Closed reduction with CT-guided screw fixation for unstable sacroiliac joint fracture-dislocation

Background Unstable posterior pelvic ring fractures and dislocations are uncommon but potentially life-threatening injuries in children. Early definitive management reduces risk of immediate complications as well as chronic pain and gait dysfunction. Conventional operative therapy carries substantial risk of extensive blood loss and iatrogenic neurological and vascular injury. Minimally invasive image-guided intervention may further reduce immediate risk and improve long-term outcome.Objective To describe CT-guided closed reduction and internal fixation (CRIF) and review outcomes of unstable fracture-dislocation of the sacroiliac (SI) joint in children.Materials and methods Between 2000 and 2003, three children (two girls, one boy) age 8–14 years were referred to interventional radiology for treatment of unstable SI joint fracture-dislocation not adequately treated with anterior external fixation alone.Results The three affected SI joints (two left, one right) were treated in a combined approach by pediatric interventional radiologists and orthopedic surgeons, using a percutaneous approach under CT guidance. Over a threaded guiding pin, 7.3 mm cannulated screws were used to achieve stable reduction of the affected SI joints. One screw was removed after slight (2 mm) migration. No neurovascular or other complications occurred. All patients had satisfactory healing with near-anatomic reduction, although recovery of the youngest was delayed by associated spinal injury.Conclusions Compared to open surgical alternatives, CRIF under CT guidance reduces operating time, decreases blood loss, and allows early definitive fixation and immediate non-weight-bearing mobilization with a low rate of complication for unstable posterior pelvic ring fractures. In addition, CT-guided placement of the guide pin may allow safer screw positioning and may minimize the total number of screws needed to achieve pelvic stability.     

Unsuspected acetaminophen toxicity in a 58-day-old infant

Acetaminophen is frequently used by both physicians and parents for the relief of pain and fever in infants and children of all age groups. It has an excellent safety profile in therapeutic doses, but hepatotoxicity can develop following both intentional or unintentional overdoses. Repetitive doses of acetaminophen, usually in supratherapeutic amounts, but not always, in ill infants have been associated with hepatotoxicity. Acetaminophen toxicity may be very difficult to diagnose in young infants when suspicion for this entity is low. In addition, initial signs and symptoms are nonspecific and biochemical evidence of hepatic damage may not become evident for 24 to 36 hours. We report the case of an infant who received multiple doses of acetaminophen during an illness who developed hepatotoxicity.     

Fetal interleukin-1 receptor antagonist gene polymorphism, intra-amniotic interleukin-1beta levels, and history of spontaneous abortion

OBJECTIVE: The purpose of this study was to determine whether fetal carriage of specific alleles of the polymorphic interleukin-1 receptor antagonist gene is associated with variations in intra-amniotic cytokine levels and previous pregnancy outcomes. STUDY DESIGN: Fetal cells in midtrimester amniotic fluid from 189 women were tested for interleukin-1 receptor antagonist intron 2 length polymorphisms. Concentrations of cytokines in amniotic fluid were tested by enzyme-linked immunosorbent assay. Pregnancy history data were obtained subsequently. RESULTS: Homozygosity for interleukin-1 receptor antagonist allele 1 was detected in 13 of 17 fetuses (76.5%) from women whose previous pregnancies all ended in spontaneous abortions, as compared with 33 of 74 fetuses (44.6%) from women with at least 1 previous term birth ( P = .02). Fetal carriage of interleukin-1 receptor antagonist allele 2 was associated with only 1 (5.9%) previous spontaneous abortion, as opposed to 31 pregnancies (41.9%) that were associated with a previous term delivery ( P = .004). A similar relationship between interleukin-1 receptor antagonist allele 1 and spontaneous abortions was observed when pregnancies of white women only were analyzed. Median mid trimester amniotic fluid interleukin-1beta concentrations were higher in women whose previous pregnancies ended in term deliveries (15.7 pg/mL), as opposed to women with 1 to 2 (6.4 pg/mL; P = .04) or > or =3 (4.1 pg/mL; P = .007) previous spontaneous abortions. Fetal carriage of interleukin-1 receptor antagonist allele 2 was associated with elevated intra-amniotic interleukin-1beta levels (16.2 pg/mL), as compared with interleukin-1 receptor antagonist allele 1 homozygotes (10.8 pg/mL; P = .03). CONCLUSION: Fetal carriage of interleukin-1 receptor antagonist allele 1 is associated with reduced intra-amniotic interleukin-1beta concentrations and an increased occurrence of spontaneous abortions in previous pregnancies.     

Cervical surveillance as an alternative to elective cervical cerclage for pregnancy management of suspected cervical incompetence

OBJECTIVE: The aim of the present study was to compare the outcome of pregnancies among patients with suspected cervical incompetence treated either by elective cervical cerclage or an alternative management program involving cervical surveillance. DESIGN, SETTING AND METHODS: A prospective cohort study was performed in two groups of patients at risk of cervical incompetence with singleton gestations attending the Royal Women's Hospital, Melbourne, Australia, from 1996 to 2000. The first group was managed by their obstetric carers with an elective cerclage, while the second group was managed conservatively as part of a cervical surveillance program offered to patients attending the Department of Perinatal Medicine for pregnancy care. This program consists of weekly visits from 16 weeks' gestation and involves alternating transvaginal ultrasound assessment of cervical morphometry with cervico-vaginal bacteriology and fetal fibronectin swabs. Empiric insertion of a cerclage is undertaken when there is evidence of significant cervical shortening (cervical canal <2.5 cm in length at 相似文献   

Preimplantation genetic diagnosis for polycystic kidney disease

OBJECTIVE: To use preimplantation genetic diagnosis for achieving a polycystic kidney disease (PKD)-free pregnancy for a couple in which the female partner was affected by PKD but whose PKD1 or PKD2 carrier status was not established. DESIGN: Case report. SETTING: The IVF program of Reproductive Genetics Institute, Chicago, Illinois. PATIENT(S): An at-risk couple with the female partner affected by PKD, whose PKD1 or PKD2 carrier status was not established. INTERVENTION(S): Removal of PB1 and PB2 and testing for three closely linked markers to PKD1 (Kg8, D16S664, and SM7) and four closely linked markers to PKD2 (D4S2922, D4S2458, D4S423, and D4S1557) after standard IVF. MAIN OUTCOME MEASURE(S): Deoxyribonucleic acid analysis of PB1 and PB2 indicating whether corresponding oocytes were PKD1 or PKD2 allele free, for the purpose of transferring only embryos resulting from mutation-free oocytes. RESULT(S): Of 11 oocytes tested by PB1 and PB2 DNA analysis, 7 were predicted to contain PKD1 or PKD2, with the remaining 4 free of both mutations. Three embryos resulting from these oocytes were transferred, yielding a twin pregnancy and the birth of two unaffected children. CONCLUSION(S): This is the first preimplantation genetic diagnosis for PKD, which resulted in the birth of healthy twins confirmed to be free of PKD1 and PKD2. Preimplantation genetic diagnosis based on linked marker analysis provides an alternative for avoiding the pregnancy and birth of children with PKD, even in at-risk couples without exact PKD1 or PKD2 carrier information.     

Intrapartum elective cesarean delivery: a previously unrecognized clinical entity

OBJECTIVE: The purpose of the study was to investigate the incidence of intrapartum patient choice cesarean delivery-patients' requesting cesarean delivery and physicians' offering it during labor-and factors possibly influencing these requests and offers. METHODS: For a 6-month period from May 1, 2002, to October 31, 2002, obstetricians were asked to complete a questionnaire after all intrapartum cesarean deliveries regarding whether cesarean delivery was offered by the obstetrician or requested by the patient before being medically indicated. Patient medical records and physician demographic information were reviewed. RESULTS: There were 422 cases that met inclusion criteria. Questionnaires were completed in 100% of cases. Cesarean delivery was offered in 13% before a clear medical indication and requested in 8.8%. Older obstetricians, maternal-fetal medicine specialists, and full-time faculty were significantly more likely to offer cesarean delivery (P =.009, P <.001, and P =.015, respectively). Patients who were unmarried or undergoing labor induction were less likely to request cesarean delivery (P =.029 and P =.035, respectively). Maternal age, parity, stage or length of labor, epidural use, gestational age, insurance status, day of week, and time of delivery did not affect whether patients requested or were offered cesarean delivery. CONCLUSION: This study documents a heretofore unrecognized clinical entity: intrapartum elective cesarean delivery. Physician characteristics, as opposed to patient characteristics or intrapartum factors, are a major determinant of whether laboring patients are being offered cesarean delivery. LEVEL OF EVIDENCE: III     

A prospective, randomized study analyzing sartorius transposition following inguinal-femoral lymphadenectomy

OBJECTIVES: Based on the reduced morbidity seen in our retrospective study, we undertook a prospective, randomized trial to determine whether transposition of the sartorius muscle improves post-operative morbidity in women with squamous cell carcinoma of the vulva undergoing inguinal-femoral lymphadenectomy. METHODS: Patients with squamous carcinoma of the vulva requiring inguinal-femoral lymphadenectomy were randomized to undergo sartorius transposition or not. All patients received perioperative antibiotics, DVT prophylaxis, and closed suction surgical site drainage. Outcomes assessed include wound cellulitis, wound breakdown, lymphocyst formation, lymphedema, and/or rehospitalization. Cohorts were compared using Fisher's exact test. Baseline characteristics were compared using Student's t test or Fischer's exact test as appropriate. Logistic regression was used to assess the impact of sartorius transposition, after adjusting for other factors. RESULTS: From June 1996 to December 2002, 61 patients underwent 99 inguinal-femoral lymphadenectomies, 28 with sartorius transposition, and 33 without. The mean (SD) age for controls and patients undergoing sartorius transposition was 63.5 (15.2) and 73.8 (13.7) years, respectively (P < 0.05). There were no statistically significant differences in BSA, tobacco use, co-morbid medical conditions, past surgical history, medication use, size of incision, duration of surgery, number of positive lymph nodes, pathologic stage, pathologic grade, pre- or postoperative hemoglobin, or length of hospitalization. There were no statistically significant differences in the incidence of wound cellulitis, wound breakdown, lymphedema, or rehospitalization. The incidence of lymphocyst formation was increased in the sartorius transposition group. After adjusting for age, however, the groups appeared similar. CONCLUSIONS: Sartorius transposition after inguinal-femoral lymphadenectomy does not reduce postoperative wound morbidity.     

Long-acting erythropoietin: clinical studies and potential uses in neonates

Aranesp (darbepoietin alfa) is a biologically modified form of recombinant human erythropoietin (rHuEpo). Two additional carbohydrate-binding sites give Aranesp a half-life about three times that of rHuEpo. Extensive studies in adults and early studies in children indicate that Aranesp can be administered far less frequently than rHuEpo with an equivalent erythropoietic effect.This article reviews these studies and reports on the in vitro effects of Aranesp on human fetal and neonatal erythroid progenitors.     

The ponderal index in triplets: III. Association with birth weight discordance

Our objective was to determine the association of the ponderal index with birth weight discordance in triplets. We analyzed data from triplets delivered at 28-37 weeks for birth weight discordance (>25% difference between the heaviest and lightest triplet). Three categories of discordance (low skew, symmetrical, and high skew) were classified according to the relative position of the middle triplet. Birth weights and the ponderal index (birth weight/[length]3) of all concordant and discordant triplet groups were compared. Of 752 triplet sets included, 184 (24.5%) were discordant. Total triplet birth weight was higher in the concordant compared to all discordant categories. As opposed to birth weight, where only the middle triplet differed according to discordance pattern, the ponderal index for the largest triplet was significantly higher in the low skew discordant group compared to the concordant and other discordant triplet groups. In contrast, the ponderal index for the smallest and middle triplets were similar among the discordant groups. We concluded that discordance in triplet pregnancies exhibits different patterns of mass (birth weight) versus size (ponderal index). Our findings suggest that it may be the size of largest triplet that determines the presence or absence or discordance in triplet gestations.