Cardiopulmonary resuscitation (CPR)-related posterior rib fractures in neonates and infants following recommended changes in CPR techniques.

Posterior rib fractures are highly indicative of non-accidental trauma (NAT) in infants. Since 2000, the "two-thumbs" technique for cardiopulmonary resuscitation (CPR) of newborns and infants has been recommended by the American Heart Association (AHA). This technique is similar to the grip on an infant's thorax while shaking. Is it possible that posterior rib fractures in newborns and infants could be caused by the "two-thumbs" technique? Using computerized databases from three German children's hospitals, we identified all infants less than 12 months old who underwent professional CPR within a 10-year period. We included all infants with anterior-posterior chest radiographs taken after CPR. Exclusion criteria were sternotomy, osteopenia, various other bone diseases and NAT. The radiographs were independently reviewed by the Chief of Pediatric Radiology (MB) and a Senior Pediatrician, Head of the local Child Protection Team (IF). Eighty infants with 546 chest radiographs were identified, and 50 of those infants underwent CPR immediately after birth. Data concerning the length of CPR was available for 41 infants. The mean length of CPR was 11min (range: 1-180min, median: 3min). On average, there were seven radiographs per infant. A total of 39 infants had a follow-up radiograph after at least 10 days. No rib fracture was visible on any chest X-ray. The results of this study suggest rib fracture after the use of the "two-thumbs" CPR technique is uncommon. Thus, there should be careful consideration of abuse when these fractures are identified, regardless of whether CPR was performed and what technique used. The discovery of rib fractures in an infant who has undergone CPR without underlying bone disease or major trauma warrants a full child protection investigation.

[Dose area product of pediatric VCUG with regard to the strongly lowered German diagnostic reference levels]. / Das MCU bei Kindern. Dosiswerte im klinischen Alltag im Hinblick auf die stark gesenkten diagnostischen Referenzwerte.

PURPOSE: To compare the dose area products of pediatric VCUG in daily practice with the dramatically reduced official German diagnostic reference levels, which are based on selected data. MATERIALS AND METHODS: 413 consecutive pediatric VCUG examinations were analyzed. RESULTS: The mean dose area product of all examinations was 0.97 dGycm². This is below the lowest reference level that is valid for neonates. In 12 cases (5.6 %) the achieved dose area product was higher than the corresponding reference level. CONCLUSION: Using the available techniques for radiation protection, it is possible in the daily routine to meet the official diagnostic reference levels for children, which have been reduced by up to 80 %, even though these levels are based on a selected, possibly non-representative data set.

Progressive lipo-lymphedema associated with increased activity of dermal fibroblasts in monoclonal gammopathy of undetermined significance: is there a causal relationship?

The pathophysiology of skin diseases associated with monoclonal gammopathies is generally unknown. Our aim was to investigate whether a monoclonal gammopathy could be a causal factor in progressive lymphedema. We describe a 75 year old patient with a rapidly progressive lipo-lymphedema and a monoclonal gammopathy of unknown significance (MGUS) suspected as a key etiological factor. Dermal fibroblasts were cultured from lesional lower leg skin and non-lesional abdominal skin and compared to healthy control fibroblasts. We found 10-fold elevated basic fibroblast growth factor 2 (FGF-2) in the patient's serum and significantly increased basal FGF-2 production of lesional and non-lesional fibroblasts compared to healthy controls. Upon restimulation with patient or healthy control serum, lesional fibroblasts showed significantly increased proliferation rates and FGF-2 production in vitro. Non-lesional abdominal fibroblasts showed an intermediate phenotype between lesional and control fibroblasts. Our findings provide the first evidence that lesional dermal fibroblasts from lipo-lymphedema with plasma cell infiltration show increased proliferation and FGF-2 production and that both local tissue factors and altered FGF-2 serum levels associated with monoclonal gammopathies might contribute to this phenotype. Thus we propose a possible pathophysiologic link between the gammopathy-associated factors and the generation of lymphedema with initial fibrogenesis aggravating pre-existing lipedema.

Measurement of magnetic susceptibility in pulsed magnetic fields using a proximity detector oscillator.

We present a novel susceptometer with a particularly small spatial footprint and no moving parts. The susceptometer is suitable for use in systems with limited space where magnetic measurements may not have been previously possible, such as in pressure cells and rotators, as well as in extremely high pulsed fields. The susceptometer is based on the proximity detector oscillator, which has a broad dynamic resonant frequency range and has so far been used predominantly for transport measurements. We show that for insulating samples, the resonance frequency behavior as a function of field consists of a magnetoresistive and an inductive component, originating, respectively, from the sensor coil and the sample. The response of the coil is modeled, and upon subtraction of the magnetoresistive component the dynamic magnetic susceptibility and magnetization can be extracted. We successfully measure the magnetization of the organic molecular magnets Cu(H(2)O)(5)(VOF(4))(H(2)O) and [Cu(HF(2))(pyz)(2)]BF(4) in pulsed magnetic fields and by comparing the results to that from a traditional extraction susceptometer confirm that the new system can be used to measure and observe magnetic susceptibilities and phase transitions.

[Acute abdomen in a patient with ANCA-associated vasculitis]. / Akutes Abdomen bei ANCA-Assoziierter Vaskulitis.

HISTORY AND FINDINGS: A 49-year-old man complained of increasing pain in the lower left abdomen. Three weeks previously joint pain had developed, and in the last 7 days the patient had noted a cutaneous rash at the lower legs. Within three days after admission a paralytic ileus developed, progressed and culminated in a small bowel perforation. In the 60 cm ileum specimen as well as in the skin lesions there was marked intra- und perivascular infiltration with neutrophil granulocytes and focal necrosis, but no granuloma. DIAGNOSIS, TREATMENT AND COURSE: As the proteinase 3 subtype of antineutrophil cytoplasmic antibodies (ANCA) was positive ANCA-associated vasculitis with gastrointestinal, cutaneous and kidney involvement was diagnosed. After initiation of cytostatic treatment with methylprednisolone boli und cyclophosphamide the patient's condition improved. The post-operative course was uneventful. CONCLUSION: ANCA-associated vasculitis rarely presents with severe gastrointestinal complications. The disease represents an interdisciplinary challenge because of its variable clinical presentation and the possibly lethal outcome if not adequately treated.

[Is the propagation speed of ultrasound in human organs a diagnostic parameter for tissue characterization?: evaluation using the liver parenchyma in children and adolescents as an example]. / Die Schallleitgeschwindigkeit im menschlichen Gewebe - ein diagnostisch verwertbarer Parameter? Evaluation am Beispiel der Leber bei Kindern und Jugendlichen.

UNLABELLED: New sonographic machines permit the measurement of the propagation speed of ultrasound (PSU) in humans. The liver seems to be an appropriate organ for examining whether the PSU may be used as a diagnostic parameter for tissue characterization since the liver is easily accessible to sonography and its variable content of fat impacts the PSU. PURPOSE: To determine whether there is a measurable correlation between obesity and PSU in the liver. METHODS: In 69 children and adolescents, the PSU in the liver was measured sonographically and correlated to BMI, age, size and weight of the children. RESULTS: A strong correlation was found between the PSU in the liver and the BMI. The PSU was significantly lower in obese children (1507 m/s) than in children with normal body weight (1564 m/s). CONCLUSION: PSU seems to be promising as an additional diagnostic parameter for characterizing liver tissue. Further evaluation is necessary.

[Professional misconduct in therapeutic relationships: developing critical attitudes in the medical community]. / Missbrauch in therapeutischen Beziehungen : Möglichkeiten zur kritischen Positionierung der Ärzteschaft.

Already the Hippocratic Oath defines maintaining boundaries in the physician-patient relationship as an essential part of medical care: "…In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or men, be they free or slaves…". The World Psychiatric Association's Declaration of Madrid 1996 specifically comments on boundary issues of physician-patient relationships in psychiatry. Boundary violations in any kind of therapeutic relationship - not only regarding psychotherapy - are both relevant and tabooed. There are hardly any options for patients concerned to find appropriate therapeutic and legal support. A public positioning of the medical profession seems to be very important. Apart from raising awareness, further important goals are prevention, guidelines for appropriate handling of victims and offenders, as well as integration of the issue in education and public discourse.

Child abuse - some aspects for neurosurgeons.

Neurosurgeons are mainly concerned with child abuse in cases of severe cranio-cerebral trauma. Aim of the present paper is to highlight the clinical picture and symptoms in cases of child abuse and our multidisciplinary approach to reveal a solid diagnosis. The detection of child abuse requires a high index of suspicion, especially in cases of subtle injuries. Besides reporting to the appropriate agencies primary goals are to terminate suspected abuse and to prevent further harm to the child. All this requires a confirmed diagnosis.

[Micronodular sonographic pattern of the spleen: a frequent finding in children and adolescents]. / Feinnoduläres Milzparenchym, ein häufiger sonografischer Befund bei Kindern und Jugendlichen.

UNLABELLED: In textbooks about abdominal sonography, the parenchyma of the spleen is described as homogeneous. However, using high-frequency probes, sonography of the spleen in children often reveals a micronodular pattern. AIM: To investigate the prevalence of a micronodular pattern in the pediatric spleen and to evaluate possible correlations to clinical parameters. METHODS: In 106 non-selected children (54 males, 52 females, mean age 7 years 10 months), the spleen was examined with a 17 MHz probe. Simultaneously the size of the spleen was measured, and other parameters such as leukocyte and thrombocyte counts were recorded. The pattern of the spleen was estimated using a four-step scale. 0: homogeneous tissue without micronodular components, 1: faint micronodular pattern/barely perceptible, 2 and 3: micronodular pattern clearly visible of moderate (2) or strong intensity (3). RESULTS: In 33 children a homogenous pattern was found (31.1 %) and in 48 children (45.3 %) a micronodular pattern of the spleen was clearly visible. A statistical correlation to spleen size or leukocyte or thrombocyte count or CRP could not be proven. 52 % of children with an enlarged spleen had a micronodular pattern, as well as 66.7 % of children with leukocytosis, 44.7 % of children with increased CRP, and 54.5 % of children with thrombocytosis. However, there was a strong statistical correlation to the age of the children with a maximum at the age of 1 to 5 years. CONCLUSION: A micronodular pattern of the spleen is frequent in children, even without clinical signs of infection. It is important to be aware of this finding and not to confuse it with pathological changes.

Selective regional perfusion of the bilateral external carotid arteries with pegylated liposomal doxorubicin and melphalan to treat metastatic malignant melanoma of the scalp.

We present the case of a 79-year-old patient with extensive metastatic malignant melanoma (MM) of the scalp. Cutaneous MM of the head and neck often presents a therapeutic challenge. Radical surgical procedures and conventional chemotherapy are often unfeasible and contraindicated because of the difficult anatomy, the extent of the tumour process, and systemic toxicity. In our patient, selective intra-arterial perfusion with pegylated liposomal doxorubicin (PLD) and melphalan was performed after catheterization of both bilateral external carotid arteries with an arterial port system. PLD 4.5 mg/m(2) and melphalan (1.35 mg/m(2), followed by 2.7 mg/m(2) after reaching tolerance) were given as short-term infusions at two-weekly intervals into the right and left external carotid arteries, respectively. After eight applications with tolerable side-effects, no MM cells were detected; however, infiltrates of lymphocytes and melanophages were seen. This case suggests that intra-arterial chemotherapy may be a useful treatment for metastatic melanoma of the scalp.

[Sonographic bladder volumetry in children: comparison of conventional B-mode sonography and automatic volumetry with a handheld scanning device without imaging]. / Sonografische Harnblasenvolumetrie bei Kindern: vergleichende Beurteilung von konventioneller B-Bild-Sonografie und automatisierter Volumetrie mit einem sonografischen Handgerät ohne Bildgebung.

PURPOSE: Evaluation of a handheld sonographic tool for the automatic estimation of bladder volume in comparison with conventional sonography in children under clinical conditions. MATERIALS AND METHODS: 139 children (age: 30 days - 17 years) were examined with both conventional sonography and the handheld scanning device BVI 6200. For conventional sonography two different formulas were used to calculate the bladder volume. RESULTS: The mean error of the three methods was 22.4 % for the handheld tool, 37.4 % for the most frequently used prolate ellipsoid formula in conventional sonography, and 23 % for an alternative formula recommended in the literature. In 19 cases the first automated sonography scan showed a false-negative result (empty bladder), while the automatically calculated volumes were between 17 and 60 ml in 5 cases of empty bladder. In one of these cases a megaureter and in another an ovarian cyst were detected by conventional ultrasound. CONCLUSION: Since pathologies are not visualized and can be misinterpreted as a nonempty bladder, the automated method should only be used in follow-up studies. In every case automated volumetry should be performed repeatedly to avoid false-negative results.

[Sonographic volumetry of the urinary bladder in paediatric patients. value of different calculation formulae taking into account a simple formula that is calculable in one's head]. / Sonografische Harnblasenvolumetrie bei Kindern und Jugendlichen: Wertigkeit verschiedener Berechnungsformeln unter Berücksichtigung einer einfachen, im Kopf berechenbaren Formel.

BACKGROUND: Volumetry of the urinary bladder is a frequently performed sonographic procedure. Usually the formula of the prolate ellipsoid is applied for this purpose. In the literature however a variety of different formulas is proposed. PURPOSE: The aim of this study was to evaluate different simple formulae used for the calculation of the bladder volume in children, taking into account a formula that is easily calculable in one's head. MATERIAL AND METHODS: 139 children were examined by sonography, 6 different formulae were applied. The bladder volume was confirmed by micturition. Only children without residual volume were included in the study. RESULTS: 82 children (mean age: 8.5 years) could be included with a mean bladder volume of 92 mL (0 to 227 mL). The mean error ranged from 20.2 % (cuboid formula) to 38.0 % (prolate ellipsoid). With decreasing bladder volume all formulae showed an increasing error and a tendency for underestimation of the bladder volume. For small volumes best results were achieved by the cuboid formula with a mean error of 26.4 %. The formula of the prolate ellipsoid yielded the worst results. The proposed truncation formula, easily calculable in one's head, showed better results than both the formula of the prolate ellipsoid and the cuboid formula. CONCLUSION: The formula of the prolate ellipsoid should not be used for bladder volumetry in children. Small bladder volumes should be calculated by multiplying the three diameters of the bladder (cuboid formula). If the calculated volume lies above 60 mL a correction factor of 0.8 should be used to avoid overestimation of the true bladder volume.

[Livid polycyclic plaques of the lower extremities]. / Livide polyzyklisch begrenzte Plaques an den unteren Extremitäten.

In 10%-55% of patients, leukemia cutis (LC) manifest as a symptom of acute myelomonocytic leukemia and is associated with a poor overall prognosis. Disseminated bluish-violet or red-brownish papules and plaques, nodules and also hemorrhagic ulcers may dominate the initial clinical picture. Importantly, nonspecific infiltrates (leukemids) must be differentiated from specific infiltrates of malignant cells in patients presenting with dermatoses and concomitant underlying hematopoietic neoplasms. The role of the dermatologist is the rapid clinical and dermatohistopathological diagnosis in order to allow immediate, adequate treatment of the patient's underlying systemic disease.

Metastatic squamous cell carcinoma of the ankle in long-standing untreated acrodermatitis chronica atrophicans.

Acrodermatitis chronica atrophicans (ACA) represents the persistent late stage of borreliosis in which Borrelia species may survive for decades. Occasionally, B-cell lymphoma may develop in these patients, and additional neoplastic complications such as basal cell carcinoma or squamous cell carcinoma (SCC) have been reported once each over the past 60 years. Here we describe, to the best of our knowledge, the first case of metastatic SCC in a European patient with long-standing ACA caused by Borrelia burgdorferi sensu stricto. Our case highlights a potential pathophysiological connection of untreated Borrelia infection with the initiation or progression of SCC and should alert dermatologists to this rare complication.