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• Re-do of a meso-Rex Bypass is a feasible option with good outcomes. • A large collateral vein is an alternative for an autologous venous conduit in a MRB. • Large collaterals ligation during MRB should be performed to avoid portal steal. In children with extrahepatic portal vein obstruction or those who develop portal vein thrombosis after liver transplant, the use of Meso-Rex Bypass (MRB) creates a more physiological state by redirecting mesenteric blood flow back into the intrahepatic portal system via a venous conduit. A 3-year-old female with biliary atresia associated with polysplenia syndrome and a surgical history of Kasai portoenterostomy procedure, and an ABO incompatible whole liver transplant. Within a year after transplant she presented with prehepatic portal hypertension, that was treated with MRB using a deceased donor ABO compatible iliac vein as conduit. Six months later, she was taken to the operating room for bypass revision, during the procedure the MRB showed no flow and no thrombus, and a large splenorenal collateral vein that was causing a portal perfusion steal phenomenon was observed. After dissecting the collateral vein, an 8 cm x8 mm segment of this vessel was used as an autologous conduit to re-do the Rex. Failed of MRB can be attributed to portal steal phenomenon, hypercoagulable disorders, bypass contraction or kinking. In this case we believe the culprit to be the former. When there is a history of longstanding portal hypertension, large collaterals develop; thus, intraoperative portal vein flow measurement is critical and ligation of large collaterals during liver transplantation and MRB should be performed to avoid portal steal phenomenon postprocedure. Using a collateral vein as an alternative autologous venous conduit is a feasible option that can have durable success. [ABSTRACT FROM AUTHOR]

Place-based social, cultural, institutional and political dynamics not only influence the innovation capacity of agricultural systems, but also the willingness of relevant actors to be involved in participatory research processes, and the dynamics of their participation. This paper critically discusses the modification and application of one particular participatory approach to agricultural systems analysis (Rapid Appraisal of Agricultural Innovation Systems [RAAIS]) to agricultural adaptation in Southeast Kazakhstan. We consider the overall effectiveness of the method as a research tool, practical issues in the implementation of workshops, definition of and selection of participant groups, as well as the questions of participation and empowerment within the workshops themselves. We find that although RAAIS is adaptable to alternative theoretical frameworks, its implementation in different socio-cultural and political contexts may require more consideration than is apparent in previous discussions. In particular, the appropriate training of workshop organisers is of crucial importance to the success of this methodology. These findings will be useful to those adapting participatory research methods to different research topics and contexts more broadly. [ABSTRACT FROM AUTHOR]

We report the case of a 15-month-old boy with retinoblastoma who developed exotropia secondary to a right medial rectus infarct after intra-arterial chemotherapy. He had unilateral sporadic group C tumor (International Classification of Retinoblastoma) and was treated with intra-arterial melphalan. One week after the first session of intra-ophthalmic arterial melphalan chemotherapy, he was noted to have orbital congestion, exotropia, and right adduction limitation. Magnetic resonance imaging was suggestive of a right medial rectus infarct. The tumor showed a good response to intra-arterial chemotherapy but the exotropia persisted. [ABSTRACT FROM AUTHOR]

Purpose Sclerotherapy is well described as a treatment for lymphatic malformations (LMs) in the head, neck, and other soft tissue areas. This study aims to evaluate the effectiveness of intralesional sclerotherapy as primary treatment for intra-abdominal LMs in children. Methods We conducted a retrospective review from 2008 to 2012 of all children with intra-abdominal LMs treated with sclerotherapy at our tertiary children's hospital. Results In this study, five patients underwent sclerotherapy as a primary intervention for intra-abdominal LMs. The ages of these patients ranged from 12 to 52months at the time of initial treatment. Doxycycline was used as the primary sclerotherapy agent. The patients required between three and five (median 3) sclerosing treatments over a period that ranged from 5 to 366 days (median 28). No child has required an operation and all LMs have decreased in size. The median decease in maximum diameter is 62% (21-67). Complete resolution has not been attained but all have experienced symptomatic relief with a median follow-up of 3 (1-24) months. Conclusions Sclerotherapy is an effective first-line therapy for intra-abdominal LMs in the pediatric population and should be considered when treating these difficult lesions. [ABSTRACT FROM AUTHOR]

Objective: Hemoptysis in the pediatric population may be caused by foreign body aspiration, cystic fibrosis, bronchiectasis, or infection. Vascular causes are uncommon. We present a rare cause of hemoptysis related to a bronchial artery pseudoaneurysm. Methods: We report the case of a child with a bronchial artery pseudoaneurysm causing hemoptysis and describe the clinical evaluation, treatment, and outcome. Results: A 12-year-old girl presented to a tertiary children's hospital with a history of daily, intermittent, moderate-volume hemoptysis. Rigid bronchoscopy showed a fresh clot occluding the right bronchus intermedius. Computed tomography angiogram was concerning for mild external vascular compression of the right mainstem bronchus. A bronchial arteriogram showed a right mid-bronchial pseudoaneurysm, which was embolized without complication. On repeat bronchoscopy, thrombus was removed from the bronchus intermedius with no new active bleeding. The patient was discharged in stable condition and did not have any more episodes of hemoptysis. Additional medical work-up did not reveal another source of the patient's bleeding. Conclusion: Hemoptysis in the pediatric population can be inflammatory, infectious, or due to systemic disease. Although extremely rare, bronchial artery pseudoaneurysm should be considered in cases of moderate to severe intermittent hemoptysis without another identifiable cause. Bronchial angiography can be both diagnostic and therapeutic. [ABSTRACT FROM AUTHOR]

A 7-year-old girl with Down syndrome and moderately severe pulmonary hypertension experienced a stroke while being treated with a calcium channel blocker. Angiography identified bilateral stenosis of the supraclinoid internal carotid arteries, stenosis or occlusion of the proximal anterior and middle cerebral arteries, and occlusion of the left posterior cerebral artery. She underwent surgery to enhance collateral blood flow to vulnerable areas of the brain. Her pulmonary hypertension therapy was changed to an oral endothelin receptor antagonist. She developed excellent collateral blood flow through external carotid arteries to each cerebral hemisphere and an improvement in blood flow through the right internal carotid artery. This case suggests that bosentan can be used safely in children with moyamoya disease. Additional studies are needed to determine whether endothelin receptor antagonists may influence the progression of moyamoya disease or the development of collateral cerebral blood flow following surgery. [ABSTRACT FROM AUTHOR]

Background: Injection of long-acting insulin at bedtime is a common therapeutic approach for patients with type 2 diabetes that is poorly controlled with oral regimens. Neutral protamine lispro (NPL) insulin has demonstrated better glycemic control and similar incidence of hypoglycemic events than that of neutral protamine Hagedorn insulin.Objective: To compare the clinical efficacy and safety of bedtime NPL insulin or insulin glargine in patients with type 2 diabetes who had suboptimal glycemic control while receiving stable doses of metformin and sulfonylurea.Design: Open-label, randomized trial.Setting: Teaching hospital (Azienda Ospedaliera Universitaria, Second University of Naples), Naples, Italy.Patients: 116 adults receiving stable doses of metformin plus sulfonylurea for longer than 90 days with hemoglobin A(1c) (HbA(1c)) levels of 7.5% to 10% and fasting plasma glucose levels of 6.7 mmol/L or greater (> or =120 mg/dL).Intervention: 10 IU of NPL insulin or insulin glargine injected subcutaneously at bedtime with weekly dose titrations to target fasting glucose levels less than 5.6 mmol/L (<100 mg/dL) in addition to stable oral regimens. Patients receiving nighttime sulfonylurea before the study were switched to metformin.Measurements: The primary outcome was change in HbA(1c) levels from baseline to week 36. Secondary outcomes were HbA(1c) levels less than 7%, self-reported hypoglycemic episodes, insulin dose, self-monitored glucose level, and body weight. Twenty patients in each group had continuous glucose monitoring for 3 consecutive days before adding insulin and at week 36.Results: Improvement in HbA(1c) levels was similar in both groups (1.83% and 1.89% for NPL and glargine, respectively). The difference between the groups was 0.06 percentage point (95% CI, -0.1 to 0.15 percentage points). Secondary outcomes did not differ between groups. Hemoglobin A(1c) levels less than 7% occurred in 62% of patients receiving NPL and 64% of patients receiving glargine (difference, 2.0 percentage points [CI, -1.1 to 5.0 percentage points]). Fasting plasma glucose levels less than 5.6 mmol/L (<100 mg/dL) occurred in 40% of patients receiving NPL and 41% of patients receiving glargine (difference, 1.0 percentage point [CI, -0.9 to 3.0 percentage points]). Any hypoglycemic event occurred in 74% of patients receiving NPL and 67% of patients receiving glargine (difference, 7 percentage points [CI, -5 to 13 percentage points]). Continuous glucose level monitoring in the patients who had this measurement did not differ statistically.Limitation: The study was not blinded, had limited power to detect differences in hypoglycemic events, and did not obtain continuous glucose level monitoring for all patients.Conclusion: Similar glycemic control occurred with the addition of NPL or glargine insulin to oral regimens in patients with poorly controlled type 2 diabetes. Hypoglycemia was similar in the 2 groups, but sample size limited the ability to make a definite safety assessment. [ABSTRACT FROM AUTHOR]

The article describes the case of a female infant with persistent left superior vena cava (LSVC) presented with mild hypoxemia. The infant, who was born at 39 weeks gestation, developed hypoxemia due to amniotic fluid aspiration. She was given supplemental oxygen therapy and was discharged at 10 days of age. However, a 1-2/6 systolic ejection murmur was heard when the infant was 2 months of age. A non-sedated transthoracic echocardiogram (TTE) noted a venous structure.