Tomislav Luetić

Intestinal duplications--experience in 6 cases.

Intestinal duplications are rare congenital anomalies, and most of them are detected in the first 2 years of life or antenatally. The clinical presentation depends on location, size, and the presence of ectopic gastric mucosa. Ultrasound scans during pregnancy result in a higher rate of antenatally detected duplications which allows early treatment and avoidance of possible complications. Resection of the duplication without adjacent bowel should be the treatment of choice. En bloc resection or partial excision with mucosectomy is advised in some cases. We present our experience with 6 patients treated in our institution from February 2002 to October 2005.

Successful use of recombinant activated FVII and aminocaproic acid in four neonates with life-threatening hemorrhage.

Reports on the use of recombinant activated factor VII (rFVIIa) to counteract hemorrhagic shock in neonates and preterm infants are increasing. rFVIIa enhances thrombin generation in situations with impaired thrombin formation and, since thrombin has a crucial role in providing hemostasis, rFVIIa is regarded as a general hemostasis agent. Full thrombin generation is necessary for the formation of a stable fibrin plug resistant to premature fibrinolysis. Antifibrinolytic drugs are not recommended for the treatment of acute bleeding. We report four neonates (one with massive postsurgical hemorrhage after ileostomy and three with severe pulmonary hemorrhage in the course of mechanical ventilation for meconium aspiration syndrome, congenital heart disease and during postoperative resuscitation after cardiac surgery for congenital heart disease) who were successfully treated with multiple administration of rFVIIa (120 μg/kg per dose) and antifibrinolytic therapy — aminocaproic acid (100 mg/kg per dose). In a fibrinolytic environment therapeutic concentrations of rFVIIa may sometimes be insufficient to produce adequate amounts of thrombin necessary for stable clot structure. Laboratory data in three of our patients with pulmonary hemorrhage (low fibrinogen levels with slightly prolonged prothrombin time) supported this thesis, so we blocked fibrinolysis with aminocaproic acid and achieved a complete clinical and laboratory therapeutic effect.

Survival of outborns with congenital diaphragmatic hernia: the role of protective ventilation, early presentation and transport distance: a retrospective cohort study

BackgroundCongenital diaphragmatic hernia (CDH) is a congenital malformation associated with life-threatening pulmonary dysfunction and high neonatal mortality. Outcomes are improved with protective ventilation, less severe pulmonary pathology, and the proximity of the treating center to the site of delivery. The major CDH treatment center in Croatia lacks a maternity ward, thus all CDH patients are transferred from local Zagreb hospitals or remote areas (outborns). In 2000 this center adopted protective ventilation for CDH management. In the present study we assess the roles of protective ventilation, transport distance, and severity of pulmonary pathology on survival of neonates with CDH.MethodsThe study was divided into Epoch I, (1990–1999, traditional ventilation to achieve normocapnia), and Epoch II, (2000–2014, protective ventilation with permissive hypercapnia). Patients were categorized by transfer distance (local hospital or remote locations) and by acuity of respiratory distress after delivery (early presentation-occurring at birth, or late presentation, ≥6 h after delivery). Survival between epochs, types of transfers, and acuity of presentation were assessed. An additional analysis was assessed for the potential association between survival and end-capillary blood CO2 (PcCO2), an indirect measure of pulmonary pathology.ResultsThere were 83 neonates, 26 in Epoch I, and 57 in Epoch II. In Epoch I 11 patients (42 %) survived, and in Epoch II 38 (67 %) (P = 0.039). Survival with early presentation (N = 63) was 48 % and with late presentation 95 % (P <0.001). Among early presentation, survival was higher in Epoch II vs. Epoch I (57 % vs. 26 %, P = 0.031). From multiple logistic regression analysis restricted to neonates with early presentation and adjusting for severity of disease, survival was improved in Epoch II (OR 4.8, 95%CI 1.3–18.0, P = 0.019). Survival was unrelated to distance of transfer but improved with lower partial pressure of PcCO2 on admission (OR 1.16, 95%CI 1.01–1.33 per 5 mmHg decrease, P = 0.031).ConclusionsThe introduction of protective ventilation was associated with improved survival in neonates with early presentation. Survival did not differ between local and remote transfers, but primarily depended on severity of pulmonary pathology as inferred from admission capillary PcCO2.

Treatment outcomes of both-bone diaphyseal paediatric forearm fractures.

BACKGROUND Elastic-stable intramedullary nailing (ESIN), is an accepted method for stabilization of unstable forearm shaft fractures in children. This study analyzed the radiographic and functional outcomes of intramedullary nailing of forearm diaphyseal fractures in children. MATERIALS AND METHODS A retrospective analysis was performed of children with forearm shaft fractures and open epiphyseal plates, treated with ESIN between 2000 and 2012 in our institution. Evaluation of cases was conducted minimum 14 months after osteosynthesis. Clinical results were evaluated according to the criteria developed by Price et al. and Flynn et al. RESULTS The study included 88 (42 boys) children. The average age of children at day injury was 10.5 ± 2.59 years (range 4-16), and at the review clinic was 13.4 ± 1.85 years (range 7-18). Forty six (52.3 %) had right forearm and 42 (47.7%) had left fracture respectively. Open reduction was required in 20 (22.7%) children. Primarily surgically were treated 62 (70.5%) children and 26 (29.5%) were operated as a second procedure after failed conservative management. There was one delayed union. Rotational forearm restriction with values between 11 and 20 degrees was present in nine children. Six children developed radial nerve hypoesthesia which eventually resolved with time. After removal of the implant one child sustained a re-fracture. The overall complication rate was 25%. Complete recovery to the original condition was noted in 76 (86.4%) children, eleven children (12.5%) had good and only one (1.1%) had poor outcome. CONCLUSION Our study suggests that ESIN osteosynthesis for diaphyseal forearm fractures remains a valid technique with very good functional results.

Malformations associated with congenital diaphragmatic hernia: Impact on survival

BACKGROUND/PURPOSE Congenital diaphragmatic hernia (CDH) is associated with high mortality. Survival is influenced by the extent of pulmonary hypoplasia and additional congenital defects. The purpose of this study was to assess the association of congenital anomalies and admission capillary carbon dioxide levels (PcCO2), as a measure of extent of pulmonary hypoplasia, on survival in neonates with CDH. METHODS This is a retrospective review of neonates with CDH admitted to a tertiary neonatal intensive care unit between 1990 and 2014. Logistic regression was used to assess whether hospital survival was associated with admission PcCO2 or associated anomalies (isolated CDH, CDH with cardiovascular anomalies, and CDH with noncardiac anomalies). The probabilities of survival (POS) score, based on birth weight and 5-min Apgar as defined by the Congenital Diaphragmatic Hernia Study Group were included as a covariate. RESULTS Of 97 patients, 55 had additional malformations (cardiovascular n=12, noncardiac anomalies n=43). POS was lower in CDH with other anomalies compared to isolated CDH. Survival rate was 61.9%, 53.5% and 41.7% in isolated CDH, CDH with noncardiac anomalies and CDH with cardiovascular anomalies, respectively. After adjusting for POS score the likelihood of survival in CDH groups with additional anomalies was similar to isolated CDH (OR 0.95, 95% CI 0.22-4.15, and 1.10, 0.39-3.08, for CDH with and without cardiovascular anomalies, respectively). After adjusting for POS score, lower PcCO2 levels (OR=1.25 per 5mmHg decrease, P=0.003) were associated with better survival. CONCLUSIONS Neonates with CDH have a high prevalence of congenital malformations. However, after adjusting for POS score the presence of additional anomalies was not associated with survival. The POS score and admission PcCO2 were important prognosticating factors for survival.

The life-threatening hemodialysis catheter heparin lock caused bleeding in a child after peritoneal catheter removal

Hemodialysis catheter patency is regularly maintained by high-concentration heparin filling, according to manufacturers recommendation. Surprisingly, there are only few reports on serious bleeding complications in children on dialysis. A case of serious, life-threatening hemorrhage in a child after tunneled peritoneal catheter removal because of hemodialysis catheter heparin lock flushing is described. Discussion of the literature data is presented. Further investigations are needed to develop the guidelines for pediatric dialysis catheter care, including the optimal concentration for heparin lock as the possible heparin alternatives, but until that moment, previously suggested guidelines to prevent hemorrhagic complications in dialyzed children should be emphasized.

Medical thermography (digital infrared thermal imaging – DITI) in paediatric forearm fractures: a pilot study

Trauma is the most common cause of hospitalisation in children, and forearm fractures comprise 35% of all paediatric fractures. One-third of forearm fractures are distal forearm fractures, which are the most common fractures in the paediatric population. This type of fracture represents an everyday problem for the paediatric surgeon. The three phases of fracture healing in paediatric trauma are associated with skin temperature changes that can be measured and then compared with standard plain radiographs of visible callus formation, and eventually these methods can be used in everyday practice. Thermographic assessment of temperature distribution within the examined tissues enables a quick, non-contact, non-invasive measurement of their temperature. Medical thermography is used as a screening method in other parts of medicine, but the use of this method in traumatology has still not been researched.

What Is the Acceptable Rate of Negative Appendectomy? Comment on Prospective Evaluation of the Added Value of Imaging within the Dutch National Diagnostic Appendicitis Guideline - Do We Forget Our Clinical Eye?

ing to Dutch guidelines, such rates may be considered unacceptable. So what is the acceptable NAR? When searching through the literature, one may find reports with considerably low NAR, that is, below 10%. However, there are several factors that apparently decrease NAR. The three largest series on pediatric appendectomy within the last two years are by Bachur that included 55,227 appendectomies (NAR 3.6%), Oyetunji that included 250,783 appendectomies (NAR 6.7%), and Cheong that included 78,625 children from US and 41,492 children from Canada (NAR 6.3 and 4.3%) [2–4] . Large database analyses report only the discharge letter diagnosis or intraoperative appearance of the appendix without analyzing the histology report. This is present in all three previously mentioned reports. Had we used this criterion, the rate of negative appendectomy in our series would be 3% since of 47 negative appendectomies, 32 (68%) were initially during operation diagnosed as inflamed appendicitis and were later on histological examination found to be non-inflamed. Further, even if histology reports are used, the histological definition of appendicitis also differs. Histological definition of inflamed appendix is not described in many reports that have low negative appendecWe read with interest the article of Schok et al. [1] . In 2014 we did an audit of our results on pediatric appendectomy (0– 18 years) in the form of a cross-sectional retrospective study that was conducted using hospital database that reviewed all appendectomies in our department in two twoyear periods (1999–2000 and 2012–2013) to see the changes after introduction of ultrasound and CT scan into practice. There were a total of 380 appendectomies performed: 154 as laparoscopic and 226 as open procedures. Regarding the pathological outcome of the operation, negative appendectomy rate (NAR) was 12% (47 patients) and perforation rate (PR) was 18% (69 patients). In children younger than 5 years of age (26 patients) PR was 30% and NAR 8%. Regarding imaging, 83 patients (22%) received preoperative ultrasound examination, and 2 received a CT scan (0.5%). The NAR and PR among children who received preoperative imaging were 8.4% (7/ 83) and 15.7% (13/83), respectively, which did not differ significantly (p > 0.05) from children who did not receive any imaging. To evaluate our results we searched Pubmed and found that NAR and PR in our series were comparable to other similar reports, including the report from Schok et al. As mentioned by the authors, accordPublished online: March 28, 2015

Giant Mycotic Right Atrial Thrombus Due to Candida dubliniensis Septicemia in a Premature Infant

Rad opisuje slucaj ekstremne mikoticne tromboze desnog atrija u nedonosceta vrlo male rodne mase te izljecenje nakon trombektomije. U prilogu rada je i poveznica na ultrazvucni prikaz flotirajuceg tromba u desnom atriju.

Postoperative Gastric Perforation in a Newborn with Duodenal Atresia

Gastric perforation (GP) in neonates is a rare entity with high mortality. Although the etiology is not completely understood, it mostly occurs in premature neonates on assisted ventilation. Combination of duodenal atresia and gastric perforation is very rare. We present a case duodenal atresia who developed gastric perforation after operetion for duodenal atresia. Analysis of the patient medical record and histology report did not reveal the etiology of the perforation.