Mediastinal pancreatic pseudocysts in children.

Mediastinal pseudocyst is an unusual complication of pancreatitis, with only four cases previously reported in children. The extent of the pseudocyst can be defined by computed tomography or magnetic resonance imaging scan and preoperative aspiration of cyst fluid for amylase level can establish the diagnosis. Endoscopic retrograde cholangiopancreatography to define ductal anatomy can help plan the appropriate drainage procedure. Although exceedingly rare, the diagnosis of pseudocyst should be considered for any cystic mass in the abdomen or thorax, even in the absence of elevated amylase or history suggesting pancreatitis.     

105Changes in Nitric Oxide Levels After Deep Dermal injury in the Female,Red Duroc Pig (FRDP)

Introduction : Hypertrophic scar is a devastating sequel to burns and other tangential skin injuries. It follows deep dermal injuries and does not occur after superficial injuries. Nitric oxide (NO) plays many important roles in wound healing from inflammation to scar remodeling. Studies have shown that expression of nitric oxide synthase and nitric oxide production are decreased in human hypertrophic scar. However little is known about NO involvement in the early stages of hypertrophic scarring, because of the lack of an animal model. It was recently reported that the female red Duroc pig (FRDP) makes thick scar, which is similar to human hypertrophic scar. We hypothesized that NO production in wounds on the female, red Duroc pig is similar to that of human hypertrophic scar and that NO involvement in deep wounds is different from that in superficial wounds. Methods : Superficial (0.015” to 0.030”) and deep (0.045” to 0.060”) wounds were created on the backs of four FRDPs. Biopsies were collected at weeks 1.5, 4, 8 and 21 post wounding including samples of uninjured skin. Nitric oxide levels were measured with the Griess reaction assay and normalized with tissue protein level. Results : Superficial wounds healed with an invisible scar whereas the deep wounds healed with scar resembling mild hypertrophic scar. The thickness of the scars from the deep wounds was significantly greater than uninjured skin and healed superficial wounds (p < 0.01). NO levels were increased at 1.5 weeks in deep wounds compared to superficial wounds and uninjured skin (p < 0.05). At 8 weeks, NO levels in deep wounds had returned to the level of uninjured tissue and superficial wounds. By 21 weeks, NO levels had decreased significantly when compared to superficial wounds (p < 0.01). There were no differences in NO levels between uninjured skin and superficial wounds at any time point (p > 0.05). Conclusions : NO production is similar in late, deep wounds on the female, red Duroc pig to that reported in the literature for human hypertrophic scar further validating this animal model. NO production is quite different after deep wounds as compared to superficial wounds in the FRDP. Early elevation in nitric oxide production might account for excessive inflammation in deep wounds that become thick scars in the FRDP. Nitric oxide regulators and effects at early stages of scar formation should be elucidated further and the FRDP appears to be a useful model.     

Management of the fetus with a cystic adenomatoid malformation

Prenatal detection and serial sonographic study of fetuses with congenital cystic adenomatoid malformation (CCAM) now makes it possible to define the natural history of this lesion, determine the pathophysiologic features that affect clinical outcome, and formulate management based on prognosis. In a series of 22 prenatally diagnosed cases, the overall prognosis depended on the effects of the lung mass and the consequent physiologic derangement: A large mass may cause mediastinal shift, hypoplasia of normal lung tissue, polyhydramnios, and cardiovascular compromise leading to fetal hydrops. Two types of CCAM were distinguished by gross anatomy, ultrasonographic findings, and prognosis. Microcystic lesions (cysts < 5 mm; solid appearance) are often associated with fetal hydrops and have a poor prognosis. Macrocystic lesions (single or multiple cysts > 5 mm) are not usually associated with hydrops and have a more favorable prognosis. Four initially large lesions partially disappeared on serial prenatal sonography, suggesting that improvement can occasionally occur during fetal life. The finding that fetuses with hydrops are at high risk for fetal or neonatal demise led to fetal surgical resection of the massively enlarged pulmonary lobe (fetal lobectomy) in two cases. Fetuses with CCAM but without hydrops have a good chance for survival with maternal transport, planned delivery, and immediate neonatal resuscitation and surgery.

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Resumen La detección prenatal y el estudio sonográfico seriado de fetos con malformación adenomatosa quística congénita (MAQC) actualmente permite definir la historia natural de esta lesión, determinar las características patofisiológicas que afectan el resultado clínico y formular un manejo basado en pronóstico. En una serie de 22 casos diagnosticados en el período prenatal, el pronóstico global dependió de los efectos de las masas pulmonares y la consecuente alteración fisiológica: una gran masa puede producir desviación mediastinal, hipoplasia del tejido pulmonar normal, polihidramnios y compromiso cardiovascular resultante en hidrops fetal. Los dos tipos de MAQC pudieron ser distinguidos por la anatomía macroscópica, los hallazgos ultrasonográficos y el pronóstico. Las lesiones microquísticas (quiste <5 mm; apariencia sólida) generalmente están asociadas con hidrops fetal y tienen un pronóstico pobre. Las lesiones macroquísticas (quistes únicos/múltiples >5 mm) usualmente no están asociados con hidrops y exhibieron un pronóstico más favorable. Cuatro lesiones inicialmente de gran tamaño desaparecieron subsiguientemente bajo observación con sonografía seriada prenatal, lo cual sugiere que ocasionalmente se presenta mejoría en el curso del desarrollo fetal. El hallazgo de que los fetos con hidrops conllevan un alto riesgo de muerte fetal o neonatal ha llevado a la resección quirúrgica prenatal del lóbulo pulmonar de volumen masivo (lobectomía fetal) en dos casos. Los fetos con MAQC pero libres de hídrops tienen una buena probabilidad de sobrevivir mediante el transporte materno, un parto programado y resucitación y cirugía neonatales inmediatas.

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Résumé L'étude échographique répétée des foetus ayant la maladie kystique (adénomateuse) congénitale du poumon (MKACP) et la détection prénatale ont contribué à augmenter nos connaissances de l'histoire naturelle de la lésion, ont aidé à préciser les données physiopathologiques qui peuvent influencer l'évolution clinique et déterminer une démarche thérapeutique basée sur le pronostic. Dans cette série de 22 cas, diagnostiqués avant la naissance, le pronostic était basé sur l'effet de masse pulmonaire et les conséquences physiologiques: une masse importante peut en effet être responsable d'une déviation du médiastin, de l'hypoplasie des tissus pulmonaires normaux, d'une hydramnios, et d'une décompensation cardiovasculaire dont le résultat global est une anasarque foetale. Selon les données anatomiques macroscopiques, échographiques et pronostiques, on peut distinguer deux types de MKACP. Les kystes microscopiques (kystes < 5 mm, allure solide) sont souvent associés à une anarsaque foetale et un mauvais pronostic. Les lésions macroscopiques (kystes solitaires ou multiples > 5 cm) ne sont pas habituellement associés à une anasarque et le pronostic est généralement plus favorable. Dans cette série, quatre lésions larges initialement, ont diminué de taille au cours de la surveillance échographique, suggérant qu'une amélioration spontanée est toujours possible pendant la vie foetale. En raison du mauvais pronostic associé à une anasarque foetale avec mort foetale ou néonatale, on a été amené à pratiquer une résection chirurgicale élargie des lobes pulmonaires dans deux cas. Les foetus avec MKACP mais sans anasarque ont de bonnes chances de survie à condition d'entourer la maternité, la naissance et les premiers jours de l'enfant avec des soins chirurgicaux et de réanimation adaptés.

     

Fetal wound healing. The ontogeny of scar formation in the non-human primate.

OBJECTIVE: This study determined how scar formation develops in a non-human primate model of fetal skin repair. SUMMARY BACKGROUND DATA: A transition from healing scarlessly to healing with scar formation characterizes skin repair in rat and sheep fetuses. New knowledge of the regulatory processes occurring in the fetal wound at the initial stages of scar formation may provide insights into the early mechanisms of scar formation. METHODS: Full-thickness wounds were made in fetal rhesus monkey lips from 75 through 114 days gestation (n = 6, term = 165 days). Wounds were harvested at 14 days postwounding and processed for histology (hematoxylin & eosin, Masson's trichrome) as well as immunohistochemistry (human type I or type III collagen). RESULTS: Wounds healed with complete restoration of normal tissue architecture in the 75-day gestation fetus. However in the 85-100 day gestation fetuses, wounds healed with an absence of hair follicles and sebaceous glands, but the dermal collagen pattern remained reticular and similar to that in unwounded dermis. At 107 days, a thin scar was present in the wound, thereby demonstrating a transition to scar formation between 100 and 107 days gestation (early 3rd trimester) in the non-human primate. CONCLUSIONS: In the non-human primate fetus, a transition from scarless repair to adult-type repair with scar formation occurs in the early third trimester. These data provide insight into the transition process; the ontogeny of scar formation is characterized initially by wounds healing without the presence of epidermal appendages but with a normal reticular dermal collagen pattern, which we term the "transition wound."     

In utero arterial embolism from renal vein thrombosis with successful postnatal thrombolytic therapy

Thromboembolic events in the pediatric age group occur most commonly in neonates, and newborns of diabetic mothers are particularly at risk. We report a newborn with right renal vein and inferior vena cava thrombosis who apparently embolized across the foramen ovale antenatally with resultant right brachial artery occlusion. The baby was delivered by cesarean section from an insulin-dependent diabetic mother. At the time of birth, there was severe right arm ischemia with absent brachial and radial pulses. There was clinical evidence of distal embolization with a "trash" lesion of the distal right middle finger as well as a midforearm area of full-thickness skin loss. Ultrasound demonstrated a right renal vein thrombosis and a 95% occlusion of the inferior vena cava. Regional urokinase therapy was instituted through a lower extremity vein with a 5,000 U/kg bolus and then 5,000 U/kg/h continuous infusion. Twelve hours of infusion of urokinase led to clinical resolution of the right arm ischemia, with return of pulses. Follow-up ultrasound showed the right renal vein thrombosis and inferior vena cava clot to be completely resolved. The right middle finger and forearm lesions subsequently have healed primarily. We report this as a case of in utero arterial embolization with successful postnatal therapy using regional urokinase infusion.     

TREATMENT OF PALMOPLANTER HYPERHIDROSIS BY IONTOPHORESIS

Twenty-seven patients with idiopathic palmoplanter hyperhidrosis were treated with Iontotherapy over a one year period. In twenty-four cases there was a good response but maintenance therapy was required every 3-4 weeks.KEY WORDS: Iontophoresis, Palmoplanter hyperhidrosis