Quantitative risk assessment of Campylobacter spp. in poultry based meat preparations as one of the factors to support the development of risk-based microbiological criteria in Belgium.

The objective of this study was to do an exercise in risk assessment on Campylobacter spp. for poultry based meat preparations in Belgium. This risk assessment was undertaken on the demand of the competent national authorities as one of the supportive factors to define risk-based microbiological criteria. The quantitative risk assessment model follows a retail to table approach and is divided in different modules. The contamination of raw chicken meat products (CMPs) was represented by a normal distribution of the natural logarithm of the concentration of Campylobacter spp. (ln[Camp]) in raw CMPs based on data from surveillance programs in Belgium. To analyse the relative impact of reducing the risk of campylobacteriosis associated with a decrease in the Campylobacter contamination level in these types of food products, the model was run for different means and standard deviations of the normal distribution of the ln[Camp] in raw CMPs. The limitation in data for the local situation in Belgium and on this particular product and more precisely the semi-quantitative nature of concentration of Campylobacter spp. due to presence/absence testing, was identified as an important information gap. Also the knowledge on the dose-response relationship of Campylobacter spp. was limited, and therefore three different approaches of dose-response modelling were compared. Two approaches (1 and 2), derived from the same study, showed that the reduction of the mean of the distribution representing the ln[Camp] in raw CMPs is the best approach to reduce the risk of Campylobacter spp. in CMPs. However, for the simulated exposure and approach 3 it was observed that the reduction of the standard deviation is the most appropriate technique to lower the risk of campylobacteriosis. Since the dose-response models used in approach 1 and 2 are based on limited data and the reduction of the mean corresponds with a complete shift of the contamination level of raw CMPs, demanding high efforts from the poultry industry, it is proposed to lower the standard deviation of the concentration of Campylobacter spp. in raw CMPs. This proposal corresponds with the elimination of the products that are highly contaminated. Simulation showed that eating raw chicken meat products can give rise to exposures that are 10(10) times higher than when the product is heated, indicating that campaigns are important to inform consumers about the necessity of an appropriate heat treatment of these type of food products.

Hepatic inflammatory pseudotumor: case report, review of the literature, and a proposal for morphologic classification.

Inflammatory pseudotumors (IPT) are uncommon mass lesions arising most typically in the lungs of young adults. These tumors are so named because of the difficulty in distinguishing them preoperatively from malignant lesions. IPT are characterized histologically by localized fibrous proliferations with infiltration by mononuclear leukocytes, particularly plasma cells. Seventeen previous cases of IPT involving the liver and biliary tree have been reported in children. In this location, IPT may lead to biliary obstruction, portal hypertension, cirrhosis and eventually hepatic failure. We describe the youngest patient ever reported with hepatic IPT (HIPT) and biliary obstruction, who was successfully managed with a left hepatic lobectomy and Kasai portoenterostomy. Based on all previous cases of HIPT in both adults and children (74 cases), we propose a morphologic classification of these lesions based on the presence of single versus multiple lesions, with individualized management. Type 1 lesions are large, solitary lesions, often with central necrosis, giving a characteristic radiographic appearance. Type 2 lesions are multiple smaller, solid nodules indistinguishable from metastatic malignancy.

Advancement flap umbilicoplasty after abdominal wall closure: postoperative results compared with normal umbilical anatomy.

BACKGROUND/PURPOSE: Umbilical reconstruction frequently is an adjunct used after repair of congenital abdominal wall defects. The authors describe a new technique of umbilicoplasty and compare their results with normal neonatal umbilical anatomy. METHODS: After fascial closure, 6 newborn infants with either gastroschisis (n = 3) or omphalocele (n = 3) underwent umbilicoplasty performed by advancing bilateral skin flaps including creation of an umbilical skin collar. The umbilical collar height, circumference, and distance from the xiphoid with respect to the pubis (ratio of xiphoid-umbilicus distance to xiphoid-pubis distance or XU:XP) were recorded and referenced to normal umbilical anatomy in additional 28 infants (24 to 40 weeks gestation [mean, 33.2 weeks] and age 2 to 131 days [mean, 26.5 days]). RESULTS: After umbilicoplasty, all infants had a near-normal-appearing umbilicus (collar height, 0.75 +/- 0.25 cm and circumference, 5.24 +/- 1.20 cm) compared with normal umbilical anatomy (collar height, 4.36 +/- 1.32 cm and circumference, 1.03 +/- 0.38 cm). However, after umbilicoplasty, the neoumbilicus was positioned more cephalad (XU:XP = 0.53 +/-.05) compared with normal (mean XU:XP, 0.67 +/- 0.07). The only complication encountered was a small dehiscence of the superior aspect of the abdominal wound. CONCLUSIONS: Closure of abdominal wall defects with simultaneous umbilicoplasty provides a cosmetically pleasing result. When performing umbilicoplasty, attempt should be made to position the neoumbilicus as inferior as possible, optimally at two thirds the distance from the xiphoid to the pubis.

Compressive orthotics in the treatment of asymmetric pectus carinatum: a preliminary report with an objective radiographic marker.

BACKGROUND/PURPOSE: Pectus carinatum (PC) traditionally has been managed with surgical reconstruction. Compressive orthosis also has resulted in subjective improvement in this defect. The goal of the authors was to develop an alternative brace and an objective radiographic marker to monitor the effects of chest wall compression on sternal protrusion. METHODS: Baseline chest computed tomography (CT) scans were obtained for 5 teenage boys with chondrogladiolar type of PC. The angle at the point of greatest sternal rotation was measured as the baseline deformity. Compressive orthosis was initiated using a custom-fitted brace. Follow-up chest CT scans were obtained to document change in sternal rotation. RESULTS: One patient was lost to follow-up after 6 months with subjective improvement. Another opted for surgical correction after 3 months, having shown a 16% decrease in sternal rotation preoperatively. Two patients showed subjective improvement corroborated by 33% and 44% decreases in sternal rotation. The fifth patient, who discontinued bracing after 1 month, showed a 25% increase 6 months later. CONCLUSIONS: Preliminary results indicate a potential role for compressive orthosis in the management of pectus carinatum. The objective radiographic marker described may be used to monitor the effects of growth or treatment with compressive orthosis.

Supplemental oxygen improves resolution of injury-induced pneumothorax.

BACKGROUND/PURPOSE: Traditionally, supplemental oxygen is administered to patients with asymptomatic pneumothorax to accelerate spontaneous resolution. However, this practice is based on models that did not include injury to the visceral pleura and ongoing pleural air leak. This study evaluated the effects of increased inspired oxygen concentration on pneumothorax resolution in a visceral pleural injury model. METHODS: A total of 27 New Zealand white rabbits were divided randomly into 3 groups: room air (RA), 40% FIO2 (40%), and 60% FIO2 (60%). A complete unilateral pneumothorax was created in each animal by a thoracoscopically guided visceral pleural puncture. The animals were then housed in designated oxygen chambers, and observers were blinded to the inspired oxygen concentration. Cross table anteroposterior chest x-rays were obtained preoperatively, postoperatively, and twice a day until the pneumothorax resolved. Time to resolution between the 3 groups was analyzed with 1-way analysis of variance (ANOVA). RESULTS: Twenty of 27 (74%) of the animals completed the study successfully. Mean time to resolution in the RA group (n = 7; 111.2 +/- 30.8 hours) was longer than in the 40% group (n = 6; 71.8 +/- 22.3 hours) and the 60% group (n = 7; 39.4 +/- 14.2 hours). The time to resolution also was longer in the 40% group than in the 60% group. Seven rabbits died before completion of the study of tension pneumothorax (3 of 7) or anesthetic complications (4 of 7). CONCLUSIONS: Supplemental oxygen improves resolution of injury-induced pneumothorax. The tradition of administering supplemental oxygen to patients with asymptomatic pneumothorax should be continued even if there is ongoing pleural air leak.

Testicular damage after surgical groin exploration for elective herniorrhaphy.

BACKGROUND/PURPOSE: Controversy exists whether to explore the contralateral groin in boys during unilateral herniorrhaphy. Proponents claim there is minimal risk of injury to the cord structures and developing testicle with contralateral exploration. However, findings have shown testicular atrophy occurred in 1% to 2% of patients after herniorrhaphy, and vasal damage is possible after routine manipulation of the spermatic cord. This study investigated the effect of routine surgical exploration of the prepubertal groin on testicular development and future fertility. METHODS: Twenty-four prepubertal Wistar rats were divided equally into 2 groups. Group 1 (sham) rats underwent unilateral inguinoscrotal incision only. Group 2 (experimental) rats underwent unilateral inguinoscrotal exploration with manipulation of the cord structures as in human inguinal exploration. At maturation, the fertility and fecundity of the males were assessed. After mating, testes were examined for mass, volume, mean seminiferous tubule diameter (MSTD), and mean testicular biopsy score (MTBS). The vasa were examined for histological injury and vasal diameter. Statistical comparisons were made by paired t test and Mann-Whitney rank sum test. RESULTS: There was a difference between the volumes of the testes when comparing the operative and nonoperative side of the 2 groups (experimental, deltavol = -0.063+/-0.123; sham, deltavol = +0.067+/-0.137; P = .029). There also was a trend toward a smaller testicular mass when comparing the two sides (experimental, deltamass = -0.045+/-0.101; sham, Amass = +0.048+/-0.123; P = .057) but did not reach significance. The MSTD and MTBS were similar between the ipsilateral and contralateral testes in both groups. Likewise, the MSTD and MTBS were similar when comparing the 2 groups. All male rats in both groups were fertile. The number of offspring produced and the number of female rats impregnated were similar between the 2 groups. There was no histological evidence of vasal injury in any of the experimental spermatic cords. The vasal diameters were similar between the 2 groups. CONCLUSION: Surgical manipulation of the prepubertal spermatic cord imparts a small, but statistically significant morphological change in testicular size without a deleterious effect on testicular development, fertility, or fecundity.

Laparoscopic diagnosis and repair of pediatric femoral hernia. Initial experience of four cases.

Femoral hernias are often misdiagnosed and treated as inguinal hernias. Thus, laparoscopic groin exploration may be a valuable means of evaluating children with presumed recurrent inguinal hernias. This study describes the feasibility of laparoscopic groin exploration and femoral hernia repair in children. Four children (aged 2, 2, 3, and 17 years) with reported unilateral recurrent inguinal hernias underwent diagnostic laparoscopy via a 4-mm pediatric laparoscope. Contralateral defects were visualized in all four patients; there were three femoral hernias and one direct inguinal hernia. None of the contralateral defects had been suspected clinically. Of the seven femoral defects, five were repaired laparoscopically. One patulous defect was repaired by reapproximating the iliopubic tract to Cooper's ligament and overlaying a preperitoneal Teflon felt(R) patch. The other four defects were repaired using a Teflon felt(R) plug and preperitoneal patch. A total of three ports were required in each patient (umbilical, suprapubic, and one in between). Two femoral defects in one patient required open repair because a large lipoma prevented adequate visualization and diagnosis. The direct inguinal hernia was also repaired using the open technique. Laparoscopic groin exploration and femoral hernia repair in pediatric patients is safe and technically feasible. Its advantages, however, such as superior diagnostic ability and simultaneous bilateral tension-free repair, need to be validated with a larger study and longer follow-up.

Heart rate and blood lactate responses during competitive Olympic boardsailing.

The rules of competitive boardsailing events were changed before the Atlanta Olympic Games. Pumping the sail (pulling repeatedly on the rig) is now allowed and the duration of races has been shortened. Eight members of the French national team (mean age 23+/-2.7 years) participated in this study. Their cardiac and metabolic responses were assessed by measuring heart rate and blood lactate concentration during various competitive events in two strengths of wind (light vs. moderate). Heart rate was higher in light (87.4+/-4.3% HRmax; mean racing time 37 min) than in moderate wind conditions (82.9+/-5.3% HRmax; mean racing time 33 min). The mean post-race blood lactate concentration (5.2+/-1.0 mmol x l(-1)) was not affected by the wind conditions. Mean heart rate was highest during downwind legs (88.0+/-3.1% HRmax; duration 7-10 min). The races consisted of two laps, the first of which induced significantly higher cardiac demands than the second. We conclude that the changes to the rules of competitive boardsailing have increased the cardiac and metabolic efforts involved.

Transinguinal laparoscopic examination of the contralateral groin in pediatric herniorrhaphy.

The authors laparoscopically assessed the contralateral groin (CG) via the symptomatic inguinal hernia in 91 patients to avoid unnecessary CG exploration and to allow for identification of asymptomatic CG hernias. Once the symptomatic hernia sac was opened, a 4.5-mm trocar was placed intraperitoneally and the CG internal ring was inspected with a 4-mm laparoscope. When compared with the authors' previous surgical policy for routine CG exploration in children younger than 2 years of age, laparoscopic findings altered the procedure performed in 42 of 91 patients (46.2%). In patients younger than 2 years of age, the CG did not require repair of an unsuspected hernia in 55.9% of patients based on laparoscopic findings. Conversely, in children 2 years of age or older, 40.4% required CG repairs of unsuspected hernias or patent processus vaginalis (PPV). Transinguinal laparoscopic examination in pediatric herniorrhaphy provides important information about the CG without the need for additional trocar sites.

A new method for inserting the atrial end of a ventriculoatrial shunt. Technical note.

This technical note describes a simple percutaneous mechanism for placement of the atrial end of ventriculoatrial shunts. The method is fast, efficient, and involves no neck dissection. No special equipment is required. Placement involves the technique of central line insertion familiar to all surgeons. This new method has been used successfully in one adult and one pediatric patient.

Inflammatory pseudocyst associated with trisomy 21 and Hirschsprung's disease.

A 15-month-old black male with trisomy 21 and Hirschsprung's disease developed an inflammatory abdominal pseudocyst 1 month after Swenson pull-through repair. Although abdominal pseudocyst associated with ventriculoperitoneal shunts, peritoneal dialysis catheters, meconium peritonitis, and pancreatitis have been reported, this is the first report of a pseudocyst developing 1 month after a surgical repair of Hirschsprung's disease.

Intestinal button implantation for obstipation and fecal impaction in children.

Chronic obstipation and fecal impaction in children can be difficult management problems for pediatricians. We describe a novel approach to the management of obstipation and fecal impaction: the implantation of the button gastrostomy device in the appendiceal stump or the terminal ileum. We report the procedure in two children. One child had pseudoobstruction syndrome complicated by recurrent obstipation; the other had cystic fibrosis complicated by recurrent obstruction from meconium ileus equivalent. Both children received a polyethylene glycol/electrolyte solution, with or without pancreatic enzymes, which was administered through the button. The children have remained essentially asymptomatic for at least 10 months. We believe that this is the first report of the use of a button gastrostomy device to successfully manage chronic obstipation and recurrent fecal impaction in children.

Needle-localized biopsy of occult breast lesions: an update.

We have performed 207 needle-localized breast biopsies for nonpalpable, mammographically suspicious lesions over the past 6 years. A mass lesion and grouped microcalcifications were associated with malignancy, while a mass with microcalcifications was never associated with malignancy. Biopsy revealed malignancy in 26 cases (12.6%), with 19 of 22 (86.4%) having no histologic evidence of axillary spread. Advanced age and a past history of a breast cancer were again the risk factors present in a significant number of the patients with a positive biopsy result. There were 11 complications (5.3%): three hematomas (1.4%), one infection (0.5%), and seven (3.4%) required a repeat biopsy to remove the suspicious lesion missed on the original biopsy. We conclude that needle-localized breast biopsy continues to be a reliable method of detecting early breast carcinoma. Given the minimal morbidity, this procedure should be done in all patients with mammographically suspicious nonpalpable breast lesions.

Surgical management of anorectal infection in the leukemic patient.

Anorectal infections are a common complication in immunocompromised patients. Such infections are multifactorial in etiology, often promoted by breaks in the anorectal mucosa and depressed leukocyte counts, both secondary to chemotherapy. Because of altered immune response to infection, diagnosis of anorectal infections in leukemic patients is often delayed, with a resultant mortality of up to 78%. Management is typically supportive for fears of extension of infection or non-healing of wounds with surgical intervention. We recently encountered a 17-year-old woman who presented with an anorectal infection heralding the onset of acute nonlymphocytic leukemia. Because of her unusual presentation, chemotherapeutic induction occurred subsequent to surgical drainage of an anorectal abscess. She demonstrated adequate healing of her wounds in the early post-operative, post-induction period. Her case and a review of the current management of anorectal infections in patients with leukemia are presented.

Current management of laryngeal and laryngotracheoesophageal clefts.

Laryngeal and laryngotracheoesophageal clefts (L-LTEC) are uncommon anomalies in neonates that cause significant morbidity secondary to aspiration, pneumonia, and respiratory distress. Other anomalies of development, such as esophageal atresia and tracheoesophageal fistula (EA-TEF), are observed in 20% of patients with L-LTEC and often confuse the radiographic and clinical picture. Repair of L-LTEC depends on the length and location of the cleft, associated anomalies, and concurrent systemic illness. For type I L-LTEC, endoscopic repair occasionally is possible with microsurgical instrumentation. With types II to IV L-LTEC, an open approach must be used. Tracheotomy is a universal requirement, often for extended periods of time. Reported here is our experience with four cases of L-LTEC managed over the past 7 years at Texas Children's Hospital.

Ventriculoatrial shunting via the azygos vein.

The treatment of hydrocephalus has evolved through many stages but the "cure" is still elusive. It is not unusual for the neurosurgeon to find that the commonly used routes for catheter placement or sites for drainage of cerebrospinal fluid (CSF) cannot be employed. The azygos vein was used to gain access to the right atrium when the CSF could not be drained into the peritoneal cavity, nor could the neck veins be used to place the catheter into the right atrium. The azygos vein is a convenient and safe route to reach the right atrium in selected patients.

Wound complications following modified radical mastectomy: an analysis of perioperative factors.

To assess the effect of perioperative factors on the incidence of postoperative wound complications, the authors retrospectively analyzed 101 patients who had undergone modified radical mastectomy. These factors included age, body weight, operative techniques, estimated blood loss, wound-catheter drainage, extent of axillary dissection, nodal involvement, and length of hospital stay. Complications included seroma (10.9%), wound infection (8.9%), wound necrosis (5%), hematoma (3%), lymphedema (2%), and pneumothorax (1%). The logistic regression method was used to analyze the data. When electrocautery was used to create the skin flaps, the probability of a wound complication was .462, a 44% increase over that calculated for the cold-knife technique (P = .05). A prolonged hospitalization accompanied the occurrence of a wound complication. No other factors reached statistical significance.

Transcatheter embolization of small bowel anastomosis: a case report and review of the literature.

A 45-year-old woman underwent exploratory laparotomy for recurrent intra-abdominal abscesses subsequent to a sigmoid resection for diverticulitis. Her postoperative course was complicated by massive hemorrhage from a small bowel anastomosis, which was successfully managed with transcatheter embolization. To our knowledge, this report documents only the second recorded successful embolization of a bleeding small bowel anastomosis. In certain high-risk patients, transcatheter embolization may be considered a useful adjunct in the management of gastrointestinal hemorrhage including anastomotic bleeding.

Needle-localized biopsy of occult breast lesions.

Over a 3 1/2-year period, we did 121 needle-localized breast biopsies for nonpalpable, mammographically suggestive lesions. The presence of a mass lesion on mammography with or without microcalcifications was associated with malignancy more frequently than microcalcifications alone. In 15 cases (12.4%), biopsy showed malignancy; 13 patients had modified radical mastectomy, with 11 (85%) having no histologic evidence of axillary metastases. Evaluation of risk factors associated with breast cancer in those patients with positive biopsy results showed that advanced age and a past history of a breast cancer were present in a significant number of patients. Four patients (3.5%) had complications; a hematoma developed in one (0.8%), and three (2.7%) required a second biopsy to remove the suggestive mammographic lesion. We conclude that needle-localized breast biopsy is a reliable tool in detecting early breast carcinoma. The procedure causes only minimal morbidity and we believe it should be done in all patients with mammographically suggestive, nonpalpable breast lesions.