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Ovarian torsion (OT) is an emergency that mandates early detection and surgical detorsion to avoid catastrophic consequences of further adnexal injury. Prompt ultrasound is critical for accurate diagnosis. Traditionally, evaluation of arterial and venous flow was used as a diagnostic tool for OT, but recent radiologic research has indicated that ovarian size and size discrepancy between sides is a better diagnostic criterion. This study seeks to determine whether ovarian size discrepancy or vascular flow to the ovary is more accurate in the diagnosis of OT in the pediatric emergency population and to better describe symptoms that distinguish OT from other abdominal and pelvic pathology.This was a retrospective, cross-sectional study evaluating all female pediatric patients, aged 1 to 18 years, who underwent a pelvic ultrasound to evaluate for OT over a 2-year period in our pediatric emergency department. Patients suitable for inclusion were identified via Nuance mPowerTM, a search engine that provides clinical analytics based on radiology reports generated within our institution.We reviewed the medical records of 193 female patients aged 1 to 18 years, all of whom had a pelvic ultrasound (with or without Doppler) to evaluate for OT during the study period. In comparing ovarian size on ultrasound, patients with OT had a significantly larger magnitude of difference in ovarian volume than patients without torsion (5.57× [interquartile range, 3-12.5] vs 1.56× [interquartile range, 1.24-2.25; P0.001]). Ovarian torsion was associated with a 33-fold increased risk of lack of arterial flow (relative risk, 33.33) and with a 9-fold increased risk of lack of venous flow (relative risk, 9.27), when compared with those patients without OT. Patients with OT were significantly more likely to have emesis and peritoneal signs on examination, as well as previous history of OT (P = 0.01, 0.02, and 0.002, respectively) than those without OT. All patients with OT reported abdominal pain.We found that a large size discrepancy between ovaries is indicative of OT. Our data also suggest that presence of Doppler flow on ultrasound cannot be used to exclude OT but that lack of Doppler flow on ultrasound is a significant diagnostic marker. As previous studies have also found, clinical symptoms of OT are nonspecific and do not offer any certainty in differentiating OT from other pathologies.

Focal Dystonia (FD) is a chronic neurological disorder, which causes twisting and repetitive movements and abnormal postures induced by involuntary sustained contractions of agonist and antagonist muscles. Based on the hypothesis that several dystonia-related brain regions, including cerebellum, are implicated in oculomotor disturbances (OCD), a number of studies investigated oculomotor function in patients with dystonia. However, conceptual clarity with respect to the used assessment tools and interpretation of the findings is lacking in the literature. This is the first article to systematically review studies that assessed oculomotor function in patients with FD. In total, 329 publications, published until September 1, 2019, were identified through MEDLINE search. Twenty out of 329 studies, involving 232 subjects in total, met the inclusion criteria. Most of the studies reported oculomotor disturbances in patients with FD. Abnormalities included asymmetry in vestibulo-ocular reflex (VOR), disturbances in saccadic functions, and prolonged latencies of eye motion. Discrepancies in the results could be explained, at least partially, by the long period of time over which the reviewed studies were published, the different methods used for testing the eye movements, and the limited number of patients assessed since the majority of data derived from case reports or small-scale studies. Further prospective studies with larger subject numbers are needed, using advanced tools for the assessment of oculomotor function in focal dystonia.

We investigated the influences of odor exposure on performance and on breathing measures. The task was composed of tracking, short-term memory, and peripheral reaction parts. During rest or while performing the task, 12 participants were exposed to 4 different odors in 2 intensities. The higher intensity of the malodors induced a short-term decrement in mean inspiration flow (Vi/Ti) after stimulus onset and impaired performance in the short-term memory task, as compared with control trials; no effect was found for the positively judged odors. The study suggests that a distractor as simple as a bad smell may pull a person off task, however briefly, and may result in a detriment to performance. Actual or potential applications of this research involve designing or securing tasks in such a way that a brief withdrawal of attention does not have fatal consequences.

Background: The microbiological basis of diaper dermatitis is not clearly elucidated, although a better knowledge of microbial colonisation can be of importance with regard to an adequate treatment. Objective: To investigate the relevance of Candida sp. and Staphylococcus aureus colonisation in diaper dermatitis and to determine the correlation between the extent of colonisation and the severity of disease. Methods: Growth of Candida sp. and S. aureus in the perianal, inguinal and oral regions was determined by positive/negative and semi-quantitative analysis in an open, multi-centre (n = 3) study. Forty-eight children with healthy skin and 28 with diaper dermatitis were analysed. The severity of diaper dermatitis was assessed using a total symptoms score. Results: Colonisation by Candida sp. was significantly more frequent in children with diaper dermatitis as compared to those with healthy skin (perianal 75 vs. 19%; inguinal 50 vs. 10%; oral 68 vs. 25%, p < 0.0003), whereas colonisation by S. aureus at the 3 swab locations was not different (p > 0.34). There was a highly significant, positive correlation between severity of disease and extent of Candida sp. colonisation at all swab locations. Conclusions: Limited microbial colonisation in diaper dermatitis is of questionable relevance, but extensive colonisation seems to aggravate the symptoms; therefore, we suggest that semi-quantitative evaluation should be preferred to the positive/negative assessment for a differential diagnosis.

Gross cystic disease of the breast may sometimes indicate an increased risk of breast cancer. Biochemical analysis of the cyst fluid could suggest which cysts are associated with breast cancer risk, as well as providing insights into the pathophysiology of this condition. The Na+/K+ ratio appears to be associated with the histological classification of the cyst. Sulfoconjugated estrogens and androgens, especially DHEA-S, are often found at high levels. A number of gross cystic disease fluid proteins (GCDFPs) have been described, and several polypeptide growth factors including EGF and IGF-I are frequently found. It is hoped that biochemical analysis of these components of breast cyst fluids will shed further light on the role of gross cysts in relation to breast cancer.

Respiratory syncytial virus (RSV) was isolated from liver tissue in a 7-month-old infant with extrahepatic biliary atresia. To our knowledge this is the first report of RSV isolation from human liver tissue.

Anal sphincter dysplasia is a congenital, often familial malformation of the anal canal. In the literature, the anomaly is poorly represented and usually referred to as anteriorly or ventrally displaced anus. The range of symptoms includes chronic constipation, severe straining at defecation, encopresis and chronic paradoxical diarrhea with fecal incontinence. One usually finds dysplasia and absent (type I) or incomplete (type II) fixation of the sphincter complex to the coccyx. Both are demonstrable by computerized tomography (CT) as well as by intraoperative dissection of the sphincter muscles. There ist also shortening of the ectodermal segment of the anal canal which is obviously responsible for the disturbed stool sensation. Posterior butterfly anoplasty combined with fixation of the sphincter complex to the coccyx usually leads to immediate improvement of defecation disorders. A genetic study on 42 patients (age 1-52 years) operated on for anal sphincter dysplasia revealed autosomal dominant inheritance with variable expression and probably incomplete penetrance of the mutated gene.

The majority of shunt dysfunctions can be easily diagnosed by puncturing the Rickham reservoir with a fine needle and estimating the intracranial pressure. Experience has, however, shown that definite shunt dysfunctions can be missed by this method. These limitations of the technique are better understood by constructing a model which enables us to simulate the pressure and flow situation in a ventricular drainage system. This experimental model has shown that in cases of partial proximal or distal blockage, the flow through the shunt system is significantly diminished but not totally stopped, and the pressure reading may thus be normal. In these cases, the shunt should be revised on the basis of clinical evidence of dysfunction.

We describe two families with pedigrees over three and two generations with nine members affected with anorectal malformations. Both pedigrees are compatible with autosomal dominant inheritance with variable penetrance and expression or with multifactorial inheritance with a high genetic load. The recurrence risk is thought to be in the range of 10% to 20% for first degree relatives of affected members.

Our series of 17 children with laryngotracheal clefts is reported. In three of four cases with a complicated postoperative course, gastroesophageal reflux (GER) has been found. Three breakdowns of the surgical repair opposed to be due to GER. Only one child with a cleft type III died, although a mortality rate of 93% is reported in the literature. GER has to be excluded before tracheoesophageal cleft surgery is undertaken.

Pulled elbow is a common injury in infancy and childhood. The history and clinical findings are usually classical, but one should never forget that the classical history can always be easily reconstructed by the examining physician. It can be estimated that in 93% of all cases a dramatic response to therapy can be observed. In the remaining 7% the most common cause for failure to treatment is an incomplete or recurrent subluxation of the radial head and distortions or fractures of the elbow. But in approx. 1% the examining physician must suspect a hidden osteomyelitis or osteoarthritis of the elbow. With adequate antibiotic therapy the prognosis is generally good. To avoid this diagnostic pitfall, it is essential to re-examine carefully all cases which do not respond to therapy in order to exclude an osteomyelitis.

We describe a boy with asymmetrical hydrocephalus in whom a marked hemiparesis of recent origin resolved completely following insertion of a shunt. In 2 children with shunted obstructive hydrocephalus due to a midline tumour a newly developed hemiparesis improved markedly in one and resolved in the other case subsequent to revision of a blocked shunt. A hemiparesis should therefore not necessarily be attributed to assumed progression of an underlying disease. Other unusual symptoms of hydrocephalus or shunt dysfunction reported in childhood as well as possible causes of hemiparesis in shunted patients are listed.

We present 4 cases in which atraumatic reduction of an intussusception was achieved only after intraoperative intravenous administration of Glucagon. Because of this observation all our cases of the past 10 years with intussusceptions where bowel resection was necessary, were reviewed. Intraoperative macroscopic and histological findings revealed that bowel resections were not only necessary because of necrosis but also because of bowel wall lesions caused by traumatic reduction or the impossibility to reduce the intussusception. This aspect and the successful use of Glucagon during operation demonstrate that Glucagon should be administered wherever atraumatic surgical reduction of intussusception is not possible. This procedure may contribute to avoid unnecessary bowel resections.

Altered motility of the intestine after laparotomy, adynamic bowel segments, blind bowel loops following bypass operations, or diverticula may cause pathological growth of intestinal microflora and thus lead to contaminated small bowel syndrome (CSBS). As a result of malabsorption in the jejunum and ileum, loss of weight, growth arrest, diarrhea, steatorrhea, megaloblastic anemia, and hypoproteinemia may occur. In addition to these, the acute symptoms of small bowel contamination, intestinal obstruction and secretory diarrhea, are less well known. A stenosis in the terminal ileum was experimentally created in Göttingen minipigs and the bacterial flora of the small bowel assessed by quantitative cultures. After 3 months the number of aerobic and anaerobic bacteria in the pre- and poststenotic region had increased by a factor of 10(2)-10(5). The acute form of CSBS was diagnosed by microbiological examination of gastric samples in 14 children. After the children were treated with orally and intravenously administered antibiotics, the symptoms disappeared within 12-36 h. Reoperations for small bowel obstruction can be avoided by conservative treatment of CSBS with antibiotics.

The main function of the colon is fluid and sodium conservation. In ileostomy patients these colonic functions are lacking. The consequence is excessive loss of fluid and sodium, failure to thrive, and skin excoriation around the ileostomy. Patients with ileostomies require 6-10 mmol/kg sodium per day. With ordinary feeds, infants receive 2-4 mmol/kg sodium; therefore the sodium deficit may be estimated at 4-6 mmol/kg per day. Monitoring of adequate sodium substitution is best carried out by measuring the concentration of sodium in spot urine. Levels higher than 10 mmol/l sodium signify an adequate oral sodium intake. During the initial period of oral feeding, glucose excretion in the ileostomy fluid must be monitored, as glucose-positive ileostomy effluence necessitates additional sodium substitution in order to activate the sodium and glucose cotransport. Thirty neonates with ileostomies were followed-up retrospectively. All patients received a sodium substitution of at least 4-6 mmol/kg orally per day. The 30 patients had a total of 4769 ileostomy-days. All patients were successfully fed orally and most of them nursed at home until closure of the ileostomy.

Two infants with dumping syndrome after Nissen's fundoplication were bolus-fed with regular cows' milk formula and with test meals containing either cooked or uncooked starch. Cows' milk formula and test meals made with cooked starch provoded dumping symptoms, hyperglycaemia and hyperinsulinaemia. Dumping symptoms vanished and normoglycaemia was established when meals contained uncooked starch as the sole carbohydrate. The findings suggest that uncooked starch has a place in the dietary control of dumping syndrome in infants and possibly in adults.

Neuronal intestinal dysplasia (NID) is a disturbance of the innervation of the gut. Its symptoms resemble the ones seen in Hirschsprung's Disease. Contrary to aganglionosis, however, there is hyperplasia of the ganglia. Our study revealed isolated NID (4/49 cases) to be eight times rarer than aganglionosis (33/49 patients). Combination of both diseases has been reported to occur in 20% of NID cases; we did however find it in 75% (12/16) of our patients. NID was located proximal to the aganglionic segment and reached the stomach in 1 case. Combination of both diseases resulted in superposition of symptoms, thus rendering impossible to differentiate between NID group A (with hypoplasia of sympathetic innervation and acute early onset) and group B (with normal sympathetic innervation and chronic, late onset) on clinical grounds only. Major malformations were present in 5/16 patients with NID; 2 of them had trisomy 21.

During the last two years eight children aged 3 months to 7 years were treated successfully for contaminated small bowel syndrome (CSBS). All patients had a history of a laparotomy in the neonatal period and showed bile stained vomiting and diarrhoea. On examination, a painful distended abdomen with hyperactive bowel sounds was found. Plain abdominal x-rays showed signs of mechanical intestinal obstruction. The diagnosis of CSBS was made by positive gram stain and cultures of samples taken via a nasogastric tube. After antibiotic treatment the symptoms disappeared within a few days. We therefore believe that CSBS should always be considered in the differential diagnosis of abdominal emergencies. Our views agree with those of other authors in so far as we feel that antibiotic therapy may help to avoid unnecessary laparotomies in such cases.

Intestinal obstruction is always accompanied by intestinal hypersecretion. This phenomenon explains the initial symptoms like bilious vomiting and abdominal distension as well as the later clinical signs of hypovolaemia and shock. The proximal hypersecretion in intestinal obstruction is incompletely understood and in the surgical literature on ileus only little attention has been paid to this crucial observation. In analogy to secretory diarrhea and because of own clinical observations we conclude that bowel contamination caused by intestinal stasis is mainly responsible for the increased intestinal secretion in bowel obstruction.

More and more refined laboratory investigations for differential diagnosis of neonatal direct hyperbilirubinaemia have been developed, but not one of them is absolutely diagnostic. All of them take time and by the time the infant is referred to the surgeon it is often too late, as the prognosis for successful surgical correction becomes rapidly worse with increasing age. Most authorities have now agreed that in cases of extrahepatic biliary atresia cirrhosis has already well developed after the second month of life. The only virtually certain methods of diagnosis are direct inspection of the gall bladder, cholangiogram, and a sizeable liver biopsy. Our clinical experience has convinced us that laparoscopy with liver biopsy and simultaneous cholangiography by transhepatic puncture of the gall bladder is the simplest, fastest and most certain method for diagnosis. It allows for early differentiation of direct hyperbilirubinemia in the neonatal age and should be carried out if the hyperbilirubinemia has persisted during the first month of life and before laboratory investigations are instituted.

Between 1982 and 1987 27 Nissen's fundoplications were carried out in our institution. Postoperatively 7 infants showed a typical dumping syndrome. The symptoms were irritability, pallor, sweating, tachycardia, lethargy, diarrhoea and vomiting. In all cases an absolute refusal of feeding was observed. The diagnosis was confirmed by a typical early postprandial hyperglycaemia with hyperinsulinaemia leading to a reactive hypoglycaemia. Additionally, we were able to demonstrate an increased HbA1c as an expression of recurrent hyperglycaemias in 3 infants. In 6 infants the dumping syndrome was of short duration and the symptoms disappeared after application of a so-called dumping diet. In this diet the easily resorbable carbohydrates are replaced by uncooked starch. But in one case we were forced to use continuous enteral nutrition because of persistence of the symptoms 1 year after the Nissen fundoplication. Complete refusal of feeding is an early symptom of the dumping syndrome. If this symptom is observed after a Nissen's fundoplication, a dumping syndrome must be excluded.

The severe consequences of prolonged impaction in the oesophagus of a fairly radiolucent foreign object (aluminium can top) in 2 children are reported. The value of endoscopy in cases of unexplained dysphagia, even in the presence of normal radiographic examination, is stressed.

In childhood perianal fistulas are frequent. The origin of the fistula is the anorectal line, especially from the Morgagni crypts. Local recurrence of abscesses are observed. Due to two observations we conclude that the fistulas caused a sepsis with E. coli. In one case meningitis and a consecutive empyema occurred, in a second case pyelonephritis. In the following we describe the patient with meningitis and subdural empyema.

The indications and technique for laparoscopy in childhood are discussed. During the last 5 years 59 laparoscopies were carried out in the Surgical Department of the University Children's Hospital, Zurich, Switzerland. These cases are described in some detail. No complications were encountered.

Five neonates with gross obstructive uropathies diagnosed in utero were operated during the first few days of life. Follow-up studies of up to 2 years postoperatively showed normal development of all the children. Radiologic investigations showed no obstruction and normal growth of renal parenchyma in all but one case, thus differing markedly from infants with gross obstructive uropathies who were diagnosed and referred to us some months after birth. The importance of prenatal diagnosis and hence early post partum treatment of obstructive uropathies appears to us proven.

T o govern a continuous, adequate information input in driving the visual modality must function as a self-regulating system. A proper visual search strategy, as manifested by the discrete fixations of the eye, can only be expected if the perceptual system is both interiorly, as well as exteriorly, oriented. This means that the next fixation of the eye, i.e., information input, must be determined by the subject's present cognitive schemata in relation to the task-oriented relative importance of different environmental elements of the visual display. T o rest rhis assumption, the eye movements, when passing an unexpected building site, of five drivers whose ages were between 22 and 32 yr. were analyzed by means of a systems theoretical approach (see Hirsig, in press). In this driving situation, three essential conditions were fulfilled to guarantee the correspondence between information input and points of fixations. These were a great load of information, avoidance of anticipation, and well-defined distinctions between the road elements. If it is possible to determine a dynamic time-discrete process model which exactly describes the pattern of eye fixations, then a causal relationship between successive fixations is indicated. The model used consists essentially of two kinds of variables which are !he pattern of eye fixation within each interval of say 0.5 sec., judged from the last known information observed, and the task-oriented importance of defined road elements ahead (summarized as environmental vector), which the driver reaches within the next few time intervals. Only the most important finding can be described here. For each driver a dynamic process model could be determined individually. This described the observed sequence of eye fixations quite accurately. The accuracy of these individual models, i.e.. the prediction error, varied among the five drivers from 0.0% to a maximum of 2.6%. The essential differences between the individual models concern the number of the environmental vectors, e.g., the length of driving path ahead in relation to travel velocity, which had to be considered to allow a proper mathematical description of the pattern of eye fixations. The number of these discrete intervals varied among the subjects on n scale of one and four, corresponding to an assumed relevant preview time of 0.5 to 2.0 sec. Because the driving route was a short distance, it was not possible to validate the models established on an independent set of data. Nevertheless, this finding supporred a causal relationship between successive fixations of the eye. The finding suggesred that the present information from fixated targets and the relative importance of the road elements ahead are an integral part of a feed-forward program governing the movements of the driver's eye toward the next target of fixation. This conclusion confirms the general notion that the visual system is both interiorly and exteriorly oriented. The information the driver seeks depends, therefore. on the information he has already picked u p in relation to the road characteristics ahead when he is under the pressure of relevant information to be processed.