Catheter-related atrial thrombosis: prevalence and risk factors in the pediatric age group—a retrospective study

Background

Catheter-related right atrial thrombosis (CRAT) is an under-studied complication of a long-term implantable venous access devices (IVAD), particularly in children with incidence rates extrapolated from the adult literature ranging between 2 and 29%. This is a single-center retrospective review of electronic medical records of children who underwent insertion of IVADs and had at least one echocardiogram performed prior to catheter removal between 2008 and 2018. Data collection included demographic information, development of CRAT, systemic infection, and administration of thrombogenic chemotherapeutic agents. We identified six patients who developed CRAT and compared them to 120 control patients. We also performed a detailed chart review for the patients who developed CRAT. Data was entered and analyzed using SPSS.

Results

A total of 764 patients underwent IVAD placement between 2008 and 2018. Six (0.79%) patients developed CRAT, and 120 patients were identified as controls that match the CRAT patients based on definitive criteria that include age, gender, chemotherapy type, steroid therapy, reason of line insertion, site of catheter insertion, tip-location at insertion, and history of systemic infections. In the CRAT group, 3 (50%) patients had their catheter tips placed in the superior vena cava-right atrial junction and 3 (50%) in the right atrium, whereas in the control group, all patients had their catheter tips placed in the superior vena cava-right atrial junction (p=0.000). Five (83.3%) patients in the CRAT group received L-asparaginase as compared to 75 (62.5%) patients in the control group (p=0.301). In the CRAT group, all patients had a history of systemic infection compared to 47 (39.2%) in the control group (p=0.180).

Conclusion

We identified 6 (0.79%) children with CRAT. Catheter-tip location within the right atrium is a potential risk factor for CRAT development in children.

HCV cure: an appropriate moment to reduce cannabis use in people living with HIV? (ANRS CO13 HEPAVIH data)

BACKGROUND

Thanks to direct-acting antivirals, hepatitis C virus (HCV) infection can be cured, with similar rates in HCV-infected and HIV-HCV co-infected patients. HCV cure is likely to foster behavioral changes in psychoactive substance use, which is highly prevalent in people living with HIV (PLWH). Cannabis is one substance that is very commonly used by PLWH, sometimes for therapeutic purposes. We aimed to identify correlates of cannabis use reduction following HCV cure in HIV-HCV co-infected cannabis users and to characterize persons who reduced their use.

METHODS

We used data collected on HCV-cured cannabis users in a cross-sectional survey nested in the ANRS CO13 HEPAVIH cohort of HIV-HCV co-infected patients, to perform logistic regression, with post-HCV cure cannabis reduction as the outcome, and socio-behavioral characteristics as potential correlates. We also characterized the study sample by comparing post-cure substance use behaviors between those who reduced their cannabis use and those who did not.

RESULTS

Among 140 HIV-infected cannabis users, 50 and 5 had reduced and increased their use, respectively, while 85 had not changed their use since HCV cure. Cannabis use reduction was significantly associated with tobacco use reduction, a decrease in fatigue level, paying more attention to one's dietary habits since HCV cure, and pre-HCV cure alcohol abstinence (p = 0.063 for alcohol use reduction).

CONCLUSIONS

Among PLWH using cannabis, post-HCV cure cannabis reduction was associated with tobacco use reduction, improved well-being, and adoption of healthy behaviors. The management of addictive behaviors should therefore be encouraged during HCV treatment.

Clinical Prognostic Factors and Outcome in Pediatric Osteosarcoma: Effect of Delay in Local Control and Degree of Necrosis in a Multidisciplinary Setting in Lebanon

PURPOSE

Outcomes in pediatric osteosarcoma have dramatically improved over the past few decades, with overall survival rates of 70% and 30% for patients with localized and metastatic disease, respectively.

PATIENTS AND METHODS

We retrospectively reviewed clinical characteristics and outcomes of 38 patients treated between 2001 and 2012 at a single institution in Lebanon. All patients received a uniform three-drug chemotherapy regimen consisting of cisplatin, doxorubicin, and methotrexate. Ifosfamide and etoposide were added to the adjuvant treatment regimen in case of metastatic disease and/or poor degree of tumor necrosis (< 90%).

RESULTS

After a median follow-up of 61 months (range, 8 to 142 months), patients with localized disease had 5-year overall and event-free survival rates of approximately 81% and 68%, respectively, whereas for metastatic disease, they were approximately 42%. The most common primary site was the long bones around the knee (n = 34; 89.5%). Six patients (15.8%) had metastatic disease to lungs, and three (7.9%) had synchronous multifocal bone disease with lung metastases. Adverse prognostic factors included nonlower extremity sites, metastasis, poor degree of necrosis, and delay of more than 4 weeks in local control. In bivariable analysis, only degree of necrosis was a prognostic predictor for survival and disease recurrence.

CONCLUSION

Treatment of pediatric osteosarcoma in a multidisciplinary cancer center in Lebanon resulted in survival similar to that in developed countries. Delay in local control was associated with worse outcome. The only statistically significant inferior outcome predictor was poor degree of necrosis at the time of local control.

Turkish version of body attitude test: Its reliability and validity

Introduction

Breast cancer (BC) may cause problems on body perception and awareness which can be perceived as a threat on body attitude among women with breast cancer.

Objectives

The Body Attitude Test (BAT) assesses subjective attitude toward women's own body.

Aim

The aim of the present study was to develop the Turkish version of the BAT and examine its reliability and validity.

Methods

The study group (SD) consisted of 72 women diagnosed with BC while 100 healthy women (HW). The women evaluated by BAT, Eating Disorder Inventory (EDI) and Self Esteem Inventory (SEI) in 7–10 days intervals. Internal consistency was determined with Cronbach's alpha coefficient. Factor analysis was conducted on BAT ratings given by control group.

Results

The mean age was 43.7 ± 8.76 of women with BC while 46.4 ± 10.84 in HW. Mean duration of cancer was 2.4 ± 0.7 years. Factor analysis showed BAT was composed of two factors as body dissatisfaction and lack of familiarity with one's body. The BAT demonstrates satisfactory level of internal reliability (α = 0.932). BAT was related with EDI subscales: drive for thinness (r = 0.741, P < 0.001), ineffectiveness (r = 0.736, P < 0.001) and body dissatisfaction (P = 0.718, P < 0.001) and SEI subscale: familial self-esteem (r = -0.629, P < 0.001).

Conclusion

The results support the validity and reliability of BAT which is able to differentiate the clinical and non-clinical form of subjective attitude toward women's own body. Turkish version of BAT could be used as an appropriate measure for assessing subjective attitude towards own body in women with and without breast cancer in Turkey.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Collaborative Pediatric Bone Tumor Program to Improve Access to Specialized Care: An Initiative by the Lebanese Children's Oncology Group

BACKGROUND

Children with malignant bone tumors have average 5-year survival rates of 60% to 70% with current multimodality therapy. Local control modalities aimed at preserving function greatly influence the quality of life of long-term survivors. In developing countries, the limited availability of multidisciplinary care and limited expertise in specialized surgery and pediatric radiation therapy, as well as financial cost, all form barriers to achieving optimal outcomes in this population.

METHODS

We describe the establishment of a collaborative pediatric bone tumor program among a group of pediatric oncologists in Lebanon and Syria. This program provides access to specialized local control at a tertiary children's cancer center to pediatric patients with newly diagnosed bone tumors at participating sites. Central review of pathology, staging, and treatment planning is performed in a multidisciplinary tumor board setting. Patients receive chemotherapy at their respective centers on a unified treatment plan. Surgery and/or radiation therapy are performed centrally by specialized staff at the children's cancer center. Cost barriers were resolved through a program development initiative led by St Jude Children's Research Hospital. Once program feasibility was achieved, the Children's Cancer Center of Lebanon Foundation, via fundraising efforts, provided continuation of program-directed funding.

RESULTS

Findings over a 3-year period showed the feasibility of this project, with timely local control and protocol adherence at eight collaborating centers. We report success in providing standard-of-care multidisciplinary therapy to this patient population with complex needs and financially challenging surgical procedures.

CONCLUSION

This initiative can serve as a model, noting that facilitating access to specialized multidisciplinary care, resolution of financial barriers, and close administrative coordination all greatly contributed to the success of the program.

Wilms tumor: Successes and challenges in management outside of cooperative clinical trials

OBJECTIVE/BACKGROUND

Management of Wilms tumor (WT) in children depends on a multidisciplinary approach to treatment, and outcomes have significantly improved as reported by cooperative group clinical trials. Here, we review the clinical outcomes of patients with WT and identify challenges and barriers encountered in multidisciplinary management outside of cooperative clinical trials.

METHODS

We retrospectively reviewed the clinical records of 35 children with WT treated between April 2002 and June 2013 at the Children's Cancer Institute in Lebanon.

RESULTS

Upfront resection was performed in 23 cases. Biopsies were performed for Stage V tumors (n=4), those with unresectable tumors or inferior vena caval thrombus (n=5), and patients who had partial surgery performed elsewhere prior to presentation (n=2). One patient died due to toxicity prior to surgery. The tumor was Stage I in eight patients, Stage II in five patients, Stages III and IV in nine patients each, and bilateral (Stage V) in four patients. Adherence to The National Wilms Tumor Study-5 recommendations was adequate. At the time of analysis, 30 patients were free of disease and four patients had relapse-all having metastatic disease initially.

CONCLUSION

The National Wilms Tumor Study-5 therapy resulted in favorable outcomes in children with nonmetastatic Wilms tumor in the setting of a multidisciplinary approach to therapy and resolution of financial barriers to medical care. Upstaging due to prior intervention and lung radiation therapy to all those with computed tomography-detected lung nodules may both have resulted in overtreatment of a subset of patients. Finally, the relatively high incidence of bilateral tumors suggests the need for further genetic and molecular studies in this patient population.

Outcome of Ewing sarcoma in a multidisciplinary setting in Lebanon

Treatment of Ewing sarcoma (ES) necessitates coordinated multi-disciplinary care. We analyzed outcome for 39 patients treated at a single institution in Lebanon, a developing country with available multidisciplinary treatment modalities, where financial barriers to care are overcome by a fundraising system. Median follow-up was 58 months. Five-year overall and event-free survival were 76% and 58%, respectively, for localized disease, and 40% and 38%, respectively, for metastatic disease. We conclude that, in a country with emerging economy, by following international protocols and ensuring availability of needed resources, outcome of patients with ES is similar to that in developed countries.

Left-sided appendicitis in children with congenital gastrointestinal malrotation: a diagnostic pitfall in the emergency department

Acute appendicitis is one of the most common conditions requiring emergency surgery. However, acute appendicitis presenting with left lower quadrant abdominal pain is extremely rare. Imaging, particularly CT , plays an important role in establishing an accurate and prompt diagnosis, as delay in diagnosis may occur due to lack of uniformity in the clinical signs and symptoms. We report a rare case of a 10-year-old boy who presented with persistent left lower quadrant pain of several days duration, in which the CT scan of the abdomen and pelvis was essential in establishing the correct diagnosis. The malpositioned inflamed appendix was clearly identified in the left side of the abdomen, with the characteristic CT findings of uncomplicated intestinal malrotation. Left-sided acute appendicitis should be considered in the differential diagnosis of young patients presenting with left lower quadrant pain, in order to avoid delay in diagnosis and guide the surgical intervention.

Intestinal polypoid arteriovenous malformation: unusual presentation in a child and review of the literature

AIM

We report a jejuno-jejunal intussusception with a polypoid arteriovenous malformation as a lead point in a 12-year-old boy, presenting with lower abdominal pain and non-bloody non-projectile vomiting.

METHODS

A computed tomography scan of the abdomen and pelvis showed proximal jejuno-jejunal intussusception in the right upper quadrant. Exploratory laparotomy revealed a 5.5 × 2.5 × 2 cm polypoid mass within the wall of the jejunum. Consequently, jejunal segment resection was performed with end to end jejunostomy. Our case is distinctive because it involves a rare vascular lesion at an atypical site, the jejunum, in a child with an unusual presentation of intussusception treated surgically.

CONCLUSION

Many paediatric benign and surgical conditions present with similar clinical symptoms; the physician in the emergency department should try to narrow the differential diagnosis and recognize surgical emergencies to avoid any delay in intervention that could be life-threatening.

Limb salvage surgery for children and adolescents with malignant bone tumors in a developing country

PURPOSE

To describe the 5-year experience of a multidisciplinary limb salvage program for children and adolescents with malignant bone tumors in Lebanon.

PATIENTS AND METHODS

Between January 2002 to February 2007, 30 children and adolescents (2 with Ewing sarcoma and 28 with osteosarcoma) underwent Limb Salvage Surgeries (LSS) at the American University of Beirut Medical Center after partnering with the multidisciplinary team at St. Judes Children's Research Hospital (SJCRH). Procedures performed included 12 Repiphysis, noninvasively expandable, prostheses inserted in skeletally immature children, 15 modular prostheses, 2 allografts and 1 rotationplasty. All patients received pre- and postoperative chemotherapy.

RESULTS

With a mean follow-up of 31 months, 20 patients are now off therapy, 4 died, and 6 are receiving chemotherapy (3 due to pulmonary recurrence). Complications of surgery included infections in three cases, failure of the expansion mechanism in two, femoral stem fracture in one, prostheses femoral stem loosening in one and wound dehiscence in one. Lengthening of Repiphysis prostheses was achieved by subjecting the limb to an electromagnetic field that would allow controlled release of the Repiphysis expansion mechanism. Ten patients underwent a total of 42 lengthening procedures with an average of 9 mm lengthened per procedure (range 2-15 mm). All patients have good function of the affected limb.

CONCLUSION

Our LSS results are comparable to those reported in the literature. Collaboration with SJCRH and fund raising were critical to the program's success. This endeavor could serve as a model for establishing LSS programs in developing countries.

Solid pseudopapillary neoplasm of the pancreas in a 12-year-old female: case report and review of the literature

Solid pseudopapillary neoplasms of the pancreas (SPNP) are rare pancreatic tumors that occur predominantly in young women, with very few cases reported in men. While the origin of the tumor may be unclear, it is characterized by a distinct histological appearance and a clinical course highlighting its low malignant potential. SPNP have an excellent prognosis and are potentially curable provided they are managed appropriately by complete surgical resection. In the rare instances where metastatic disease is encountered, surgical debulking has been shown to prolong survival. The role of chemotherapy and radiation therapy in the management of SPNP is still controversial. We report here on an unusual occurrence of SPNP in the area of the head of the pancreas in a 12-year-old female treated by pancreatico-duodenectomy, together with a review of the literature.

Gallstone pancreatitis in children: atypical presentation and review

Pancreatitis in children is less common than in adults and is mostly related to trauma, infection and anatomical anomalies. Gallstone pancreatitis is an even rarer entity in infants and children. We present an unusual case of gallstone pancreatitis in a 17- month-old girl who presented with jaundice of 1 month duration. The laboratory studies showed conjugated hyperbilirubinaemia with associated acute pancreatitis and pseudo-hyponatraemia secondary to the markedly elevated lipid profile. Further evaluations revealed obstruction at the Ampulla of Vater with no evidence of a choledochal cyst and no mass lesion seen in the pancreas. The patient initially underwent urgent decompressive cholecystostomy with intraoperative cholecystography. When the biochemical parameters improved, the patient underwent formal cholecystectomy with common bile duct exploration, extraction of multiple impacted stones in the ampullary region and Fogarty balloon sphincterotomy. The post-operative course was uneventful.

CONCLUSION

Acute gallstone pancreatitis in children may present as jaundice or abdominal pain. Recognition, early diagnosis and surgical intervention are the mainstay for a good outcome.

Acute respiratory distress associated with external jugular vein catheterization in the newborn

We report on the acute onset of respiratory distress secondary to fluid accumulation in the chest within hours of placement of an external jugular venous line in a newborn. External jugular venous catheterization in the newborn is a procedure with potentially serious complications, and should be avoided unless the patient is monitored closely.

Efficiency of interphase fluorescence in situ hybridization for BCR/ABL on peripheral blood smears for monitoring of CML patients: a comparison with bone marrow findings

Conventional cytogenetic analysis (CCA) is the standard method for monitoring of the Philadelphia (Ph) chromosome in chronic myeloid leukemia (CML). Evaluation of breakpoint cluster region/abelson murine leukemia (BCR/ABL) fusion using interphase fluorescence in situ hybridization on peripheral blood smears (PB-FISH) might be another approach allowing more frequent and less invasive follow-up investigations. Herein, BCR/ABL fusion gene was assessed on 21 PB smears from 16 CML patients in chronic phase. Results of PB-FISH were compared with those of CCA and interphase FISH on bone marrow aspirates (BM-FISH). PB-FISH analysis was combined with CD3 immunophenotyping that allowed simultaneous investigation of the leukemic status of CD3(+) T lymphocytes and scoring CD3(-) cells for BCR/ABL fusion gene. Moreover, the frequency of BCR/ABL fusion in nonlymphoid PB cells was estimated according to the differential leukocyte counts. The incidence of BCR/ABL(+) fusion signals in CD3(+) T cells of CML patients was 5.3% (SD +/- 1.9) and did not exceed the normal cut-off value of 8%. A significant correlation (P < 0.001) was found between results of PB-FISH and methods of BM analysis (CCA or BM-FISH). Correction of PB-FISH results to include only nonlymphoid or CD3(-) cells reduced the mean of differences and improved agreement between PB-FISH and CCA or BM-FISH methods. The best agreement was noted between CCA and PB-FISH on nonlymphoid cells. On the other hand, results of BM-FISH agreed well with those of PB-FISH on CD3(-) cells. These findings imply that PB-FISH on nonlymphoid or CD3(-) cells is reliable and may replace BM analysis for monitoring of response to treatment in CML patients.

Treatment of anemia in low-risk myelodysplastic syndromes with amifostine. In vitro testing of response

Amifostine (AMF) promotes in vitro growth and survival of hematopoietic progenitors. In this study we evaluated the efficacy of AMF in the treatment of anemia in patients with low-risk myelodysplastic syndromes (MDS) and the possible predicting value for response to AMF therapy of two types of in vitro clonogenic assays. Two different doses of AMF, 300 mg/m2 (group A, 11 patients) or 400 mg/m2 (group B, 16 patients), were studied. AMF was given three times weekly for 3 weeks, i.v., followed by 2 weeks off therapy. Patients were evaluated after two cycles of treatment. Partially or nonresponding patients of group A received 400 mg/m2 AMF and were reevaluated. An increase of hemoglobin (Hb) values of more than 2 g/dl and a 100% decrease in transfusion requirements for at least 6 weeks were defined as a complete response (CR) while an increase of Hb values of 1-2 g/dl or a 50% decrease in transfusion requirements was considered as a partial response (PR). In group A, two out of 11 (18.1%) patients achieved a CR with the initial dose and one of the nine that received 400 mg/m2 AMF achieved a PR. In group B, three out of 16 (18.7%) patients achieved a PR; the overall response rate in both groups was 22.2%. In group A, bone marrow progenitor assay was performed pre- and post-amifostine treatment. Erythroid burst-forming units (BFU-E) were increased in six out of 11 (54.5%) patients, and this increase preceded the rise in Hb levels in three of them. In group B, a clonogenic assay was performed in 11 out of 16 patients before AMF treatment. In vitro results after pretreatment with 500 microM amifostine confirmed the response of two MDS patients that achieved a PR. No response in vitro was observed in all eight nonresponding patients and in one PR patient. The lack of response in the clonogenic assays predicted for nonresponse to treatment with a predictive power of 91.8%. We conclude that 300 mg/m2 is an adequate initial treatment for low-risk MDS patients and both clonogenic assays have a strong predicting value for response to treatment.

Valproic acid, trichostatin and their combination with hemin preferentially enhance gamma-globin gene expression in human erythroid liquid cultures

BACKGROUND AND OBJECTIVES

In addition to conventional therapy, current treatment of thalassemia and sickle cell anemia includes inducers of hemoglobin F synthesis (hydroxyurea, erythropoietin, azacytidine and butyrate). However, because of concerns about the dose-limiting myelotoxicity, potential carcinogenicity and high cost of the above agents, an intensive search for less toxic or more effective drugs is ongoing. In this study we tested the effect of valproic acid and trichostatin, alone or in combination with hemin, on gamma chain synthesis in human erythroid liquid cultures.

DESIGN AND METHODS

The agents were tested on erythroid human liquid cultures derived from normal peripheral blood, peripheral blood from beta(s)/beta(thal) patients, normal cord blood and normal bone marrow samples. The effect of the agents was expressed as increase of gamma/gamma+beta m-RNA, measured with competitive reverse transcriptase-polymerase chain recation (RT-PCR), or as increase of HbF, measured by high performance liquid chromatography (HPLC).

RESULTS

Addition of valproic acid or trichostatin to human erythroid cell cultures preferentially enhanced gamma mRNA synthesis in all blood samples (2.9 to 3.5-fold). The addition of hemin enhanced the effect up to 10-fold.

INTERPRETATION AND CONCLUSIONS

Valproic acid, trichostatin and their combination with hemin (all three FDA-approved drugs) preferentially increase gamma-globin chain synthesis and may be helpful for the treatment of hemoglobinopathies.

Multiple ipsilateral congenital diaphragmatic pathologies: rarities to consider

BACKGROUND

Bilaterality of congenital diaphragmatic pathologies is well documented in the English literature. Nevertheless, ipsilateral simultaneous congenital diaphragmatic pathologies, though rare, are worth revisiting to shed more light into their embryology and management.

METHODS

A review of the literature for reported cases of multiple ipsilateral congenital diaphragmatic pathologies was performed. Their findings, management and outcomes were classified and reviewed, in addition to reporting and comparison with a new case from our medical center.

RESULTS

Two patients were adult females with multiple defects in the right central tendon of the diaphragm. The remaining four were all pediatric cases. Two had double congenital hernial defects on the same side and two had the defect associated with ipsilateral diaphragmatic eventration. Our case is the third one with diaphragmatic eventration, but the first being associated with a posterolateral defect on the same side. Its presentation with acute rectal bleeding proved difficult to diagnose.

CONCLUSION

There are various postulated theories concerning the pathogenesis of ipsilateral pathologies during embryologic development of the diaphragm. Management of asymptomatic congenital eventrations remains debatable. However, when symptoms become apparent, ipsilateral defects though rare, should be considered and prompt surgical management through a thoracotomy or laparotomy approach is recommended.

Evaluation at single cell level of residual Philadelphia negative hemopoietic stem cells in chronic phase CML patients

In chronic myeloid leukemia, accurate determination of Ph(-) Hemopoietic stem cells (HSC) in peripheral blood (PB), bone marrow (BM) and leukapheresis products is important for the selection of patients for whom mobilization, collection, and autografting of Ph(-) HSC are envisaged. To this effect, the BCR/ABL fusion was assessed at the single cell level in 25 sets of PB and BM samples using dual-color I-FISH in immunophenotyped CD34(+) cells and RT-PCR of individual CFU-GM colonies. In 15 cases found to be 100% Ph(+), the respective BCR/ABL gene was absent in 30% of CD34(+) cells, while the respective transcripts could not be identified in 17% of CFU-GM. The mean percentage of BCR/ABL(-) CD34(+) cells and CFU-GM cells was higher (38% and 29%, respectively) in untreated patients than in treated patients (24% and 7%, respectively). In eight cases with cytogenetic response (CgR), the percentage of Ph(-) metaphases correlated with the level of BCR/ABL(-) colonies in BM and PB and with the proportion of BCR/ABL(-) CD34(+) cells in the BM. Immunophenotyping and FISH was fast, easy, always informative, and quantitative for the BCR/ABL(-) CD34(+) cells. Our results show that (a) at early diagnosis a high frequency of BCR/ABL(-) HSC circulate in the PB and that Ph(-) hematopoiesis is not completely suppressed; (b) although normal clonogenic cells decline rapidly within a few months after diagnosis, appreciable numbers of normal CD34(+) cells survive in chronic phase, especially in patients with CgR.

Aspergillus vertebral osteomyelitis in a child with a primary monocyte killing defect: response to GM-CSF therapy

We report the first case of vertebral aspergillosis in a child with a primary defect in monocyte killing, an extremely rare immunodeficiency The diagnosis of defective monocyte killing was made by an in vitro assay that showed normal killing of Staphylococcus aureus by the patient's neutrophils but impaired killing by his monocytes. Importantly, the extensive granulomatous infection that involved the vertebral column, posterior mediastinum, pleura, and lung was not responsive to aggressive treatment with a combination of liposomal amphotericin B. intralesional amphotericin B. itraconazole, and granulocyte transfusions. Dramatic clinical and radiological improvement was only seen after the addition of granulocyte macrophage-colony stimulating factor (GM-CSF) to his treatment regimen. The use of GM-CSF in the treatment of invasive aspergillosis in immunocompromised patients requires further evaluation.

Urinary retention secondary to müllerian duct remnant in an infant

To date only 2 cases of urinary retention secondary to a müllerian duct cyst have been reported in infancy. We report a third case of bladder outlet obstruction caused by massive dilatation of persistent müllerian remnant in a 2 month old boy, the youngest to date. Surgical intervention was done because patient continued to have retention following conservative management. The cyst was large, located in the midline, and was associated with an absent left kidney.

Abdominal situs inversus with congenital duodenal stenosis: rare association

Abdominal situs inversus carries a significant mortality because the majority of cases (95 %) have associated cardiac and splenic defects. A review of all cases reported in the English literature confirms in addition the presence of significant gastro-intestinal pathologies, mainly annular pancreas, midgut volvulus and duodenal atresia. We report on an additional case of abdominal situs inversus without cardiac or splenic abnormalities, who had partial duodenal obstruction secondary to a mucosal diaphragm. This seems to be the thirteenth case associated with duodenal obstruction and the sixth case secondary to a mucosal duodenal diaphragm, to date, in this setting.

Congenital diaphragmatic hernia and eventration

A review of 52 consecutive cases of congenital diaphragmatic hernia composed of 36 cases of Bochdalek hernia (B.H.) 13 of diaphragmatic eventration (D.E.), and 3 of diaphragmatic agenesis (D.A.) is reviewed critically. The operative mortality rate in Bochdalek hernia was 8.3% but became 20% with reference to the 15 infants with B.H. operated in the first 24 hrs. of life and 31.5% with reference to all 19 infants requiring repair of the diaphragmatic defect during the first day after birth. The operative mortality in D.A. was 100% and was nil in D.E. The mortality appeared related directly to prematurity, early age at operation, preoperative hypoxemia (PaO2 less than or equal to 60), hypercarbia, (PaCO2 greater than or equal to 60), and acidosis (pH less than or equal to 7.0), association with life-threatening anomalies affecting the lungs and its vessels, the heart, the size of the diaphragmatic defect and of the celomic cavity, the postoperative development of NEC and of obstructing intestinal adhesions. Eight of the 33 survivors (24%) with B.H. developed intestinal obstruction secondary to adhesions 2 months to 14 years after operation, of whom 7 required surgical intervention, and 3 bowel resections. The total mortality rate in B.H. was 14% and the rate in this series of combined defects was 15%.

Injuries to vessels of neck

A personal experience at the American University Medical Center with vascular neck injuries occurring between May and December 1976 is reported. Five unusual cases are presented and discussed, their ages ranging between 10 and 25 years. The causative agent was shrapnel in four and bullet in one. Four of the five cases had multiple associated injuries. The vessels involved were the carotid artery with internal jugular vein in two cases, the subclavian vein in one, the superior thyroid artery in one, and the carotid and vertebral arteries in one. The treatment consisted of a combined cervico-thoracic approach in two cases, a claviculectomy in one, suture-ligation and aneurysmectomy in four and venous graft to the artery in one. The complications consisted of postoperative bleeding in one case, partial facial nerve paresis in another, and superficial wound infection in a third. No deaths occurred among the five complicated cases presented.

Double zonal aganglionosis in long segment Hirschsprung's disease with a "skip area" in transverse colon

The case of an infant with Hirschsprung's disease involving the rectum, entire colon, cecum, appendix, terminal ileum and sparing the midtransverse colon is described. The purpose of the report is to submit an additional illustration of this rarely documented aspect of intestinal aganglionosis.