Tracheobronchial injury by blunt trauma in children: is emergency tracheobronchoscopy always necessary?

PURPOSE: To discuss the usefulness of CT scan in initial management of well tolerated tracheobronchial injuries and the place of tracheoscopy. METHODS: We report our experience of three cases treated for tracheobronchial rupture resulting from three different mechanisms and review the literature. Three boys, aged 4 to 10 years, were referred to our institution for tracheobronchial rupture. Two of them presented with subcutaneous emphysema after a minor trauma, the third was a polytrauma referred after a severe car crash and was already intubated. We emphasise the importance of an initial CT scan, as this allowed us twice to confirm the tracheal wound prior to tracheoscopy. We discuss the necessity of performing a tracheoscopy in the case of a well tolerated lesion, as this procedure clearly worsened the ventilatory state in one of our cases. Moreover, one of our cases illustrates the fact that even a minor trauma can lead to life-threatening respiratory distress. All the lesions observed in our study were linear and were managed by thoracic drainage; they were then closely monitored and required no further surgical procedure. CONCLUSION: Tracheobronchial rupture in children can result from minor cervical traumas and in such cases special attention must be paid to mild discomfort or subcutaneous emphysema on admission. Initial CT scan can be very helpful in visualising the level of the rupture and its consequences with respect to the pulmonary parenchyma. One can question the necessity for tracheoscopy in well tolerated lesion, as its results do not always improve the therapeutic outcome.     

Subperiosteal chondroma. Diagnostic contribution of x-ray computed tomography. Apropos of 2 cases

Results of CT scan exploration are reported in two cases of subperiosteal chondroma, one in a 4 year old child affecting the anterior tibial tuberosity the other in a 9 year old child involving the upper end of humerus. Data from CT scan imaging were undoubtedly superior to those of conventional radiography and appear to be characteristic of this benign cartilaginous tumor, greatly facilitating correlation between clinical, radiological and pathologic findings. The scanner should allow certain situations to be dedramatized and the surgical attitude adapted when the functional prognosis is involved.     

Lamotrigine in the treatment of painful diabetic neuropathy

An open trial was conducted to study the potential efficacy of lamotrigine, a novel antiepileptic agent that blocks voltage-sensitive sodium channels and inhibits the release of glutamate, in relieving the pain associated with diabetic neuropathy. Subsequent to a 1 week washout period from previous analgesics, lamotrigine was administered at a dose of 25 mg/day for 1 week. The dose was doubled on a weekly basis up to 400 mg/day over 6 weeks. The McGill pain questionnaire (MPQ), spontaneous pain and a series of mechanical and thermal stimuli-induced pain were measured with the use of 0–100 visual analogue scale (VAS), on seven office visits. Pain level was also recorded by each patient twice daily, 1 week before, during, and 2 weeks after the treatment period with the use of a 0–10 numerical pain scale (NPS). Quantitative mechanical (Von Frey filaments) and thermal testing (QTT), and routine blood tests were performed at the beginning and at the end of the study. Thirteen patients completed the study. Spontaneous pain measured by VAS and NPS gradually dropped from a baseline of 49 ± 8 and 6.8 ± 0.6, to 20 ± 8.6 ( p < 0.001) and 4.3 ± 0.9 ( p < 0.001), respectively, at the end of the treatment period. Similarly, cold allodynia dropped from 38 ± 9.2 to 16 ± 15.3 ( p = 0.01), and the MPQ score from 13.6 ± 0.8 to 11.0 ± 1.5 ( p < 0.01). In contrast, no significant changes were found in the QTT, mechanical pain thresholds and laboratory results. Two patients were withdrawn from the study because of adverse effects. A long-term follow up showed that most patients were still using lamotrigine 6 months after the end of the study. The results of the study suggest that lamotrigine is potentially effective and safe in treating painful diabetic neuropathy.     

Variations in Helicobacter pylori lipopolysaccharide to evade the innate immune component surfactant protein D

Helicobacter pylori is a common and persistent human pathogen of the gastric mucosa. Surfactant protein D (SP-D), a component of innate immunity, is expressed in the human gastric mucosa and is capable of aggregating H. pylori. Wide variation in the SP-D binding affinity to H. pylori has been observed in clinical isolates and laboratory-adapted strains. The aim of this study was to reveal potential mechanisms responsible for evading SP-D binding and establishing persistent infection. An escape variant, J178V, was generated in vitro, and the lipopolysaccharide (LPS) structure of the variant was compared to that of the parental strain, J178. The genetic basis for structural variation was explored by sequencing LPS biosynthesis genes. SP-D binding to clinical isolates was demonstrated by fluorescence-activated cell sorter analyses. Here, we show that H. pylori evades SP-D binding through phase variation in lipopolysaccharide. This phenomenon is linked to changes in the fucosylation of the O chain, which was concomitant with slipped-strand mispairing in a poly(C) tract of the fucosyltransferase A (fucT1) gene. SP-D binding organisms are predominant in mucus in vivo (P = 0.02), suggesting that SP-D facilitates physical elimination. Phase variation to evade SP-D contributes to the persistence of this common gastric pathogen.     

Pseudo-angiomatous hyperplasia of mammary stroma: a case with gigantomastia

Pseudo-angiomatous hyperplasia of mammary stroma (PASH) is a histopathological entity which is a microscopic fortuitous finding in mammary biopsies performed for different reasons. It may be symptomatic and appears then as a palpable lump. The term pseudo-angiomatous emphasizes the characteristic aspect of the stroma simulating a vascular tumor. We report a case of PASH in a 71 year-old woman who presented a recurring breast mass with rapid swelling of the mammary gland (70 x 60 x 20 cm) treated by mastectomy. PASH must be distinguished from a well-differentiated angiosarcoma. It is ruled out by immunohistochemistry.     

Detection and characterization of new influenza B virus variants in 2002

One-hundred five influenza B-positive specimens obtained from southeast Asia in 2002 were categorized on the basis of DNA sequencing of HA1 gene as well as real-time PCR analysis of the NA gene. Phylogenetic analysis of the HA1 gene sequences showed that the majority of the viruses (96.2%) belonged to the B/Victoria/2/87 lineage, while a smaller percentage of the viruses (3.8%) belonged to the B/Yamagata/16/88 lineage. The B/Yamagata/16/88 viruses displayed significant antigenic drift in the deduced amino acid sequences of the HA1 protein, and the B/Victoria/2/87-like viruses consisted of B/Hong Kong/1351/02-like (72.3%) and B/Hong Kong/330/01-like (27.7%) viruses. The B/Hong Kong/1351/02-like viruses were reassortants with the HA gene belonging to the B/Victoria/2/87 lineage and the NA gene belonging to the B/Yamagata/16/88 lineage, whereas both the HA and NA genes of B/Hong Kong/330/01 virus belonged to the B/Victoria/2/87 lineage. In this study, however, all the B/Hong Kong/330/01-like isolates exhibited the B/Yamagata/16/88-like NA gene, which likely resulted from reassortment of B/Hong Kong/330/01 and B/Hong Kong/1351/02 viruses during coinfection. Additional molecular characterization of the six internal genes showed that the M, NS, PA, and PB2 genes of the new variants were B/Hong Kong/1351/02 in origin, whereas the NP and PA genes retained the B/Hong Kong/330/01 origin. Interestingly, these new variants all appeared late in the year 2002. These results support the notion that influenza B viruses continued to evolve through antigenic drift and shift.     

Ultrastructural and elemental analysis of calcification of advanced swine aortic atherosclerosis

During progression and in the early phase on a regression regimen, calcification of the necrotic portion of the atheroma of swine abdominal aorta occurred primarily in degenerated cells or in membranous, vesicular cellular degradation products which varied in size, shape, and the amount of mineral deposit. Calcium appeared to be deposited in amorphous granular or needle-like crystalline forms. Energy dispersive X-ray and line profile analysis showed that the major elements in the heavily calcified portions of the plaques were calcium and phosphorus. There was a direct relationship between the distribution and concentration of these elements indicating that the mineral deposit was a calcium phosphate. Select area electron diffraction analysis of grossly calcified portions of the plaque gave a diffraction pattern identical to that of calcium hydroxyapatite. Calcification was not observed to occur on elastic tissue or collagen fibers.