In vivo selection of a multidrug-resistant Aeromonas salmonicida during medicinal leech therapy.

We report the selection in a 15-year-old boy of a multidrug-resistant, extended-spectrum ß-lactamase (ESBL)-producing Aeromonas salmonicida after medicinal leech therapy that required an antibiotic prophylaxis based on piperacillin/tazobactam and cotrimoxazole. Whole genome sequencing of the strain indeed revealed 13 antibiotic resistance genes, including the ESBL CTX-M-3 and the unusual ß-lactamase SCO-1.

National survey on abdominal trauma practices of pediatric surgeons.

INTRODUCTION: Pediatric blunt abdominal trauma is a frequent reason for hospital admission, but there are no established guidelines to assess these patients. Our study aims to evaluate the diagnostic process used by pediatric surgeons in Switzerland to evaluate abdominal trauma. MATERIAL AND METHODS: A scenario-based survey was carried out among Swiss pediatric surgeons. Respondents were asked to report on their management of children with blunt abdominal trauma. RESULTS: The response rate was 46% (26 of 54). The clinical signs considered the most important were abdominal examination and palpation (100%), auscultation (81%), external genital exam (77%) and Glasgow Coma Scale (77%). The most frequent laboratory exams requested were urine analysis (100%), complete blood count (96%), liver function tests (85%) and coagulation tests (77%). 42% of the physicians asked for an abdominal ultrasound for every patient with blunt abdominal trauma. 58% reported that some patients do not need a CT scan despite anomalies in the initial workup. There were significant variations in the clinical assessment of patients with minor blunt abdominal trauma. Abnormal ultrasounds, but not abnormal liver functions tests, prompted clinicians to obtain CT scans. When evaluating the probability of organ injury after a full workup, clinicians relied on the results of the ultrasound but not on liver function tests. A normal CT scan did not appear to reassure physicians if the patient still presented with mild abdominal pain. CONCLUSIONS: There is a wide variation in the clinical assessment, request for laboratory tests and use of radiological exams among Swiss pediatric surgeons. Further studies are required on the evaluation of abdominal organ injuries in children.

Liver function tests in children with blunt abdominal traumas.

BACKGROUND: Previous studies have suggested that there are cut-off values for liver function tests (LFTs) beneath which significant liver injury can be excluded after blunt abdominal trauma in children. Our objective is to test this hypothesis in our patient population. METHODS: The LFTs of all consecutive patients admitted in Geneva from January 1, 2001 to December 31, 2004 following blunt abdominal trauma were analysed and compared to radiological (ultrasound and/or computed tomography scan) findings and final outcome. RESULTS: Of 115 patients identified, sixteen had radiological evidence of liver injury. These patients had significantly (p < 0.01) increased aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values (474 +/- 369 IU/l and 442 +/- 383 IU/l, respectively) compared to patients without liver injury (AST 88 +/- 161 IU/l and ALT 68 +/- 137 IU/l). Among the sixteen patients with liver injury, ten (63 %) had AST < 450 IU/l and seven (44 %) had ALT < 250 IU/l. Two patients had radiological evidence of OIS grade 3 liver injury with AST as low as 95 and 92, and ALT of 80 and 86, below all cut-off values recommended in the literature. CONCLUSION: In our experience, low LFT values at admission could not rule out significant liver injury. The diagnosis of such lesions still relies on clinical and radiological findings, as do other intra-abdominal organ injuries.

Use of a mechanical leech in a reverse-flow radial forearm flap: case report.

The reverse-flow radial forearm flap provides excellent coverage for distal upper-limb defects. It is simply raised and does not require microsurgical skills. However, since its vascular pedicle is reversed, its venous outflow can be significantly diminished because of the venous valves. The authors present the case of a 16-year-old patient with a sagittal amputation of the radial aspect of the right thumb, who manifested at the time of surgery marked venous engorgement of a reverse-flow radial forearm flap. This was successfully relieved by the placement of a mechanical leech consisting of a Silastic rubber catheter--of the kind used to gain central vascular access in newborns--introduced in the lumen of the reversed vein at the extremity of the flap. This permitted intermittent evacuation of blood from the flap postoperatively, contributing to the success of this procedure. The technique used is detailed and pertinent literature is reviewed.

Etiology and management of pediatric chylothorax.

OBJECTIVES: To determine the incidence and etiology of chylothorax and to assess our therapeutic management approach. STUDY DESIGN: We reviewed 51 patients diagnosed with chylothorax over a 12-year period. Cause, interval between operation and diagnosis, duration of chylothorax, and total volume loss per weight were recorded. RESULTS: Chylothorax was diagnosed in 46 children after cardiothoracic surgery, giving an incidence of 2.5% (46/1842); in 1 child chylothorax occurred after chest trauma, and in 4 the chylothorax was congenital or a manifestation of lymph angiomatosis. Three etiologic groups were identified: group 1, direct injury to the thoracic duct (33/51 = 65%); group 2, thrombosis and/or high venous pressure in the superior vena cava (14/51 = 27%); and group 3, congenital (4/51 = 8%). Conservative treatment was the only treatment in 80% of the patients. Surgical procedures consisted of 4 ligations of the thoracic duct, placement of 7 pleurodesis shunts, and placement of 2 pleuroperitoneal shunts. Patients in groups 2 and 3 were at higher risk for failure of conservative treatment (P <. 005). Longer duration of chylothorax and higher volume of drainage were present in group 2 compared with group 1 (P <.01). CONCLUSION: Conservative treatment was successful in 80% of the patients with our management approach. Prevention, early recognition, and treatment of potential complications, such as superior vena cava thrombosis or obstruction, may further improve success of conservative treatment. Congenital chylothorax seems different and may require a specific approach.

[Value of the Pediatric Trauma Score in routine hospital practice--apropos of a prospective one-year trial]. / Utilité du Pediatric Trauma Score dans la pratique hospitalière quotidienne--à propos d'une série prospective d'un an.

AIM: To test the usefulness of the Pediatric Trauma Score (PTS) in a university hospital setting. METHODS: All injured children who were admitted to our emergency room during a one year period were prospectively studies. The study was performed at the Pediatric University Hospital of Geneva. Patients were divided into two groups: group one included severely injured children with a PTS equal or lower 8 and group two included patients with a PTS greater than 8. RESULTS: A total of 6804 injured children were admitted to our emergency room and 927 (14%) were hospitalized. In group one (104 children, 1.5%), six patients died whereas in group two (823 children, 12%), all patients survived. In addition, children in group one demonstrated a significant higher number of general anesthesia, a longer stay in the ICU and a longer stay, and an increased number of sequelae 3 months after trauma. DISCUSSION: Our result confirm the usefulness of the PTS and the cutoff value of 8 in pediatric trauma. In addition, the study underlines the important morbidity and the residual sequelae after severe trauma in children. CONCLUSION: The PTS should be used in all injured children in order to identify patients at risk. This would allow to begin an appropriate treatment or, if necessary, initiate a transfer to a surgical pediatric center without delay.

A silicone-coated nylon dressing reduces healing time in burned paediatric patients in comparison with standard sulfadiazine treatment: a prospective randomized trial.

Mepitel is a new grid like silicone coated nylon dressing containing no additional biological compounds. We describe a prospective randomized pilot study comparing Mepitel to the standard silver sulfadiazine cream (Flamazine) dressing for the topical treatment of paediatric burns. Seventy-six children presenting within 24 h of injury with a non previously treated burn were randomly assigned to Mepitel treatment (group M) or Flamazine treatment (group F). Age, sex, surface area of burn and causal agent were noted at admission. The depth of the burn, cumulative number of dressings, presence or absence of a complete epithelial cover, infection, bleeding and allergy were noted at each dressing change. There were 41 children in group M and 35 children in group F. Five children were subsequently withdrawn from each group because they required skin grafting. Analysis of the above mentioned criteria showed no statistical difference between the two groups except for the healing time (group M: 7.58+/-3.12, group F: 11.26+/-6.02, p < 0.01) and the number of dressings (group M: 3.64+/-1.5, group F: 5.13+/-2.9, p < 0.05). Mepitel has proved to be an easy-to-remove dressing, adhering only to intact skin. The faster healing time found in the Mepitel group may be related to a direct effect of silicone on epithelial growth or to a decrease in surface-cell damage compared to the silver sulfadiazine group. This attractive product will be further assessed on a larger scale trial to confirm our observations.

Surgical pitfalls in a patient with type IV Ehlers-Danlos syndrome and spontaneous colonic rupture. Report of a case.

PURPOSE: This paper intends to stress the importance of early diagnosis and discuss surgical treatment of Type IV Ehlers-Danlos syndrome (EDS-4), an autosomal dominant connective tissue disease characterized by typical features of the face and extremities, inappropriate and easy bruising, and extreme tissue fragility, which may lead to dramatic and often fatal complications, mostly spontaneous arterial or intestinal rupture. METHODS: We report the case of a 41-year-old female who presented with spontaneous perforation of the sigmoid colon. RESULTS: The patient was seen over a nine-year period, during which time she required six operations and presented with a great number of surgical complications including stenosis of an end-colostomy, repeated subocclusive episodes caused by intraperitoneal adhesions, and enterocutaneous fistulas, finally ending with an ileostomy and short bowel syndrome. It is only after a difficult laparotomy for ovarian cyst excision, marked by numerous adhesions and friable bowel, that the diagnosis of EDS-4 was considered and established. CONCLUSIONS: In case of "idiopathic" spontaneous perforation of the colon in a young adult, features of EDS-4 should be thoroughly looked into and, if found, skin fibroblast culture with collagen Type III analysis performed. The surgical treatment of choice consists of subtotal colectomy and permanent end-ileostomy. In case of patient refusal, a second-stage ileorectal anastomosis can be performed but carries the high risk of anastomotic leakage.

The addition of lipids increases the total parenteral nutrition-associated cholestasis in the rat.

Cholestasis is one of the most frequent complications of Total Parenteral Nutrition (TPN). Among the components of TPN, amino acids (AA) and dextrose are considered responsible in terms of quantity. The aim of this study was to determine whether IV lipids have a protective effect on the liver lesions induced by TPN, as well as on the bile flow in rats. Two groups of 6 animals, 6 receiving TPN containing AA and dextrose (Group A-D) and 6 receiving AA, dextrose and lipids (Group A-D-L) were studied. Both groups received the same amount of AA (3.4 g/day) and the same amount of energy (50 kcal/day). The TPN lasted 3 days, after which blood samples were obtained for liver function tests and the bile flow was determined gravimetrically, subsequently the liver was removed for histological analysis. A significant weight loss (p < 0.01) was observed in both groups (Group A-D: -13 +/- 4 g; Group A-D-L: -16 +/- 2g). The bile flow was significantly lowered in A-D-L at 10.14 +/- 1.27 microliters/minute when compared to Group A-D (15.61 +/- 1.31 microliters/minute). The Aspartate Amino Transferase (AST) plasma level was elevated at 188 +/- 20 UI in Group A-D and at 185 +/- 33 UI in Group A-D-L. Gamma-Glutamyl-Transferase (gamma-GT) plasma level was in the normal range in both groups. In conclusion, this study indicates that TPN-associated cholestasis is significantly increased by lipid addition. However, the hepatocellular necrosis seems unchanged.

Intrahepatic biliary lesions following blunt liver trauma in children--is nonoperative management or conservative operative treatment always safe?

Nonoperative management of blunt liver injuries has become standard care for children, in the absence of hemodynamic instability. However, attention has to be drawn to biliary complications which can manifest themselves after a latent period, even in the presence of rupture of main biliary ducts. Peripheral bile duct lesions are easily treated by wide drainage. However, the extremely rare intrahepatic main bile duct lesions require other treatments. We report 2 cases of severe liver trauma associated with intrahepatic bile duct lesions: the first, managed nonoperatively, developed biliary peritonitis on day 21. Lesions of the main right biliary ducts were discovered. Because the right liver vascularization was not compromised, an intrahepatic biliary reconstruction was performed through a large hepatotomy according to the functional anatomy. The second child, who had an emergency laparotomy on admission, suffered nevertheless from a bilioma, drained on day 38. Because of increasing daily bile flow through the drain a second laparotomy was performed that demonstrated a biliary leak from a main segmental duct. Resection of the segment cured the patient. These two cases illustrate the occurrence of intrahepatic main bile duct lesions, clinically apparent after a latent period, following blunt trauma of the liver treated by nonsurgical or conservative surgical management. Intrahepatic biliary reconstruction is an alternative to liver resection when viable vascularization of the involved sector justifies its preservation.

[Sutures in dentistry. Traditional and PTFE materials]. / Suture in odontoiatria. Fili tradizionali e in PTFE.

Suture material in PTFE is successfully used in vascular and orthopaedic surgery since many years. More recently it has been applied also in periodontal surgeries, in the guided tissue regeneration technique, thanks to its chemical-physical, mechanical and biological characteristics. The Authors tried to evaluate the indications for the use of this material in different situations in the dental practice. Furthermore a microbiologic study has been carried out, both in vivo and in vitro, and this material has been compared with the twisted coated silk to evaluate the different bacteriological characteristics. In particular it has been demonstrated the reduced adhesion of PTFE in comparison to the twisted silk. This characteristic seemed to be even more relevant after a longer stay of the materials in the oral cavity.