Torsion of a giant mesenteric lipoma

Mesenteric lipoma is a rare benign neoplastic condition that can grow to be very large and mimic other midgut fatty tumors. These benign tumors can cause various gastrointestinal symptoms such as obstruction and abdominal pain. We report the case of a 9-year-old boy who presented with a small bowel obstruction caused by torsion of a large mesenteric lipoma. This is an important but unusual tumor and should be considered in the differential of fatty lesions within the mesentery.     

CT versus MR in neonatal brain imaging at term

BACKGROUND: Recent reports have highlighted the lifetime risk of malignancy from using ionizing radiation in pediatric imaging. Computed tomography (CT), which uses ionizing radiation, is employed extensively for neonatal brain imaging of term infants. Magnetic resonance (MR) provides an alternative that does not use ionizing radiation. OBJECTIVE: The purpose of this study was to assess the cross-modality agreement and interobserver agreement of CT and MR brain imaging of the term or near-term neonate. MATERIALS AND METHODS: Brain CT and MR images of 48 neonates were retrospectively reviewed by two pediatric neuroradiologists. CT and MR examinations had been obtained within 72 h of one another in all patients. CT was obtained with 5 mm collimation (KV=120, mAs=340). MR consisted of T1-weighted imaging (TR/TE=300/14; 4-mm slice thickness/1-mm gap), T2-weighted imaging (TR/TE/etl= 3000/126/16; 4-mm slice thickness/1-mm gap), and line scan diffusion imaging (LSDI) (TR/TE/b factor=1258/63/750; nominal 4-mm slice thickness/3-mm gap). The brain was categorized as normal or abnormal on both CT and MR. RESULTS: Ischemic injury was the most common brain abnormality demonstrated. McNemar's test indicated no significant difference between CT and MR test results for reader 1 (P=0.22) or reader 2 (P=0.45). The readers agreed on the presence or absence of abnormality on CT in 40 patients (83.3%) and on MR in 45 patients (93.8%). For CT, the kappa coefficient indicated excellent interobserver agreement (kappa=0.68), although the lower limit of the 95% confidence interval extends to kappa=0.55, which indicates only good-to-moderate agreement. For MR, the kappa coefficient indicated almost perfect interobserver agreement (kappa=0.88) with the 95% confidence interval extending to a lower limit of kappa=0.76, which represents excellent agreement. CONCLUSION. Because MR demonstrates findings similar to CT and has greater interobserver agreement, it appears that MR is a superior test to CT in determining brain abnormalities in the term neonate. Furthermore, since MR eliminates the use of ionizing radiation, a putative cause of malignancy, it should be the standard in neonatal brain imaging. Future efforts should be directed to improving neonatal access to MR to avoid the routine use of CT in infants.     

Linezolid versus cefadroxil in the treatment of skin and skin structure infections in children

BACKGROUND: Skin and skin structure infections are common reasons for visits to pediatricians, accounting for up to 18%. Staphylococcus aureus and Streptococcus pyogenes are the most frequently isolated Gram-positive pathogens in uncomplicated skin infections. Increasingly outpatient infections involve antibiotic-resistant Gram-positive pathogens including methicillin-resistant S. aureus. METHODS: This randomized, blinded, comparator-controlled, multinational trial compared the efficacy and safety of linezolid and cefadroxil for treatment of uncomplicated skin/skin structure infections in pediatric patients. Children ages 5 to 11 years were to receive linezolid suspension [10 mg/kg (up to 600 mg)] or cefadroxil suspension [15 mg/kg (up to 500 mg)] every 12 h. Patients ages 12 to 17 years were to receive linezolid tablets (600 mg) or cefadroxil capsules (500 mg) every 12 h. Therapy lasted 10 to 21 consecutive days with a follow-up visit 10 to 21 days posttherapy. RESULTS: Linezolid and cefadroxil were consistently effective treatments across all primary and secondary efficacy assessments. At follow-up cure rates were 88.7% (205 of 231) for linezolid-treated and 86.2% (193 of 224) for cefadroxil-treated intent-to-treat patients; cure rates were 91.0% (201 of 221) for linezolid-treated and 90.0% (189 of 210) for cefadroxil-treated clinically evaluable patients. S. aureus was eradicated in 89.6% (120 of 134) linezolid-treated and 88.8% (111 of 125) cefadroxil-treated microbiologically evaluable patients. Gastrointestinal complaints were the most common adverse events reported, without significant differences between treatment groups, and myelosuppression was not observed in this study. CONCLUSIONS: Linezolid is well-tolerated and as effective as cefadroxil in treating uncomplicated skin infections in pediatric patients. Linezolid effectively treated infections caused by S. aureus, methicillin-resistant S. aureus and S. pyogenes.     

Time spent by primary care practices on pediatric influenza vaccination visits: implications for universal influenza vaccination

OBJECTIVE: To measure the time currently spent by primary care practice personnel, and the examination room occupancy time for childhood influenza vaccination visits, to assess the practicality of annual influenza vaccination of all preschool children. SETTING: Seven primary care practices serving one fourth of the children living in Rochester, NY. PATIENTS: Ninety-two children seen for influenza vaccination visits in the 2000-2001 vaccination season. METHODS: Using a standardized protocol, practice staff measured the time spent on check-in, nurse or physician examination, and the actual influenza vaccination process. Waiting and "hands-on" times were determined, as well as total visit and room occupancy times. Nonparametric tests and multivariable models were used to analyze the time spent for components of the visits and to compare time spent by different age groups and practice types (suburban or urban). RESULTS: The median duration of the influenza vaccination visit was 14 minutes (25th to 75th percentiles range, 9-25 minutes) across the 7 practices, with visits to urban practices being longer (22 minutes) than visits to suburban practices (9 minutes). Eighty percent of patient time involved waiting, primarily in examination rooms. The major components of influenza vaccination visits included waiting room time (4 minutes in suburban practices vs 8 minutes in urban practices; P<.01), and time in the examination room (5 minutes vs 14 minutes, respectively; P<.001), during which only 1 to 2 minutes (for both suburban and urban practices) were for hands-on vaccinations. Only 5% of visits were examined by a physician or nurse practitioner. Visit times did not vary by age. CONCLUSIONS: Although the personnel time for influenza vaccination visits was short, there was substantial patient waiting and long occupancy of examination rooms. If universal influenza vaccination is to be efficiently managed in primary care practices, it may be necessary to implement "vaccination clinics" or sessions in which large numbers of children are scheduled for influenza vaccinations at times when adequate rooms and dedicated nursing staff are available.     

Fixed flexion deformity and flexion after knee arthroplasty. What happens in the first 12 months after surgery and can a poor outcome be predicted?

Fixed flexion deformity and flexion of 284 knee replacements were recorded pre-operatively at 6 weeks and 12 months after surgery. Eighteen knees (6.3%) achieved unsatisfactory movements at 12 months. Seven knees (2.4%) had a fixed flexion greater than 10 degrees, six (2.1%) had flexion less than 90 degrees and five (1.8%) had both. The only pre-operative variable of predictive value for a poor outcome was a high fixed flexion deformity (10 out of 52 knees P<0.001). Only one out of 15 knees with limited pre-operative flexion was restricted afterwards. Seven knees (2.4%) with good pre-operative movements developed either limited flexion or a fixed flexion greater than 10 degrees, none had both. There were no post-operative events which contributed to this. Eight knees (2.8%) achieved very poor movements. In each case there was a significant post-operative event which contributed to this. Overall, the flexion achieved at 12 months was directly related to the pre-operative flexion. Those knees with <90 degrees of flexion gained 29.3 degrees (S.D. 18). Those with 130 degrees or greater flexion lost 15.2 degrees (S.D. 13.6). The mean pre-operative fixed flexion was reduced by 50% at 6 weeks and again at 12 months. Knees with a high fixed flexion deformity alone pre-operatively have an increased risk of developing stiffness afterwards even if the deformity is corrected at surgery. In most cases significant post-operative events play a major role in this outcome. A small percentage of knees develop stiffness without any obvious explanation.     

Down-regulation of sonic hedgehog expression in pulmonary hypoplasia is associated with congenital diaphragmatic hernia

The pathogenesis of pulmonary hypoplasia associated with congenital diaphragmatic hernia (CDH) is unknown. The sonic hedgehog (Shh) cascade is crucial for the patterning of the early respiratory system in mice. To establish whether Shh plays a role in the pathogenesis of lung hypoplasia in CDH, we investigated the gestation-specific expression of Shh in normal rat and human lungs using in situ hybridization and immunohistochemistry. The expression pattern was compared with that of age-matched samples of hypoplastic lungs associated with CDH in humans and in the 2,4-dichlorophenyl-p-nitrophenylether (nitrofen) rat model. Our results showed that in normal controls the expression of Shh increased with advancing gestation, peaked in the late pseudoglandular stage, and declined thereafter. The expression of Shh is initially down-regulated in pulmonary hypoplasia associated with CDH and peaks instead during the late canalicular stage. These data indicate that maximal expression of Shh occurs when respiratory bronchioles develop and thinning of the interstitium takes place, suggesting that Shh may play a role in these processes. Furthermore, we observed that Shh inhibited fetal lung fibroblast proliferation in vitro. Therefore, it is tempting to speculate that alterations in Shh expression may affect these developmental processes, thereby contributing to the pulmonary abnormality in CDH.     

Management of the umbilical cord--a guide to best care

Updating cord care, using evidence-based research, is the best way forward for midwives everywhere. Only then, can we teach women to care for their infants in the safest possible way. This will not only avoid confusion, but also will lead to continuity of care and reduced infection rates. Lastly, but not to be underestimated, is cost-effectiveness. Savings can be made as a result of the reduced need to use antiseptic products. Added to this is the potential savings to be made in midwives' time, which is the most expensive commodity in the care of mother and baby. At present, extra visits are usually as a direct result of cord separation problems. Finally there is the cost, both financial and emotional, of neonatal mortality and morbidity, as a result of omphalitis.     

Role of mental imagery in a property verification task: FMRI evidence for perceptual representations of conceptual knowledge

Is our knowledge about the appearance of objects more closely related to verbal thought or to perception? In a behavioural study using a property verification task, Kosslyn (1976) reported that there are both amodal and perceptual representations of concepts, but that amodal representations may be more easily accessed. However, Solomon (1997) argued that due to the nature of Kosslyn's stimuli, subjects may be able to bypass semantics entirely and perform this task using differences in the strength of association between words in true trials (e.g., cat-whiskers) and those in false trials (e.g., mouse-stinger). Solomon found no evidence for amodal representations when the task materials were altered to include associated false trials (e.g., cat-litter), which require semantic processing, as opposed to associative strategies. In the current study, we used fMRI to examine the response of regions of visual association cortex while subjects performed a property verification task with either associated or unassociated false trials. We found reliable activity across subjects within the left fusiform gyrus when true trials were intermixed with associated false trials but not when true trials were intermixed with unassociated false trials. Our data support the idea that conceptual knowledge is organised visually and that it is grounded in the perceptual system.