results.

AIM

We report the usage of a collagen-elastin matrix during single-step wound closure technique of severe full-thickness facial burns in 15 children with large burned body surface area, and also we review the literature about pediatric facial burns.

RESULTS

There were 15 pediatric patients with severe facial burns, 8 girls and 7 boys ranging in age from 10 months to 12 years, mean age 7 years and 6 months old. The facial burn surface area (FBSA) among the patients includes seven patients with 100%, five with 75%, and three with 50%. The average total body surface area (TBSA) for the patients was 72%, ranging between 50 and 90%. 5 of the patients' admissions were late, more than four days after burns while the rest of the patients were admitted within the first four days (acute admission time). The burns were caused by flame in eight of the patients, bomb blast in four, and scalding in three. All patients were treated by the simultaneous application of the collagen-elastin matrix and an unmeshed split thickness skin graft at Turgut Özal Medical Center, Pediatric Burn Center, Malatya, Turkey. After the treatment only two patients needed a second operation for revision of the grafts. All grafts transplanted to the face survived. The average Vancouver scar scales (VSS) were 2.55±1.42, ranging between one and six, in the first 10 of 15 patients at the end of 6 months postoperatively. VSS measurements of the last 5 patients were not taken since the 6 months postoperative period was not over.

CONCLUSION

In regard to early results, graft quality was close to normal skin in terms of vascularity, elasticity, pliability, texture and color. Esthetic and functional results have been encouraging. This study shows us that the collagen-elastin matrix as a dermal substitute is a useful adjunct, which may result in quick healing with satisfying esthetic and functional results. It also may enhance short and long-term results in after burn facial wound closure in children.

Congenital distal esophageal obstruction caused by intraluminal mucosal web

Here, we report a case with intraluminal membrane (web) located in the lower esophagus causing complete obstruction. Esophagogram revealed complete obstruction near the esophagogastric junction. Surgical excision of the esophageal membrane was performed. To our knowledge, only a few cases with membranous esophageal atresia have been reported. It must be remembered in neonates who cannot tolerate feeding.

Antibiotic and hyperbaric oxygen therapy in the management of post-operative discitis

OBJECTIVE

Despite the use of antibiotics, the management of postoperative discitis (POD) still presents a challenge. This study was designed to evaluate the effect of adjuvant hyperbaric oxygen (HBO2) therapy on the duration of antibiotic treatment.

METHODS

Between 1999 and 2004, 22 patients diagnosed with POD were treated with antibiotic and HBO2 therapy. There were 14 male (63.6%) and 8 female (36.3%) patients, and their mean age at the time of surgery was 45.4 years (range, 20-59 years). Diagnosis of a POD was established on the basis of clinical, laboratory, and radiographic findings. All patients were given a 4-week course of vancomycin (1g i.v. every 12 h). Additionally, patients received HBO2 (100% O2 at 2.4 ATA for 90 min) twice daily for the initial five consecutive days, and an additional treatment (100% O2 at 2.4 ATA for 90 min daily) was given for 25 days. The duration of follow-up was 24 months.

RESULTS

This treatment modality allowed infection control and healing for all 22 patients with 0% recurrence rate. HBO2 treatment was tolerated well.

CONCLUSION

This series represents the first reported group of POD patients treated with antibiotic and HBO2 therapy. Our preliminary results indicate that the length of time on antibiotic therapy can be shortened with the use of HBO2 as an adjunctive treatment. Erythrocyte sedimentation rates and serum C-reactive protein levels returned to the preoperative levels earlier (within 8-30 days after the initiation of treatment) and a reasonable length of immobility was obtained (mean 12.2 days). After completion of the one-month period of antibiotic and HBO2 therapy, patients were accepted disease-free regarding pain and mobility.

Tracheal agenesis and esophageal atresia with proximal and distal bronchoesophageal fistulas

Tracheal agenesis (TA) is an extremely rare, typically fatal congenital tracheal malformation. Lack of prenatal symptoms and emergent presentation usually lead to a failure to arrive at the correct diagnosis and manage the airway properly before the onset of irreversible cerebral anoxia. Esophageal atresia (EA) encompasses a group of congenital anomalies comprising an interruption of the continuity of the esophagus with or without a persistent communication with the trachea. In 86% of cases, there is a distal tracheoesophageal fistula (TEF); in 7%, there is no fistulous connection, whereas in 4%, there is a TEF without atresia. We report the case of an infant born with TA and EA with proximal and distal bronchoesophageal fistulas. During 3 consecutive antenatal ultrasound examinations, there had been polyhydramniosis, difficulty visualizing the stomach, and dilatation of proximal esophagus, leading to a presumptive diagnosis of EA. The clinical presentation, embryology, classification, and surgical management are discussed.

Urethral polyps in children: A review of the literature and report of two cases

A solitary polyp of the urethra is a rare benign fibroepithelial growth and has often been described in boys. Its occurrence in girls is exceptional. In the present paper, two children with solitary polyps of the urethra are presented and discussed. The first case was an 18-month-old boy with a posterior urethral polyp arising from the posterior urethra and extending to the bladder. It was excised by cystostomy because of an unsuccessful endoscopic removal attempt. The second case was a 2-year-old girl with an interlabial mass arising from the posterior wall of urethra and protruding from the external urethral meatus. It was excised transurethrally.

The effects of orchiopexy on serum anti-Müllerian hormone levels in unilateral cryptorchid infants

BACKGROUND/PURPOSE

In males, serum anti-Müllerian hormone (AMH) reflects Sertoli cell function and provides an estimate of seminiferous tubular integrity. It has been suggested that comparison of AMH levels before and after surgery could be useful to determine effectiveness of the treatment. In this study, we determined the serum AMH levels in infants with unilateral cryptorchidism before and after orchiopexy procedure and compared these data with the AMH values in age-matched controls.

METHODS

The study population was 20 cryptorchid children with unilateral palpable testes who underwent orchiopexy as a cryptorchid group, and 20 healthy children who underwent circumcision as a control group. All children are 12 months of age. Serum AMH levels were measured at just before surgery (at 12 month old) and 6 months after surgery (at 18 month old).

RESULTS AND CONCLUSIONS

All undescended testes were found to be normal in size and in the superficial inguinal pouch or subcutaneous region of the groin at surgery. With regard to the preoperative serum AMH levels, there was a significant difference between the cryptorchid and the control groups (40.04 +/- 4.97 ng/ml versus 53.46 +/- 7.51 ng/ml) (P < 0.05). Similarly, the postoperative serum AMH levels were lower in cryptorchid children than in controls (39.27 +/- 4.58 ng/ml versus 52.79 +/- 6.27 ng/ml) (P < 0.05). In cryptorchid children, serum AMH levels measured at 6 months after orchiopexy were similar with preoperative basal levels (40.04 +/- 4.97 ng/ml versus 39.27 +/- 4.58 ng/ml) (P > 0.05). AMH levels in children with unilateral palpable undescended testes remain unchanged 6 months after orchiopexy performed at 1 year of age. This is the first report in literature regarding the effect of orchiopexy on the serum AMH levels.

Interferon-alpha reduces the development of experimental necrotizing enterocolitis

Cytokines had important role in the pathogenesis of necrotizing enterocolitis (NEC). The aim of this study is to investigate if IFN-alpha has a prophylaxic effect on experimental NEC development in newborn rat pups. Twenty eight Wistar Albino newborn rat pups were divided into three groups. Control group rats were breast-fed, NEC group and interferon (IFN) group rat pups were hand-fed with premature newborn formula. IFN-alpha was administered subcutaneously at a dose of 50,000 IU/rat/day in IFN group. NEC was induced experimentally by cold stress twice a day in IFN and NEC groups. On the fourth day, the rats were killed, and all the intestine were removed to determine the tissue level of malonaldehyde (MDA) and histologic changes. The microscopic lesions in the NEC group rats were virtually the same as those seen in neonatal NEC, with severe separation of submucosa and/or lamina propria, loss of villi and in some cases necrosis to extention the muscularis. In contrast, in the rats treated with IFN, lesions were moderate separation of submucosa and/or lamina propria, edema in submucosal and muscular layers. Intestinal injury score and MDA levels in NEC group were significantly higher than in the IFN group (P<0.05). In conclusion it was suggested that IFN-alpha was effective in reducing the severity of NEC in rat pups.

Plasma D-Lactic Acid Level: A Useful Marker to Distinguish Perforated From Acute Simple Appendicitis

Early diagnosis of perforated appendicitis is important for reducing morbidity rates. The aim of this study was to determine the value and utility of plasma D-lactic acid levels in identifying the type of appendicitis. In this clinical study, plasma D-lactic acid levels were assessed in 44 consecutive paediatric patients (23 with acute appendicitis, 21 with perforated appendicitis) before laparotomy. D-lactic acid levels were determined by an enzymatic spectrophotometric technique using a D-lactic acid dehydrogenase kit. Patients with perforated appendicitis had higher D-lactic acid levels (3.970 +/- 0.687 mg/dL) than patients in the control group (0.478 +/- 0.149 mg/dL) and patients with acute appendicitis (1.409 +/- 0.324 mg/dL; p < 0.05). For a plasma D-lactic acid level greater than 2.5 mg/dL, the sensitivity and specificity of the D-lactic acid assay were 96% and 87%, respectively. The positive predictive value was 87%, the negative predictive value was 96%, and the diagnostic value was 91%. These results suggest that the measurement of plasma D-lactic acid levels may be a useful adjunct to clinical and radiological findings in distinguishing perforated from acute non-perforated appendicitis in children.

Teratoma arising from anomalous common bile ducts: a case report

Teratoma arising from extrahepatic common ducts is very rare entity. The authors found 2 teratoma cases originating from common bile duct in the literature. As a third case, the authors report on a 4-month-old girl with benign cystic teratoma arising from distal common hepatic bile duct and with anomalous common bile ducts. Surgical management of the patient also is discussed.

Bardet-Biedl syndrome associated with vaginal atresia: a case report

This is a case report of Bardet-Biedl syndrome associated with vaginal atresia diagnosed in a 15-year-old girl. She had mild mental retardation; obesity; nistagmus, retinitis pigmentosa and optic atrophy in both eyes; accessory digit on the left hand; polydactyly in lower extremities; a mobile, painful, nonfixed mass of 6 cm in diameter in the pelvic region; a palpable cystic mass in front of the rectal wall; and no vaginal opening. Secondary sex characteristics were determined. The vaginal atresia was distinguished from vaginal agenesis by the presence of proximal vagina in radiological examination.

Regional anesthesia is a good alternative to general anesthesia in pediatric surgery: Experience in 1,554 children

BACKGROUND/PURPOSE

Although caudal and spinal blocks are modern and safe techniques, in many centers children still are operated on under general anesthesia (GA), or the blocks are used for postoperative analgesia after GA in infraumbilical operations. The authors aimed to document the results and the complications of 1,554 regional anesthesia cases, thereby assessing their validity.

METHODS

The analysis of 1,459 caudal and 95 spinal blocks cases collected until January 2001 in children from newborn to 12 years of age are documented retrospectively. The types of anesthesia analyzed in the study were caudal block (CB) only, CB plus GA, GA plus CB, GA plus spinal block, and spinal block only.

RESULTS

There were 1,338 caudal and 95 spinal block cases that clinically were satisfactory. Because the duration of CB was not sufficient in 39 cases, GA was used. Failure to produce a CB occurred in 82 cases (5.57%). There were 257 of 1,338 patients operated on under GA and supported by caudal block for postoperative analgesia.

CONCLUSIONS

Caudal anesthesia seems to be an inexpensive, simple, and effective technique not only as a supplement for postoperative analgesia, but also as a single method of anesthesia. and the authors recommend its use in a wider setting of clinical entities in infraumbilical surgical procedures of children.

Cramp finding: can it be used as a new diagnostic and prognostic factor in lumbar disc surgery?

In this prospective study, the validity and the importance of a new finding (cramp finding) in the diagnosis and outcome after lumbar disc surgery were tested. The test is performed with the person in prone position. Against a forceful knee flexion, the examiner holds the leg with one hand and applies a force to overcome the knee flexion. The finding is positive if the examined person feels a disturbing cramp in the leg or thigh. The study was performed between October 1997 and December 1999. Besides the cramp finding, the classical disc herniation examination, including mechanical and neurological findings, magnetic resonance (MR) imaging tests, and laboratory findings were checked pre- and postoperatively. The positive cramp finding in the operated group was 72% (n=133) preoperatively and straight leg raising (SLR) test was positive in all of them. Cramp finding was positive in 70%, 52%, 34%, and 8% of patients postoperatively in the first, 3rd, 12th and 24th months, respectively. The presented finding appears to be as valuable as the SLR, and especially contralateral SLR, tests in lumbar disc surgery. Cramp finding is also important in outcome evaluation.

Multiple coronary artery aneurysms combined with abdominal aortic aneurysm

Coronary artery aneurysm (CAA) is defined as coronary dilatation which exceeds the diameter of a normal adjacent segment or the diameter of the patients's largest coronary vessel by as much as 1.5 times. It is an uncommon pathology with a frequency of 1-4% in routine autopsies or coronary angiographies. Atherosclerosis plays an important role in the development of CAA, and it may be a predominant cause in the majority of patients. However, the timing of surgical intervention and the treatment options for CAA are still controversial. In this report, we present a patient who had multiple CAAs of all main coronary arteries and abdominal aortic aneurysm. Different treatment modalities and indications are also discussed.

Determination of serum bile acids routinely may prevent delay in diagnosis of total parenteral nutrition-induced cholestasis

BACKGROUND/PURPOSE

Early diagnosis of development of cholestasis is a current major problem for patients receiving total parenteral nutrition (TPN). Conventional tests for hepatic function such as serum transaminases and alkaline phosphatase do not often reflect simultaneously histopathologic changes of the liver. The aim of this study is to find out the relationships between conventional hepatic function tests, total serum bile acid concentrations (TSBA), and the histopathologic changes in the liver during TPN administration in rats.

METHODS

Forty Albino rats were divided into four experimental groups, each consisting of 10 rats, as follows: control group (C), 0.9% saline for 14 days; T7 group, TPN for 7 days; T14 group, TPN for 14 days; T7O7 group, TPN for 7 days and then 0.9% saline for the next 7 days. All solutions were administered by infusion through intraperitoneal catheter in two equal doses. During the experiment, rats also maintained on rat chow and water ad libitum. Levels of serum glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, alkaline phosphatase, and TSBA were measured. Liver was evaluated histopathologically by light microscope and then Morphological Cholestasis Index (MCI) was calculated.

RESULTS

Cholestasis was present in all experimental groups except control. Levels of transaminases and alkaline phosphatase were not correlated with the histopathologic changes (P > .05), but TSBA concentrations were correlated with MCI in all groups (P< .01). TSBA concentrations and MCI in all groups also were correlated with the duration of exposure with TPN (P< .01).

CONCLUSIONS

Measurement of TSBA seems to be more sensitive in early diagnosis of TPN-induced cholestasis. Therefore, periodical determination of TSBA during TPN administration can be done routinely.

The effects of acetylsalicylic acid, interferon-alpha, and vitamin E on prevention of parenteral nutrition-associated cholestasis: an experimental study

BACKGROUND

Cholestasis is one of the major complications of parenteral nutrition. The purpose of this experimental study was to detect the effects of acetylsalicylic acid (ASA), vitamin E (Vit E), and interferon-alpha (IFN-alpha) on prevention of parenteral nutrition-associated cholestasis.

METHODS

Ten experimental groups, each consisting of 10 4-week-old Wistar albino rats, were formed: control 10- and 20-day groups (C10 and C20), parenteral nutrition-only 10- and 20-day groups (T10 and T20), ASA-supplemented parenteral nutrition 10- and 20-day groups (TA10 and TA20), Vit E-supplemented parenteral nutrition 10- and 20-day groups (TE10 and TE20), and IFN-alpha-supplemented 10- and 20-day groups (TF10 and TF20). Acetylsalicylic acid, Vit E, and IFN-alpha were administered in the parenteral nutrition solution through an intraperitoneal route. At the end of the study, serum total bile acids, serum aspartate and alanine aminotransferases, and alkaline phosphatase were measured biochemically. In addition, the histopathologic findings of cholestasis were evaluated by using a morphologic portal inflammation index.

RESULTS

Although the difference in the serum levels of transferases and alkaline phosphatase was not significant among all groups (p > 0.05), it was significant in total bile acid levels (p < 0.05). There was also a significant correlation between the histopathologic changes of the liver and serum total bile acid concentrations (p < 0.05). Portal inflammation in varying degrees was seen in all experimental groups, but not in the control groups. Serum total bile acid concentrations in parenteral nutrition groups receiving ASA were significantly lower than those in the parenteral nutrition-only group (p < 0.01). Although Vit E-supplemented parenteral nutrition was effective in preventing the development of cholestasis in the 10-day group (p < 0.05), it was not effective in the 20-day group when compared with incidence of cholestasis in the parenteral nutrition-only group (p > 0.05). Conversely, IFN-alpha-supplemented parenteral nutrition had no effect on cholestasis in the 10-day group (p > 0.05) but lowered cholestasis in the 20-day group when compared with incidence the parenteral nutrition-only group (p < 0.05).

CONCLUSION

Our results indicate that acetylsalicylic acid may be beneficial in preventing, and (alpha-interferon in treating, parenteral nutrition-associated cholestasis.

Blood transfusion requirements in children with blunt spleen and liver injuries

The records of 174 children sustaining blunt spleen and liver injuries in a 16-year period were analyzed retrospectively to determine blood transfusion requirements in surgically versus conservatively managed patients. The whole study group consisted of 97 spleen, 70 liver, and 7 combined spleen and liver injuries respectively. Seventy-eight patients were managed conservatively while 96 children had undergone various operative procedures. The hematocrit (Hct) values, transfused blood volumes (ml/kg), and length of hospital stay were compared between the non-operative and operative treatment groups. Although the initial Hct values were found to be similar in non-operative versus operative groups (26.7% +/- 2.7% vs. 24.8% +/- 3.5%), transfused blood volumes were significantly higher in the surgically treated group respectively (20.9 ml/kg vs. 39.5 ml/kg) (p < 0.05). Similarly, mean length of hospital stay was longer in the surgical groups. Associated injuries were seen in 105 (60.3%) patients distributed randomly among two study groups. Twelve patients in the series died of other system/organ involvement. There were no deaths in isolated spleen and/or liver injuries. Increased blood transfusion requirement in surgical groups may be due to excessive bleeding prior to the operation which virtually provides the indication for laparotomy. Manipulation and suturing enhances additional bleeding to elevate the total volume to be delivered. Operative choice should be spared for very selected cases, and conservative management is safe; procedures such as splenorrhaphy are not superior to observation therapy as a means of controlling intraabdominal bleeding.

Aluminum in total parenteral nutrition solutions produces portal inflammation in rats

BACKGROUND

Aluminum contaminates parenteral nutrition solutions and accumulates in bone and liver of patients receiving total parenteral nutrition therapy. Although previous reports have shown that parenteral administration of aluminum in pharmacologic doses to rats results in the production of elevated total serum bile acid concentrations alone or in combination with decreased bile flow, they have failed to demonstrate any abnormalities in the histologic appearance of liver tissue. The effects of aluminum in total parenteral nutrition and of aluminum chloride on total serum bile acid concentrations, aluminum contents of the liver, and histopathologic changes in the liver were studied in rats.

METHODS

The aluminum concentrations in the aluminum chloride solution and total parenteral nutrition formula were equal (300 microg/l). They were given intraperitoneally as follows: control group, 0.9% saline for 14 days; T7 group, total parenteral nutrition for 7 days; A7 group, aluminum chloride for 7 days; A14 group, aluminum chloride for 14 days; T7A7 group, total parenteral nutrition for 7 days and aluminum chloride for the next 7 days; and T7O7 group, total parenteral nutrition for 7 days and 0.9% saline for the next 7 days. Volumes of 0.9% saline, aluminum chloride, and total parenteral nutrition given to rats were equal. During the experiment, rats were maintained on rat chow and water ad libitum. Serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, alkaline phosphatase, and bile acid concentrations and aluminum content of the liver were measured. The liver was evaluated histopathologically by light microscope, and a morphologic portal inflammation index was calculated.

RESULTS

Portal inflammation was present in all groups except the control group. The morphologic portal inflammation correlated with hepatic aluminum accumulation in all groups and was the highest in the T7A7 group. Levels of serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, and alkaline phosphatase did not correlate with the histopathologic findings, but serum bile acid concentrations correlated with morphologic portal inflammation and hepatic aluminum accumulation in all groups. Hepatic aluminum accumulation also correlated with the duration of exposure to total parenteral nutrition and aluminum chloride concentration.

CONCLUSION

Aluminum in contaminating doses, not in pharmacologic doses, accumulates in the liver and can produce hepatobiliary dysfunction characterized by portal inflammation detectable in histologic examination of liver tissue.

Pilomatricoma in children: a prospective study

Pilomatricoma is a skin appendage tumor that frequently involves the skin of the head, neck, and upper extremities in young children. In this prospective study, we present and discuss the characteristics of our patients with pilomatricoma. During the years 1984 to 1994, 15 children (9 girls and 6 boys) with pilomatricoma were admitted to our service. Their ages ranged from 3 to 13 years (mean age 9 years). All of the lesions of these patients were excised totally. On histopathologic examination, calcification was found in all of the specimens. No invasion or malignancy was observed by light microscopy. All patients have been followed up periodically by the same surgeons. Interestingly, we found two familial occurrences and four multiple occurrences. Although our series was too small for accurate statistical evaluation, multiple and familial occurrences of pilomatricoma (26.7% and 13.3%, respectively) were higher than in previously reported series.

Neonatal bladder rupture: an unusual complication of umbilical catheterization

Bladder injury in the neonatal period is an exceedingly rare phenomenon that is usually iatrogenic. Bladder rupture as a complication of umbilical catheterization in a newborn with urinary ascites, respiratory distress and hematuria is presented and discussed.

Gastroesophageal reflux: a determinant in the outcome of caustic esophageal burns

Deep circumferencial burns of the esophagus always result in stricture formation and obstruction of the lumen. The usual treatment of caustic esophageal strictures is long-term esophageal dilatations. A new method of treatment, long-term stenting of the strictured esophagus gave superior results when compared with the classic dilatation therapy (healing rates, 68% v 33%; P < .01). Although success in the stent group was very satisfactory, the 32% failure rate requires explanation. In the years between 1991 and 1993, 53 stent-treated patients were screened for gastroesophageal reflux (GER). All patients were investigated with 24-hour ambulatory distal esophageal pHmetry. In 18 patients reflux index (RI) was found to be below 4. In 14 patients RI was between 4.1 and 19. In the final group of 21 patients RI was over 20 (minimum, 21.8; maximum, 72.8). When these data were compared with the healing rates of the patients, it was found that none of the 21 patients with RI over 20 responded to the described therapy. We conclude that the esophagus, after a serious caustic insult, not only narrows but also shortens thus altering the lower esophageal sphincter function leading to serious GER. Therefore all caustic esophageal burn patients should be screened for GER periodically during the dilatation or stent therapy programs, and GER should be controlled before RI approaches 20.

Gastrointestinal perforations in children: a continuing challenge to nonoperative treatment of blunt abdominal trauma

The present trend towards conservative management of hemodynamically stable pediatric trauma patients may be increasing the risk of delay in the diagnosis of traumatic hollow viscus perforations (HVP). The purpose of this study is to determine whether there is a delay in the diagnosis of HVP because of expectant management. A survey of factors leading to diagnostic delay was also made and the value of current diagnostic tools were reevaluated. In 1,283 trauma admissions between 1980-1994, 34 patients were operated for HVP caused by blunt abdominal trauma. Sites of perforation were; stomach (four), duodenum (five), jejunum (12), ileum (nine), and jejunum/ileum (four). Signs of peritoneal irritation were positive in 32 of 34 patients. There was free air in only six of 24 abdominal roentgenograms. Free peritoneal fluid without solid organ injury was detected in only four out of 13 patients with ultrasound. Peritoneal lavage was diagnostic in eight of nine patients. Time from admission to operating room averaged 24 +/- 4.1 (mean +/- standard deviation) hours. Eleven patients died after the operation mostly because of accompanying head injury. Only two of the deaths were the result of sepsis originating from the perforated bowel. There is an apparent delay in the diagnosis of traumatic HVP in this series. Signs of peritoneal irritation are the most consistent findings of HVP after blunt abdominal trauma in children. Persistence of abdominal signs indicates peritoneal lavage, which has a high diagnostic sensitivity for HVP compared to other diagnostic modalities.

Unilateral inguinal hernia in girls: is routine contralateral exploration justified?

To determine the incidence of contralateral hernia development after unilateral inguinal hernia repair in girls, collected case series from two large hospitals were analyzed retrospectively. Among the 294 girls who had analyzed repair of a unilateral inguinal hernia (during a 15-year period), 245 could be traced; the mean follow-up period was 8.4 years. In 25 (10.2%) of the patients, contralateral hernia developed, mostly within one year (4 months to 6.5 years). The incidence of contralateral hernia development with respect to the original side of the inguinal hernia was significantly higher (19%) for the originally left-sided hernias than for the right-sided ones (6%) (P < .01). Although the incidence of contralateral hernia development for girls with a left inguinal hernia decreased as age increased, it was still 14.9% for the girls age 3 and up. Contralateral exploration should not be routine for girls who have a right-sided hernia, at any age. For left-sided hernias, it may be performed routinely for girls up to 2 years of age, and selectively for older patients.

The Rapunzel syndrome: a case report and review of the literature

The Rapunzel syndrome, found characteristically in girls with varying gastrointestinal symptoms, is a rare form of gastric trichobezoar extending throughout the bowel. The previously reported cases have different clinical and pathological features affecting the mortality. We describe a new case preoperatively diagnosed with none of the complications previously reported.

Segmental dilatation of intestine: a case report and review of the literature

Segmental dilatation of intestine (SDI) is a rare disorder that leads to functional obstruction without stenosis and normally functioning ganglion cells. The etiology of the disease is unknown. Definitive treatment consists of segmental resection of the dilated segment with end-to-end anastomosis.

Surgical treatment of hepatic hydatid disease in children

Fifty-one patients were operated on because of hydatid disease of the liver from 1980-1990. There were 29 male and 22 female patients with a mean age of 10 years (range 3 to 15 years). Thirty-two cysts were located in the right lobe, 6 were in the left lobe and 13 were bilateral. Introflexion was carried out in 27 patients, omentoplasty in 12, marsupialization in 8, capitonnage in 3 and total cystectomy in one patient. There were no deaths. Postoperative morbidity and mean postoperative stay were the lowest in patients treated by introflexion. We concluded that introflexion is a safe and valid surgical technique for patients with hydatid liver disease.