Primary sternal osteomyelitis: a case series and review of the literature

Purpose

Primary sternal osteomyelitis is rare in the pediatric population.

Methods

We present 4 recent cases that demonstrate a wide range in age, presenting features, and clinical course, and we performed a literature review.

Result

A combination of diagnostic aspiration with prolonged appropriate antibiotic therapy led to successful resolution in all cases. Surgical debridement should be reserved for cases that do not respond to medical therapy.

Conclusion

Sternal osteomyelitis is a rare condition in children that usually resolves with aspiration and prolonged antibiotic therapy.     

Treatment of toxic epidermal necrolysis in a pediatric patient with a nanocrystalline silver dressing

Background/Purpose

To report a case of toxic epidermal necrolysis (TEN) involving 90% body surface area, successfully treated with a nanocrystalline silver dressing (Acticoat, Smith & Nephew, Largo, FL).

Methods

A review of the hospital and acute wound center patient records and the recent English medical literature regarding TEN and nanocrystalline silver dressing.

Results

We found only 1 report of TEN treated with a nanocrystalline silver dressing. The nanocrystalline silver dressing was both effective in preventing wound infection and convenient for treating our patient with TEN.

Conclusion

The use of nanocrystalline silver dressing should be considered for the treatment of TEN.     

If a picture is worth a thousand words, what is a trauma computerized tomography panel worth?

Background

There has been a progressive increase in the use of computerized tomography (CT) scans for evaluating trauma patients. The purpose of this study was to quantify that trend and consider the implications it holds for resource use.

Methods

Data were combined from the trauma registry and the radiology department’s administrative information system at a level I trauma center to define the radiographic use patterns applied to all trauma activations during a 3-month sampling period in each of 4 years.

Results

Trauma activations increased by 21% whereas total radiographic studies increased by 82%. The proportion of CT scans to total studies increased progressively from 18% to 27%. The average number of CT studies per patient increased from 2.68 ± 3.09 to 6.88 ± 7.50. CT use increased for patients presenting by primary or secondary transport, regardless of triage classification. In the final sampling period, CT scans alone generated an average of 3,726 images per day to be reviewed.

Conclusions

Increasing use of multi-image studies is facilitated by improvements in technology and medical-legal pressures. However, extensive imaging can stress overburdened trauma systems. Additional studies are needed to assess the implications of increasing radiographic use on trauma outcomes.     

Residual fistula after laparoscopically assisted anorectoplasty: is it a rare problem?

Purpose

Although various urologic complications have been reported after abdominoperineal pull-through and posterior sagittal anorectoplasty for the treatment of high-type imperforate anus, reports regarding complications after laparoscopically assisted anorectoplasty (LAARP) are surprisingly rare. Here, we discuss the potential complications of LAARP.

Methods

A retrospective study was conducted of 24 patients treated with LAARP from 2000 to 2006. The clinical and operative records were reviewed. Of the 24 patients, 18 were evaluated postoperatively by screening magnetic resonance imaging (MRI).

Results

The 24 participants are composed of patients with rectoprostatic urethral fistula (n = 15), rectal agenesis (n = 3), rectovesical fistula (n = 2), rectovaginal fistula (n = 2), and cloaca (n = 2). Defecatory function after LAARP was satisfactory. None of the patients had dysuria or urinary infection postoperatively. Cystic formations posterior to the urethra were demonstrated in 9 of the 18 cases examined by MRI. Postoperative voiding cystourethrography failed to demonstrate the lesion in 6 of 9 patients. The types of imperforate anus in this subgroup were rectoprostatic urethral fistula (n = 7), rectovesical fistula (n = 1), and rectal agenesis without fistula (n = 1). Average cyst diameter was 22 ± 19 mm. Two patients with large cysts (62 and 42 mm) underwent surgical resection.

Conclusions

Although satisfactory fecal continence could be achieved by LAARP, we experienced 2 cases with a large residual fistula that required surgical resection. In addition, screening MRI demonstrated the presence of cystic formations in 9 of 18 patients. We recommend that MRI be performed routinely during follow-up of patients treated with LAARP.     

Value of 18-FDG-positron emission tomography/computed tomography before and after transarterial chemoembolization in patients with hepatocellular carcinoma undergoing liver transplantation: initial results

Introduction

Liver transplantation is the treatment of choice for various types of end-stage liver disease and the most appropriate alternative for the treatment of hepatocellular carcinoma (HCC)-associated liver cirrhosis. The aim of this study was to describe our initial experience with the use of 18-FDG positron emission tomography (PET)/computed tomography CT before and after transarterial chemoembolization (TACE) in HCC patients undergoing liver transplantation, seeking to predict the percentage of tumor necrosis achieved by TACE procedures.

Patients and Methods

From January 2007 through December 2009, 39 patients with HCC and liver cirrhosis were included in our liver transplantation program. We selected the 6 subjects who underwent 18-fluorodeoxyglucose PET/CT (18-FDG PET/CT) pre- and post-TACE.

Results

The median SUV (standarized uptake value) in the lesions studied were 4 (range, 2.79-6.95) before TACE with a median post-TACE SUV of 0 (range, 0-4). Among patients whose post-TACE SUV decreased to <3, the percentage of necrosis after studying the hepatectomy was >80%.

Conclusion

Performance of an 18-FDG PET/CT before and after TACE and comparison of SUV in patients with HCC awaiting liver transplantation provided valuable information regarding the effectiveness of TACE.     

Interpretation of radiologic abnormalities in patients with chronically infected ingrown toenails with regard to a possible exogenic osteomyelitis

Background

Chronic infection of ingrown toenails may lead to exogenous osteomyelitis. Therefore, plain x-rays are commonly taken in children with significant inflammation. We evaluated the preoperative radiologic findings and their clinical significance, especially with regard to exogenic osteomyelitis.

Patients and methods

We retrospectively evaluated all patients who underwent surgery for infected ingrown toenails during a 5-year period. Data collection included the history of infection, preoperative laboratory tests, preoperative x-rays, and intraoperative presentation.

Findings

One hundred thirty-four patients with infected ingrown nails of the hallux underwent 161 surgical procedures. Mean age at surgery was 14.1 years. Preoperative x-rays were taken in 113 (70.2%) cases. The treating surgeon classified 76 (67.2%) x-rays as negative (no bone affection), 16 (14.2%) as positive (definite bone affection), and 21 (18.6%) as suspicious for bone affection. Only 11 (30%) of 37 children with positive or suspicious x-rays showed bone affection during surgery, which presented as a softening of the cortical bone. None of the children had significantly elevated inflammation markers in the preoperative laboratory tests. Children with positive or suspicious x-rays had a significant longer history of infection compared to those without radiologic abnormalities (8 vs 4.5 weeks mean; P = .024). A reevaluation of the x-rays by an experienced radiologist was undertaken and revealed no case of definite osteolysis.

Conclusion

In about one third of all infected ingrown toenails, radiologic changes of the distal phalanx occur. These changes primarily represent periostal reactions. A typical osteomyelitis as a complication of chronically infected ingrown toenails is rare.     

Dynamic magnetic resonance imaging of the pelvic floor in children and adolescents with vesical and anorectal malformations

Background

Magnetic resonance imaging (MRI) of the pelvic floor allows better assessment of pelvic pathology and has a potential as an adjunct for therapy planning. In complex congenital malformations of the pelvic floor and continence organs, it plays a major role in assessing urinary and fecal incontinence or constipation, especially when performed as a dynamic investigation such as MRI defecography.

Patients and Methods

Twenty-three patients (3-21 years old) with urinary and/or fecal incontinence or constipation attributable to congenital malformations of the pelvic region presented at our institution. The diagnoses were anorectal malformations (18), bladder exstrophy (2), and cloacal exstrophy (3). All patients underwent static and dynamic MRI of the pelvic floor with rest, squeeze, and evacuation in supine position.

Results

Morphology and function of the pelvic floor and pelvic organs could be demonstrated in each case. The reason for urinary incontinence, fecal incontinence, or constipation could be defined, and an individual therapeutic management concept was made based upon the data obtained by the investigation.

Conclusions

The advantages of this method, in comparison to others, are direct visualization of the pelvic floor muscles and continence organs and their anatomical relationship during different functional actions. Pelvic floor dysfunction is often the reason for fecal and urinary incontinence and can be detected by MRI. Especially in children, minimizing radiation exposure is of major concern. Disadvantages are the costs and long investigation time.     

The use of vacuum assisted closure therapy in the management of Fournier's gangrene

Background

Vacuum Assisted Closure (VAC; Kinetic Concepts, Inc., San Antonio, TX) has been used to successfully treat a variety of complex wounds. This technique was investigated for use in managing Fournier's gangrene following initial debridement.

Methods

Ten patients with Fournier's gangrene were treated in this study. After initial surgical debridement, 5 were treated using conventional therapy and 5 were treated with VAC at each dressing change. The effectiveness and cost of VAC for this indication were assessed; patient and physician satisfaction were also determined.

Results

Conventional and VAC treatment were equally effective in healing the wounds. The total costs of each treatment were similar. With the use of VAC, patients had fewer dressing changes, less pain, fewer skipped meals, and greater mobility. Hands-on treatment time was decreased for physicians using VAC.

Conclusions

VAC therapy is an effective and economical way to manage Fournier's gangrene. Patients and physicians were more satisfied with VAC therapy than with conventional treatment.     

Surgical treatment in Paget's disease of the breast

Background

The aim of this study was to evaluate the outcomes of surgical treatment of Paget's disease of the breast, with special emphasis on magnetic resonance imaging (MRI) and sentinel node biopsy (SNB).

Methods

The study included 58 consecutive patients with Paget's disease treated from 1995 to 2006.

Results

Twenty-five patients had ductal carcinoma in situ, and 31 had invasive carcinoma. MRI was performed in 14 patients, with positive findings in 7 patients, 5 of whom had negative findings on conventional imaging. The overall mastectomy rate was 76%. Eighteen patients underwent SNB, and 26 patients underwent full or partial axillary clearance. Fourteen patients had no axillary surgery. One patient had local recurrence after breast conservation, and another had axillary recurrence after negative results on SNB. Six patients had distant metastases. Four patients died of breast cancer.

Conclusions

Paget's disease is frequently associated with peripheral or multicentric cancer. MRI may be helpful when considering breast conservation or omitting axillary nodal staging.     

Screening cervical spine MRI after normal cervical spine CT scans in patients in whom cervical spine injury cannot be excluded by physical examination

Background

Cervical spine injuries can occur in as many as 10% of patients with blunt trauma with mental status changes from closed head injuries. Despite normal results on cervical spine computed tomography (CT), magnetic resonance imaging (MRI) is often recommended to exclude ligamentous or soft tissue injury.

Methods

A retrospective review was conducted of trauma patients admitted to a level I trauma center from 2002 to 2006, in whom cervical spine injuries could not be excluded by physical examination. All patients with normal results on cervical spine CT followed by cervical spine MRI were included in the analysis.

Results

One hundred twenty patients underwent MRI to examine their cervical spines. Seven patients had abnormal MRI findings suggestive of acute traumatic injury. No MRI studies led to operative intervention. Screening MRI increased from 1% of comatose patients in 2002 to 18% in 2006.

Conclusions

The use of MRI in patients with normal results on cervical spine CT does not appear to alter treatment.     

Wound infection after colostomy closure for imperforate anus in children: utility of preoperative oral antibiotics

Background/Purpose

There is little published data on the efficacy of surgical infection prophylaxis in children. The purpose of this study was to assess wound infection rate in children undergoing colostomy closure for imperforate anus and evaluate the impact of bowel preparation and antibiotics.

Methods

Children younger than 18 years with imperforate anus who had a colostomy closure between January 1996 and December 2007 were identified. Data collected included demographics, bowel preparation, antibiotics, operative details, and postoperative infections. Comparison of mechanical bowel preparation and intravenous antibiotics with and without oral antibiotics was compared using χ² tests. Significance was defined as P < .05.

Results

A total of 118 patients were identified. Primary skin closure was done in 97%. Mechanical bowel preparation was used in 93%, intravenous antibiotics in 97%, and oral preoperative antibiotics in 52%. Wound infections occurred in 14% (n = 17). The addition of oral antibiotics to the standard regimen of mechanical bowel preparation with intravenous antibiotics did not alter infection rate (13% versus 17%, P = .64).

Conclusion

Wound infection in children undergoing elective colostomy closure for imperforate anus was 14%. Infection rate was not affected by use of oral antibiotics. Future studies may allow specific guideline development for infection prophylaxis in pediatric patients.     

Early experience with PET/CT scan in the evaluation of pediatric abdominal neoplasms

Purpose

Positron emission tomography/computerized tomography (PET/CT) scan provides both functional and anatomical information in a single diagnostic test. It has the potential to be a valuable tool in the evaluation of pediatric abdominal tumors. The goal of this study is to report our early experience with this technology.

Methods

Children who underwent PET/CT scan in the workup for abdominal neoplasms between July 2005 and January 2008 were identified. Retrospective review of all radiologic studies, operative notes, and pathologic reports was undertaken.

Results

A total of 36 patients were collected. These included Burkitt's lymphoma (8), neuroblastoma (7), rhabdomyosarcoma (6), ovarian tumor (3), Wilms' tumor (2), hepatocellular carcinoma (2), paraganglioma (1), germ cell tumor (1), undifferentiated sarcoma (1), renal primitive neuroectodermal tumor (1), gastrointestinal stromal tumor (1), adrenocortical carcinoma (1), inflammatory pseudotumor (1), and adrenal adenoma (1). All neoplasms were fluorodeoxyglucose (FDG) were avid. Our experience identified several potential uses for PET/CT scan in this group of patients. These include (1) preoperative staging, (2) selection of appropriate site for biopsy, (3) identification of occult metastatic disease, (4) follow-up for residual or recurrent disease, and (5) assessment of response to chemotherapy. It can also be valuable when the standard diagnostic studies are equivocal or conflicting.

Conclusions

Preliminary data indicate that PET/CT is a promising tool in the evaluation of pediatric abdominal malignancies. The delineation of the exact role of this diagnostic modality will require additional experience.     

An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed tomography in children

Purpose

The increased use of computed tomography (CT) to diagnose appendicitis in children has led to a concern for the possibility of increased CT-related cancer morbidity. We designed a clinical protocol for the diagnosis and treatment of appendicitis in children in an attempt to decrease the use of CT scans at our institution.

Methods

Patients who had surgical consultation for suspected appendicitis were placed on the clinical protocol. Data concerning diagnosis and treatment were collected prospectively. Retrospective data from patients admitted to our institution with acute appendicitis before the clinical protocol were collected as historical controls.

Results

One hundred twelve patients were diagnosed and treated by our protocol between June and November 2009. Of these, 100 patients underwent an appendectomy for acute appendicitis. They were compared with 146 patients from 2007. In-house CT use decreased from 71.2% to 51.7% (P = .01). Preoperative ultrasound use increased from 2.7% to 21% (P < .001). The negative appendectomy rate increased (6.8% vs 11%, P = .25).

Conclusions

Our findings suggest that the implementation of an evidence-based clinical protocol for the diagnosis and treatment of acute appendicitis in children may safely decrease the use of CT scans and increase the use of ultrasound.     

An established extracorporeal membrane oxygenation protocol promotes survival in extreme hypothermia

Background

Historical reports indicate that active rewarming with extracorporeal membrane oxygenation (ECMO) can salvage a patient after hypothermic cardiac arrest. We created a protocol that includes ECMO for extreme hypothermia to guide rewarming of the hypothermic patient.

Methods

A retrospective review of the ECMO rewarming protocol (2004-2006) was conducted.

Results

The active rewarming protocol is a flowchart that is available on our hospital intranet and can be accessed in the trauma bay. A severely hypothermic patient triggers the activation of a TRAUMA ONE-OP ECMO response. During the 2-year period, there were 5 activations of the system and 4 children were placed on ECMO. Two of the 4 were dramatically salvaged and eventually discharged neurologically intact. All 5 children were found pulseless at the scene before transport. The average time from the injury occurrence to arrival was 94 minutes (range, 41-181 minutes). Mean cardiopulmonary resuscitation time was 78.2 minutes (range, 37-152 minutes). The mean core temperature on arrival was 25.4°C (range, 20.4°C-28.6°C). The average time from arrival to ECMO cannulation was 25.5 minutes (range, 16-37 minutes).

Conclusion

A preemptive strategy for the severely hypothermic patient provides an organized approach and prompt response. Expeditious rewarming can make the difference in an opportunity for survival.     

Omental infarction--a mimicker of acute appendicitis in children

Purpose

The aim of this study was to review the presenting features of pediatric patients found to have omental infarction with a normal appendix at surgery.

Methods

A retrospective review was conducted of all patients with surgically proven omental infarction treated at KK Women's and Children's Hospital between May 1997 and January 2004.

Results

Twelve children (10 boys and 2 girls) were treated for primary omental infarction. The mean age was 9.0 ± 1.42 years. The mean weight was 41.3 ± 9.65 kg, with 6 (50%) above the 97th percentile and the remainder were between the 50th and 97th percentile. All 12 children presented with right-sided abdominal pain. At presentation, 9 had low-grade fever of 37.3°C or higher, with the maximum temperature recorded at 37.9°C. The mean total white blood cell count was 13.3 ± 2.66. Significant neutrophilia (relative percentage, >70%; absolute neutrophils, >8000) was noted in 9 children. Eight children underwent radiological imaging, which included ultrasonography (n = 3) and/or computed tomography (CT) (n = 7) of the abdomen. Preoperative diagnosis was made on 4 CT scans. Surgical resection resulted in immediate resolution of symptoms.

Conclusion

Omental infarction often mimics acute appendicitis preoperatively, although CT may be diagnostic. Surgical resection of the affected omentum expedites clinical recovery.     

The correlation of the D-dimer test and biphasic computed tomography with mesenteric computed tomography angiography in the diagnosis of acute mesenteric ischemia

Background

Early diagnosis is the main factor to improve the outcome of acute mesenteric ischemia (AMI). The goal of this study was to assess the correlation of the D-dimer test and biphasic computed tomography (CT) with mesenteric CT angiography for the diagnosis of AMI.

Methods

Selected consecutive patients with a clinical suspicion of AMI were admitted to the study. Blood samples were taken before biphasic CT with mesenteric CT angiography examination.

Results

The sensitivity and specificity values of biphasic CT with mesenteric CT angiography were 92.9% and 89.5%, respectively. The sensitivity and specificity of D-dimer testing for the diagnosis of AMI were 94.7% and 78.6%, respectively. D-dimer levels higher than 3.17 μg fibrinogen equivalent units/mL were more specific (P < .0001) and acted similarly to the biphasic CT with mesenteric CT angiography in the diagnosis of AMI.

Conclusions

In the setting of early diagnosis of AMI, the D-dimer test may improve our ability to diagnose patients in whom we cannot use multidetector row CT with CT angiography.     

Is there concordance of invasive breast cancer pathologic tumor size with magnetic resonance imaging?

Background

In the era of breast conservation therapy, preoperative imaging is imperative in planning a single definitive surgical treatment.

Methods

We performed a retrospective review of a prospectively collected database of patients treated at a single institution for invasive breast cancer over 5 years. Clinical and pathologic variables were analyzed with respect to magnetic resonance imaging (MRI) and pathologic tumor size using analysis of variance F tests and chi-square tests.

Results

Of 190 patients, 53% had concordance of MRI and pathologic cancer size within .5 cm. MRI overestimated 33% and underestimated 15% of tumors. Neoadjuvant chemotherapy and lymph node status were associated with discordance. Among tumors overestimated by MRI, 65% had additional significant findings in the breast tissue around the main lesion: satellite lesions, ductal carcinoma in situ, and/or lymphovascular invasion.

Conclusions

Breast MRI is concordant with pathologic tumor size within .5 cm among 53% of patients. Most patients with tumors overestimated by MRI have significant findings in the surrounding breast tissue, the excision of which would be expected to benefit the patient.     

Postoperative biochemical liver function after major hepatic resection in children

Background/Purpose

There are no detailed reports of the profile of biochemical liver function tests (LFTs) after partial hepatectomy in children. The study aims to establish normal profiles of standard LFTs after major liver resection in noncirrhotic children; the effects of preoperative chemotherapy were also analyzed.

Methods

Clinical and biochemical data were collected from a consecutive series of children who had undergone a primary major liver resection for a hepatic tumor. Chemotherapy details were recorded. Children who had more than 4 liver segments resected were compared with those undergoing lesser resections. Those with and without preoperative chemotherapy were also compared.

Results

A total of 22 children underwent major liver resection at a median age of 24 months (range, 2 weeks to 16 years). Fifteen received preoperative chemotherapy. Peak derangements in all standard LFTs occurred on day 1 to day 2 postoperatively. Normal plasma levels of bilirubin and albumin were present by day 5, international normalized ratio and alkaline phosphatase by day 7, and alanine aminotransferase by 1 to 2 weeks. Peak alanine aminotransferase and international normalized ratio values tended to be higher in children having more extensive liver resections. Preoperative chemotherapy given up to 3 weeks before surgery had no major effect on LFT recovery profiles. Hypophosphatemia was maximal on day 2.

Conclusions

Postoperative LFTs showed a more rapid resolution than typically seen after partial hepatectomy in adults. Preoperative chemotherapy had no major effects on postresection LFT profiles.     

Geographic information system localization of community-acquired MRSA soft tissue abscesses

Background

Soft tissue infections with methicillin-resistant Staphylococcus aureus (MRSA) pose an ever-increasing risk to children in the community. Although historically these infections were limited to children with prolonged hospitalization, the authors have seen an increase in community-acquired infections in children without identifiable risk factors. The goal of this study is to determine the incidence of truly community-acquired MRSA soft tissue infections in our community and geographically map regions of increased risk.

Methods

After obtaining the institutional review board's approval, a retrospective chart review was conducted on 195 patients records who underwent an incision and drainage of soft tissue infections from January 1, 2000, to December 31, 2003. Thirteen patients were excluded from the study because no cultures were taken at the time of incision and drainage.

Results

The most common organism isolated from wound culture was S aureus, 40% (73/182), of which 45% (33/73) were MRSA. Eighty-one percent (27/33) of MRSA infections were in Springfield, 1 of 18 towns represented in the patient population. Geographic information system analysis identified a significant MRSA cluster 1.96 km in diameter within the city of Springfield.

Conclusions

Geography proved to be a significant risk factor for presenting with MRSA infection. Geographic maps of antibiotic resistance can be used to guide physician antibiotic selection before culture results are available. This has significant implications for the health care provider in proper antibiotic selection within the community.     

Appendicitis in the child with a ventriculo-peritoneal shunt: a 30-year review

Purpose

Each year, about 270 children are treated at our hospital for appendicitis, and there are 200 ventriculo-peritoneal (VP) shunt procedures. The incidence of primary peritonitis after a VP shunt is 8% to 12%. The purpose of this article is to try and differentiate these 2 entities.

Methods

From 1973 to 2003 inclusive, appendicitis was diagnosed in 8 children with a VP shunt at our hospital; there were 7 boys and 1 girl with 5 acute appendicitis and 3 ruptured appendices. The first case was diagnosed on purely clinical grounds, whereas the last 7 were confirmed by ultrasonography and/or computed tomography.

Results

All 8 had appendectomy and the shunt was exteriorized in the 3 children with a ruptured appendix. There were no postoperative problems, and the 8 children remained well.

Conclusion

Acute appendicitis can and does rarely occur in children with VP shunts; however, in such situations, the correct diagnosis can be confirmed by imaging. The shunt must be temporarily exteriorized if the appendix is ruptured.