From Severe Anemia to Intestinal Hemangiomatosis, a Bumpy Road-A Case Report and Literature Review.

Gastrointestinal hemangiomas (GIH) are unusual vascular tumors found anywhere alongside the GI tract, the small bowel being the most common site. Diagnosis requires good clinical insight and modern imaging. This is a comprehensive review of the literature, starting from a new pediatric case diagnosed through exploratory laparotomy after complex imaging techniques failed. This research was conducted on published articles from the past 25 years. We identified seventeen original papers (two series of cases with three and two patients, respectively, and fifteen case reports). The female/male ratio was 1.5. The youngest patient was a 3-week-old boy, and the was oldest a 17-year-old girl. The most common localization was the jejunum (eight cases), followed by the ileum (four), colon (three), stomach (two), and rectum (one). Seven children had cavernous and four had capillary hemangiomas. Eight patients presented gastrointestinal bleeding, seven had refractory anemia, such as our index patient, three had recurrent abdominal pain, and two had bowel obstruction. Surgical assessment was successful in fifteen cases; three cases experienced great outcomes with oral propranolol, one child was treated successfully with sirolimus, and for one patient, endoscopic treatment was the best choice. The authors present the case of a female patient admitted to the Pediatrics Department of "Grigore Alexandrescu" Emergency Children's Hospital from 25 February to 28 March 2019 for severe anemia, refractory to oral iron treatment, and recurrent blood infusions. No clear bleeding cause had been found. Although very uncommon, intestinal hemangiomas can express puzzling, life-threatening symptoms. We should keep in mind this disorder in cases of unresponsive chronic anemia.

Clostridium difficile infection in pediatric patients (Review).

Clostridium difficile (C. difficile) infection (CDI) is the most common cause of healthcare-associated diarrhea and among adults, the worldwide incidence rate of the infection is increasing. There is a small amount of data in the literature for pediatric patients, but most indicate an increasing trend. C. difficile is a constituent of the normal microbiota; however, under specific conditions that cause a disruption of the normal bacterial flora, colonization of C. difficile and the released toxins that cause inflammation and mucosal damage occurs. Risk factors for CDI at any age include hospitalization, exposure to antibiotics, administration of proton pump inhibitors, invasive mechanical ventilation, immunosuppression and presence of associated comorbidities. Clinical manifestations range from asymptomatic colonization to fulminant disease characterized by toxic megacolon, intestinal perforation and, rarely, death. The aim of the present review was to outline the features of CDI in pediatric patients.

Intelligent Diagnosis of Thyroid Ultrasound Imaging Using an Ensemble of Deep Learning Methods.

Background and Objectives: At present, thyroid disorders have a great incidence in the worldwide population, so the development of alternative methods for improving the diagnosis process is necessary. Materials and Methods: For this purpose, we developed an ensemble method that fused two deep learning models, one based on convolutional neural network and the other based on transfer learning. For the first model, called 5-CNN, we developed an efficient end-to-end trained model with five convolutional layers, while for the second model, the pre-trained VGG-19 architecture was repurposed, optimized and trained. We trained and validated our models using a dataset of ultrasound images consisting of four types of thyroidal images: autoimmune, nodular, micro-nodular, and normal. Results: Excellent results were obtained by the ensemble CNN-VGG method, which outperformed the 5-CNN and VGG-19 models: 97.35% for the overall test accuracy with an overall specificity of 98.43%, sensitivity of 95.75%, positive and negative predictive value of 95.41%, and 98.05%. The micro average areas under each receiver operating characteristic curves was 0.96. The results were also validated by two physicians: an endocrinologist and a pediatrician. Conclusions: We proposed a new deep learning study for classifying ultrasound thyroidal images to assist physicians in the diagnosis process.

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (Review).

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are clinically characterized by the sudden onset of obsessive-compulsive manifestations, motor and verbal tics, as well as other behavioral symptoms in a group of children with B-hemolytic streptococcal infection. PANDAS are considered autoimmune diseases because the streptococcal infection and response can be demonstrated. The most frequent physiopathological mechanism is molecular mimicry: A foreign antigen shares sequence or structural similarities with self-antigens. A thorough review of the literature was carried out using the PubMed database and SCOPUS, searching for immunological, clinical and microbiological aspects, as well as the treatment of the PANDAS syndrome. The diagnosis is clinical and it requires a careful medical history and a thorough physical examination, while the treatment is complex. Untreated or unrecognized manifestations of PANDAS can increase the risk of obsessive-compulsive manifestations and tics during adulthood. Taking this into consideration, further studies are required to establish the best method of therapy.

Non-Steroidal Anti-Inflammatory Drug Etoricoxib Facilitates the Application of Individualized Exercise Programs in Patients with Ankylosing Spondylitis.

Background and objectives: The main objective of this study is to highlight the efficiency of different therapeutic means in patients with ankylosing spondylitis, resulting in the improvement of their quality of life. Materials and Methods: We conducted a randomized, longitudinal, controlled trial on 92 patients with ankylosing spondylitis over a period of 6 years. Disease activity was assessed using the BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) score. The assessment of functional disabilities was performed using BASFI (Bath Ankylosing Spondylitis Functional Index). We assessed the quality of life using the HAQ questionnaire (Health Assessment Questionnaire). Based on the HAQ, we calculated the minimum number of patients to be treated for 52 weeks to prevent a decrease in the quality of life for at least one of them (the number needed to treat (NNT)). Results: For the combination therapy group, the result we obtained was 2, lower than the other therapies compared (the medication group and the group with physical exercise). We point out a correlation between the improvement of the functional status (BASFI) and the increase of the quality of life (HAQ), estimated as moderately high (0.8). The superiority of the effects of the combined treatment, in which we combined a nonsteroidal anti-inflammatory drug (etoricoxib) to the exercise program, is reflected by the model of the significant improvements (p < 0.05) obtained for the functional status and quality of life scores (BASFI and HAQ). Conclusions: The nonsteroidal anti-inflammatory drugs, in our case, etoricoxib, facilitate the application of individualized exercise programs in patients with ankylosing spondylitis.

Atypical debut manifestations in juvenile idiopathic arthritis.

Considering that destructive articular lesions may occur in the first stages of the illness, it is difficult but necessary to establish a diagnosis of Juvenile Idiopathic Arthritis (JIA) in due time. The authors present the case of a 9-year-old girl admitted to the Pediatrics Clinic of the "Filantropia" Municipal Hospital in Craiova, Romania, on November 26, 2002, for bilateral pain in the tarsometatarsal and carpometatarsal joints that had begun approximately four weeks before. After the clinical examination and paraclinical investigations, a diagnosis of unspecified arthritis is established and the adequate treatment is begun. Two months later, the patient returns to the clinic with bilateral knee pain and swelling. The results of laboratory tests indicate the persistence of anemia and of the inflammatory syndrome. The diagnosis of JIA is established. The evolution of the patient is unfavorable, both from a clinical point of view (a large number of articulations affected, a persistent rash, hepatomegaly) and a paraclinical one (increased acute phase reactants and radiological changes occurring two years after the onset of the illness).

The arthroscopy-histological criterion link in the result's estimation of the endoscopic treatment by resection of the knee's meniscus lesions.

The authors present the results of a statistical, clinical, imaging X-ray and optical microscopic studies of some lesions of knee's meniscus, the arthroscopy allowing this structure's biopsy during the endoscopic procedures of resection. These histological criterions are very important estimation factors of long-term results of these techniques, often the microstructure looking different to the appearing normal macroscopic aspect.

Plaque-type morphea in children.

We present the case of a girl, aged 8-year-old, with a history of acrocyanosis and repeated respiratory infections with beta-hemolytic streptococcus, which was consulted for the presence of skin lesions in the right buttock area. Clinical examination showed, in the right buttock region, an oval plaque with a diameter about 12 cm, hard, well defined, with irregular outline. The biopsy was performed and it revealed typical aspects of plaque-type morphea. The epidermis was mostly atrophic, with areas of ridge reduction; an important proliferation of collagen fibers within superficial and deep dermis and an abundant lymphocytic inflammatory infiltrate throughout the dermal thickness reaching hypodermic level and infiltrating it. General treatment consisted of antibiotics; vitamin E; local treatment with topical cortisone; analogues of vitamin D3 to which we associated topical adjuvants with repairing and healing role applied to the biopsied area. Evolution was favorable after three months of treatment, with obvious improvement of skin lesions; skin became more elastic and the purple red contour ring disappeared.

Supratentorial pilocytic astrocytoma in children.

Brain tumors hold second place in tumoral pediatric pathology and have a complex etiopathogeny. The authors describe the case of a child aged 2 years and 4 months with increased intracranial pressure, symptomatology accompanied by rapid deterioration of general condition. Head CT imaging examination showed intra-nevraxial replacement space process, supratentorial. Histopathological examination revealed the typical grade I pilocytic astrocytoma. Time of diagnosis and surgical intervention is essential for further evolution and prognosis.

Subungual exostosis of the big toe.

The subungual exostosis is a benign bone tumor on the distal phalanx of a digit, beneath or adjacent to the nail, often bringing in discussion many differential diagnosis. We present a 14-year-old boy with a cutaneous nodular lesion, painful to the easy touch on the latero-internal half of the nail of right big toe with extension in the cutaneous part of this. He suffered many treatments, especially cauterization, but with recurrence. In the present, the radiological findings of the affected finger and the histopathological ones from the fragment excised confirmed the diagnosis of subungual exostosis. The local excision of the entire region with the removal of the cartilaginous cap has been followed by a silent period without recurrences of almost two years when he as revised.

The arthroscopy-histological criterion link in endoscopic "repair" treatment of chondral and chondralbone lesions of the knee.

The authors present the results of optical microscopic studies of some lesions of cartilage and subchondral bone of the knee, the arthroscopy allowing this structure's biopsy during the endoscopic procedures. These histological criteria are very important estimation factors of long term results of these "repair" techniques, the microstructure showing the real biological status of these specific tissues.