Optimal radiologic position of an umbilical venous catheter tip as determined by echocardiography in very low birth weight newborns.

OBJECTIVE: To compare chest X-ray with echocardiogram (ECHO) in the localization of an umbilical venous catheter (UVC) tip in very low birth weight infants (VLBW). Secondary objectives determined the association between techniques for tip placement by the vertebral body level on X-ray, as well as the length of the thoracic inferior vena cava-right atrial (TIVC-RA) junction by ECHO. STUDY DESIGN: Prospective, sequentially enrolled, masked, single regional perinatal center study. Shortly after birth, one or more anterior-posterior X-rays were ordered by the clinical team to verify that the UVC tip was fixed in the central right atrium (cRA) or at the TIVC-RA junction. An echocardiogram was performed as soon as possible after the last X-ray and UVC tip location was interpreted by a pediatric cardiologist. The pediatric radiologist and cardiologist were masked with regard to each other's reading. RESULTS: The newborns (n = 51) were 27 (±3) weeks by gestational age with birth weights of 1029 (±288) grams (mean±SD). The radiologist read 50 UVC tips (98%) in the cRA or TIVC-RA junction and 1 (2%) in the LA. The cardiologist read 22 (43%) in the cRA or TIVC-RA, 21 (41%) in the LA and 8 (16%) tips could not be located in the heart. When the UVC tip was interpreted by X-ray as located in the TIVC-RA junction 8/29 (28%) were in the LA by echocardiogram. There was no agreement between vertebral level and tip position in the TIVC-RA junction, RA or LA. The TIVC-RA junction measured 6±1 mm and correlated with birth weight r = 0.54 (p < 0.001). CONCLUSION: In VLBW newborns, placement of the UVC tip into the cRA or TIVC-RA junction by X-ray does not avoid misplacement in the left atrium as demonstrated by echocardiography. For VLBW infants, it is suggested that echocardiography may be helpful in verifying that the original placement or migration of the UVC tip into the LA has not occurred.

Dopamine and serotonin signaling during two sensitive developmental periods differentially impact adult aggressive and affective behaviors in mice.

Pharmacologic blockade of monoamine oxidase A (MAOA) or serotonin transporter (5-HTT) has antidepressant and anxiolytic efficacy in adulthood. Yet, genetically conferred MAOA or 5-HTT hypoactivity is associated with altered aggression and increased anxiety/depression. Here we test the hypothesis that increased monoamine signaling during development causes these paradoxical aggressive and affective phenotypes. We find that pharmacologic MAOA blockade during early postnatal development (P2-P21) but not during peri-adolescence (P22-41) increases anxiety- and depression-like behavior in adult (>P90) mice, mimicking the effect of P2-21 5-HTT inhibition. Moreover, MAOA blockade during peri-adolescence, but not P2-21 or P182-201, increases adult aggressive behavior, and 5-HTT blockade from P22-P41 reduced adult aggression. Blockade of the dopamine transporter, but not the norepinephrine transporter, during P22-41 also increases adult aggressive behavior. Thus, P2-21 is a sensitive period during which 5-HT modulates adult anxiety/depression-like behavior, and P22-41 is a sensitive period during which DA and 5-HT bi-directionally modulate adult aggression. Permanently altered DAergic function as a consequence of increased P22-P41 monoamine signaling might underlie altered aggression. In support of this hypothesis, we find altered aggression correlating positively with locomotor response to amphetamine challenge in adulthood. Proving that altered DA function and aggression are causally linked, we demonstrate that optogenetic activation of VTA DAergic neurons increases aggression. It therefore appears that genetic and pharmacologic factors impacting dopamine and serotonin signaling during sensitive developmental periods can modulate adult monoaminergic function and thereby alter risk for aggressive and emotional dysfunction.

Abnormally small adenoids in HIV-infected children.

A number of diverse head and neck manifestations of HIV infection have been described, including adenoidal hypertrophy. We report a series of HIV-infected children in which 9 of 18 had abnormally small or radiographically absent adenoidal tissue. This finding did not, however, seem to correlate with several parameters for the severity or stage of illness.

Candida epiglottitis presenting as stridor in a child with HIV infection.

Invasive laryngeal candidiasis is an uncommon cause of epiglottitis, seen most often in immunocompromised or antibiotic-treated patients. We present the clinical and radiographic findings in an HIV-infected infant who developed significant stridor due to candidal epiglottitis. Stridor or hoarseness of unknown cause in an immunocompromised patient should lead to prompt evaluation for opportunistic laryngeal infection.

Hypertrophic osteoarthropathy in a young child with adult respiratory distress syndrome (ARDS) secondary to burns.

A case of hypertrophic osteoarthropathy (HOA) is presented in a 14-month-old girl with adult respiratory distress syndrome (ARDS) secondary to severe burn injury. The child developed clubbing during a lengthy and tumultuous hospitalization for her underlying lung disease, and hypertrophic osteoarthropathy was demonstrated radiologically.

Two smooth muscle tumors in the airway of an HIV-infected child.

Tumors of smooth muscle origin are rare in childhood. We report a case of multiple bronchial leiomyomata in a seven year old girl with clinical HIV infection who presented with new onset of wheezing. Clinical details of this case have been published elsewhere, but without imaging studies [1].

The sonographic appearance of the hemorrhagic ovarian cyst in adolescents.

Pelvic sonography was performed on ten teenaged girls who were proven by surgery to have hemorrhagic ovarian cysts. Pathologically, four were follicular ovarian cysts, while three were corpus luteal cysts, and the exact nature of three was undetermined. At sonography, these masses had variable appearances, ranging from anechoic to moderately echoic with septa and thick walls. All these features are nonspecific and can be encountered in other adnexal masses. The changing sonographic appearance of the hemorrhagic ovarian cyst due to clot lysis is helpful in establishing the diagnosis, and was demonstrated in two cases. These ten cases are discussed, the varied sonographic appearances are described and a review of pertinent literature is included.

Scrotal migration of ventriculoperitoneal shunts.

Ventriculoperitoneal diversion of cerebrospinal fluid in infants and children with hydrocephalus has become the procedure of choice over the last 15 years. It has replaced ventriculoatrial shunts, resulting in a marked decrease in the complication rate after such procedures. Four cases of migration of the shunt tip through patent processus vaginalis resulting in scrotal hydrocele are presented.

Atypical measles syndrome: pathologic and serologic findings.

The clinical course of measles occurring in 17 adolescents who had previously received killed measles vaccine is described. All adolescents had a peripheral dermatitis. Fifteen had characteristic pulmonary infiltrates. Serologic study in six adolescents using immunoprecipitation of 35S-methionine-labeled measles virus antigens revealed that 5/6 acute sera lacked antibody to the hemolysin antigen whereas 5/6 sera contained antibody to hemagglutinin antigen. Skin biopsies, obtained from three patients, demonstrate a combination of an Arthus reaction and delayed hypersensitivity. The typical measles histologic complex was absent. Measles virions were seen in the deep dermal blood vessels. The serologic and histopathologic presentation of this disease indicates that killed vaccine does not adequately induce antibody to the hemolysin (F) which is necessary to prevent cell-to-cell spread of paramyxoviruses. Killed vaccine does, however, produce hemagglutinin antibody and simultaneously incites later hypersensitivity to wild virus infection, producing the unusual dermatopathologic reaction seen.

Amniography in prenatal diagnosis.

The increasing use of prenatal diagnostic methods, including sonography and amniotic fluid analysis, has made it possible to suspect certain fetal defects at an early gestational age. In selected cases, accurate diagnosis of the specific malformation may have an effect on fetal and neonatal prognosis, and on prenatal counseling of the parents. As part of a large regional screening program for neural tube defects, we performed 28 midtrimester amniograms. We found 14 neural tube defects (nine spina bifida, four anencephaly, one Meckel syndrome), four abdominal wall defects, two tumors, and eight normal examinations. Radiographic examples of these malformations are presented, including previously undescribed findings in meningomyeloceles. The place of amniography in prenatal diagnosis is discussed.

Bone scintigraphy for neonatal osteomyelitis: simulation by extravasation of intravenous calcium.

Intravenously administered calcium gluconate has become increasingly popular in the treatment of neonatal tetany. Occasionally, extravasation results in cellulitis, leading to a clinical diagnosis of superimposed osteomyelitis. Osseous scintigraphy, as the accepted modality in the early detection of osteomyelitis, would tend to be used in this circumstance. This case illustrates a false-positive result, probably due to soft-tissue calcification.

Haemophilus influenzae sepsis leading to pericarditis despite antimicrobial therapy.

Acute purulent pericarditis is a well-recognized, though infrequently seen, manifestation of systemic Haemophilus influenzae type b disease. We recently studied two pediatric patients who developed signs of this septic complication during appropriate antibiotic treatment for bacteremia. These case reports should alert physicians to the possibility that pericarditis may become clinically evident in patients with systemic H. influenzae infections many days after initiation of appropriate therapy. The pathophysiology, diagnostic modalities and therapy are briefly reviewed.