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Background The incidence of tularemia has recently increased throughout Europe. Pediatric tularemia typically presents with ulceroglandular or glandular disease and requires antimicrobial therapy not used in the empirical management of childhood acute lymphadenitis. We describe the clinical presentation and course in a case series comprising 20 patients. Methods This is a retrospective analysis of a single-center case series of microbiologically confirmed tularemia in patients Results Nineteen patients (95%) presented with ulceroglandular (n = 14) or glandular disease (n = 5), respectively. A characteristic entry site lesion (eschar) was present in 14 (74%). Fever was present at illness onset in 15 patients (75%) and disappeared in all patients before targeted therapy was initiated. The diagnosis was confirmed by serology in 18 patients (90%). While immunochromatography was positive as early as on day 7, a microagglutination test titer 1:≥160 was found no earlier than on day 13. Sixteen patients (80%) were initially treated with an antimicrobial agent ineffective against F. tularensis. The median delay (range) from illness onset to initiation of targeted therapy was 12 (6–40) days. Surgical incision and drainage were ultimately performed in 12 patients (60%). Conclusions Pediatric tularemia in Switzerland usually presents with early, self-limiting fever and a characteristic entry site lesion with regional lymphadenopathy draining the scalp or legs. Particularly in association with a tick exposure history, this presentation may allow early first-line therapy with an agent specifically targeting F. tularensis, potentially obviating the need for surgical therapy.

Objectives: True congenital pancreatic cysts (CPC) are extremely rare, only 27 cysts were reported so far in children under 3 years of age. With several new cases reported here, conclusions for diagnostic work up and treatment can be drawn. Material and Methods: 4 cases with CPC are analyzed retrospectively and reviewed together with all previously published cases. Results: Girls were affected by CPC about twice as frequent as boys, cysts were localized more often in the tail than in the head or body of the pancreas. Unilocular cysts are seen more frequent than multilocular cysts. Diagnosis can be made by prenatal or postnatal ultrasound. Usually, total excision of the cyst(s) was performed and prognosis was good in otherwise healthy children. Conclusion: This rare diagnosis should be considered when cystic lesions appear in routine antenatal ultrasound. The benign nature of these cysts together with a certain risk for complications when left in place justifies for a planned surgical approach in the neonate aiming at total excision of the cyst with preservation of the pancreas. Ultrasound is sufficient for preoperative imaging. Keywords: Pancreatic cyst; Congenital; Prenatal diagnosis; Pediatric

Background: The aim of this study was to examine mechanical, microbiologic, and morphologic changes of the appendicle rim to assess if it is appropriate to dissect the appendix with the ultrasound-activated scalpel (UAS) during laparoscopic appendectomy. Materials and Methods: After laparoscopic resection of the appendix, using conventional Roeder slings, we investigated 50 appendicle rims with an in vitro procedure. The overall time of dissection of the mesoappendix with UAS was noted. Following removal, the appendix was dissected in vitro with the UAS one cme from the resection rim. Seal-burst pressures were recorded. Bacterial cultures of the UAS-resected rim were compared with those of the scissors resected rim. Tissue changes were quantified histologically with hematoxylin and eosin (HE) stains. Results: The average time to dissect the mesoappendix was 228 seconds (25-900). Bacterial culture growths were less in the UAS-resected probes (7 versus 36 positive probes; (p>0.01). HE-stained tissues revealed mean histologic changes in the lamina propria muscularis externa of 2mm depth. The seal-burst pressure levels of the appendicle lumen had a mean of 420mbar. Seal-burst pressures and depths of histologic changes were not dependent on the different stages of appendicitis investigated, gender, or age groups. Seal-burst pressure levels were not related to different depths of tissue changes (P=0.64). Conclusions: The UAS is a rapid instrument for laparoscopic appendectomy and appears to be safe with respect to stability, sterility and tissue changes. It avoids complex time consuming instrument change manoeuvres and current transmission, which may induce intra- and postoperative complications. Our results suggest that keeping a safety margin of at least 5mm from the bowel would be sufficient to avoid thermal damage. Copyright 2010, Mary Ann Liebert, Inc. 20 2 199 204

Diese randomisierte doppelblinde placebokontrollierte Studie untersucht erstmals die Hustenaktivität mittels objektiver Hustenanalyse bei der Bronchoskopie nach unterschiedlichen Dosierungen einer Prämedikation mit Codein und Atropin. Codein führte während und nach der Untersuchung zu einer signifikanten Reduktion der Hustenaktivität während die Verwendung von Atropin Sekretproduktion und Arrhythmien minderte. Die Wirkung von Atropin ist dabei geringer ausgeprägt. Klinisch relevante Nebenwirkungen wurden nicht beobachtet. Eine Prämedikation mit Codein in einer Dosierung von 7,5mg, 30min vor Untersuchungsbeginn s.c. verabreicht, kann aufgrund der Ergebnisse dieser Studie (Evidenz-Grad A, Ib) als Routinemaßnahme diskutiert werden. This first randomised doubleblind controlled trial investigates cough activity during bronchoscopy with objective cough analysis after the administration of codein and atropine in different dosages. Codein led to a significant reduction in cough activity during and after the examination. Atropine revealed a trend in reducing secretion and arrhythmias. There were no clinically relevant side effects. On the basis of these results a premedication with codein 7.5mg s.c. 30 min. prior to bronchsocopy can therefore be discussed as a routine procedure (evidence level A, Ib).