Uncomplicated Clinical Course Research Articles

Pathophysiologic mechanisms, clinical features and treatment of idiopathic neutropenia

The term idiopathic neutropenia describes a benign disorder of granulopoiesis characterized by the unexplained reduction in the absolute neutrophil count below the lower limit of the normal range for a prolonged period. Recent studies have provided evidence that this neutropenic condition comprises two distinct disease entities on the basis of the underlying pathogenetic mechanisms: first, the primary autoimmune neutropenia mediated by autoantibodies against mature neutrophils and/or their bone marrow progenitor/precursor cells; and second, the previously named chronic idiopathic neutropenia, that might now be called chronic immunologic neutropenia, characterized by T-cell- and cytokine-mediated suppression of granulopoiesis. Despite the differences in the bone marrow granulocytic progenitor cell reserves that actually reflect the differences in the implicated pathophysiologic mechanisms, both disease entities usually display an uncomplicated clinical course with minimal symptoms. Treatment decisions should be individualized on the basis of patients’ clinical course and the indicated therapies are analyzed in this review. The clinical and laboratory data characterizing these neutropenic conditions and the available in vitro data that have led to remarkable progress in the understanding of the pathophysiology of both disorders are also summarized.

Kingella kingae: A Pediatric Pathogen of Increasing Importance

As the result of the use of blood culture vials for seeding joint and bone exudates, and nucleic acid amplification methods, Kingella kingae is emerging as an important pathogen in patients <3 years of age. The organism is carried asymptomatically in the oropharynx of young children, coinciding with the age of increased attack rate of invasive disease, and propagates through close personal contact. Carriage of K. kingae is a dynamic process with frequent turnover of strains after weeks or months of continuous or intermittent colonization. Colonizing K. kingae enters the bloodstream through breaches in the respiratory mucosa and disseminates to bones, joints, or the endocardium. Daycare attendance increases the risk for K. kingae acquisition and transmission, and outbreaks of invasive disease have been reported among children in daycare. The most common manifestations of K. kingae disease in children are skeletal system infections (in 56% of patients), bacteremia (in 39%), pneumonia (in 4%), and endocarditis (in 1%). The clinical presentation is often subtle and laboratory tests are frequently normal, requiring a high index of suspicion. The organism is susceptible to most antibiotics, and with the exception of cases of endocarditis, invasive K. kingae infections usually run a benign uncomplicated clinical course.

Bordetella holmesii bacteremia in sickle cell disease

Patients with sickle cell disease (SCD) have an increased risk of invasive bacterial infection because of hyposplenism. Bordetella holmesii is a recently described Gram-negative coccobacillus with an apparent predilection for asplenic hosts. We report two patients with SCD and B. holmesii bacteremia. Fastidious growth in culture and a typically uncomplicated clinical course distinguish B. holmesii infection from other invasive bacterial infections in SCD. Providers for patients with SCD should be aware of this pathogen and ensure that their microbiology laboratories are capable of isolating and identifying this organism.

Changes in glomerular filtration rate after cardiac surgery with cardiopulmonary bypass in patients with mild preoperative renal dysfunction

BackgroundCardiac surgery with cardiopulmonary bypass (CPB) is commonly perceived as a risk factor for decline in renal function, especially in patients with preoperative renal dysfunction. There are few data on the effects of CPB on renal function in patients with mild preoperative renal dysfunction. The purpose of this study was to evaluate renal function in patients with pre-existing mild renal dysfunction undergoing cardiac surgery with CPB. MethodsIn a multicentre study cohort we measured prospectively the glomerular filtration rate (GFR) by radioactive markers both before operation and on the 7th postoperative day in cardiac surgical patients with preoperative serum creatinine >120 μmol l−1 (n=56). In a subgroup of patients (n=14) in addition to the GFR, the effective renal plasma flow (ERPF) and the filtration fraction (FF) were measured. ResultsWhile preoperative GFR [77.9 (25.5) ml min−1] increased to 84.4 (23.7) ml min−1 (P=0.005) 1 week after surgery, ERPF did not change [295.8 (75.2) ml min−1 and 295.9 (75.9) ml min−1, respectively; P=0.8]. In accordance, the FF increased from 0.27 (0.05) (before operation) to 0.30 (0.04) (Day 7, P=0.01). ConclusionOur results oppose the view that cardiac surgery with CPB adversely affects renal function in patients with preoperative mild renal dysfunction and an uncomplicated clinical course.

Early relapse in a patient with Hodgkin’s disease and negative interim FDG-PET

The role of F-18-fluorodeoxyglucose positron emission tomography (FDG-PET) in the assessment of lymphoma patients is well established, and PET is routinely used for initial staging, early evaluation of treatment response, and identification of disease relapse. The early evaluation of response to therapy (interim PET) has been reported to be an accurate predictor of progression-free survival, and end-treatment PET has been suggested to be unnecessary if interim PET results are negative. We report on a patient with Hodgkin's disease with a positive PET scan at presentation and a negative interim PET (carried out after three cycles of adriamycin, bleomycin, vinblastine, and dacarbazine; ABVD). Despite uncomplicated clinical course, end-treatment PET (following six cycles) was positive, showing a very early relapse. For this reason, patient underwent further treatment; however, a complete remission was not obtained, and a poor prognosis is expected. This case testifies the possibility of early relapse of lymphoma even in the case of negative interim PET; it also supports the usefulness of end-treatment PET scan in lymphoma patients.

Metabolic syndrome and risk of fetal neural tube defects

complicated versus 21.2% uncomplicated pregnancies (Pb0.001). Thirty-seven (10.5%) placentas showed more than 1 abnormality. Pathology was more likely to be documented in the presence of more than 1 obstetric complication. In such situations, the possibility of detecting more than 1 pathologic diagnosis increased (Table 1). Pathological chorioamnionitis was more common in cases of abruptio placentae compared to those with an uncomplicated clinical course (19.0% versus 3.0%, P=0.031), even when chorioamnionitis was not suspected clinically. Pathologies were noted in 62.2% IUFD, 61.9% abruption, 57.5% chorioamnionitis, 54.2% IUGR, 52.4% HT, and 51.7% MS cases. The highest pathology yield was from placentas submitted for abruption with IUFD (6/8, 75%) and chorioamnionitis with high grade fever (11/14, 78.6%). In IUFD, the result was similar in those less than 500 g (11/19, 57.9%) and those more than 500 g (22/34, 64.7%). Placentas were normal in 5/13 (38.5%) cases with the clinical diagnosis of abruptio placentae and chorioamnionitis. Factors for this suboptimal yield should be sought and amended. Residency training programs that stress the importance of placental pathology, recruitment of pathologists experienced in placental pathology with appropriate technical support, utilization of adequate staining techniques and sensitive markers, adherence to guidelines for placental pathologic examination, and adequate communication between obstetricians and pathologists are needed [2]. Such a plan might initially increase costs but improve the long-term outcome and hence compliance with recommendations.

Cell‐Free DNA Levels as a Prognostic Marker in Acute Myocardial Infarction

Cell-free DNA that originates from cell death, circulates in peripheral blood. There are indications that the infarcted myocardium contributes to an increase of cell-free DNA levels. Our aims were to quantify levels of cell-free DNA in patients with acute myocardial infarction (AMI) and examine their correlation with myocardial markers and with postinfarction (PI) clinical course. Thirteen patients (age 57 +/- 16 year) admitted with AMI and who underwent thrombolysis with reteplase within 6 h from the onset of chest pain were studied. PB samples were collected on admission and for 5 consecutive days. Creatine kinase (CK) and troponin I (TnI) were measured on admission and every 8 h for 3 consecutive days. Clinical events were recorded throughout the hospitalization period. Cell-free DNA levels were also measured in 30 healthy controls. Log-transformed mean (+/-SE) of maximum free DNA values in patients higher than controls (6873 +/- 357 g.e./mL verses 4112 +/- 234 g.e./mL, P < 0.0001). Log-transformed maximum values of CK and TnI were correlated with log-transformed free DNA values of first (r = 0.62, P = 0.02/r = 0.68, P = 0.01) and second (r = 0.57, P = 0.04/r = 0.72, P = 0.0053) PI day. Nine patients (group A) had an uncomplicated PI clinical course and four patients (group B) had recorded events (three with angina and one death). Free DNA levels on the second PI day were higher in group B than group A (1298.0 +/- 796.0 g.e./mL verses 244.6 +/- 257.7 g.e./mL, P = 0.003). In conclusion, free DNA levels are significantly higher in patients with AMI than in controls and may play a role in the prognosis of these patients.

Osteonecrosis in Patients Infected With HIV

There is a paucity of data on clinical epidemiology of osteonecrosis in HIV-infected patients. We aimed to describe patients' characteristics and natural history of this poorly known condition. All cases of symptomatic HIV-related osteonecrosis diagnosed from 1990 through 2003 in 19 Spanish clinics were reviewed. Functional status at the last visit was assessed with the validated Western Ontario and McMaster Universities Index questionnaire. Of 54 patients analyzed, 29 (53.7%) had a single bone necrosis, and 25 (46.3%) had 2 or more sites involved. Progression of symptoms happened more often in patients with hip involvement (17/39 vs 0/8 patients; P = 0.019). Twenty patients (37%) required surgical intervention. Male sex and higher CD4 cell count were associated with surgery on multivariable analysis. Overall, at the end of the follow-up period, half of the patients had moderate to severe disability (Western Ontario and McMaster Universities Index score > or =60). During a follow-up period of 137 person-years, only 2 new episodes of osteonecrosis were observed (rate of recurrences, 1.5/100 person-years; 95% confidence interval, 0.4-5.1). HIV-related osteonecrosis is associated with significant disability over time. Location of bone necrosis, sex, and CD4 cell count may influence the outcome. The risk for recurrences for patients who have experienced 1 episode is low.

Evaluation of vascularized graft reconstruction of the mandible with Tc-99m MDP bone scintigraphy

The aim of this study was to evaluate the value of bone scintigraphy for the assessment of graft viability following vascularized bone grafts in patients with mandibular reconstruction. We investigated 16 patients with vascularized grafts from the fibula (13 patients) and iliac crest (3 patients) in the last 8 years. For the follow up of all these patients, Tc-99m MDP bone scintigraphy was performed between 2-10 days postoperatively. SPECT study was included in 5 patients. For the evaluation of the grafts, a six-grade scoring system was used. The grading system was based on a comparison of tracer uptake between graft and the cranium. The uptake was defined as increasing from grade 6 to grade 1. Thirteen of the 16 grafts had an uncomplicated clinical course. Complications in the graft occurred in three patients. In the analysis of planar scintigrams, patients with uncomplicated healing showed increased uptake in 12 of the 13 grafts (grade 1-3) and 1 showed the same level tracer uptake compared to cranium (grade 4). In the failed 3 grafts, decreased uptake was observed (grade 5 and 6). In 5 patients, SPECT was performed in addition to planar imaging. In these patients, 4 of the 5 grafts had an uncomplicated clinical course and 1 had a complicated one. In the analysis of SPECT images, while all the grafts with an uncomplicated clinical course exhibited increased uptake (grade 1-3), the failed graft showed decreased uptake (grade 6). Three-phase bone scintigraphy performed within 10 days after the mandibular reconstruction is a useful tool to monitor the viability and early complications of vascularized mandibular bone grafts. SPECT is also recommended. It may contribute to interpretation of the bone scans and to precise assessment of graft viability.

Serum lipofuscin as a prognostic indicator of adult respiratory distress syndrome and multiple organ failure.

Toxic oxygen free radical damage is thought to play an important role in events such as trauma and sepsis, in which adult respiratory distress syndrome (ARDS) and multiple organ failure (MOF) are the major causes of late death. Serum lipofuscin concentration has been proposed as an indicator of lipid peroxidation caused by toxic oxygen free radicals. Serum lipofuscin level was measured in 75 healthy controls and sequentially in 66 patients in the intensive care unit; the latter included 18 patients who had undergone elective major vascular surgery, 20 after repair of ruptured abdominal aortic aneurysm and 28 with severe blunt trauma. Fifteen of the 66 patients died within 2 days. Ten of the remaining 51 patients developed ARDS and/or MOF and 41 had an uncomplicated postoperative course. Serum lipofuscin concentration in controls showed a positive correlation with age. Compared with controls, all three patient groups had significantly increased lipofuscin concentrations during the first day after major vascular surgery, trauma or shock. In addition, the ten patients who subsequently developed ARDS and/or MOF showed significantly increased lipofuscin levels on day 1, compared with those in the 41 who had an uncomplicated clinical course. The concentration of serum lipofuscin, which may act as a simple and valuable measure of grading oxidative stress, is positively related to the incidence of subsequent ARDS and/or MOF in patients at risk of these syndromes.

Effect of topic defibrillation on serum markers of myocardial damage

Serum levels of cardiac enzymes and troponins after external cardioversion (ECV) for atrial defibrillation and atrial flutter, and after endocardiac cardioverter defibrillation by implantable cardioverter defibrillator (ICD), have been well investigated. The aim of this study was to assess the effects of topic defibrillation (TD), after cardiac surgery, on cardiac enzymes in patients with uncomplicated clinical course. Biochemical markers were analyzed prospectively for 20 patients after TD (group A) and for 20 patients that were not defibrillated (Control group). We obtained serum concentrations of cardiac Troponin I (cTnI), total creatine-kinase (CK), CK MB isoenzyme (CK-MB), Myoglobin (Myo) in both groups. The difference in cTnI plasma level and curve of raise was not statistically significant between the two groups, but there was a difference in the CK-MB and Myoglobin curve of raise between the two groups. Topic defibrillation does not influence the increase of cTnI, so a high cTnI should be correlated to myocardial damage and not to TD. In patients that received TD, it would be preferable to use cTnI as a marker of myocardial disease than CK-MB which is influenced by the TD.

Valor pronóstico de los niveles plasmáticos de troponina en el tromboembolismo pulmonar: una revisión sistemática y metaanálisis

Objective. Analyze possible association between serum troponin levels and clinical evolution of patients with pulmonary thromboembolism through a systematic review of the literature. Data source. Search for original studies in Medline, Embase, Cochrane Library, Pascal, Medion and ISI Proceedings, and review of the references of the recovered articles. Study selection. Cohort studies with information on initial levels of troponin and occurrence of hospital mortality, unfavorable clinical course, or right ventricular overload in the echocardiogram were chosen. Data extraction. Data of the odds radio (OR), sensitivity, specificity, likelihood ratios (LR), population studied, type of test used, and methodology quality of the study were obtained in duplicate. Results. A total of 13 studies, that included 1,293 patients, were identified. The studies were relatively homogeneous for each outcome and no threshold effect or signs of publication bias were detected. Elevated levels of troponin identified a subgroup of patients with high risk of: dying during hospitalization (OR 6.20; 95% CI 4.04-9.52), presenting echocardiographic signs of right ventricular overload (OR 8.04; 95% CI 4.40-16.69) and having an unfavorable clinical course (OR 14.58; 95% CI 6.82-31.16). Normal levels of troponin identified a group of patients with favorable clinical course (LR 0.23; 95% CI 0.13-0.41). Conclusions. Troponin levels are useful to stratify risk in patients with pulmonary thromboembolism. In the individual patient, normal levels of troponin indicate a high likelihood of having an uncomplicated clinical course.

Generalized arterial calcification of infancy: Different clinical courses in two affected siblings

Generalized arterial calcification of infancy (GACI) is a rare autosomal recessive disease caused by mutations in ENPP1. Due to extensive calcification of the arterial media associated with intimal proliferation leading to vascular occlusion, most affected children die within the first 6 months of life. We report on two Taiwanese siblings with an identical genotype, but different clinical course. The male sibling developed heart failure and severe hypertension, and died at the age of 6 weeks despite of treatment with bisphosphonates, ACE inhibitors, and hydralazine. The subsequent female, who was monitored closely pre- and post-natally, is having an uncomplicated clinical course up to the age of 1(1/2) year now. There were similar characteristic sonographic and roentgenographic findings in both siblings in early infancy. In both siblings, the same compound heterozygous mutations (c.1025G > T [p.Gly342Val] and c.1112A > T [Tyr371Phe]) in ENPP1 were identified. Despite the same genotype and similar sonographic and radiographic features in early infancy, the phenotype of GACI can vary to a great extent within one family.

Tramadol and Vocal Cord Closure

TRAMADOL is an analgesic acting as both a weak opioid agonist and an inhibitor of monoamine neurotransmitter reuptake. It also provides effective postoperative analgesia. 1 Unlike other opioids, it is well tolerated and has no clinically relevant effects on cardiovascular parameters; therefore, it is widely administered and may prove particularly useful in patients with poor cardiopulmonary function, including the elderly, and in patients with nonsteroidal antiinflammatory drug contraindications.

Detection of fetal cardiac anomalies in diabetic mothers: The utility of fetal echocardiography

FETAL ECHOCARDIOGRAPHY SCOTT PETERSEN, MICHAEL PITT, JANICE HENDERSON, JUDE CRINO, Johns Hopkins University, OBGYN/MFM, Baltimore, Maryland, Johns Hopkins University, School of Medicine, Baltimore, Maryland OBJECTIVE: Infants of diabetic mothers are more likely to have congenital cardiac malformations than the general population. In our institution, we obtain a four-chamber view (4CH) as well as outflow tracts (LVOT, RVOT) on all fetuses and refer pre-gestational diabetics for a fetal echocardiogram. The objective of this study was to determine the utility of a fetal echocardiogram after a normal anomaly scan. STUDY DESIGN: Pre-gestational diabetic mothers were identified who had undergone screening ultrasound and fetal echocardiography at our hospital during the last four years. A retrospective review of maternal records was conducted to obtain these study results. Neonatal records were reviewed, when available, for confirmation of antenatal findings. RESULTS: One hundren and eighty-one patients had both a sonographic 3view evaluation of the heart (4CH, LVOT, RVOT) and a fetal echocardiogram attempted, of which 146 had both completed. In this subgroup, eleven neonates (n = 67) were identified with abnormal postnatal echocardiograms. Four had clinically relevant cardiac disease which we defined as the need for surgical or medical intervention. The sensitivity for detecting clinically relevant disease was 75% (NPV 98.4%) for both sonographic methods (a VSD requiring surgical correction was not detected by either method). One fetus with a normal 3-view evaluation was found to have pulmonary stenosis with mild pulmonary and tricuspid regurgitation by fetal echocardiogram. These findings were confirmed in the neonatal period, but the child has had an uncomplicated clinical course. CONCLUSION: In our pre-gestational diabetic population, 3-view screening of the heart and fetal echocardiography have similar detection rates for cardiac anomalies. Given the high cost and limited availability of fetal echocardiography, 3-view screening alone may identify the majority of clinically important cardiac lesions. Fetal echocardiography may be reserved for suspected cardiac anomalies on a screening sonogram or patients with an incomplete study. 624 MAGNETIC RESONANCE IMAGING OF THE CERVIX DURING PREGNANCY: EFFECT OF GESTATIONAL AGE AND PRIOR VAGINAL BIRTH MICHAEL HOUSE, MARK O’CALLAGHAN, JONATHAN KINI, DANNY WU, SAMUEL PATZ, STEPHANE BAHRAMI, RAFEEQUE BHADELIA, Tufts-New England Medical Center, Maternal Fetal Medicine, Boston, Massachusetts, Tufts-New England Medical Center, Radiology, Boston, Massachusetts OBJECTIVE: To investigate how gestational age and prior vaginal birth affect cervical anatomy on MR imaging during pregnancy. STUDY DESIGN: In 56 consecutive pregnant patients referred to MRI for a suspected fetal or placental abnormality, high-resolution images of the cervix were obtained. A 1.5 Tesla system was used with a phased array surface coil. A proton density pulse sequence was chosen (TR 9900 ms, TE 10 ms). MRI image measurement was performed using a standardized image processing protocol. The following outcome variables were measured: (1) signal intensity of the cervical stroma (normalized to the signal intensity of the bladder contents); (2) cross-sectional area of the cervical canal and cervical stroma; and (3) angle of the cervix with respect to the uterus. Gestational age and obstetric history were recorded. Regression was used to determine whether the outcome variables were affected by gestational age or prior vaginal birth. RESULTS: Adequate images were obtained in 53 of 57 patients, at gestational ages 17–36 weeks. 1. Decreased contrast between the cervical stroma and the bladder was observed with increasing gestational age, reflecting increased stroma hydration. For example, the mean relative signal intensity at 20 weeks gestation was 0.84 (95% confidence interval [CI] 0.81–0.86). The mean relative signal intensity at 32 weeks was 0.92 (95% CI 0.88–0.95), a 10% increase compared to 20 weeks. 2. As gestational age increased 12 weeks, the mean cross-sectional area of the cervical canal and cervical stroma increased 31% (95% CI 0-73) and 31% (95% CI 11-55), respectively. 3. The mean anterior angle of the cervical canal was greater than the posterior angle (127 vs 95 degrees, P ! .001) and did not vary with gestational age. None of the outcome variables were affected by prior vaginal birth. CONCLUSION: MR imaging of the cervix demonstrated that increasing gestational age was associated with increased cross-sectional area and increased stroma hydration. Prior vaginal birth did not affect cervical anatomy on MR imaging.

Clinical spectrum of acute compartment syndrome of the thigh and its relation to associated injuries.

The reason for the described clinical variability of acute compartment syndrome of the thigh, with high morbidity and mortality in some patients and an uncomplicated clinical course in others, is not known. To better define the clinical spectrum and factors determining the clinical course of this rare clinical entity, we did a retrospective multicenter study of 28 patients with 29 thigh compartment syndromes. The leading cause of acute thigh compartment syndrome was blunt trauma from motor vehicle accidents (46%) or contusion (39%). Pain with passive motion was present in all patients who were conscious, followed by paresthesia (60%), and paralysis (42%). The anterior compartment was involved most frequently with mean compartment pressure of 58 +/- 3 mm Hg. Myonecrosis, sepsis, and need for skin grafting were observed more frequently in patients with ipsilateral femur fracture. Only 7% of patients with isolated thigh compartment syndromes had short-term complications compared with 57% of patients with ipsilateral femur fractures. The incidence of complications correlated with the time to fasciotomy. Mortality was limited to patients with high injury severity scores. The clinical spectrum of thigh compartment syndrome is comparable with that of other compartment syndromes and its clinical course is determined by its associated injuries.

The value of ultrasound examination of the lungs in predicting bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is one of the most serious complications of neonatal mechanical ventilation. Early diagnosis may influence treatment options such as early steroid administration. To assess the role of US of the lungs in predicting the development of BPD in infants with hyaline membrane disease (HMD) and to determine the earliest possible age at which the diagnosis of BPD could be made with certainty. Consecutive premature newborn infants requiring assisted ventilation during 1997-1998 who were admitted because of HMD were studied prospectively. US of the lungs was performed within 3 days of birth and three times a week thereafter until discharge from the neonatal intensive care unit. Each patient was also clinically and radiographically evaluated for the presence or absence of BPD at day 28 of life. Lung US scans were correlated with the development of BPD. Retrodiaphragmatic hyperechogenicity (RH) was initially observed in 28 of the 36 patients with HMD, but resolved completely in 24 (96%) of 25 infants who had an uncomplicated clinical course. In eight of the ten infants who developed BPD, RH persisted. Day 9 was the earliest day where persistence of abnormal RH was observed with the highest predictor values for the development of BPD. Lung US is a valuable technique for predicting the development of BPD.

Urachal remnants: an enigma.

To determine what should be done with incidentally discovered urachal remnants. A 10-year retrospective study revealed 24 patients with urachal remnants. The histology of the urachal remnants was reviewed. A review of the data on urachal carcinoma in adults diagnosed and treated during the same period in an adjacent adult hospital was carried out. A review of the literature was also performed. In the 23 patients where histology was available 17 had normal urothelial lining and 6 (25%) showed abnormal epithelium. This included colonic epithelium, small intestinal epithelium and squamous epithelium. Four of the patients with abnormal epithelium were in the group of "incidental removals". During the 10-year period, 4 cases of urachal carcinoma were managed at the adult urology centre. Three had extensive disease at presentation. Two died of the disease while the third died of myocardial infarction 5 months after resection. Only one was alive at one-year follow-up. The occurrence of such documented complications makes a strong case for "prophylactic" surgery when urachal remnants are diagnosed incidentally or recognised during other operative procedures. All paediatric patients who underwent excision of urachal remnants had an uncomplicated clinical course.

The Role of Follow-up Imaging in Paediatric Blunt Abdominal Trauma

AIM: To assess the role of follow-up imaging in paediatric blunt abdominal trauma. METHOD: All children who underwent CT scanning of their abdomen at our institution following acute blunt injury between January 1997 and December 2000 were included in the study. Case notes where researched for details regarding mechanism of injury, initial clinical presentation, acute management, complications and follow-up until discharge. Reports of imaging investigations were retrieved from the RIS database. RESULTS: In the study period 75 children underwent CT scanning of their abdomen as a primary investigation for acute blunt abdominal trauma. Of these, 12 were normal, 52 showed evidence of intra-abdominal organ injury and 11 showed findings other than abdominal organ injury. Of the 52 children that sustained intra-abdominal organ injury, 48 (92%) were treated conservatively. 4 (8%) underwent emergency surgery, 3 for bowel injury and 1 for renal trauma. Of the 48 that were treated conservatively, 9 had a complicated clinical course with 7 showing complications on follow-up imaging. The remaining 39 children had an uneventful clinical course with follow-up imaging by CT or US in 34. None showed complications that required a change in management. CONCLUSION: In our series, follow-up imaging did not contribute to further management in children with an uncomplicated clinical course following blunt abdominal trauma. Mizzi, A. etal. (2002) Clinical Radiology57, 908–912.

The -260 C-->T promoter polymorphism of the lipopolysaccharide receptor CD14 and severe sepsis in trauma patients.

CD14, expressed on the cell surface of monocytes and hepatic Kupffer cells, interacts with Gram-positive and Gram-negative bacteria. Upon CD14 stimulation, these cells respond with the enhanced release of cytokines involved in the pathophysiology of sepsis. The purpose of this study was to evaluate whether the genotype distribution of the -260 C-->T promoter polymorphism of the CD14 gene is associated with the development of severe sepsis in trauma patients. Fifty-eight severely injured blunt trauma patients with an injury severity score of 16 or more and without pre-existing chronic diseases. Genotyping for the single nucleotide exchange polymorphism of the CD14 gene was performed by means of a real-time polymerase chain reaction with fluorescence-labeled hybridization probes. Diagnosis of severe sepsis was based on the criteria of the ACCP/SCCM criteria. Fourteen out of the 58 patients (24.6%) developed a trauma-related severe sepsis. The overall allele frequency was 0.58 for the C allele and 0.42 for the T allele. The genotype distribution (TT 0.19, CT 0.47 and CC 0.35) did not differ significantly from a previously reported control group of healthy blood donors. There was no significant difference of the genotype distribution or allele frequency between trauma patients with severe sepsis and patients with an uncomplicated clinical course. This pilot study suggests that the CD14 -260 polymorphism is not associated with an increased risk of severe sepsis in trauma patients.