Assessment of interpretation of paediatric skeletal radiographs in the emergency room

AIM

To assess the performance of paediatric skeletal radiography interpretation in the emergency department.

MATERIALS AND METHODS

In a large paediatric referral centre, data from trauma patients with initially misdiagnosed skeletal radiography was collected from October 2014 to June 2015. Data analysis focused on demographic data, region of the injury and clinical consequences as well as outcome of treatment.

RESULTS

In 125 of 2,316 patients aged from 1-17 years an initial misdiagnosis was documented (5.4%). Misdiagnosis was detected and corrected the next day in a routine review attended by an experienced paediatric radiologist. False-negative interpretation (missed fracture) was found in 62 and false-positive (overdiagnosis) interpretation in 63 patients. The highest error rate was found in elbow radiography (12%) followed by wrist (8%), fingers (4.5%), metacarpus (4.2%), and toes (3.5%). The most frequently missed fracture was supracondylar elbow fracture (n=12). In case of initially missed fractures treatment was adjusted delayed the next day. In none of these patients, were repositioning or open surgical procedures necessary. No misdiagnosis resulted in additional morbidity.

CONCLUSION

Misinterpretation of paediatric skeletal radiography by paediatric emergency physicians occurred frequently. The majority of diagnostic errors occurred in a few regions. None of these misdiagnoses negatively affected patients' health. A routine review by an experienced paediatric radiologist is mandatory, but may suffice the next day.

Ileostomy Complications in Infants less than 1500 grams - Frequent but Manageable

Background: In very low birth weight infants abdominal emergency surgery may result in ileostomy formation. We observed a frequent stoma complications in these patients. This retrospective analysis put light on ileostomy-related problems and complications in very low birth weight (VLBW) infants.

Materials and Methods: In a seven-year retrospective chart review (2008 - 2014) infants with ileostomy formation weighing less than 1500 grams at time of operation were identified and reviewed. Data analysis included demographic data, complications and short term outcomes.

Results: Thirty patients were included. Ileostomy was formed for spontaneous intestinal perforation (SIP) (n=17), meconium obstruction of prematurity (MOP) (n=6), midgut volvulus (MV) (n=5), necrotizing enterocolitis (NEC) (n=1) and Hirschsprung’s disease (HD) (n=1). Three patients died before ileostomy reversal was considered. In seven patients planned ileostomy reversal was done. Twenty infants had stoma related complications (stoma prolapse, prestomal obstruction, stoma retraction, high output stoma, peristomal skin excoriation, and stomal ischemia). Complications did not correlate with underlying diseases. Stomal complications necessitated earlier stoma reversal (mean 62 days). Postoperative complications after stoma reversal occurred in three children (wound dehiscence, adhesion ileus, anastomotic stricture).

Conclusions: Although ileostomy related complications are frequent in very low birth weight infants, mortality is low. Morbidity is manageable.

Videofluoroscopy of deglutition in children after repair of esophageal atresia

Purpose: To evaluate the functional disorders of the oral and pharyngeal phases of deglutition after repair of esophageal atresia in children.

Material and Methods: 19 children (10 girls, 9 boys, mean age 22 months) underwent videofluoroscopy of deglutition after repair of esophageal atresia. The videofluoroscopic studies were assessed according to functional and morphological changes in the oral, pharyngeal and esophageal phases. The persistence of radiologic findings on videofluoroscopy was determined.

Results: The oral phase was normal in all patients. The main functional disorder of the pharyngeal phase was aspiration in 7 (37%) children. A completely normal deglutition in the pharyngeal and esophageal phases was not seen in any patient.

Conclusion: Videofluoroscopy after repair of esophageal atresia is helpful in differentiation of functional and morphological disorders that can lead to prandial aspiration and have an influence on the decision about continued therapy.

Sinus sternoclavicularis: a congenital cervical sinus

We try to characterize a previously rather neglected congenital cervical sinus located in the sternoclavicular area in five children. This sinus showed extension to the left sternoclavicular joint in all patients, so we call this congenital lesion "sinus sternoclavicularis." With knowledge of this congenital lesion, diagnosis can easily be established based on case history and clinical examination; no further radiological tests are required. Surgical excision is the treatment of choice. The chance of recurrence seems to be high because of misinterpretation of the lesion.

Haemoptysis in a teenager: late diagnosis of unnoticed foreign body aspiration

Chest X-ray in a 17-year-old boy, presenting with haemoptysis, revealed a radiopaque foreign body (FB) in the right lower lobe. There was no history of aspiration. CT located the needle-shaped FB in the right posterobasal lower lobe segment bronchus. In bronchoscopy, the FB turned out to be a pin, of which the radiolucent plastic head was embedded in the peribronchial tissue. Extraction by flexible and rigid bronchoscopy failed; finally, thoracotomy and bronchotomy had to be performed to remove the pin. In delayed diagnosis of a tracheobronchial FB, CT scan is not only necessary to localise the FB but also to depict or rule out secondary pulmonary changes. Nevertheless, radiolucent components of a metallic FB might be invisible even in CT, leading to underestimation of its size and extension. Late diagnosis complicates removal of tracheobronchial foreign bodies and may even necessitate open surgery, including pulmonary resections.

Early postnatal diagnosis of Costello syndrome

Costello syndrome is a rare congenital disease with typical craniofacial and musculoskeletal features, cutaneous lesions, cardiac defects and cancer susceptibility. Affected patients show severe feeding difficulties for the first years of life and developmental delay. We present the case of a patient, in whom fetal tachycardia, polyhdramnios and physical characteristics led to an early diagnosis of Costello syndrome. Based on this patient we describe challenges and problems of therapeutic management of infants with Costello syndrome.

Perinatal neuroblastoma of the pancreas

Neuroblastoma is the most common solid tumor in infancy. Arising from the neural crest these tumors are usually located along the sympathetic chain from the neck to the pelvis and in the adrenal medulla. We report the case of a 3-week-old boy presenting with recurrent episodes of colicky pain. After ultrasound examination, magnetic resonance imaging and laboratory data a pancreatic neuroblastoma was suspected. Tumor resection via distal pancreatectomy and histologic investigation confirmed the diagnosis. Surgery is the treatment of choice in children with pancreatic masses, and is usually well tolerated even in the neonatal period. Conclusive diagnosis can be frequently established only by tumor resection or biopsy. Pancreatic neuroblastoma is an extremely rare tumor with only a few cases described in literature.

[Closing gastroschisis: a distinct entity with high morbidity and mortality]

PURPOSE

We correlate severe bowel damage in gastroschisis to the rare intrauterine event of narrowing of the abdominal wall around the protruding intestines. We describe this "closing gastroschisis" as a distinct entity. Prenatal ultrasound findings as gastric or bowel dilation were compared to the postnatal findings in order to find markers for an early in utero diagnosis of closing gastroschisis. Early diagnosis could prompt timely delivery to save the compromised bowel and avoid short gut syndrome.

MATERIALS AND METHODS

We documented the pre- and postnatal course of our patients with gastroschisis from 2007 to 2009.  Closing gastroschisis was suspected antenatally and confirmed postnatally. We identified 5 out of 18 patients showing closure of the abdominal wall with varying degrees of bowel damage. Prenatal ultrasound findings were correlated to the postnatally confirmed extent of intestinal damage.

RESULTS

We could not find consistent ultrasound markers for prenatal diagnosis of closing gastroschisis. In prenatal ultrasound three patients presented significant gastric dilation and then experienced severe courses postnatally due to segmental gut necrosis. One of these three died and the other two developed short gut syndrome. In one case progressive intraabdominal loop dilation with simultaneous shrinking of the extraabdominal loops occurred corresponding to closing gastroschisis with segmental midgut necrosis.

CONCLUSION

Closing gastroschisis must be seen as a special form of gastroschisis. Extended intestinal damage is often life-threatening. In longitudinal observation dynamics of fetal ultrasound findings can lead to the diagnosis of closing gastroschisis. Progressive intraabdominal loop dilation is always highly suspicious and must lead to close follow-up and timely delivery.

Altered consciousness and lethargy from compromised intestinal blood flow in children

Altered state of consciousness and lethargy could be early and cardinal complaints in diseases that actually originate within the abdomen. Thirteen children were seen at our departments in whom impairment of the individual's mental state preceded the appearance of common gastrointestinal symptoms. Whereas in infants with intussusception of childhood neurological signs and symptoms have been rarely mentioned, references to an altered state of consciousness and lethargy in volvulus, strangulation or bowel incarceration have not been previously reported. Recognition of this possibility, however, should be taken into account in the diagnostic work-up of children presenting with inexplicable alterations of their mental state.

Imaging of the scrotum in children

Clinical examination of the scrotum is difficult due to the small size of the testes and the epididymis in infants and young children, and eliciting patients' history is challenging. Therefore imaging of the scrotum in childhood bears great importance. Ultrasound is the standard imaging technique of choice providing the clinicians with a definitive diagnosis in most cases. However, in conditions of testicular torsion and epididymoorchitis--the most common differential diagnosis of scrotal pain--ultrasound findings can be inconclusive and further evaluation is required. Since there is a large overlap between paediatric and adult pathology, differences from adults in anatomy and pathology must be considered when evaluating the paediatric scrotum.

Cervicofacial lymphadenitis due to atypical mycobacteria: a surgical disease

Despite the increasing prevalence of cervicofacial lymphadenitis due to atypical mycobacteria (AMB) in children, the true nature of AMB infection in clinical practice is poorly understood. The purpose of our study was to define the most common signs and symptoms, and to establish a workable scheme of diagnosis and treatment. Patients fulfilling the criteria of AMB infection (i.e., clinical signs, positive cultures or polymerase chain reaction, histologic features) were included in the study. All children underwent a standard surgical procedure, depending on pretreatment and the course of the disease. Sixteen infants presented with characteristic unilateral lymphadenopathy predominantly involving the submandibular area (13/16). Eight children had been initially treated at various institutions by fine-needle puncture or incision, and 7 of the 16 patients had received antituberculous multidrug treatment for a varying length of time. Complete excision of the affected lymph nodes was the definitive treatment in all patients. Three children had transient marginal mandibular nerve paralysis that resolved within a few months in all cases. Recognition of the characteristic features of AMB adenitis may permit early diagnosis and appropriate surgical treatment.

Longitudinal observation of antenatally detected congenital lung malformations (CLM): natural history, clinical outcome and long-term follow-up

OBJECTIVE

The objective of the study is to present longitudinal observations in antenatally detected congenital lung malformations (CLM), particularly pulmonary sequestration (PS) and cystic adenomatoid malformation (CAM).

METHODS

Fetuses found to have a CLM on prenatal ultrasound (US) were included in this study and followed up until delivery. In all newborns radiographs and computerized tomography (CT) studies of the thorax were performed. Surgical procedures included sequesterectomy, lobectomy, segmentectomy, and non-anatomic resection. Based on prenatal US findings, intrauterine course, postpartum chest radiographs and CT scans, as well as clinical signs and surgical findings patients were divided into six groups.

RESULTS

Over a period of 6 years, routine prenatal US revealed suggestion of CLM in a series of 35 consecutive fetuses. In six cases pregnancy was terminated or the fetuses suffered fetal demise. Another four fetuses became symptomatic in utero when sequential scanning revealed hydrops, hydrothorax, and enlargement of cysts or polyhydramnios. Three cases in this group received serial therapeutic amniocentesis and serial puncture of either the hydrothorax or intrapulmonary cysts. After postpartum treatment in the intensive care unit surgical procedures were performed uneventfully and confirmed the diagnosis of CAM, PS or hybrid type lesions. In 11 patients US findings were considered to demonstrate spontaneous resolution of the lesion, but disappearance without sequelae could be confirmed only in six infants. Five infants were shown to have persistent CLM on postpartum CT scans. These infants underwent resection of the lesion within the first year of life. In 11 fetuses CLM were continuously demonstrated during pregnancy with only slight changes in size and structure. Postpartum the infants were asymptomatic and were subjected to a systematic plan of diagnostic work-up and treatment. Surgery in these infants revealed a large number of hybrid type lesions (n=5). In three infants, the primary diagnosis of PS or CAM had to be corrected during the diagnostic and therapeutic work-up.

CONCLUSION

CLM are diagnosed antenatally with an increasing frequency and are shown to be quite different from previously applied concepts. The expected clinical outcome is far better than thought to be possible.

Fetal liver magnetic resonance imaging in anterior body wall defects: a study of specimens from the museum of pathology

PURPOSE

The purpose of the study was to evaluate the appearance of liver anatomy in fetuses with complex anterior body wall defects (ABWD) using magnetic resonance imaging (MRI).

METHODS

Nineteen specimens from the National Museum of Pathological Anatomy (Vienna) with a wide range of ABWD were studied on a 1.5-T MR scanner (T1- and T2-weighted sequences) with special focus on the liver and the relationship between the large lesion and the adjacent structures.

RESULTS

The contrast of T2-weighted sequences was superior to that of the T1-weighted images. The liver was found in an intraabdominal location in 3 cases and in a completely extraabdominal location in 11 fetuses. Five fetuses had a very special configuration or position of the liver. Furthermore, the images showed an anteriorly located confluence of hepatic veins into the inferior vena cava in 5 specimens. Associated malformations of the complexly structured malformations involved the urogenital tract, the central nervous system (CNS), the cardiac system and the musculoskeletal system. Prenatal fast magnetic resonance imaging (MRI) in one fetus confirmed the liver in a both inside/outside position, whereas the diagnosis at fetal ultrasound scan (US) in this case had been uncertain.

CONCLUSIONS

These results show that MRI may play an important part in antenatal diagnosis of ABWD, complementary to prenatal US. Prenatal fast MRI should be considered if fetal US yields ambiguous findings.

Blutung in ein kavern�ses retroperitoneales Lymphangiom nach stumpfem Bauchtrauma

The case of a 12-year-old boy with hemorrhage into a previously unknown retroperitoneal lesion following blunt abdominal trauma is reported. Diagnostic work-up of a post-traumatic surgical acute abdomen revealed a giant multicystic tumor in the retroperitoneum, which could be completely removed. Histological examination confirmed the suspected diagnosis of congenital lymphangioma. Attention should be drawn to the possible coincidence of trauma and a preexisting asymptomatic lesion. Knowledge of the characteristic ultrasonographic and computer tomographic features is essential in order to make a correct diagnosis.

[MR imaging in congenital complicated anterior body wall defects]

INTRODUCTION

Aim of this study was to estimate the value of postmortem MR imaging in evaluation of specimen with congenital anterior body wall defects of the museum of pathologic-anatomy.

MATERIAL AND METHODS

We examined 19 specimen with a 1.5 Tesla unit by using T 1 - and T 2 -weighted sagittal and coronal sequences. In some specimen additional axial T 2 -weighted images were obtained. We evaluated the site of the bowel, the liver, the heart and presence of associated disorders.

RESULTS

The bowels were completely intraabdominal, in two specimen, completely extraabdominal in 12 specimen and in 5 specimen intra- and extraabdominal. The liver was in two specimen completely extraabdominal/ in 12 completely intracorporal, and in 5 specimen intra- and extraabdominal. In 5 cases the heart was located extraanatomically. In 12 specimen we found disorders of the spine and the extremities. Congenital disorders of the kidneys were found in 6 specimen.

CONCLUSION

MR imaging is of great value in the assessment of congenital anterior body wall defects. In the light of ultrafast sequences the role of fetal MR imaging in the evaluation of congenital body wall defects may be mandatory in the future.

Severe liver haemorrhage during laparotomy in very low birthweight infants

A review is presented of severe liver haemorrhage as a serious complication in surgery on very low birthweight (VLBW) infants. Clinical data and pathological findings, as well as the outcome of the treatment, of five VLBW infants (<1000 g) who experienced liver haemorrhage during surgical exploration for necrotizing enterocolitis or spontaneous intestinal perforation were reviewed retrospectively. At the time of surgery, all infants had signs and symptoms of impending sepsis. The bleeding was predominantly "spontaneous" without obvious iatrogenic liver damage. In three infants, severe liver haemorrhage could be stabilized by early liver tamponade using absorbable thrombostatic sponges and polyglactin mesh.

CONCLUSION

Intraoperative liver haemorrhage potentially life-threatening complication of surgery in preterm infants, which is not frequently investigated. Immediate perihepatic liver packing may be used to achieve adequate bleeding control.

Spontaneous localized intestinal perforation in very-low-birth-weight infants: a distinct clinical entity different from necrotizing enterocolitis

BACKGROUND

Idiopathic spontaneous intestinal perforation (SIP), a distinct clinical entity different from necrotizing enterocolitis (NEC), has an increasing prevalence in very-low-birth-weight infants. The aims of our study were to define patient characteristics and potential risk factors for premature infants with SIP compared with infants subjected to surgical treatment for NEC.

STUDY DESIGN

The medical records of 29 premature infants with either SIP (n = 13) or NEC (n = 16) were reviewed retrospectively.

RESULTS

Infants who experienced SIP were smaller at birth, had lower Apgar scores, and required more intensive neonatal resuscitation. An increased rate of premature rupture of membranes in infants with SIP (8/13 versus 6/16) was not associated with a higher rate of infection in mothers or infants. The onset of illness in SIP was significantly earlier than in NEC (p = 0.022). In contrast to patients with NEC (7/16), 11 of 13 patients in the SIP group had received indomethacin (p = 0.02). Bluish discoloration of the abdomen (8/13), a gasless abdomen (8/13), and the absence of pneumatosis intestinalis (0/13) were further significant markers in infants with SIP. At operation, SIP was always located in the terminal ileum in an antimesenteric position (13/13), and the remaining bowel appeared grossly normal. In most cases of SIP (10/13), the histologic investigation revealed an area of hemorrhagic necrosis without the typical coagulation necrosis seen predominantly in NEC.

CONCLUSIONS

Based on clinical presentation and radiologic and intraoperative findings, SIP is a distinct pathologic entity in very-low-birth-weight infants and can be differentiated from classic NEC. Detected early, SIP can be treated by simple procedures (sutures, or resection and primary anastomosis) with a low rate of morbidity and mortality.

Ureteropelvic junction disruption following blunt abdominal trauma

We report here on a case of avulsion of the ureteropelvic junction in a 7-year-old boy who was injured in a car accident. Severe brain trauma took precedence over signs and symptoms of blunt abdominal trauma, but 24 hours after the accident, progressive distension of the abdomen required further evaluation. Ultrasound examination and a computed tomography scan revealed disruption of the ureteropelvic junction. Simple primary anastomosis was performed. We discuss the characteristics of this unusual injury and include a review of the literature.

Videofluoroscopy of deglutition in children after repair of esophageal atresia

PURPOSE

To evaluate the functional disorders of the oral and pharyngeal phases of deglutition after repair of esophageal atresia in children.

MATERIAL AND METHODS

19 children (10 girls, 9 boys, mean age 22 months) underwent videofluoroscopy of deglutition after repair of esophageal atresia. The videofluoroscopic studies were assessed according to functional and morphological changes in the oral, pharyngeal and esophageal phases. The persistence of radiologic findings on videofluoroscopy was determined.

RESULTS

The oral phase was normal in all patients. The main functional disorder of the pharyngeal phase was aspiration in 7 (37%) children. A completely normal deglutition in the pharyngeal and esophageal phases was not seen in any patient.

CONCLUSION

Videofluoroscopy after repair of esophageal atresia is helpful in differentiation of functional and morphological disorders that can lead to prandial aspiration and have an influence on the decision about continued therapy.

[The intrauterine rupture of the fetal bladder as a complication of low urinary tract obstruction]

Lower urinary tract obstruction in fetuses causes megacystis, megaureter and hydronephrosis. The spontaneous rupture of the fetal bladder represents a rare complication in cases of total bladder outlet obstruction. We report about two different cases, present pre- and postnatal therapeutic regimes and discuss the possibility of spontaneous healing of a ruptured fetal bladder before delivery.

Duodeno-jejunal atresia with volvulus, absent dorsal mesentery, and absent superior mesenteric artery: a hereditary compound structure in duodenal atresia?

Duodenal atresia predominantly represents an isolated entity, but could also be part of a complexly structured intestinal malformation. We report four children, including two from one family, with duodeno-jejunal atresia associated with malrotation, volvulus, and absent parietal attachment of the mesentery. Gross absence of the mesentery and absence of distal parts of the superior mesenteric artery were the most remarkable findings. The small intestine was supplied retrogradely from the right colic artery. Consideration of embryological theories of this malformation takes into account the important role of the duodeno-jejunal flexure during the process of entry of the small bowel loops into the abdomen. Familial occurrence suggests autosomal recessive inheritance. We propose differentiating the pathoanatomical findings in our patients from classical apple peel small bowel syndrome (APSB).

Recurrent respiratory tract infections and dysphagia in a child with an aortic vascular ring

Recurrent respiratory tract infections and dysphagia after the first years of life are rarely caused by vascular rings, and only a high index of clinical suspicion helps to avoid diagnostic delay and inappropriate treatment. Diagnostic workup in a 2-year-old girl with acute foreign body impaction into the esophagus and frequent respiratory tract infections revealed right descending aortic arch with ligamentum arteriosum as the cause of extrinsic esophageal-tracheal compression. Dividing the ligament gave release to the encircled esophagus and trachea. Relief of symptoms was achieved immediately after surgery.

Splenosis mimicking tumor recurrence in renal cell carcinoma: detection on selective spleen scintigraphy

A 2-year-old boy had been operated on for a giant renal cell carcinoma including splenectomy because of disrupture of the splenic capsule. During a follow-up examination, 3 nodules were detected by ultrasound in the splenorenal area. This gave reason to suspect tumor recurrence. Considering the possibility of splenosis, a selective spleen scan using denatured red blood cells was performed as a final diagnostic step. This method confirmed the nodules as representing splenic tissue. Splenosis should be included in the differential diagnosis of solid masses in the postsplenectomy patient.

Limb-body wall complex: a compound anomaly pattern in body-wall defects

Our presentation of four cases demonstrates the essential features of limb-body wall complex (LBWC), representing a compound anomaly pattern in body-wall defects. The diagnosis of this entity is based on two of the three following characteristics: (1) exencephaly/encephalocele and facial clefts; (2) thoraco- and/or abdominoschisis; and (3) limb defects. A definite association with internal anomalies and severe kyphoscoliosis makes a more distinct concept of the pathogenesis reasonable. Limb-body wall malformations result from a malfunction of the ectodermal placodes involving the early embryonic folding process. The poor prognosis of LBWC calls for early antenatal diagnosis.

Proctocolitis in breast fed infants: a contribution to differential diagnosis of haematochezia in early childhood

Dietary protein induced proctocolitis in exclusively breast fed infants is rarely taken into consideration as a cause of rectal bleeding or blood streaked stool in the neonatal period and early infancy. Eleven babies are presented in whom it is believed that bleeding through the rectum was due to proctocolitis as a result of allergy triggered by cows' milk protein transferred to the infants via the breast milk. Colonoscopy was performed in five infants, revealing benign eosinophilic proctocolitis. Standard treatment was the exclusion of the allergen from the mother's diet. Resolution of visible rectal bleeding took place within 72 to 96 hours after elimination of the offending protein from the mother's diet.

Intraabdominal extralobar pulmonary sequestration exhibiting cystic adenomatoid malformation: prenatal diagnosis and characterization of a left suprarenal mass in the newborn

An intraabdominal extrathoracic pulmonary sequestration (IEPS) was detected by prenatal ultrasound in a fetus of 19 weeks' gestation. The well-defined echogenic mass, including multiple cystic areas, was located in the left suprarenal region. Knowledge of the characteristic ultrasound appearance helped to differentiate between neuroblastoma and IEPS before surgical treatment. Histologic examination showed an association between IEPS and features of cystic adenomatoid malformation type 2.

Sonographic diagnosis of intussusception of the appendix vermiformis

We present 2 cases of intussusception of the appendix vermiformis (IAV) in children. Sonographic examination demonstrated a lead point within a characteristic multiconcentric ring sign, and longitudinal sonograms showed the inverted appendix protruding into the cecal lumen. A contrast-enema study, using a water-soluble contrast medium, was performed in each case, and a "coiled-spring" sign or "spiral shell" appearance confirmed the diagnosis. A surgical reduction of the appendix and an appendectomy were performed in each case.

Prenatal diagnosis of fetal urinary ascites

We report on a rare in utero appearance of the rupture of the fetal bladder caused by low urinary tract obstruction with subsequent urinary ascites. The findings on prenatal sonography, postnatal X-ray examinations and postnatal surgical treatment are described and the literature is reviewed.

[Isolated rupture of the jejunum after trauma in a child. A complex mechanism of injury with difficult diagnosis]

Isolated rupture of the lower jejunum after blunt abdominal trauma is rare. The pediatric population, especially school-aged children, sustains these isolated injuries due to blunt trauma more frequently than adults. The lack of severe clinical symptoms in the beginning and therefore a delay in diagnosis are the main problems of these traumatic injuries. We report on a 7-year-old girl who sustained isolated rupture of the lower part of the jejunum secondary to blunt trauma. The purpose of this report is to illustrate the complex mechanism of injury. Additionally, we discuss the different ways of diagnosis with a review of the literature.

[Orthostasis in halothane anesthesia. A model situation for studying cerebrovascular autoregulation in infants]

Halothane causes impairment of cerebrovascular reactivity and autoregulation. We used transcranial Doppler sonography (TCD) to investigate the reaction patterns of cerebral blood flow velocities (CBFV) during a standardized orthostatic maneuver after premedication and during halothane anesthesia in infants. After premedication orthostasis led to no significant changes in CBFV. During halothane anesthesia CBFV was significantly higher than after premedication, and orthostasis induced a significant decrease in CBFV compared to values obtained in horizontal position. Heart rate and mean blood pressure were significantly lower than before medication during halothane anesthesia. The observed changes in CBFV during halothane anesthesia represent a characteristic pattern of impaired cerebral autoregulation. The changes in CBFV and heart rate demonstrate that neither systemic nor cerebral hemodynamics compensate for hydrostatic inducement during halothane anesthesia. The tilting test is a useful tool for determining cerebral autoregulation capacity in infants.

Traumatic pharyngo-oesophageal perforation in the newborn: a condition mimicking oesophageal atresia

Two newborn infants with traumatic perforation of the pharyngo-oesophageal region are presented. This injury was induced by pharyngeal suction catheters and/or vigorous attempts at nasogastric or tracheal intubation during resuscitation of the newborn. The true nature of this condition remained unrecognized and the babies were thus referred with a tentative diagnosis of oesophageal atresia. The perforation itself could be treated successfully without surgery, despite a severe complication in one infant resulting from inadvertent use of barium sulphate contrast medium. Raising awareness of the possibility of this injury should help in avoiding this complication by gentle and skilful action during newborn resuscitation, particularly in the premature infant.

Tracheal agenesis: evaluation by helical computed tomography

We present a newborn infant with type II tracheal agenesis. Helical CT was performed and confirmed the diagnosis. Retrospective coronal and sagittal multiplanar reconstructions clearly demonstrated the complex anatomy of the malformation. The absence of a significant portion of healthy trachea did not present any possibility for surgical correction.

[Josef Weinlechner (1829-1906). Pioneer in Vienna pediatric surgery]

The history of paediatric surgery in Vienna has not been clearly documented so far, especially its development during the second half of the nineteenth century. Josef Weinlechner (1829-1906) is one of the outstanding paediatric surgeons in Vienna during this time. We present an overview of his biography, his position as head of the department of surgery at the St. Anna Children's Hospital, and also discuss his publications concerning various aspects of paediatric surgery. Of particular interest was the discovery of his application for the qualification of a postdoctoral lecturer ("Habilitation") in the archives of the University of Vienna. In this application, Weinlechner refers to his specialisation as that of a paediatric surgeon.

Fatal neonatal Salmonella enteritidis sepsis

A case history of a fatal neonatal infection caused by Salmonella enteritidis group D is reported. The baby deteriorated rapidly at 24 hours after birth with clinical signs and symptoms of an acute abdomen. Bloody diarrhea led to a tentative diagnosis of midgut volvulus or necrotizing enterocolitis. Autopsy and bacteriologic investigation revealed sepsis by S. enteritidis group D. The same organism was found in cultures taken from stool and vaginal swabs from the mother. This clearly confirmed transmission of the infection during delivery.