"Real-Time Neuromonitoring" Increases the Safety and Non-Invasiveness and Shortens the Duration of Idiopathic Scoliosis Surgery.

Introduction: A practical solution to the incidental unreliability of intraoperative neuromonitoring (IONM) may be the simultaneous neurophysiological recording and control of the surgical field through a camera (the concept of "Real-time" IONM). During "Real-time" IONM, the surgeon is immediately warned about the possibility of damage to the neural structures during, but not after, standard idiopathic scoliosis (IS) corrective surgery procedures (the concept of "Surgeon-neurophysiologist" interactive, verbal IONM). This study aimed to compare the advantages, utilities, reliabilities, and time consumption of the two IONM scenarios. Methods: Studies were performed in two similar groups of patients undergoing surgery primarily due to Lenke 2 idiopathic scoliosis (N = 120), when both IONM approaches were applied. Neurophysiological evaluations of the spinal transmission were performed pre- (T0), intra- (before (T1) and after (T2) surgery), and postoperatively (T3), as well as once in healthy volunteers (control, N = 60). Non-invasive and innovative recordings of the motor evoked potentials (MEPs) bilaterally from the peroneal (PER) nerve and tibialis anterior (TA) muscle were performed with surface electrodes as a result of transcranial magnetic stimulation (TMS) or electrical stimulation (TES) at T0-T3. Results: In both groups, the MEP amplitudes and latencies recorded from the PER nerve were approximately 67% lower and 3.1 ms shorter than those recorded from the TA muscle. The MEP recording parameters differed similarly at T0-T3 compared to the control group. In all patients, the MEP parameters induced by TMS (T0) and TES (T1) did not differ. The MEP amplitude parameters recorded from the TA and PER at T1 and T2 indicated a bilateral improvement in the neural spinal conduction due to the surgical intervention. The TMS-induced MEP amplitude at T3 further increased bilaterally. In both IONM groups, an average 51.8 BIS level of anesthesia did not affect the variability in the MEP amplitude, especially in the PER recordings when the applied TES strength was 98.2 mA. The number of fluctuations in the MEP parameters was closely related to the number of warnings from the neurophysiologist during the transpedicular screw implantation, corrective rod implantation, and distraction, derotation, and compression procedures, and it was higher in the "Surgeon-neurophysiologist" IONM group. The average duration of surgery was shorter by approximately one hour in the "Real-time" IONM group. The number of two-way communications between the surgeon and the neurophysiologist and vice versa in the "Real-time" IONM group decreased by approximately half. Conclusions: This study proves the superiority of using "Real-time" IONM over the standard "Surgeon-neurophysiologist" IONM procedure in increasing the safety and non-invasiveness, shortening the time, and lowering the costs of the surgical treatment of IS patients. The modifications of the MEP nerve-conduction-recording technology with surface electrodes from nerves enable precise and reliable information on the pediatric patient's neurological condition at every stage of the applied surgical procedures, even under conditions of slight fluctuations in anesthesia.

Comparison of Motor Evoked Potentials Neuromonitoring Following Pre- and Postoperative Transcranial Magnetic Stimulation and Intraoperative Electrical Stimulation in Patients Undergoing Surgical Correction of Idiopathic Scoliosis.

The relationships between the results of pre- and intraoperative motor evoked potential recordings during neuromonitoring and whether idiopathic scoliosis (IS) surgical correction improves the spinal efferent transmission have not been specified in detail. This study aims to compare the results of surface-recorded electromyography (EMG), electroneurography (ENG, M, and F-waves), and especially motor evoked potential (MEP) recordings from tibialis anterior muscle (TA) bilaterally in 353 girls with right idiopathic scoliosis (types 1-3 according to Lenke classification). It has not yet been documented whether the results of MEP recordings induced by transcranial single magnetic stimulus (TMS, pre- and postoperatively) and trains of electrical stimuli (TES; intraoperatively in T0-before surgery, T1-after pedicle screws implantation, and T2-after scoliosis curvature distraction and derotation following two-rod implantation) can be compared for diagnostic verification of the improvement of spinal cord neural transmission. We attempted to determine whether the constant level of optimal anesthesia during certain surgical steps of scoliosis treatment affects the parameters of MEPs recorded during neuromonitoring procedures. No neurological deficits have been observed postoperatively. The values of amplitudes but not latencies in MEP recordings evoked with TMS in IS patients compared before and after surgery indicated a slight improvement in efferent neural transmission. The results of all neurophysiological studies in IS patients were significantly asymmetrical and recorded worse on the concave side, suggesting greater neurological motor deficits at p = 0.04. The surgeries brought significant improvement (p = 0.04) in the parameters of amplitudes of sEMG recordings; however, the consequences of abnormalities in the activity of TA motor units were still reflected. ENG study results showed the symptoms of the axonal-type injury in peroneal motor fibers improving only on the concave side at p = 0.04, in parallel with F-wave parameters, which suggests that derotation and distraction might result in restoring the proper relations of the lumbar ventral roots in the spinal central canal, resembling their decompression. There were no significant differences detected in the amplitudes or latencies of MEPs induced with TMS or TES when comparing the parameters recorded preoperatively and intraoperatively in T0. The amplitudes of TES-evoked MEPs increased gradually at p = 0.04 in the subsequent periods (T1 and T2) of observation. A reduction in MEP latency at p = 0.05 was observed only at the end of the IS surgery. Studies on the possible connections between the level of anesthesia fluctuations and the required TMS stimulus strength, as well as the MEP amplitude changes measured in T0-T2, revealed a lack of relationships. These might not be the factors influencing the efferent transmission in spinal pathways beside the surgical procedures. Pre- (TMS-evoked) and intraoperative (TES-evoked) recordings are reliable for evaluating the patient's neurological status before and during surgical scoliosis correction procedures. An increase in MEP amplitude parameters recorded on both sides after scoliosis surgery proves the immediate improvement of the total efferent spinal cord transmission. Considering comparative pre- and postoperative sEMG and ENG recordings, it can be concluded that surgeries might directly result in additional lumbar ventral root decompression. We can conclude that MEP parameter changes are determined by the surgery procedures during neuromonitoring, not the anesthesia conditions if they are kept stable, which influences a decrease in the number of false-positive neuromonitoring warnings.

Assessment of Metabolic Syndrome and Kidney and Heart Function in Childhood Cancer Survivors.

BACKGROUND: The survivors of childhood cancer suffer from a number of long-term side effects. These include atherosclerosis and cardiovascular diseases (CVDs) that develop earlier in adulthood than in the rest of the population. The aim of this study was to identify prognostic factors of developing atherosclerosis before the development of symptomatic CVD. METHODS: A total of 141 children that were 7-18 years old were examined; there were 116 survivors of childhood malignancies (hematopoietic and lymphoproliferative malignancies-52; neuroblastoma-22; Wilms tumor-24; other solid tumors-18) and 25 healthy controls. Anthropometric measurements, blood pressure measurements, ultrasonography of the abdomen, echocardiography, and laboratory tests were performed. RESULTS: There were no significant differences in gender distribution, time from the end of the treatment, weight, BMI, prevalence of central obesity, blood pressure and resistive index of the renal arteries, lipid profile, or glucose and fibrinogen levels. Patients with solid tumors had a significantly lower height and worse renal function. Patients with hematological malignancies significantly presented the lowest shortening fraction of the left ventricle. The salusin ß levels were significantly higher in the control group than among the patients. CONCLUSIONS: The type and severity of side effects are closely related to the type of neoplasm and the treatment that has been undergone. Careful observation and regular follow-up are necessary.

Update on neuromonitoring procedures applied during surgery of the spine - observational study.

Introduction: Motor evoked potentials (MEPs) are currently considered as a more useful method for neurophysiological intraoperative monitoring than somatosensory evoked potentials in cases of surgery applied to patients with adolescent idiopathic scoliosis. The non-invasive approach is preferred to modify MEP recordings, criticizing, in many cases, the fundamentalism for neurophysiological monitoring based only on needle recordings. The aim of the review is to provide our own experience and practical guidelines with reference to neuromonitoring innovations. Material and methods: Recordings of MEPs with surface electrodes instead of needle electrodes including nerve instead of muscle combinations during neurophysiological monitoring associated with surgical interventions to the spine have become more relevant for pediatric purposes, avoiding the anesthesiology-related influences. Observations on 280 patients with Lenke A-C types of spine curvature are presented before and after the surgical correction. Results: The MEPs recorded from nerves do not undergo fluctuations at different stages of scoliosis corrections and the anesthesia effect more than MEPs recorded from muscles. The use of non-invasive surface electrodes during neuromonitoring for MEP recordings shortens the total time of the surgical procedure without diminishing the precision of the neural transmission evaluation. The quality of MEP recordings during intraoperative neuromonitoring from muscles can be significantly influenced by the depth of anesthesia or administration of muscle relaxants but not those recorded from nerves. Conclusions: The proposed definition of "real-time" neuromonitoring comprises the immediate warning from a neurophysiologist about the changes in a patient's neurological status during scoliosis surgery (especially during pedicle screws' implantation, corrective rods' implantation, correction, distraction and derotation of the spine curvature) exactly during the successive steps of corrective procedures. This is possible due to the simultaneous observation of MEP recordings and a camera image of the surgical field. This procedure clearly increases safety and limits financial claims resulting from possible complications.

Estrogen Receptor Type 1 and Type 2 Presence in Paravertebral Skeletal Muscles: Expression Level and Relation to Phenotype in Children with Idiopathic Scoliosis.

The study aimed to detect the presence and assess the expression levels of the estrogen receptors type 1 (ESR1) and type 2 (ESR2) within paravertebral skeletal muscles of female patients with idiopathic scoliosis (IS) in relation to phenotype parameters. Intraoperatively, the muscle samples were obtained from 35 adolescent females. The RT-qPCR, western blot and immunohistochemistry techniques were applied. The ESR1 and ESR2 were detected within paravertebral skeletal muscle cells, either the superficial or the deep ones. The ESR1 expression level was significantly higher in the deep muscles compared to the superficial ones. A left-right asymmetry of the ESR1 and ESR2 expression level was demonstrated in the deep muscles. There was a significant relationship between the expression asymmetry and either the Cobb angle or the progression risk factor: both parameters decreased to the smallest values in the case of symmetric ESR1 or ESR2 expression, while they increased with increasing expression asymmetry. In conclusion, the ESR1 and ESR2 presence was confirmed in skeletal paravertebral muscles of patients with idiopathic scoliosis. The increased expression level and asymmetry of estrogen receptors in deep skeletal muscles was related to increasing scoliotic deformity magnitude or increasing risk of deformity deterioration. These findings may highlight the etiopathogenesis of IS in children.

Lymphoepithelial Cyst of the Salivary Gland in a Small Ruminant Lentivirus-Positive Goat.

The lymphoepithelial cyst (LEC) of the major salivary gland is a rare lesion described in medical literature. It is found in human immunodeficiency virus (HIV)-infected patients and considered an early manifestation of this infection. Despite the variety of theories, the origin of this lesion remains controversial. No veterinary studies on LEC have been published so far. This study is the first-ever that aims to describe histopathological, histochemical, and immunohistochemical features of a LEC located adjacent to the salivary gland of a goat. The goat proved seropositive for the small ruminant lentivirus, showed clinical signs of caprine arthritis-encephalitis, and had caprine arthritis-encephalitis virus (CAEV)-infected cells in the lung. The histopathology revealed a cystic lesion lined mainly with squamous epithelium surrounded by a lymphoid component, containing a mucus-negative material and a few nonbirefringent structures corresponding to amylase crystalloids. Using immunohistochemistry, CAEV-positive cells were detected in macrophages, LEC epithelial cells, and the salivary gland. The B cells were mainly in the germinal centres, the intraepithelial lymphocytes expressed CD3 and Bcl-2, and the proliferative activity was low. This study showed that LEC had many similar histological and immunohistochemical features to those seen in humans. However, further studies are required in this respect.

Sinusoidal obstruction syndrome in a paediatric patient with acute lymphoblastic leukaemia after completion of reinduction therapy according to ALL Intercontinental Berlin-Frankfurt-Münster 2009.

Sinusoidal obstruction syndrome (SOS), also termed veno-occlusive disease (VOD) of the liver, is a well-known complication of haematopoietic stem cell transplantation (HSCT) both in children and adults. In the medical literature there are occasional reports of SOS in patients receiving conventional chemotherapy. In children with solid tumours this entity occurs during treatment of nephroblastoma, rhabdomyosarcoma, and medulloblastoma. In the late 1990s SOS was quite often observed as the complication of oral 6-thioguanine (6-TG) in patients suffering from acute lymphoblastic leukaemia (ALL), who received 6-TG throughout maintenance. In current protocols, the syndrome has become uncommon because treatment with 6-TG is limited to two weeks of oral therapy. Here, we report a case of a nine-year-old boy with ALL, who developed sinusoidal obstruction syndrome shortly after completing the reinduction block of chemotherapy (cyclophosphamide, cytarabine, thioguanine) according to the ALL Intercontinental Berlin-Frankfurt-Münster 2009 (ALL IC BFM 2009) treatment protocol.

The influence of caffeine administered at 10°C on bone tissue development.

INTRODUCTION AND OBJECTIVE: Caffeine is a natural methylxanthine widespread throughout the food industry. Many research studies have shown that caffeine readily crosses the placenta causing teratogenic and embryotoxic effects. The objective of this study was to assess the influence of caffeine, administered at 10°C, on the development of a rat's bone tissue, with particular reference to elemental bone composition using an X-ray microprobe. MATERIALS AND METHODS: The research was conducted on white rats of the Wistar strain. The fertilized females were divided into two groups: an Experimental Group (Group E) and a Control Group (Group C). The females in Group E were given caffeine orally (at 10°C) in 30 mg/day doses from the 8(th) - 21(st) day of pregnancy. The females in Group C were given water at the same temperature. The foetuses were used to assess the growth and mineralization of the skeleton. Qualitative analysis of the morphology and mineralization of bones was conducted using the alcian-alizarin method. For calcium and potassium analysis, an X-ray microprobe was used. RESULTS: By staining the skeleton using the alcian-alizarin method, changes in 47 Group E foetuses were observed. The frequency of the development variants in the Group E rats was statistically higher, compared with Group C. CONCLUSIONS: On the basis of these results, it can be concluded that caffeine in high doses disturbs the development of bone tissue. An additional factor which enhances the adverse effects of this substance on bone tissue is the temperature of the administered solution (10(o)C). In the Experimental Group, a significant decrease in the calcium level, as well as an increase in the potassium level, was observed. The X-ray microprobe can be a perfect complement to the methods which enable determination of the mineralization of osseous tissue.

Right Ventricle Mass Removal from Tricuspid Valve Apparatus: An Unusual Thromboembolic Complication of Severe Ketoacidosis.

The presence of a pathologic mass in the right ventricle (RV) may lead to hemodynamic consequences and to a life-threatening incident of pulmonary embolism. The diagnosis of an unstable thrombus in the right heart chamber usually necessitates intensive treatment to dissolve or remove the pathology. We present a report of an unusual complication of severe ketoacidosis: thrombus in the right ventricle, removed from the tricuspid valve (TV) apparatus. A four-year-old boy was diagnosed with diabetes mellitus (DM) type I de novo. During hospitalization, a 13.9 × 8.4 mm tumor in the RV was found in a routine cardiac ultrasound. The patient was referred for surgical removal of the floating lesion from the RV. The procedure was performed via midline sternotomy with extracorporeal circulation (ECC) and mild hypothermia. Control echocardiography showed complete tumor excision with normal atrioventricular valves and heart function. Surgical removal of the thrombus from the tricuspid valve apparatus was effective, safe, and a definitive therapy for thromboembolic complication of pediatric severe ketoacidosis.

Expression of Estrogen Receptor Coactivator Proline-, Glutamic Acid- and Leucine-Rich Protein 1 within Paraspinal Muscles in Adolescents with Idiopathic Scoliosis.

PURPOSE: The aim of this study was to detect and assess the estrogen receptor (ESR) coactivator PELP1 expression within human paraspinal skeletal muscles in patients suffering from idiopathic scoliosis. METHODS: During surgical correction of scoliosis the muscle biopsies harvested in 29 females. Presence of PELP1, ESR1 and ESR2 genes transcripts was studied using RT-qPCR technique while immunohistochemistry and western blot methods were used to detect the PEPL1 protein presence. RESULTS: PELP1 expression in deep paraspinal muscles revealed higher than in superficial back muscles (p = 0.005). Positive immunohistochemical staining for PELP1 was observed in the nuclei of the paraspinal muscle cells. Western blot revealed PELP1 protein in all samples. No significant difference in PELP1 expression between the convex and the concave scoliosis side (p>0.05) was found. In deep paraspinal back muscles, a significant correlation between the PELP1 expression level on the concave side and the Cobb angle (r = 0.4; p<0.05) was noted as well as between the PELP1 and ESR1 expression level (r = 0.7; p<0.05) while no correlation between PELP1 and ESR2 expression level was found. CONCLUSION: To our knowledge, three techniques for the first time demonstrated the presence of the PELP1 in paraspinal muscles of patients with idiopathic scoliosis. The PELP1 potential regulatory impact on back muscle function is to be further investigated.

The effects of caffeine administered at different temperatures on foetal development.

An easy access to products containing caffeine makes it widely consumed to excess by the general population, including pregnant women. Beverages containing caffeine are consumed at different temperatures (iced, hot, room temperature). Caffeine easily passes through biological membranes, including the blood-brain barrier, the placental barrier, and can also enter the amniotic fluid, breast milk and semen. The aim of this study was to evaluate the relationship between caffeine's developmental toxicity, and the solution's temperature (both low and high) administered to pregnant female rats. Fertilized females were randomly divided into two main groups: an experimental (E) and a control group (C). The experimental groups received caffeine (30mg/day) in 10 (E1), 25 (E2) and 45(o)C (E3). The females in the control group were given water at the same temperature (C1, C2 and C3). On the day 21 of pregnancy, the pregnant females were killed by decapitation, using a specially prepared laboratory guillotine, after which the mothers' internal organs were weighed. Additionally, the offspring were examined using standard teratological methods. The study found that caffeine administered to pregnant females at a dose of 30mg/day and at the temperatures of 10°C, 25°C or 45°C did not produce any teratogenic effects. The only sign of its adverse effect was the appearance of developmental abnormalities in the form of haematomas and saturated bleeding in the internal organs. These changes most frequently occurred in foetuses of females which received caffeine at 10°C or 45°C.

The human balance system and gender.

The human body balance system is a complex system of organs and mechanisms, which generate postural reactions to counter the displacement from the equilibrium position of the body centre of gravity, and which control eye movement in order to maintain a stable image of the environment. Computerised Dynamic Posturography (CDP) allows for a quantitative and objective assessment of the sen- sory and motor components of the body balance control system as well as of the integration and adaptive mechanisms in the central nervous system. The aim of this study was to determine the differences, when maintaining body balance, based on the gender of young, healthy people using CDP. The study was carried out on a group of 43 healthy subjects by comparing the effectiveness of the balance system in 22 women and 21 men aged between 20 and 26 years, between 171 and 177 cm in height, and without any clinical symptoms of balance disorders. The men and women were selected such that they did not differ significantly in height and BMI. Using the Equitest posturograph manufactured by NeuroCom International Inc. the following tests were performed: Sensory Organisation Test (SOT), Motor Control Test (MCT) and the Adaptation Test (ADT). The gender of young healthy individuals without any clinical symptoms of balance disorders also does not affect the effectiveness of the sensory system and the use of this signal in maintaining body balance.

Influence of caffeine administered at 45 °C on bone tissue development.

INTRODUCTION AND OBJECTIVE: Caffeine is one of the world's most commonly ingested alkaloids which easily permeates the placenta. The teratogenic and embryotoxic influence of large doses of caffeine has been established in many experimental studies on animals. The objective of this work was to assess the influence of caffeine, administered at 45 °C, on the development of the bone tissue of rats, with particular reference to elemental bone composition using an X-ray microprobe. MATERIALS AND METHODS: The research was conducted on white rats of the Wistar strain. The fertilized females were divided into two groups: an Experimental Group (Group E) and a Control Group (Group C). The females in Group E were given caffeine orally (at 45 °C) in 30 mg/day doses from the 8th to the 21st day of pregnancy. The females in Group C were given water at the same temperature. The fetuses were used to assess the growth and mineralization of the skeleton. A qualitative analysis of the morphology and mineralization of bones was conducted using the alcian-alizarin method. For calcium and potassium analysis, an X-ray microprobe was used. RESULTS: By staining the skeleton using the alcian-alizarin method, changes in 52 of Group E fetuses were observed. The frequency of the development variants in the Group E rats was statistically higher, compared with Group C. CONCLUSIONS: Receiving caffeine at a higher temperature may result in different pharmacodynamics and significantly change tolerance to it. In Group E, a significant decrease in the calcium level, as well as an increase in the potassium level, was observed. The X-ray microprobe can be a perfect complement to the methods which enable determination of the mineralization of osseous tissue.

The influence of lead on the biomechanical properties of bone tissue in rats.

INTRODUCTION AND OBJECTIVE: Environmental lead (Pb) is a serious public health problem. At high levels, Pb is devastating to almost all organs. On the other hand, it is difficult to determine a safe level of exposure to Pb. More than 90% of the Pb in the adult human body and 70% in a child's body is stored in the bones. In the presented study, the effects of lead exposure on bones were studied for rats treated orally with Pb acetate in drinking water for 14 days. The hypothesis was tested that lead exposure negatively affects bone structure. MATERIALS AND METHODS: Femur strength was measured in a three-point bending test, whereas infrared spectroscopy (FTIR) was used to measure molecular structural changes. RESULTS: Lead significantly decreased the ratio of area of two types of vibrational transitions, which are highly specific to mineral to matrix ratio. The results of the biomechanical study show that femurs of rats treated by Pb-acetate appeared to be weaker than bones of the control group, and may produce a condition for the development of higher risk of fractures. Additionally, a great difference in body mass was observed between control and the Pb acetate-treated groups. CONCLUSIONS: The lower bone mineral content and the weaker mechanical properties of bones from Pb-treated rats are associated with the pathologic state dependent of the exposure of lead.

Fatty foci within the heart diagnosed with ECG-gated multi-slice computed tomography: frequency and morphology.

BACKGROUND: The purpose of our study was to analyze the frequency of focal fatty replacement (FR) of the heart, as well as the distribution and detailed morphology of FR in a large group of patients referred to multi-slice computed tomography with ECG-gating examinations (ECG-MSCT) for various clinical reasons. MATERIAL AND METHODS: The ECG-MSCT examinations of 1830 consecutive patients were analyzed. The examinations were performed using 8-row (1015 patients) and 64-row (815 patients) MSCT, in pre- and post-contrast scanning. We analyzed the morphology of FR, the dimensions and densities of changes, as well as the morphology and localization of FR with regard to clinical diagnosis. RESULTS: 204 subjects (11.1%) had FR within the heart (113 men; 91 women; mean age 57.8 years); 66% of fatty foci were seen only in the native scanning. The distribution of the fat was: right ventricle (RV) 31.9%, left ventricle (LV) 21.5%, biventricular 39.7%, interventricular or atrial septum 5.9%, and atria 1%. In the RV, fat was localized mainly in the papillary muscles, while in the LV fat was mainly subendocardial (p<0.001). The morphology of the fat was: linear 61.6%, oval 14.8%, punctuate 10.6%, irregular 10.2%, and bilobular 2.8%. Fat was primarily located subendocardially in the LV in patients after myocardial infarction. In patients with suspected coronary artery disease, it was mainly observed subpericardially in the RV and in papillary muscles (p<0.001). CONCLUSIONS: The incidental frequency of FR within the heart in patients diagnosed with the ECG-MSCT examinations is about 11%. Pre-contrast scanning is the most valuable for FR assessment.

The effect of height and BMI on computer dynamic posturography parameters in women.

The human body's posture control is a complex system of organs and mechanisms which controls the body's centre of gravity (COG) over its base of support (BOS). Computerised Dynamic Posturography (CDP) allows for the quantitative and objective assessment of the sensory and motor components of the body's posture control system as well as of the integration and adaptation mechanisms in the central nervous system. The aim of this study was to assess the relationships between the body's height and BMI on CDP results in a group of young healthy women without any clinical symptoms of balance disorders. It was found that the MS depended significantly on the height and BMI of the subjects as well as on the SOT conditions. As the height and BMI increased the MS value decreased. The postural response latency (LC) in the MCT statistically significantly depended only on height and showed a positive correlation. The postural response latency increased with height. The postural response amplitude for both right and left lower limbs significantly depended on height and BMI, but only for the backward movement of the platform. The response amplitude for all platform translations under all MCT conditions increased with height and BMI. The body's resultant imbalance caused by the platform perturbations in the ADT was greater in shorter people and those with a lower BMI.

Intermediate ray deficiency--a new type of lower limb hypoplasia.

OBJECTIVE: Diagnosis of fibular hemimelia is based on the identification of absence or shortening of the fibula in relation to the tibia. Despite the existence of different classifications of this congenital deficiency, certain morphological forms defy proper classification. One such form is absence of foot rays with leg shortening in the presence of an entire fibula. In these cases, foot morphology suggests that central foot rays, not lateral ones, are affected by the deficiency; thus justifying the hypothesis concerning the existence of a separate type of hypoplasia, which may be named "intermediate ray deficiency" (IRD). MATERIALS AND METHODS: Nine patients with IRD, with an average age of 9.4 years at diagnosis (2.9-15), were analyzed. Clinical and radiographic parameters of the leg and foot were recorded according to the Stanitski classification of fibular hemimelia. The position of the lateral and medial malleoli was assessed. Axial alignment was analyzed according to the Paley method. RESULTS: The number of foot rays in eight cases was 4, while in one case, it was 3. Talocalcaneal synostosis was observed in seven cases. The shape of the ankle joint was spherical in six cases, horizontal in two cases and valgus in one case. The position of the lateral malleolus was slightly higher compared to normal. An average functional leg length discrepancy was 4.4 cm. The average percentage of fibular shortening was 9.5 %, tibial shortening 8.7 % and femoral shortening 3.3 %. In all of the cases, slight knee valgus was observed on the femoral level (average 3.3°) and tibial level (average 2.0°). As a result, criteria for IRD diagnosis were proposed. CONCLUSION: "Intermediate ray deficiency" might be defined as a separate type of lower limb hypoplasia.

Ultrasound assessment of thrombotic complications in pediatric patients with tunneled central venous catheters.

Central venous access consists in inserting a vascular catheter to the vena cava and placing its tip in the vicinity of the opening to the right atrium. In the patients of the Clinic of Pediatrics, Hematology and Oncology at the Academic Clinical Centre of the Medical University in Gdansk, such implantation procedures are conducted 40-50 times in a year using Broviac/Hickman catheters that are placed in the subclavian vein. In the Ultrasound and Biopsy Laboratory at the clinic mentioned above, approximately 200-250 examinations have been conducted since 2005 to assess the central venous access. Implantation of a catheter considerably increases the comfort of patients who require a long-term venous access. Nevertheless, it is an invasive procedure, burdened with a risk of numerous, early and late complications. The late complications are associated with implanted catheters and include catheter-related thrombosis. The aim of this paper was to present three patients of the Clinic of Pediatrics, Hematology and Oncology at the Academic Clinical Centre of the Medical University in Gdansk, in whom thrombotic complications occurred as a result of long-term central venous catheters. The paper also discusses the possibilities of using sonography in the assessment of such complications. In the presented patients, it was possible to determine the size and localization of a thrombus which enabled effective treatment in two cases. The pathomechanism of catheter-related thrombosis was explained and the risk factors of such complications were discussed. The attention was paid to the necessity of conducting ultrasound examinations in pediatric patients with inserted catheters as soon as the first symptoms of thrombosis appear. Based on own observations and despite the lack of validation of ultrasound imaging in the assessment of central catheters, we believe that this method is highly promising and can be recommended for the assessment of thrombotic complications in pediatric patients with central venous catheters.

Optimal management of idiopathic scoliosis in adolescence.

Idiopathic scoliosis is a three-dimensional deformity of the growing spine, affecting 2%-3% of adolescents. Although benign in the majority of patients, the natural course of the disease may result in significant disturbance of body morphology, reduced thoracic volume, impaired respiration, increased rates of back pain, and serious esthetic concerns. Risk of deterioration is highest during the pubertal growth spurt and increases the risk of pathologic spinal curvature, increasing angular value, trunk imbalance, and thoracic deformity. Early clinical detection of scoliosis relies on careful examination of trunk shape and is subject to screening programs in some regions. Treatment options are physiotherapy, corrective bracing, or surgery for mild, moderate, or severe scoliosis, respectively, with both the actual degree of deformity and prognosis being taken into account. Physiotherapy used in mild idiopathic scoliosis comprises general training of the trunk musculature and physical capacity, while specific physiotherapeutic techniques aim to address the spinal curvature itself, attempting to achieve self-correction with active trunk movements developed in a three-dimensional space by an instructed adolescent under visual and proprioceptive control. Moderate but progressive idiopathic scoliosis in skeletally immature adolescents can be successfully halted using a corrective brace which has to be worn full time for several months or until skeletal maturity, and is able to prevent more severe deformity and avoid the need for surgical treatment. Surgery is the treatment of choice for severe idiopathic scoliosis which is rapidly progressive, with early onset, late diagnosis, and neglected or failed conservative treatment. The psychologic impact of idiopathic scoliosis, a chronic disease occurring in the psychologically fragile period of adolescence, is important because of its body distorting character and the onerous treatment required, either conservative or surgical. Optimal management of idiopathic scoliosis requires cooperation within a professional team which includes the entire therapeutic spectrum, extending from simple watchful observation of nonprogressive mild deformities through to early surgery for rapidly deteriorating curvature. Probably most demanding is adequate management with regard to the individual course of the disease in a given patient, while avoiding overtreatment or undertreatment.

Use of X-ray microprobe to diagnose bone tissue demineralization after caffeine administration.

Caffeine is a methylxanthine which permeates the placenta. In studies on animals, it has been shown to produce teratogenic and embryotoxic effects in large doses. The objective of this study was to assess the influence of caffeine on the development of bone tissue, with particular reference to elemental bone composition using an X-ray microprobe. The research was conducted on rats. The fertilized females were randomly divided into an experimental and a control group. The experimental group was given caffeine orally in 30 mg/day doses from the 8th to the 21st day of pregnancy, while the control group was given water. The fetuses were used to assess the growth and mineralization of the skeleton. On the basis of double dyeing, a qualitative analysis of the bone morphology and mineralization was conducted. For calcium and potassium analysis, an X-ray microprobe was used. In 67 fetuses from the experimental group, changes in skeleton staining with the alcian-alizarin method were noticed. The frequency of the development of variants in the experimental group was statistically higher. In the experimental group,a significant decrease in the calcium level, as well as an increase in the potassium level, was observed. The X-ray microprobe's undoubted advantage is that is offers a quick qualitative and quantitative analysis of the elemental composition of the examined samples. Employing this new technique may furnish us with new capabilities when investigating the essence of the pathology process.