Endobronchial tuberculosis complicated with Staphylococcus aureus pneumonia and empyema in a child

Childhood tuberculosis might have unusual clinical presentation. A seven-year-old female patient was admitted with fever and pleural effusion. Her pneumonia resolved following 21-day treatment period. An atelectatic appearance remained on the right middle zone in her chest X-ray. Tuberculin skin test showed 13 mm induration. Triple drug antituberculosis treatment was started. Since atelectasis persisted on her follow-up radiograph one month later, bronchoscopy was performed which revealed a hemorrhagic polypoid mass occluding the right upper lobe anterior segment orifice. Surgical removal was performed by right upper lobectomy. The pathological diagnosis was necrotizing granulomatous infection suggesting tuberculosis. The patient has been well on follow-up after completing a nine-month course of antituberculous treatment.     

Psychoneuroimmunology and the pediatric surgeon

The mind–body connection is receiving increasing scrutiny in a large number of clinical settings, although research has lagged in the pediatric specialties. Psychoneuroimmunology (PNI) is a novel interdisciplinary scientific field that examines the relationship of the mind to the patient's neurologic, endocrine, and immune systems by examining critical parameters such as the effects of mental stress on wound healing and infection rates. Techniques that modify a patient's emotional and mental responses to illness and surgery have positive effects on their physiology resulting in improved recoveries and higher patient satisfaction rates. In the appropriate clinical settings, an awareness of PNI can enhance outcomes for pediatric surgical patients.     

Robotics and the pediatric surgeon

Surgical robots are enabling devices for minimally invasive (laparoscopic) surgery (MIS). They use a computer to enhance a surgeon's skills as hand movements are transmitted to robotic arms. The computer filters tremor, which becomes important at high magnifications of 10 to 15 times available in MIS. It also provides motion scaling so that large hand movements are converted to very small movements of the robotic arm. The robotic arms also have wrists that make suturing and knot tying far more accurate and efficient. Surgical robots are currently used clinically for procedures such as MIS Nissen fundoplication, cholecystectomy, and splenectomy. Laboratory experience indicates that they may provide advantages for newborn procedures such as portoenterostomy for biliary atresia and repair of esophageal atresia and tracheoesophageal fistula. They have a potential for making possible MIS procedures, which can only be done open now, and for introducing entirely new procedures as well as for the performance of procedures by operators distant from the patient.     

Endobronchial metastases from carcinoma of the breast

We report the case histories of four patients with endobronchial metastases from breast cancer, two of whom died of resultant respiratory insufficiency. To aid in earlier diagnosis and thus permit more rapid application of specific therapy, we characterized the epidemiology and presenting symptoms of these patients and 38 additional patients with endobronchial metastases from breast carcinoma that have been reported in the literature. The average age at presentation with endobronchial metastases was 55, and the average time from diagnosis of the breast primary lesion to the endobronchial metastasis was 77 months. Cough occurred in 71% of patients; wheezing and hemoptysis occurred in 25%. Segmental atelectasis occurred in 57% on chest roentgenogram. Average survival of patients from the time of diagnosis of endobronchial metastasis was 21 months; median survival was 19 months.     

The ethics consultation and the pediatric surgeon

The cultural, ethnic, religious, socioeconomic, and educational diversity of the patient population and the expanded surgical options provided by innovation and technology can pose significant ethical challenges. The questions confronting pediatric surgeons and their patients? families have greater complexity, and both the pediatric surgeon and the family perceive increasing vulnerability and uncertainty. The analysis and management of ethical issues in pediatric surgery cannot simply be extrapolated from the approach applied to adult cases. By reviewing the history of the events that contributed to the creation and utilization of hospital ethics committees and examining the role of the ethics consultant in the context of pediatric surgical care, practitioners and trainees will be better able to address these multifaceted situations.     

Endobronchial polyp in a neonate

Respiratory distress in the neonate with collapse/hyperinflation of the lung can be because of a number of causes, which includes extraluminal, parenchymal and endobronchial lesions. Endobronchial tumour and polyps as the cause of collapse/hyperinflation in newborns are quite rare. We report a case of preterm newborn with respiratory distress secondary to endobronchial inflammatory granuloma and discuss the relevant issues in diagnosis and management.     

Computers and the pediatric surgeon: a primer

Computers have become an integral part of surgical practice. To use and maintain computers effectively, the surgeon must have a basic knowledge of the inner workings of the computer. It also is helpful to understand how the systems have evolved. Medical computing started in the financial department of large hospitals. From there it expanded to clinical data systems. Coincident with the development of clinical data systems was the introduction of the IBM personal computer in 1981 and the development of the Internet. All these events led to the use of the personal computer as a communication tool. This will shape much of how we use computers in the coming millennium. The computer is made up of several component parts. The brain of the computer is the central processing unit (CPU), which performs all of the calculations in the computer. The CPU works in concert with the random access memory (RAM) and hardware peripherals to perform tasks as directed by a program. To use this increasingly complex tool effectively, the pediatric surgeon must have a basic knowledge of information systems. It is through this knowledge that information systems may be used to enhance the efficiency of pediatric surgical practice.     

Prenatal counselling and the role of the paediatric surgeon

With the development of prenatal ultrasound and of foetal medicine, the paediatric surgeon has extended his knowledge of the natural history of surgical malformations. He is a part of the prenatal team and parents should always be referred to him when a surgical malformation is suspected, even when termination of pregnancy is planned because of an expected poor prognosis. Direct contact between the prenatal medicine specialist and the paediatric surgeon is also highly recommended to ensure continuity in the messages delivered to the parents. Postnatal counselling does not compare with prenatal counselling, and the paediatric surgeon has learned from the obstetrician to modulate his talk by including other conditions that might affect the outcome of the foetus, especially genetically determined syndromes. When the foetal malformation is diagnosed very early, especially in the first trimester, it therefore seems important for the consultation with the paediatric surgeon to be scheduled when the complementary exams required by the anomalies diagnosed are done, in order to avoid later contradictory messages. Repeated consultations should be favoured as they allow provision of more precise information regarding changes in ultrasound and/or MRI images and so decrease parents׳ anxiety and help them to take their decision. Foetal surgery, which has reached various stages of development in different countries, requires paediatric surgeons and obstetricians to join forces to optimise procedures and evaluate their benefit/risk ratio. Since 2004, the National Rare Disease Plan in France has allowed the creation of Rare Disease Centres, which deal with congenital malformations and produce recommendations for the health care pathway of these patients by means of a multidisciplinary approach. This greatly enhances interdisciplinary communication and ensures that best care is provided to the parents-to-be and to their child.     

Endobronchial tuberculous granuloma in children.

Endobronchial tuberculosis is rare in children, in whom it is usually a complication of primary tuberculosis. Endobronchial involvement may adopt several forms, with granuloma being infrequent. Here we report on 10 cases of endobronchial tuberculous granuloma diagnosed and treated in our Paediatric Surgery Service between 1991 and 2004. In 2 cases the presentation was acute and constituted the first manifestation of TB; the remaining patients were undergoing treatment or had been treated for primary TB, and presented with clinical symptoms or radiological signs that led us to suspect endobronchial involvement. In all cases the granuloma was removed by bronchoscopy. Patients received conventional medical TB treatment, with corticoids for 4 weeks following granuloma removal. The clinical course was favourable in all cases and on follow-up we saw no complications. Endobronchial tuberculous granuloma should be borne in mind in children with symptoms or signs of airway obstruction and especially during the course of tuberculosis treatment.