Post-pubertal mucinous cystadenoma of the pancreas

A 14-year-old patient with a mucinous cystadenoma of the pancreas (MCAP) is presented. She presented with a palpable left-sided abdominal mass and underwent a left hemipancreatectomy. MCAP occurs mostly in middle-aged women, and no post-pubertal cases have been reported to date in the English literature. Accepted: 1 May 2000     

Neonatal benign sacrococcygeal teratoma with N-type rectobulbar fistula

A unique case of benign sacrococcygeal teratoma associated with an N-type rectobulbar fistula is reported. Accepted: 12 September 1997     

Epidermoid cyst in a wandering spleen

A wandering spleen and splenic cysts are uncommon conditions in children. A combination of both entities has only rarely been reported in the literature. Another case of this complex pathology in 12-year-old girl is presented. She was initially referred for evaluation of a large abdominal mass. Diagnostic studies raised the suspicion of a hematoma in an abnormally located spleen, but the definitive diagnosis was established at laparotomy. Successful surgical management consisted of total cystectomy and splenopexy. Accepted: 6 November 1997     

Umbilical granuloma: a new approach to an old problem

Umbilical granuloma (UG) is the most common umbilical abnormality in neonates, causing inflammation and drainage. Most fail to epithelialize and persist for more than 2 months. The common treatment is application of a 75% silver nitrate stick, usually repeated two to three times over a number of clinic visits. Burns have been reported following spillage onto the surrounding tissues. During a 10-year period, 302 neonates were treated for UG using excision and application of absorbable hemostatic materials. Healing was uneventful in all cases, and no complications have been encountered to date. This technique is simple, safe, and inexpensive, and obviates the need for repeated outpatient visits. Accepted: 30 October 2000     

Anomalous pancreaticobiliary union and chronic pancreatitis: rare presentation with biliary peritonitis

Anomalous pancreaticobiliary union (APBU) has varied presentations. We report the case of a 12-year-old female who presented with biliary peritonitis due to a perforation of the common bile duct due to impaction of a pancreatic calculus at the duodenal␣ papilla. She had a long common-biliary channel and pancreas divisum with chronic calcific pancreatitis involving the pancreatic head and neck. To our knowledge, this is the first such reported case in the literature. Accepted: 15 June 2000     

Functional outcome after pyeloplasty for unilateral symptomatic hydronephrosis

The functional outcome and factors influencing improvement after pyeloplasty for ureteropelvic junction (UPJ) obstruction are still debated. This retrospective study was aimed at evaluating the factors associated with functional improvement in symptomatic unilateral hydronephrosis (HDN). Patients (n = 68) who underwent successful pyeloplasty for unilateral symptomatic UPJ obstruction without any other associated urological abnormality were included. Preoperative evaluation included a diuretic renogram (DR) to confirm obstruction and assess the split renal function (SRF). A follow-up DR was obtained 3 months and 1, 2, and 5 years postoperatively. An absolute increase in the differential function of the operated kidney by over 5% was considered significant; such kidneys were classified as improved (group A) and the others as unimproved (group B). The difference between the preoperative and 3-month SRF was highly significant (P < 0.001). Significant (P < 0.01) improvement in SRF continued until 1 year after pyeloplasty. Patients who presented with a mass had significantly greater improvement (P < 0.05) than those who presented with other clinical features. In group A, a significantly higher number of patients presented with a mass. It was also evident that patients aged less than 1 year showed significantly greater (P < 0.01) improvement in SRF than older patients. Thus, in unilateral symptomatic HDN with impaired function, patients who present with a mass or those in whom pyeloplasty was performed before 1 year of age showed significantly greater improvement.     

Pneumatic dilatation for childhood achalasia

Treatment of achalasia by pneumatic balloon dilatation (PBD) is well established in adults. Due to limited experience and the rarity of the condition in children, there are relatively few reports in the paediatric literature. Although PBD has been reported as a primary method of treatment, there are no reports of secondary PBD for childhood achalasia. Between 1995 and 1999, five patients underwent treatment for achalasia (age: 9–14 years; M:F=4:1). The presenting symptoms were dysphagia (5), vomiting episodes (2), aspiration (1), food-bolus obstruction (1), and failure to thrive (1). In all patients a barium swallow and manometry were used to confirm the diagnosis. Three underwent primary PBD. Two who had previously undergone surgical myotomy underwent secondary PBD for recurrence of symptoms. Dilatation was performed using a 35-mm balloon with the child under general anaesthesia. Technical success was defined as demonstration of a waist under screening at lower pressures followed by abolition of the waist at higher pressures. In addition to reviewing our results, a systematic review of the literature was performed (Medline, Cochrane Library, Pubmed, Embase). Three patients (primary dilatation) showed excellent improvement after a single dilatation. In two cases (secondary dilatation) three and five attempts were required. No complications were encountered. The mean follow-up period was 2 years (1–3.5 years) and four patients remained asymptomatic, an overall success rate of 80%. The literature review revealed similar good results in most of the recent reports. Thus, PBD as a primary treatment for childhood achalasia has a success rate of 70%–90% with minimal side effects, short hospital stay, and good patient acceptability over an operation. We have also established the usefulness of this method as a secondary treatment when symptoms recur after surgery. Accepted: 1 September 2000     

Germ-cell degeneration in experimental unilateral cryptorchidism: role of apoptosis

We investigated the possible involvement of apoptosis in the increased germ-cell degeneration in undescended testes (UDT). Experimental unilateral cryptorchidism was induced in 21-day-old rats, and both testes were removed for in-situ TUNEL staining of apoptotic cells at 1, 3, 7, 10, and 14 days postoperation. A gradual increase in the incidence of apoptosis was seen at 21–28 days of age in the control testes, followed by a decrease thereafter. After 10 days postoperation, the weight of the UDT was significantly lower than that of the contralateral descended testis (CDT) and the controls. However, the weight of scrotal testes in each group was similar. UDTs demonstrated a markedly increased incidence of apoptosis. By 7 days postoperation, the percentage of seminiferous tubules containing apoptotic germ cells significantly increased in UDTs compared with that in CDTs and controls (P < 0.001). Moreover, there was a significant difference in the percentage of seminiferous tubules containing apoptotic germ cells between CDTs and controls (P < 0.01). In addition, an increased incidence of seminiferous tubules containing 8–10 and >10 apoptotic germ cells from 7, 10, and 14 days postoperation in UDTs was detected. In-situ TUNEL analysis demonstrated spermatocytes to be the main type of germ cells affected in all groups. These findings suggest that spermatogenesis decreases not only in the␣UDT, but also in the CDT, and that the germ-cell degeneration in cryptorchidism took the form of apoptosis.     

Is infertility after surgery for cryptorchidism congenital or acquired?

We evaluated whether deletions of the DAZ (deleted in azoospermia) gene, abnormal karyotypes or hypogonadotropic hypogonadism (HH) were demonstrable in infertile men who had undergone surgery in childhood for cryptorchidism with a simultaneous testicular biopsy that demonstrated no or almost no germ cells. In six men with infertility after surgery for cryptorchidism, the adult karyotype and analyses for the DAZ gene, serum follicle-stimulating hormone, luteinizing hormone, and testosterone were performed from a peripheral blood sample. Testicular volume was also measured. All patients exhibited a 46,XY karyotype. There were no deletions of the DAZ-gene, no HH and no testicular atrophy. The infertility was thus not proved to be congenital, and consequently, surgical treatment is indicated before the germ cells disappear from undescended testes. This appears to be before 15 months of age.     

Herpes virus (KSHV) associated kaposi sarcoma in a 3-year-old child with non-HIV-induced immunodeficiency

A 3-year-old boy of German descent suffered from two episodes of Streptococcus pneumoniae meningitis within 2 months. One month previously, the first skin lesion of Kaposi sarcoma (KS) had been observed behind his right ear. During the following 2 years KS disseminated not only mucocutaneously but also to visceral organs. Immunological evaluation revealed severe lymphocytopenia with reduced helper/suppressor T-cell ratio and impaired humoral immune response to pneumococci. Extensive laboratory tests gave no evidence for known immunocompromising infections. However, recently described DNA sequences from a Kaposi sarcoma-associated herpesvirus (KSHV) could be identified within skin tissue. As chemotherapy failed to stop tumour progression the patient was referred for bone marrow transplantation. Eighteen months later the KS is in remission and the patient in a good general condition. Conclusion The case supports the hypothesis that KSHV is involved in the aetiology of KS. Bone marrow transplantation is possibly a therapeutic option for KS in patients with immunodeficiency not related to human immunodeficiency virus infection. Received: 1 August 1996 / Accepted: 15 December 1996     

Hemisplenectomy for giant splenic cysts in children

To analyse the clinical features and outcome following surgery of giant splenic cysts in␣children, all patients presenting to a children's hospital over the years 1987–1996 were reviewed. Variables analysed included presenting symptoms, method of diagnosis, operative procedure, and complications. Six patients (aged 8–16 years) presented with abdominal pain or a large abdominal mass. Ultrasound examination demonstrated large (>5 cm) unilocular splenic cysts. Five of the six children underwent hemisplenectomy without complication or blood transfusion. The remaining patient had an infected cyst, for which total splenectomy was necessary because of major intraoperative haemorrhage. Hemisplenectomy is based on accurate dissection of the splenic hilum with clear knowledge of the intracapsular vascular anatomy of the spleen. Preoperative vaccination is recommended in the event that splenectomy is required. This retrospective review concludes that hemisplenectomy for splenic cysts is a safe procedure in children. Accepted: 3 November 1997     

Upregulated tumor necrosis factor-α gene expression in the hypoplastic lung in patients with congenital diaphragmatic hernia

Recent studies using animal models of congenital diaphragmatic hernia (CDH) have reported a reduction in both surfactant (SF) phospholipids and proteins in CDH lungs compared to controls, resulting in biophysical and physiologic impairment of SF function in the hypoplastic CDH lung. Furthermore, SF replacement has been shown to improve physiological function in CDH lungs. Tumor necrosis factor-α (TNF-α) is a polypeptide whose overproduction has been implicated in the pathogenesis of a number of pathological conditions, such as neonatal and adult respiratory distress syndrome. TNF-α has been shown to selectively inhibit the de-novo synthesis of SF phospholipid components in type II pneumocytes. It has been demonstrated that TNF-α is synthesized locally in lung and functions in an autocrine/paracrine mode. The aim of this study was to investigate TNF-α messenger RNA (mRNA) expression in hypoplastic CDH lung using in-situ hybridization histochemistry, to determine the molecular basis of the SF deficiency in the hypoplastic CDH lung. Lung-tissue samples were obtained at autopsy from 7 full-term newborns (age range: 1–21 days) with CDH and 4 stillborns with CDH. Normal lung tissue from eight infants with sudden infant death syndrome (age range: 5–30 days) acted as controls. In-situ hybridization was performed using TNF-α specific and digoxigenin-labeled oligonucleotide probe and visualized by nitroblue tetrazolium staining. In control lung tissue, mRNA expression of TNF-α was absent or weak in type II pneumocytes and alveolar macrophages. In contrast, mRNA expression of TNF-α was markedly increased in both type II pneumocytes and alveolar macrophages in hypoplastic CDH lung. Our findings of up-regulated TNF-α gene expression in CDH lung suggest that the SF deficiency observed in hypoplastic CDH lung may be the result of increased local production of TNF-α. Accepted: 26 May 1998     

Neuroblastoma and insulin-like growth factor system

Neuroblastoma is, at the same time, the most common and the most puzzling extracranial solid tumour in childhood, being able to regress spontaneously despite widespread dissemination, showing a striking high incidence of the in situ form, and, finally, being resistant even to aggressive chemotherapy. The reasons of this bizarre behaviour are still largely unknown due to our little knowledge of neuroblastoma pathophysiology. There is increasing body of evidence that the insulin-like growth factor system plays a crucial role in the proliferation and differentiation of neuroblastoma cells and it is conceivable that a better knowledge of this role might potentially lead to new and more effective therapeutic strategies. Here we review the most recent insights into the biology of neuroblastoma, focusing on the close links with the insulin-like growth factor system and the potential clinical perspectives. Received: 13 May 1996 and in revised form: 15 July 1996 / Accepted: 15 July 1996     

Diphallus associated with partial caudal duplication

A 23-year-old man with similar pathology has presented in March 1998 for primary management of his diphallus and anorectal duplication. Accepted: 20 September 1997     

A thyroxine dosage of 8 μg/kg per day is appropriate for the initial treatment of the majority of infants with congenital hypothyroidism

 The adequate l-thyroxine dosage for the initial treatment of infants with congenital hypothyroidism is a subject of controversy. Some recommend higher dosages (> 10 μg/kg/day) to ensure adequate levels, while others advocate lower dosages to permit normalisation of thyroid status. The aim of this study was to evaluate the␣results of a treatment strategy using an initial dosage of 7.5–8.0 μg/kg per day, TSH measurements being␣taken at 15 and 30 days of treatment. Fifty one newborns infants with primary congenital hypothyroidism␣detected by neonatal screening were treated with the same therapeutic strategy. A mean l-thyroxine dosage of 7.9 μg/kg per day at the onset of treatment and 6.6 μg/kg/d at 2 months, normalised the FT₄ and FT₃ levels at 15 days in 100% and TSH levels at 2 months in 90% of cases. Many patients showed elevated levels of FT₄ and a systematic higher initial dosage could expose many infants to a dangerous hyperthyroidism. Patients with abnormal TSH levels at 2 months already had higher TSH levels in the first 8 weeks of life and, despite higher l-thyroxine dosage, also exhibited lower FT₄ and FT₃ levels. These patients who needed an early increase in dosage had already shown a more profound ante and neonatal hypothyroidism. This subgroup of patients require a higher dosage of thyroxine and early assessment of FT₄, FT₃ and TSH levels are required for optimum dosage choice. Conclusion Even though a subgroup of patients may require a higher dosage of l-thyroxine, an initial␣dosage of 7.5–8.0 μg/kg per day, with an early assessment of␣FT₄, FT₃, and TSH levels, is adequate for the treatment of the majority of infants with congenital hypothyroidism. Received: 17 August 1995 / Accepted 10 June 1996     

Helicobacter pylori and hypergastrinemia in children with recurrent abdominal pain

Recurrent abdominal pain (RAP) is a significant problem in the pediatric population, and there has been much recent interest in the role that Helicobacter pylori (Hp) might play in this disorder. In this case control study, the authors aimed to determine whether Hp is an agent responsible for RAP, and to assess fasting gastrin concentrations in children with and without RAP in the Hp-positive and -negative groups. The study was conducted in 42 patients with RAP and 50 healthy children attending routine day-case surgery as a control group, aged 3 to 15 years, over a 12-month period. Of the 42 children with RAP, 30 were seropositive (71.4%) for Hp IgG, and of 50 children in the control group, 32 were seropositive (64%) for Hp IgG (P > 0.05). We found that Hp infection was as high in healthy children as in children with RAP. The mean fasting gastrin levels in 62 Hp-seropositive children (60.4 ng/l) were not different from those in 30 Hp-seronegative children (57.3 ng/l) and those in 42 children with RAP (58.2 ng/l) were also not significantly different from those in 50 healthy children (62.9 ng/l). Thus, no association between childhood Hp infection, hypergastrinemia, and RAP was found in our Turkish population. Accepted: 26 May 1998     

Postoperative complications after surgery for typhoid perforation in children in Ghana

One of the most severe complications of typhoid fever is perforation of the ileum (TPI); it is also a cause of high morbidity and mortality in endemic areas. After surgery for TPI, other complications may set in postoperatively, compounding the problem. A prospective study of 121 children who were operated upon for TPI to identify the postoperative complications showed that the most common was wound infection. The most serious were: mechanical intestinal obstruction, abdominal dehiscence, and enterocutaneous fistulae. Physicians caring for such children should be aware of these complications and their mode of presentation so as to quickly and decisively manage them to prevent more deaths. Accepted: 8 April 1998     

Comparison of the pulmonary vasculature in newborns and stillborns with congenital diaphragmatic hernia

The purpose of this study was to compare structural changes in the pulmonary vasculature in newborns with congenital diaphragmatic hernia (CDH) complicated by persistent pulmonary hypertension (PPH) and stillborns with CDH. Victorian blue van Gieson (VVG) staining and immunostaining with anti-alpha smooth-muscle actin (ASMA) was performed on lung tissue obtained at autopsy from 23 newborns with CDH complicated by PPH, 7 stillborns with CDH, and 11 age-matched controls with sudden infant death syndrome (SIDS). The degrees of adventitial and medial thickness and area were measured in pulmonary arteries with an external diameter (ED) of <75 μm, 75–100 μm, 100–150 μm, 150–250 μm, 250–500 μm, and >500 μm by image analyzer and compared statistically. The degrees of adventitial and medial thickness and area were measured in pulmonary veins with an ED of <100 μm, 100–200 μm, and >200 μm by image analyzer and compared statistically. In order to determine whether the characteristic structural changes were size-related, each was related to ED. There was a significant increase in adventitial thickness and area in arteries of all sizes in both newborns and stillborns with CDH compared to SIDS patients (P < 0.05). The degree of medial thickness in newborns and stillborns with CDH was significantly increased compared to SIDS patients (P < 0.01). The degree of medial area was significantly increased for arteries with ED less than 100 μm (P < 0.05) in newborns and stillborns with CDH compared with SIDS patients. There was a significant increase in adventitial thickness and area in veins of all sizes in newborns with CDH compared to stillborns with CDH and SIDS (P < 0.05). The degree of adventitial thickness and area of pulmonary veins were similar in stillborns with CDH and SIDS. There were no significant differences in medial thickness of veins between the three groups. The presence of abnormally thick-walled pulmonary arteries in stillborns with CDH suggests that the intrapulmonary arteries in CDH may become excessively muscularized during fetal life, becoming unable to adapt normally at birth. The absence of structural changes in pulmonary veins in stillborns with CDH suggests that the pulmonary venous changes observed in newborns with CDH complicated by PPH occur after birth as a result of increases in transvascular pressure or a response to release of peptide growth factors. Accepted: 10 March 1998     

Ascorbic acid enhances hydroxyl radical formation in iron-fortified infant cereals and infant formulas

Infant cereals and formulas are usually fortified with iron to prevent iron deficiency. To enhance iron bioavailability, supplemental ascorbic acid is recommended. Ascorbic acid is considered to be an antioxidant in vivo, but has pro-oxidant effects when exposed to non-protein-bound iron. We measured formation of free radicals in cereals and infant formulas after addition of ascorbic acid. The production of hydroxyl radicals was assessed by hydroxylation of salicylic acid to 2,5-dihydroxybenzoic acid (2,5-DHBA). Production of 2,5-DHBA increased with increasing ascorbic acid doses added. Addition of 0.8 mM ascorbic acid to breast milk produced less radicals (0.03 ± 0.05 μM) than addition of ascorbic acid to low-iron formula (0.13 ± 0.08 μM, P = 0.019), medium-iron formula (0.34 ± 0.12 μM, P < 0.0001) or high-iron formula (0.44 ± 0.08 μM, P < 0.0001). Even when iron content in breast milk was adjusted to a level comparable with that of formulas, production of 2,5-DHBA was lower. Breast milk seems to contain substances that reduce hydroxyl radical formation. Conclusion Supplemental ascorbic acid causes hydro-xyl radical formation in iron-fortified infant nutrients in vitro. Received: 30 March 1996 / Accepted in revised form: 10 December 1996