Cardiac injury due to accidental discharge of nail gun.

BACKGROUND: Since 1991, the incidence of injuries associated with pneumatic and explosive powered nail guns has steadily been rising due to increasing use of these devices by the untrained consumer. The vast majority of injuries involve the extremities, but injuries have been reported to occur in virtually every area of the body. OBJECTIVE: Discuss the epidemiology, pathophysiology, and management of penetrating cardiac nail gun injuries. CASE REPORT: A 33-year-old man sustained a penetrating cardiac injury from accidental discharge of a nail gun. The patient had successful repair of a laceration to his right ventricle. CONCLUSIONS: Penetrating cardiac injuries from pneumatic nail guns are rare and have mortality similar to stab wounds. Improved safety mechanisms and training are the keys to prevention. Consideration also should be given to implementing legislation restricting the sale of nail guns.

Demonstration of a state-insensitive, compensated nanofiber trap.

We report the experimental realization of an optical trap that localizes single Cs atoms ≃215 nm from the surface of a dielectric nanofiber. By operating at magic wavelengths for pairs of counterpropagating red- and blue-detuned trapping beams, differential scalar light shifts are eliminated, and vector shifts are suppressed by ≈250. We thereby measure an absorption linewidth Γ/2π=5.7±0.1 MHz for the Cs 6S(1/2), F=4→6P(3/2), F'=5 transition, where Γ0/2π=5.2 MHz in free space. An optical depth d≃66 is observed, corresponding to an optical depth per atom d1≃0.08. These advances provide an important capability for the implementation of functional quantum optical networks and precision atomic spectroscopy near dielectric surfaces.

Efficient routing of single photons by one atom and a microtoroidal cavity.

Single photons from a coherent input are efficiently redirected to a separate output by way of a fiber-coupled microtoroidal cavity interacting with individual cesium atoms. By operating in an overcoupled regime for the input-output to a tapered fiber, our system functions as a quantum router with high efficiency for photon sorting. Single photons are reflected and excess photons transmitted, as confirmed by observations of photon antibunching (bunching) for the reflected (transmitted) light. Our photon router is robust against large variations of atomic position and input power, with the observed photon antibunching persisting for intracavity photon number 0.03 < or approximately similar n < or approximately similar 0.7.

Consensus recommendations on estrogen receptor testing in breast cancer by immunohistochemistry.

Estrogen receptor (ER) status in breast cancer is currently the most important predictive biomarker that determines breast cancer prognosis after treatment with endocrine therapy. Although immunohistochemistry has been widely viewed as the gold standard methodology for ER testing in breast cancer, lack of standardized procedures, and lack of regulatory adherence to testing guidelines has resulted in high rates of "false-negative" results worldwide. Standardized testing is only possible after all aspects of ER testing--preanalytical, analytical, and postanalytical, have been closely controlled. A meeting of the "ad-hoc committee" of expert pathologists, technologists, and scientists, representing academic centers, reference laboratories, and various agencies, issued standardization testing recommendations, aimed at optimization of clinical ER testing environment, as a step toward improved standardized testing.

Relationship between walking levels and perceptions of the local neighbourhood environment.

OBJECTIVE: To explore the relationship between frequency of walking trips, perceptions of the local environment and individual travel preferences in children. DESIGN: Cross-sectional questionnaire-based study. SETTING: Six primary schools in Birmingham, UK, range of socioeconomic classifications. PARTICIPANTS: 473 children aged 9-11 years (82% response rate), including 250 (52.9%) boys and 160 (33.8%) from ethnic minority populations. OUTCOME MEASURES: The primary outcome measure was level of walking (high or low) based on self-reported walking frequency in the past week. Secondary outcome measures included child perceptions of seven aspects of the local environment and individual travel preference. All outcomes were measured through questionnaires administered at school in the presence of a researcher. RESULTS: 198 (41.9%) children were classified as high walkers and 275 (58.1%) as low walkers. After adjusting for confounding factors, high walkers were more likely to perceive heavy traffic surrounding their homes (odds ratio (OR) 1.55, 95% confidence interval (CI) 1.03 to 2.33), unsafe streets (OR 1.88, 95% CI 1.27 to 2.80) and prefer healthier modes of travel (OR 1.67, 95% CI 2.56 to 1.08). High walkers were less likely to worry about strangers (OR 0.66, 95% CI 0.45 to 1.02) and less likely to report no parks or sports grounds nearby (OR 0.66, 95% CI 0.42 to 1.02). Children from ethnic minority groups walked significantly less than white children (mean number of walking trips 16.8 and 21.9, respectively, p<0.001). CONCLUSIONS: Certain environmental perceptions are related to walking levels in children. Awareness of these may help in the development of future interventions, and also enable healthcare professionals to encourage walking by providing case-specific and appropriate advice.

Impairment of fetal growth potential and neonatal encephalopathy.

OBJECTIVE: This study was undertaken to determine the frequency of growth impairment in neonates with encephalopathy. STUDY DESIGN: In a case-control design, neonates with neonatal encephalopathy (NE) meeting criteria for an acute intrapartum hypoxic event (IHE, n = 21) and those who did not meet these criteria (n = 20) were compared with controls. The controls were 42 neonates without complications matched 2:1 for gestational age with IHE cases. The percentile of growth potential, a measure of the weight expected in the absence of pathological conditions, was calculated for each fetus. RESULTS: More neonates with NE with and without IHE were below the 10th percentile of growth potential compared with controls (7/21 [33%] and 6/20 [30%] vs 1/42 [2.4%], odds ratio [95% CI] = 20.5 [2.2-114.0] and 17.6 [1.8-102.5], respectively). These associations remained significant after controlling for gestational age and birth weight. CONCLUSION: A large proportion of neonates with NE demonstrate signs of antepartum injury reflected in the impairment of their growth. This association was similar in the presence or absence of IHE, indicating that antepartum injury has a causative rather than predisposing character in many cases of IHE.

The impact of imaging in the management of intussusception owing to pathologic lead points in children. A review of 43 cases.

OBJECTIVE: To review the imaging appearances, management and outcome of a large number of children with intussusception owing to pathologic lead points (PLP) in an attempt to define the role of various imaging modalities in this clinical setting. MATERIALS AND METHODS: Review of the records and imaging studies of 43 children with intussusception due to PLP diagnosed between 1986 and 1999. RESULTS: The commonest PLP found were Meckel diverticulum, polyps, Henoch-Schonlein purpura and cystic fibrosis. PLP were depicted on sonography in 23 (66%) of 35 patients, on computed tomography in 5 (71%) of 7, on air enema in 3 (11%) of 28, and on barium enema in 6 (40%) of 15. Air enema successfully reduced 60% of the intussusceptions. Nine children had recurrent intussusceptions. CONCLUSION: Sonography depicted two-thirds of PLP and provided a specific diagnosis in nearly one-third of our series. Our review does not provide sufficient data on how to continue the investigation of those patients in whom sonography does not depict a PLP but in whom there is a high index of suspicion for its presence. It remains a diagnostic challenge as to how to search for PLP in these patients, and other imaging modalities have to be requested according to each particular case.

Spontaneous reduction of intussusception: clinical spectrum, management and outcome.

BACKGROUND: To analyze the spectrum of clinical features, management and outcome of children with documented spontaneous reduction of intussusception (SROI). MATERIALS AND METHODS: Review of records of 50 children (33 boys, 17 girls; age range 11 days-15 years; mean age 4 years) with documented SROI, in whom intussusception was initially diagnosed by sonography (US) in 44, air enema in 2, and computed tomography in 4, in the 6-year period 1992-1998. RESULTS: Symptoms suggestive of intussusception were present in 21 (3 of whom had Henoch-Schönlein purpura and 4 had previous ileocolic intussusception reduced by air enema). Intussusception was an incidental finding in the other 29, in 28 of whom the finding was in the small bowel. Intussusception was limited to the small bowel in 43 and was ileocolic in 7. SROI was usually documented on US. Laparotomy performed in only 4 showed no evidence of intussusception or pathologic lead point. Outcome in all patients was favorable. CONCLUSIONS: SROI may present in symptomatic or asymptomatic children and occurs more commonly than previously reported. These intussusceptions are usually short-segment, small-bowel intussusceptions with no recognizable lead point. In asymptomatic patients, conservative observation is warranted. Intervention should be dictated by the clinical findings in symptomatic patients.

Colo-colic intussusception associated with pneumatosis cystoides intestinalis.

This paper describes pneumatosis cystoides intestinalis in association with colo-colic intussusception in a young teenager. The intussusception was easily reduced at barium enema. The recognition of the characteristic filling defects in the barium column facilitates a correct diagnosis. This association has only been reported previously in six adults.

Patterns of recurrence of intussusception in children: a 17-year review.

PURPOSE: Patterns of recurrence of intussusception (INT) were reviewed to determine whether changes in management have affected the rate and patterns of recurrence as well as long-term outcome in children with multiple (i. e., 2 or more) recurrences. MATERIALS AND METHODS: Review was done of 763 children with 876 intussusceptions, including (1) recurrence rate, (2) patterns of recurrence (number of and interval between recurrences), (3) reducibility, (4) pathologic lead points (PLP), (5) operative findings and (6) long-term follow-up in those with multiple recurrences. RESULTS: Above features (1)-(6) were the same in those managed with barium enema (1979-1985) and those managed with air enema (1985-1996). Overall recurrence rate was 9 %; 11 % with barium enema and 8 % with air enema. Sixty-nine patients had 113 recurrences: 47/69 (68 %) and 1 recurrence and 22/69 (32 %) had multiple recurrences. Multiple recurrences presented as isolated episodes or in clusters up to 8 years. Reducibility was 100 % for initial INT and 95 % for recurrent episodes; there were no perforations. Surgery, in 4 with irreducible recurrence, revealed no PLP. PLP were present in 5 (8 %): 2 (4 %) with 1 recurrence and 3 (14 %) with multiple recurrences. No pattern of recurrence was predictive for PLP. Long-term follow-up (up to 15 years) available in 11 with multiple recurrences revealed a favourable outcome. CONCLUSIONS: Rates and patterns of recurrence did not change with altered management. Because of the high reduction rate of recurrences, lack of perforation and favourable long-term follow-up, we recommend radiological reduction for recurrent INT. Multiple recurrences are not a contraindication. A careful search for PLP is mandatory. Surgery should be reserved for irreducible recurrences or for demonstrated PLP.

The value of sonography, CT and air enema for detection of complicated Meckel diverticulum in children with nonspecific clinical presentation.

BACKGROUND: Complicated Meckel diverticulum (MD) in children does not always present with painless rectal bleeding and its presentation can then produce a difficult diagnostic dilemma. In this clinical setting, sonography (US), CT or even air enema may be the first modality chosen to evaluate these children rather than the radionuclide Meckel scan (RNMS). PURPOSE: To assess the value of US, CT and air enema for detection of complicated MD. MATERIALS AND METHODS: Review of clinical, imaging, surgical and pathological findings in 64 children (55 males, 9 females) aged 4 days -14 years (mean = 3.7 years) with MD seen during an 8-year period, 1990-1997. RESULTS: (a) In 33 patients with rectal bleeding, MD was detected on RNMS in 32. Ten of these 32 had other imaging studies, all of which were negative. (b) The other 31 patients, with varied clinical presentations, did not undergo RNMS. In these 31 and the 1 with a negative RNMS, 14 (44 %) had imaging features highly suggestive for the diagnosis of MD on US in all 14, on CT in 1, and on air enema in 3. The radiological spectrum of the inflamed, hemorrhagic MD is illustrated. CONCLUSION: The inflamed, hemorrhagic and the inverted, intussuscepted MD have a spectrum of features recognizable on US, CT and air enema. Some of these appearances are specific, others are not. Knowledge of and recognition of these features will facilitate detection of complicated MD in larger numbers of children presenting with symptoms other than the classic history of painless rectal bleeding and also in those with normal RNMS.

The appearance of inverted Meckel diverticulum with intussusception on air enema.

This paper presents the appearances of inverted Meckel diverticulum with an irreducible intussusception on air enema in four children. The inverted Meckel diverticulum appeared as a bulbous (3) or triangular (1) filling defect in the air column projecting off the distal end of the soft tissue mass of the irreducible intussusceptum. The bulbous defect appears to be highly suggestive, and may be specific, for inverted Meckel diverticulum. Earlier recognition of the presence of the Meckel diverticulum as the lead point of the intussusception could have changed the management in two of the children.

The diagnosis of malrotation during air enema procedure.

This paper describes the correct diagnosis of cecal malposition, suggesting midgut malrotation, during air enema examination in seven patients. It is possible to diagnose cecal malposition by air enema, even in the presence of a reducible intussusception.

Intussusception in the 1990s: has 25 years made a difference?

To evaluate the current management of the infant and child with intussusception, the medical records of 188 consecutive intussusception patients over 5 years (1985-1990) were reviewed and compared to our series from 25 years ago (1959-1968). The peak months changed from May and June to January and July. Duration of symptoms and signs prior to diagnosis increased by one-third to 35 h with, however, a decrease in the incidence of pain, vomiting, abdominal mass, and rectal blood. Air was the only contrast used for the hydrostatic enema in the present series and was tried in every case with 81% success; this is a major improvement from 45% in the old series. There were three perforations (1.4%) with air-enema attempts compared with 1 (0.2%) 25 years ago. Recently only 19% of patients required operation but 30% needed resection; 55% of the patients in the older series required operation and 20% needed resection. Ten percent of intussusceptions continue to be found spontaneously reduced at operation. There were many less pathologic lead points in the newer series. The recurrences increased from 4% to 7%, but their reduction rate also increased from 31% with barium to 100% with air. There were no deaths in the last 25 years.

Sonographic appearances of inverted Meckel diverticulum with intussusception.

This study illustrates the sonographic findings of inverted Meckel diverticulum acting as a lead point of an intussusception in five patients. In four patients, the inverted diverticulum was seen as a segment of blind-ending, thick-walled bowel projecting for a variable distance from the apex of the intussusceptum. The larger diverticula had a characteristic bulbous shape. The central serosal surface of the inverted diverticulum was filled with fluid in one patient, with fluid and fat in another, and with echogenic fat only in the other two. The presence of fat was confirmed by CT in one patient. The features illustrated in these four patients appear to be specific. In the fifth patient, the sonogram revealed a nonspecific echogenic mass at the apex of the intussusceptum. Recognition of these features on sonography may obviate the need for further investigation.

Intussusception. Issues and controversies related to diagnosis and reduction.

Diagnosis and management of intussusception remain controversial. The authors discuss the evolution of changes and advances in practice and procedures. They advocate sonographic diagnosis and air enema reduction; the abdominal radiograph is reserved for children with clinical evidence of peritonitis and suspected perforation, if clinical findings are unusual, or if the sonographic examination is equivocal.

Intussusception: ability of fluoroscopic images obtained during air enemas to depict lead points and other abnormalities.

PURPOSE: To evaluate the ability of fluoroscopic images obtained during air enemas to depict or exclude lead points of intussusceptions and other abnormalities that require surgical treatment in the absence of intussusception. MATERIALS AND METHODS: The clinical, radiologic, surgical, and pathologic findings were reviewed in 14 patients with lead points or other lesions. RESULTS: Fluoroscopic images failed to depict a lead point in 10 patients. The air enema easily reduced intussusceptions with benign lead points in seven patients. Fluoroscopic images depicted pathologic lead points in two patients and were normal in two patients with intussusception. Fluoroscopic images failed to depict an abnormality that required surgery in the absence of intussusception in two patients. CONCLUSION: Successful reduction of an intussusception does not always rule out a lead point. Other imaging studies, the patient's condition, and laparotomy may also be necessary to diagnose and treat lead points and other lesions.