Basal cell carcinomata: Risk factors for incomplete excision and results of re-excision.

INTRODUCTION: Re-excision of incompletely excised basal cell carcinomas (BCCs) can be unsatisfactory in the absence of residual tumours. Recommended guidelines do suggest re-excision as a treatment modality; however, its value has been questioned due to low or variable residual tumour presence. We analysed the incomplete excision and re-excision rates and the presence of residual tumours over an 18-month period in a single unit. METHOD: Using pathology results and case notes, 2586 primary excisions of BCCs in 1717 patients were reviewed. RESULTS: The incomplete excision rate was reported to be 7.1% (184/2586). Excision of a lesion by multiple excision lesion procedure was associated with a higher rate of incomplete excision when compared to single lesion excision procedure (61.5% vs. 38.5%). Of the incompletely excised BCCs, 33.6% (62/184) were re-excised, of which 62.9% (39/62) had residual tumours. Although the figures are small, most anatomical sites examined had a residual tumour presence >50%. CONCLUSION: After evaluating each patient individually, considering the high residual tumour rate, re-excision of an incompletely excised BCC would be a worthwhile procedure.

Does post-mastectomy radiotherapy affect the outcome and prevalence of complications in immediate DIEP breast reconstruction? A prospective cohort study.

INTRODUCTION: The decision to perform immediate deep inferior epigastric perforator (DIEP) flap reconstruction in patients requiring post-mastectomy radiation therapy (PMRT) is controversial, and often influenced by the increased potential of complications. We assessed the outcome and complications of irradiated immediate DIEP-reconstructed flaps in a two-surgeon series in our department. METHODS: Data collected prospectively from all patients undergoing immediate DIEP reconstruction under the two senior authors' care over 24 months were reviewed. Patients receiving previous radiation were excluded. Included patients were divided into two groups - requiring or not requiring PMRT. Primary outcome measures were fat necrosis, surgery for removal of fat necrosis, volume loss requiring surgery, wound complications and flap survival. All patients with a clinical diagnosis of post-radiation fat necrosis had an ultrasound scan. RESULTS: The series included 112 patients with a total of 156 flaps (44 bilateral, 68 unilateral). In 61/156 flaps the patients received PMRT (Group A) whilst 95/156 did not (Group B). Demographics in both groups were similar. Outcomes in PMRT vs. no PMRT, respectively were: fat necrosis 11.5% vs. 6.35% (p = 0.199); surgery for removal of fat necrosis 6.6% vs. 4.2% (p = 0.383); volume enhancement surgery 4.9% vs. 5.2% (p = 0.617); minor wound healing delay, 3.2% vs. 7% (p = 0.433); major wound healing delay 2.5% vs. 5.7% (p = 0.558). 0/61 flaps were lost in group A and 2/95 in group B. CONCLUSION: Although studies have shown the deleterious effects of post-operative radiotherapy on breast free flaps, our department offers immediate breast reconstruction with the acceptance of the risk/benefit profile. We found no increase in complication rates in patients undergoing immediate DIEP reconstruction receiving PMRT, and the outcome was not adversely affected. As part of an ongoing study, we do not feel that post-mastectomy radiotherapy precludes the decision for immediate free-flap breast reconstruction.

Association of Mycoplasma pneumoniae infection with Henoch-Schonlein purpura.

We present a child with Henoch-Schonlein purpura and Mycoplasma pneumoniae infection, an association that was rarely described in the literature. The infection was confirmed serologically and by using PCR.

The diversity of juvenile sarcoidosis symptoms.

We report a case of juvenile sarcoidosis, emphasizing the variety of clinical manifestations. The child had uveitis, which is among the most common manifestations of the disease. However, fever of unknown origin, glomerulonephritis and lymphadenopathy were also noticed, underscoring the diversity of the clinical spectrum of the disease.

Menetrier's disease associated with Helicobacter pylori: three cases with sonographic findings and a literature review.

Menetrier's disease is a rare cause of protein-losing gastropathy characterised by hypertrophy of the gastric folds. Three cases are reported. Helicobacter pylori was detected by culture and CLO test in two cases and on follow-up gastroscopy in the other. The first two patients were given eradication therapy and hypertrophic gastropathy resolved whereas in the third the disease remitted prior to the eradication treatment. Typical sonographic features were thickened gastric wall with preservation of the wall stratification. A review of the literature found eight cases of Menetrier's disease associated with H. pylori in children and these cases are briefly reviewed. H. pylori infection should be considered in all children with Menetrier's disease and, if isolated, eradication treatment should be administered.

Off-label use in Germany - a current appraisal of gynaecologic university departments.

OBJECTIVE: The off-label use, referring to the applicability of pharmaceutical drugs beyond the submitted and from the Federal Institute for Drugs and Medical Devices (BfArM, Bundesamt für Arzneimittel und Medizinprodukte) certified and approved administration, is the subject of controversial discussions. The application can be considered in case of severe illness - if no therapeutic alternatives are available - or it exists as a founded perspective for achieving therapeutic success. METHODS: A latitudinal study for evaluating the application of off-label use supplements was performed at 43 German university and academic teaching hospitals. Five doctors at each hospital applied off-label pharmaceutical drugs and were called upon to share their personal experience to the application of those medications. RESULTS: 75 (35%) questionnaires were returned out of 22 (51%) medical centres with 215 contacted physicians. Off-label use was common for 65 (91%) of the physicians. Only 9% of them obviate the application of off-label drugs. About a half of the medication is related to application in obstetrics (54%) and in most cases on an every day basis. Uterotonics were the most commonly used off-label medications (34%). The main part of information about off-label use is obtained from personal information of colleagues (66%) and personal experience (58%). 34% of physicians think that off label use is risky. Interestingly, the view about off label use of medication varies considerably among physicians from various hospitals. CONCLUSIONS: The application of off-label pharmaceutical drugs in Germany seems to be a well established practice. More than 90% of participators of our trial use at least one medication outside the administration. This includes particularly prostaglandins, anti-hypertonic therapeutics and chemotherapeutics.

Uveitis: an isolated complication of post-streptococcal syndrome.

A child with anterior uveitis as the sole manifestation of group A streptococcal infection is described. There was a history of a 'viral' upper respiratory tract infection 2 weeks before the onset of uveitis. A post-streptococcal phenomenon was diagnosed on the basis of serial ASO titre (ASOT) monitoring. There are few reports of patients with post-streptococcal uveitis. ASOT monitoring should be included in the work-up of uveitis of undetermined aetiology.

Is there an association between wheezing and pneumonia?

Objective The aim of this study was to investigate whether there is a relationship in school aged children between wheezing and pneumonia prior, during, or following the pneumonia episode. Patients-Methods One hundred and three children with community acquired pneumonia who were hospitalised were recruited along with 55 controls. Results During hospitalisation wheezing was audible in 11/103 (10.6%) patients with pneumonia and in none of the controls (p=0.009). Wheezing ever or asthma was elicited in 29/103(28%) patients with pneumonia and in 8/55 (14.5%) of the controls and this difference was not significant. Two years after the hospitalisation with pneumonia, wheezing episodes occurred in 12/103 with pneumonia and 1/55 of the controls (p=0.034). Among those who developed asthma following pneumonia 11/12 also had wheezing prior to pneumonia. Conclusion There is an excess of wheezing prior, during, and after an episode of pneumonia in school aged children and therefore children with pneumonia should be followed up carefully

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Is there an association between wheezing and pneumonia?

OBJECTIVE: The aim of this study was to investigate whether there is a relationship in school aged children between wheezing and pneumonia prior, during, or following the pneumonia episode. PATIENTS-METHODS: One hundred and three children with community acquired pneumonia who were hospitalised were recruited along with 55 controls. RESULTS: During hospitalisation wheezing was audible in 11/103 (10.6%) patients with pneumonia and in none of the controls (p=0.009). Wheezing ever or asthma was elicited in 29/103(28%) patients with pneumonia and in 8/55 (14.5%) of the controls and this difference was not significant. Two years after the hospitalisation with pneumonia, wheezing episodes occurred in 12/103 with pneumonia and 1/55 of the controls (p=0.034). Among those who developed asthma following pneumonia 11/12 also had wheezing prior to pneumonia. CONCLUSION: There is an excess of wheezing prior, during, and after an episode of pneumonia in school aged children and therefore children with pneumonia should be followed up carefully.

Splitting the dose of neonatal BCG vaccination: a naïve practice.

Bilateral axillary lymphadenitis complicating BCG vaccination in both arms (0.025 ml) in an immunocompetent 13-month-old boy is described. Prompt administration of isoniazid and erythromycin did not prevent suppuration of the affected lymph nodes. It was managed by bilateral surgical excision of the nodes.

Clinical notations on bacteremic cavitating pneumococcal pneumonia in nonvaccinated immunocompetent children.

We describe 10 children who developed lung cavitation during the treatment of bacteremic pneumococcal lobar pneumonia. Chest CT scan showed extensive consolidation with several small lucencies and air-filled cavities. Invasive procedures like aggressive pleural intervention were not needed and the children recovered attaining normal lung function on long-term follow-up.

Endothelin 1 levels in relation to clinical presentation and outcome of Henoch Schonlein purpura.

BACKGROUND: Henoch Schonlein purpura (HSP) is a common vasculitis of small vessels whereas endothelin-1 (ET-1) is usually reported elevated in vasculities and systematic inflammation. The aim of the present study was to investigate whether ET-1 levels are correlated with the clinical presentation and the outcome of HSP. METHODS: The study sample consisted of thirty consecutive patients with HSP. An equal number of healthy patients of similar age and the same gender were served as controls. The patients' age range was 2-12.6 years with a mean +/- SD = 6.3 +/- 3 years. All patients had a physical examination with a renal, and an overall clinical score. Blood and urinary biochemistry, immunology investigation, a skin biopsy and ET-1 measurements in blood and urine samples were made at presentation, 1 month later and 1 year after the appearance of HSP. The controls underwent the same investigation with the exception of skin biopsy. RESULTS: ET-1 levels in plasma and urine did not differ between patients and controls at three distinct time points. Furthermore the ET-1 were not correlated with the clinical score and renal involvement was independent from the ET-1 measurements. However, the urinary ET-1 levels were a significant predictor of the duration of the acute phase of HSP (HR = 0.98, p = 0.032, CI0.96-0.99). The ET-1 levels did not correlate with the duration of renal involvement. CONCLUSION: Urinary ET-1 levels are a useful marker for the duration of the acute phase of HSP but not for the length of renal involvement.

Home and leisure activities and childhood knee injuries.

AIM: To assess the relative occurrence of non motor-vehicle knee injuries and identify important clusters that can be targeted for preventive interventions. METHODS: The study subjects covered 2167 children (0-14 years) who suffered non motor-vehicle knee injuries out of 66870 registered during a three-year period in an established Emergency Department Injury Surveillance System (EDISS). A more serious joint injury was identified in 263 (12%) children, whereas the remaining 1904 children had only soft tissue knee injuries. RESULTS: The incidence of non motor-vehicle knee injuries was estimated at 6.5 per 1000 children-years. Both the incidence of knee injuries and the male-to-female ratio increase with increasing age, reflecting the gender and age pattern of physical activity. Three clusters were identified: The first consisted of more serious knee injuries among older children, frequently resulting after a fall from stairs or a collision in school during winter months; the second cluster consisted of rather minor knee injuries occurring mostly among younger girls at home or in playgrounds, following a fall after stumbling or hit by an object while playing, especially during the summer; the third cluster comprised injuries among older boys, sustained mainly subsequent to overexertion in a sports area. CONCLUSION: Knee injuries tend to be more common among boys but more serious among girls. More and less serious knee injuries tend to fall into distinct clusters that could facilitate prioritization of preventive measures.

The impact of Greece's childhood tuberculosis screening programme on the epidemiological indexes in the greater Athens area.

SETTING: A hospital referral centre for childhood tuberculosis in Athens. OBJECTIVE: To evaluate the effectiveness of the screening programme implemented for childhood tuberculosis, through its impact on the epidemiological index. DESIGN: In Greece, tuberculosis has been systematically screened for in children since 1991 using the tuberculin skin test. The epidemiological and clinical profiles of all tuberculous children who attended the TB clinic were compared. The children were divided into those who attended in 1982-1990 and those who did so in 1991-1999. RESULTS: A total of 1122 TB patients were screened. In the second period there was an increase in numbers of immigrant children (3% vs. 28%, P = 0.0001), the rate of extra-pulmonary TB decreased (16% vs. 7.6%, P = 0.0001), patients identified by the screening programme increased (19% vs. 57%, P = 0.0001) and the number of symptomatic children fell (51% vs. 16%, P = 0.0001). The proportion of children who failed to attend for regular follow-up was lower during the second period (20% vs. 7%, P = 0.0001). CONCLUSIONS: Our study suggests that the screening programme applied in Greece during the last decade has contributed to the early identification of tuberculosis, and the limitation of symptomatic patients and extrapulmonary TB cases.

Myomectomy as a pregnancy-preserving option in the carefully selected patient.

OBJECTIVES: To present the indications for myomectomy during pregnancy and to discuss complications possibly related and unrelated to the procedure. METHOD AND RESULTS: A 33-year-old patient at 18 weeks of gestation underwent removal of a 1,570-gram symptomatic fundic myoma. Histologically the patient had a leiomyomatous neoplasm of uncertain malignant potential. The pregnancy was continued under sequential observation with magnetic resonance imaging and ultrasound. At 36 weeks of gestation a healthy girl with an upper extremity limb defect was born via cesarean section. Follow-up of the mother and the child was uneventful. CONCLUSIONS: Certain known risk factors in pregnant women with myomas can predispose to complications during pregnancy. Women with such risk factors or women who have failed medical therapy should be offered the option of undergoing myomectomy as a pregnancy-preserving procedure.

Countrywide estimation of the burden of injuries in Greece: a limited resources approach.

BACKGROUND: We have assessed the ability of the Emergency Department Injury Surveillance System (EDISS), a registration network operating with limited resources, to predict the burden and pattern of injuries in the whole Greece. METHODS: We have compared hospitalizations calculated on the basis of EDISS with those routinely recorded by the National Statistical Service countrywide. EDISS relies on data collected in the Emergency Departments of four hospitals, two located in the Greater Athens area, and two district hospitals in the remaining Greece. EDISS data concern hospitalized and non-hospitalized patients of all ages, with all types of injuries irrespectively of their etiology or intent. RESULTS: Over a three-year period 148 835 subjects with injuries were interviewed. Using sampling ratios of 2.2% for all injuries outside Greater Athens and for adults in Greater Athens but 28.9% for childhood injuries, the total annual number of injuries in Greece was estimated at 1.53 million (95% confidence interval: 1.48-1.57 million). Of those, about 18% concern children less than 15 years old. The difference between the EDISS estimated and the actually recorded hospitalized injuries was, in preliminary terms, acceptable. DISCUSSION: Of the ten major categories of injuries, seven among children and five among adults have shown deviations of less than 20%. For the remaining categories deviations were larger but in only one instance did the difference exceed 50%. It is concluded, that for a small and relatively homogeneous country, like Greece, injury data provided by four large hospitals can generate reasonably reliable estimates for large categories of injuries.

Evidence on the infectious etiology of childhood leukemia: the role of low herd immunity (Greece).

OBJECTIVE: Acute lymphoblastic leukemia (ALL) among children may be a rare outcome of a delayed non-specific infection in situations of overall low herd immunity. We evaluated the hypothesis as to whether newly diagnosed ALL cases, compared to their controls, are characterized by lower herd immunity, as reflected in a more seronegative spectrum to several agents, with the exception of a strongly positive response to a single infectious agent, assumed to trigger ALL. METHODS: The study included 94 incident cases of ALL, from all pediatric hematology-oncology units of Greece, and 94, matched for age and gender, controls hospitalized with minor non-infectious conditions. The past exposure to common infections was assessed using 10 serological markers. RESULTS: There was little evidence for an association of ALL with the serology of any of the studied infectious agents among the very young children. In contrast, among children aged 5 years or older, leukemia was inversely associated with seropositivity to Epstein-Barr virus, human herpes virus-6, Mycoplasma pneumoniae and parvovirus B19. CONCLUSIONS: Among children aged 5 years or older the risk of leukemia may be higher when the low herd immunity for several agents is challenged by late infection from an agent that, as a rule, would attack children at a younger age.