The assessment of primitive or metastatic malignant pulmonary tumors in children.

BACKGROUND: The purpose of our study is to assess primitive and secondary malignant pulmonary tumors in children. The presence of lung tumors in newborns and infants is a point of interest to specialists in pediatric surgery, thoracic surgery and genetics due to the high death rate. The 5-years survival rate communicated by EUROCARE-study is less than 10% for primitive tumors and less than 15% in lung metastases. MATERIALS AND METHOD: We performed a retrospective study which analysed 11 children with pulmonary primary ormetastatic tumors admitted in the Pediatric Surgery Department "Prof. Dr. Al. Pesamosca" of the Emergency Clinical Hospital for Children "Maria Sklodowska Curie",Bucharest. The analysed and operated patients underwent surgery by Prof. Dr. Al. Pesamosca and the authors during the period of 1985-2011. In our series there where 4 primitive lung tumors and 7 secondary ones: 8 underwent surgery and 2 died before being operated on. The incidence of primitive pulmonary lung malignancies is higher for females, 3 to1, and secondary ones are more frequent in males, 6 to 1. RESULTS: Patients with primitive pulmonary malignancies were late diagnosed. Their age ranged between 1 to 6 years;3 were operated on, out of which 2 died, and 1 operated still survives. The 7 patients with secondary pulmonary malignancies were late diagnosed, too, probably as a consequence of a late diagnosis of the origin tumor. CONCLUSIONS: Even if all malignancies require an early diagnosis and treatment, this aim regarding malignant lung tumors is still a desideratum animating all practitioners. Primitive tumors are diagnosed presenting the main clinical manifestation abroncho pulmonary infection. Secondary lung malignancies are usually asymptomatic and are diagnosed when monitoring a patient for a malignancy with another origin. Chemotherapy,radiotherapy and surgery of malignant primitive tumors or metastatic ones in children remain unsatisfactory because of the late diagnosis and the limited methods of treatment. Nowadays genetics identified the responsible oncogenes for pulmonary blastic explosion and better results could be obtained by genetic surgery.

Upper and lower limb length equalization: diagnosis, limb lengthening and curtailment, epiphysiodesis.

INTRODUCTION: This article contains notions and guidelines derived from the current therapeutic approach used in the Pediatric Orthopedics Clinic of "M.S. Curie" Hospital, Bucharest. The purpose of this work is to illustrate the clinic's experience theoretically and by means of images. METHODS: This article is based on 25 years of clinical experience (1986-2011), gained at Mangalia Regional Hospital and the Pediatric Orthopedics Clinic of "M.S. Curie" Hospital in Bucharest, having treated more than 250 such cases. In post-traumatic shortenings with associated soft tissue injuries we used double leveled corticotomies and lengthening. The lengthening rarely exceeded 10 cm, especially for congenital deformities and repeated lengthening. From 2001 onwards, all lengthening operations included the intramedullary implantation of one or two TEN rods, with the purpose of reducing the time to fixator removal and to shrink the healing index. In the last five years we frequently used minimally invasive osteotomies after the placement of TEN implants, achieving the separation of a small fragment that sites itself between the major fragments. The lengthening rate was 1 mm per day, broken down in four steps (0.25 mm every 6 hours). For difficult cases, such as congenital pseudarthroses or the presence of scar tissue around the osteotomy site, we recommended 0.75 mm of lengthening per day (0.25 mm every 8 hours). For congenital pseudarthroses we used controlled epiphysiolysis and bone transport. For inequalities ranging 3 to 5 cm we used temporary epiphysiodesis, initially with staples, and subsequently with "8", "H" and "I" plates. Limb shortening followed by locked intramedullary fixation was reserved for those patients who did not follow through with the evaluation program and who could not benefit from temporary epiphysiodesis. RESULTS: The amount of lengthening per segment varied between 3 and 17 cm. The longest staged lengthening measured 20 cm, in two stages, and the greatest overall lengthening was 25 cm for an entire lower limb. An appropriate stabilization, followed by the adequate choice of osteotomy site and the postoperative weight loading of the limb ensured a quick and qualitative healing process. COMPLICATIONS: Less than half of the patients suffered complications, most of them being minor ones. Pseudarthroses have been treated by compaction of the site, followed by distraction, and/or the injection of BMP (Bone Morphogenic Protein). We saw no complications after epiphysiodesis or limb shortening. CONCLUSIONS: Limb lengthening procedures up to 5 cm lead to rapid consolidation and minimal complications. Lengthenings exceeding 5 cm require a good psychological preparation and careful monitoring. In lengthenings more than 10 cm, a faster rate of consolidation requires a double corticotomy, the use of intramedullary fixation and the immobilization of adjacent joints. In Lobstein's disease, good results can be obtained by the use of an Ilizarov external fixator. Restoring limb length equality by temporary epiphysiodesis, around the age of 10-12, is the least aggressive method and is very effective. Limb shortening by segmental resection should become obsolete.

Malignant bone tumors: therapeutical strategies related to localization.

Modular concept of reconstruction in malignant bone tumors in children and adolescents is trying to solve a complex problem in order to replace a certain bone segment of various sizes or joint, fully adjustable and fully aware ofmorpho-functional features related to the child's age. Given the high frequency of malignant bone tumors in children, occupying the third place in osteoarticular pathology, after injuries and malformations, due to the progress made in terms of knowledge and identifying certain factors (genetical, biological, immunological, etc.) and the increasing life expectancy of these sick children, paediatric orthopedics should offer the possibility of reconstruction of the resected segment. One of the basic concerns in this regard is modular endoprosthetic reconstruction of the resected area, adapted to each case and each bone or osteoarticular segment. Amputation is no longer the only option in the modern treatment in children and adolescent bone malignancies, being often replaced with increasing size piece resection and reconstruction with large massive cortical bone grafts or modular endoprosthetic replacement.

[Renovascular hypertension: symptoms and signs. Clinical study on 20 patients]. / Hipertensiunea arteriala de origine renala: simptome si manifestari. Studiu clinic pe 20 pacienti.

OBJECTIVES: symptoms in renovascular hypertension can be wrong interpreted, which leads to a late diagnostic, after discover the determination disease. MATERIALS AND METHODS: the study on the renovascular hypertension was made on 20 patients, aged between 2 and 36 years old, diagnosed with reno-ureteral malformations, pyelonephritis, reno-ureteral reflux and renal trauma as a determination disease, leads to manifestation types that guide the diagnostic: neuro-psychiatric signs, weight loss, renal signs and digestive signs. Beginning from these signs the arterial hypertension was diagnosed and the investigations determined the causes. RESULTS: Periodic postoperative evaluation at 3 months, during a period between 4 months and 7 years, individualised 4 evolutional clinical types: AHT with lumbar pain, AHT with no clinical signs, AHT with ophthalmologic signs and AHT with encephalitis like signs. CONCLUSIONS: symptoms in renovascular hypertension don't have pathognomonic clues and the identified signs, one type or all together, enforce the evaluation or even the monitoring of the arterial tension at least 30 days. If the values exceed the normal, complex investigations will be made in order to determine the specific cause of the AHT.

[Theoretical considerations and comments on the physiopathology in renovascular hypertension]. / Consideratii teoretice si comentarii privind fiziopatologia hipertensiunii arteriale de origine renovasculara.

The researches performed during the last four decades did not elucidate completely the pathogenic mechanism of the renovascular hypertension. The present knowledge considers that the origins of renovascular hypertension are the imbalance between the renal hypotensive system located in the medullar renal site (antihypertensive and hypotensive substances) and the renal hypertensive system (renin-angiotensin-aldosterone) located cortically. As an additional mechanism in producing hypertension is involved the disorder of hydro electrolytic metabolism, as a result of decreased excretory function, inducing an increase of plasmatic natrium level, of volemia and interstitial liquid.

Reno-ureteral diseases inducing hypertension in children.

UNLABELLED: Revealing the cause of renal hypertension is a major objective in medical practice. A series of investigations are required in order to elucidate the primary disease and then the treatment surgical and/or medical. The transitory hypertension of adolescent is not discussed in this paper. Measuring the blood pressure in children is often neglected and the evaluation of the hypertension is performed after the diagnosis of the renovascular disease. AIMS: The classification of renovascular hypertension in children and the statistical evaluation of its etiology in order to reveal the most frequent renovascular disease are a topical work of several authors. A guide of the most frequent causes of hypertension in children edited after the studies of several authors may lead to a complete classification and describe a complexed concept regarding diagnosis, evaluation and treatment of the patients. MATERIALS AND METHODS: This paper displays an analytic study on 19 patients, aged between 2 and 15 years, diagnosed with hypertension and presenting signs and symptoms of hypertension. Four of the 19 patients needed medical treatment, 12, surgical treatment, and for three patients the treatment was mixed. RESULTS: The renal hypertension was determined by aberrant renal arteries in four cases, by pyelonephritis in four cases, by reno-pyeloureteral duplication with congenital megaureter in two cases and by transversal renal rupture, renal agenesis, horse shoe kidney, glomerulonephritis and Wilms tumor, in one case each. In our study, the parenchymal diseases predominated (12 cases of 19-63.1%) over the 7 cases with renovascular lesions--36.9%. Among the parenchymal diseases seven are unilateral, six reno-ureteral malformations and a pyelonephritis, and five are bilateral, four pyelonephritis and a glomerulonephritis.Those seven cases of renovascular lesions include six indirect lesions (three hydronephrosis, one Wilms tumor, one renal abscess, one renal trauma) and one case of congenital vascular anomaly without stenosis (renal agenesis). CONCLUSIONS: All reno-ureteral diseases included in Ursea-Ionescu-Târgoviste classification can induce hypertension but renovascular hypertension does not appear in all cases. The diagnosis of the reno-ureteral diseases inducing hypertension in children permits the treatment of hypertension and reno-ureteral illness. The analytic study of diagnostic and treatment methods of different diseases and authors may select the most efficient methods and orientate towards a new therapeutical concept and/or evaluation system. The treatment of the reno-ureteral diseases inducing hypertension avoids the development of some serious complications: the retinopathy, the chronic renal failure, the cerebrovascular accidents.

Acute osteomyelitis--special cases with particularities related to specific locations.

In the clinical practice of paediatric orthopaedic surgery, there are a few cases of acute osteomyelitis which are not characterized by general and local infectious syndrome, making the diagnosis difficult and leading to severe complications. The specific locations, seldom affected, are the spine, pubis, ilium, ischium, sacrum and coccyx. Comparing with other regions, spinal osteomyelitis is less frequent (1:80). It affects not only children, sometimes aged under one year, but also adults of 40-50 years old. The infection may be located in the vertebral body or vertebral arch. Osteomyelitis of the pubis is diagnosed too late if based only on clinical data. The bone abscess is frequently located in the horizontal branch. During the first three days of evolution, the patient has an acute infectious syndrome and tenderness in pelvic area. Osteomyelitis of the ilium is the most frequent osteomyelitis of the hip bones. The abscess may diffuse anteriorly in the Scarpa triangle or may infiltrate the lesser pelvis. The lack of local signs may lead to serious errors, which may determine severe complications, including death. The infection of the ischium is extremely rare. The local infectious syndrome becomes apparent late and consists of gluteal and perineal swelling. Most frequently, the osteomyelitis of the sacrum is also diagnosed late and clinically appears like septicemia, meningitis or peritonitis. Being situated close to the skin, the osteomyelitis of the coccyx is easily diagnosed, but it appears only exceptionally.

Current opinions regarding the spinal cord ischemia syndrome.

Spinal cord ischemia syndrome (SCIS) is a serious complication which may occur after either internal or surgical diseases in newborn, young children, teenagers and adults; it is also followed by paraplegia. The onset is acute in 95% of cases. In the other cases the onset may be subacute, developing within one week, or it may be chronic, with slow, progressive development, within a few months to a year. The etiology and pathogenesis of this syndrome raises the interest of many medical fields, such as anatomy, physiology, internal medicine, surgical and imaging specialties. In current medical practice the role of spinal arteriography in diagnosing spinal cord ischemia is essential. Arteriography reveals obstructive lesions in the emerging area of the lumber artery, located between T8 and T12 in 85% of patients. Usually, after diagnosing this syndrome, it may be very difficult to reveal the underlying disease and it may require several investigations such as normal and 3D CT scans, SCIS, cerebral or myelic densitometries. This condition may be caused by metabolic congenital or acquired diseases, infectious vascular diseases, osteoporosis: it may also occur after general or peridural anaesthesia or surgical procedures such as spine surgery, neuro- and cardio-vascular surgery, vertebral and myelic trauma and so on. Treatment for this syndrome will be conducted with respect to the underlying disease. Prognosis may depend on patient's age and it is usually difficult to estimate due to the impossibility of determining the type and extent of the medullary lesion (axonotmesis, neurotmesis or other lesions).

Renovascular hypertension in children: symptoms and manifestations. A 19 patients clinical study.

UNLABELLED: The symptomatology in renovascular hypertension in children may be sometimes misunderstood, leading to the establishment of a late diagnosis, even after the inducing disease is diagnozed. METHODS: The main types of manifestations on which the diagonsis was established: neuropsychiatric, weight loss, renal and digestive manifestations were studied in 19 patients, age ranged 2 to 15 years old in which the main causes diagnosed were reno-ureteral malformations, pyelonephritis, reno-ureteral reflux and renal trauma. Starting from these observations the diagnosis of arterial hypertension was established and the further investigations have shown the real causes of arterial hypertension noticed. RESULTS: The periodic postoperative evaluation performed every three months over a peri6d ranging from 4 months to 7 years individualized 4 clinical evolutive types: Arterial Hypertension with lumbar pain, without any clinical manifestation, with ophthalmologic manifestations and with encephalopathic manifestations. CONCLUSIONS: Symptomatology in renovascular hypertension has no pathognomonic indices and the observed manifestations being single or all together impose the evaluation of blood pressure or even more, the monitoring of it over a long period, for at least 30 days. If the values of blood pressure are greater than the normal accepted ones, more complex investigations are required in order to establish a certain etiology of the hypertensive status.