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Subcutaneous Fat Necrosis

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841. Xenotransplantation (Follow-up)

endothelial cells (pECs) and promote intravascular coagulation. After contact with human/primate blood, clots quickly develop in pECs. The increased clot formation may be immunologically mediated, or may be the result of specific hormone regulators. Lee et al. recently examined this question. [ ] Incubation of pECs with human tumor necrosis factor alpha (TNF-α) or interleukin-1α (IL-1α) caused an increase in porcine tissue factor (TF) activity and mRNA; however, those changes were not seen when (...) alginate macroencapsulation devices. [ ] Adult pig islet cells were encapsulated in microcapsules implanted in the kidney or in a subcutaneous macrodevice in streptozocin-treated cynomolgus monkeys; in the latter group, diabetes was controlled for 6 months without immune suppression. This remarkable advance could pave the way for a variety of future human trials. The regulation of T-regulatory cells Still another approach involves inducing host immune tolerance and tissue accommodation; if the host

2014 eMedicine Pediatrics

842. Amenorrhea (Follow-up)

is straightforward. Previous Next: Diet and Activity Women with findings suggestive of an eating disorder should be evaluated by a multidisciplinary team with special expertise in these disorders. Nutritional counseling alone is inadequate therapy for these women. In some cases, nutritional deficiencies induced by dieting and exercise can cause amenorrhea even in the absence of a psychiatric disorder. Strict fat restriction often plays a role. Frequently, simply explaining the need to balance energy expenditure (...) , Murphy R, Smith P, DePaoli AM, et al. Recombinant human leptin in women with hypothalamic amenorrhea. N Engl J Med . 2004 Sep 2. 351(10):987-97. . Kyriakidis M, Caetano L, Anastasiadou N, Karasu T, Lashen H. Functional hypothalamic amenorrhoea: leptin treatment, dietary intervention and counselling as alternatives to traditional practice - systematic review. Eur J Obstet Gynecol Reprod Biol . 2016 Mar. 198:131-7. . Jayasena CN, Nijher GM, Chaudhri OB, Murphy KG, Ranger A, Lim A, et al. Subcutaneous

2014 eMedicine Pediatrics

843. Omphalitis (Diagnosis)

, endocarditis and liver abscess formation, abdominal complications (eg, spontaneous evisceration, peritonitis, bowel obstruction, abdominal or retroperitoneal abscess, abscess of the falciform ligament), and death. [ , , , ] Necrotizing fasciitis This is a florid bacterial infection of the skin, subcutaneous fat, and superficial and deep fascia that complicates 8-16% of cases of neonatal omphalitis. [ , , , , , , ] It is characterized by rapidly spreading infection and severe systemic toxicity. Necrotizing (...) the subcutaneous tissues to involve fascial planes (necrotizing fasciitis), abdominal wall musculature(myonecrosis), and, when the bacteria invade the umbilical vessels, the umbilical and portal veins (phlebitis). The factors that cause colonization to progress to infection are not well understood. The image below shows the anatomic relationship between the umbilicus and its embryologic attachments. Anatomic relationship between the umbilicus and its embryologic attachments. Previous Next: Etiology Omphalitis

2014 eMedicine Pediatrics

844. Omphalitis (Overview)

, endocarditis and liver abscess formation, abdominal complications (eg, spontaneous evisceration, peritonitis, bowel obstruction, abdominal or retroperitoneal abscess, abscess of the falciform ligament), and death. [ , , , ] Necrotizing fasciitis This is a florid bacterial infection of the skin, subcutaneous fat, and superficial and deep fascia that complicates 8-16% of cases of neonatal omphalitis. [ , , , , , , ] It is characterized by rapidly spreading infection and severe systemic toxicity. Necrotizing (...) the subcutaneous tissues to involve fascial planes (necrotizing fasciitis), abdominal wall musculature(myonecrosis), and, when the bacteria invade the umbilical vessels, the umbilical and portal veins (phlebitis). The factors that cause colonization to progress to infection are not well understood. The image below shows the anatomic relationship between the umbilicus and its embryologic attachments. Anatomic relationship between the umbilicus and its embryologic attachments. Previous Next: Etiology Omphalitis

2014 eMedicine Pediatrics

845. Disorders of the Breast (Overview)

. They are treated with complete surgical excision and can recur if not completely removed. Trauma Trauma to the breast, iatrogenic or blunt, may result in a palpable mass. The trauma causes fat necrosis, or breakdown of the adipose tissue. To complicate the diagnosis, women may or may not recall the inciting event. In addition, women may examine a traumatized breast and discover a mass that was present prior to the event. On physical examination, the mass is sometimes indistinguishable from a cancer. US (...) , mammography, and even magnetic resonance imaging (MRI) of the breast may be unable to discern the difference, leading to biopsies in concerning masses. Although pathognomonic for fat necrosis, key features—including peripheral calcifications, fibrotic scar, and echogenic internal bands—may also be consistent with breast cancer. [ ] Findings of lipid cysts or US evidence of fat necrosis may assist in the decision to monitor a palpable abnormality or perform a biopsy. [ ] Fibrocystic changes Fibrocystic

2014 eMedicine Pediatrics

846. Amenorrhea (Overview)

. Kallmann syndrome most commonly occurs as an X-linked recessive disorder caused by a KAL1 defect. Autosomal dominant and autosomal recessive inheritances are less common. [ , ] For detailed information, see . Evidence suggests a negative correlation between body fat levels and menstrual abnormalities. A critical body fat level must be present for the reproductive system to function normally. In some female athletes, the synergistic effects of excessive exercise and disordered eating cause severe (...) Gynecol Reprod Biol . 2016 Mar. 198:131-7. . Jayasena CN, Nijher GM, Chaudhri OB, Murphy KG, Ranger A, Lim A, et al. Subcutaneous injection of kisspeptin-54 acutely stimulates gonadotropin secretion in women with hypothalamic amenorrhea, but chronic administration causes tachyphylaxis. J Clin Endocrinol Metab . 2009 Nov. 94(11):4315-23. . Erb TM, Gerschultz K, Gold MA, Sanfilippo JS. Primary amenorrhea in a young adult with sickle cell disease: a case report and brief literature review on adolescent

2014 eMedicine Pediatrics

847. Birth Trauma (Overview)

below): Abrasions Erythema petechia Ecchymosis Lacerations Subcutaneous fat necrosis Location of injury in soft tissue planes on the scalp and head. Skull injuries with a favorable long-term prognosis include the following: Caput succedaneum Cephalhematoma Linear fractures Facial injuries with a favorable long-term prognosis include the following: Subconjunctival hemorrhage Retinal hemorrhage Musculoskeletal injuries with a favorable long-term prognosis include the following: Clavicular fractures (...) sometimes may occur as scalpel cuts during cesarean delivery or during instrumental delivery (ie, vacuum, forceps). Infection remains a risk, but most of these lesions uneventfully heal. Management consists of careful cleaning, application of antibiotic ointment, and observation. Bring edges together using Steri-Strips. Lacerations occasionally require suturing. Subcutaneous fat necrosis Subcutaneous fat necrosis is not usually detected at birth. Irregular, hard, nonpitting, subcutaneous plaques

2014 eMedicine Pediatrics

848. Obesity (Follow-up)

are difficult to achieve and sustain in children and adolescents as well as adults, initiating counseling and therapy may be prudent with realistic goals that emphasize gradual reductions in body fat and BMI and maintenance of weight loss rather than a rapid return to ideal body weight. Reductions in body weight are accompanied by equivalent reductions in energy expenditure. Consequently, maintenance of a given weight in a patient with obesity necessitates a lower energy intake than maintenance (...) weight control. Exercise reduces weight accretion through increases in energy expenditure and has favorable effects on cardiovascular status, decreases body fat and total cholesterol levels, increases lean body mass and high-density lipoprotein (HDL) levels, and improves psychologic well-being. Controlled trials have demonstrated that lifestyle exercise programs, in association with dietary restrictions, provide long-term weight control in children and adolescents. The results from a systematic

2014 eMedicine Pediatrics

849. Amenorrhea (Treatment)

is straightforward. Previous Next: Diet and Activity Women with findings suggestive of an eating disorder should be evaluated by a multidisciplinary team with special expertise in these disorders. Nutritional counseling alone is inadequate therapy for these women. In some cases, nutritional deficiencies induced by dieting and exercise can cause amenorrhea even in the absence of a psychiatric disorder. Strict fat restriction often plays a role. Frequently, simply explaining the need to balance energy expenditure (...) , Murphy R, Smith P, DePaoli AM, et al. Recombinant human leptin in women with hypothalamic amenorrhea. N Engl J Med . 2004 Sep 2. 351(10):987-97. . Kyriakidis M, Caetano L, Anastasiadou N, Karasu T, Lashen H. Functional hypothalamic amenorrhoea: leptin treatment, dietary intervention and counselling as alternatives to traditional practice - systematic review. Eur J Obstet Gynecol Reprod Biol . 2016 Mar. 198:131-7. . Jayasena CN, Nijher GM, Chaudhri OB, Murphy KG, Ranger A, Lim A, et al. Subcutaneous

2014 eMedicine Pediatrics

850. Burns, Chemical (Diagnosis)

as liquefaction necrosis. This involves denaturing of proteins as well as saponification of fats, which does not limit tissue penetration. Hydrofluoric acid is somewhat different from other acids in that it produces a liquefaction necrosis. The severity of the burn is related to a number of factors, including the pH of the agent, the concentration of the agent, the length of the contact time, the volume of the offending agent, and the physical form of the agent. The ingestion of solid pellets of alkaline (...) it gives up the proton; the strength of a base is determined by how avidly it binds the proton. The strength of acids and bases is defined by using the pH scale, which ranges from 1-14 and is logarithmic. A strong acid has a pH of 1, and a strong base has a pH of 14. A pH of 7 is neutral. Next: Pathophysiology Most acids produce a coagulation necrosis by denaturing proteins, forming a coagulum (eg, eschar) that limits the penetration of the acid. Bases typically produce a more severe injury known

2014 eMedicine Pediatrics

851. Colorectal Tumors (Diagnosis)

, as well as irregularities on the serosal surface. This cut also shows severe tumor infiltration of the colonic mesentery surrounding the mesenteric and retroperitoneal vessels. Coronal CT scan demonstrating the profuse tumoral infiltration of the ascending colonic mesentery surrounding mesenteric and portal vessels. Also note the thickness of the colonic hepatic flexure. Surgical specimen after right hemicolectomy, including the terminal ileum up to the transverse colon. Mesenteric fat, vessels (...) and lymph nodes were resected en block with the ascending colon. The large intestine has been opened longitudinally. Note the tumor on the right lower quadrant of the image, with severe thickness of the wall, areas of necrosis and hemorrhage, and some stippled calcifications. See , a Critical Images slideshow, to help identify the features of benign lesions as well as those with malignant potential. Next: Polypoid Disease of the Gastrointestinal Tract Not all polyposis syndromes are familial. Familial

2014 eMedicine Pediatrics

852. Intraosseous Cannulation (Diagnosis)

can also be limited by making only one attempt per tibia. Repeated attempts in the same bone allow fluid to flow through the previous holes produced in the bone. Extravasation of hypertonic or caustic medications, such as sodium bicarbonate, dopamine, or calcium chloride, can result in necrosis of the muscle. Infection and are relatively rare complications and occur most commonly if aseptic technique is not followed during insertion. Children with can develop this complication, as well. Cellulitis (...) at the insertion site has also been reported. Other possible complications include local hematoma, pain, fracture and growth plate injuries (with incorrect placement), and fat microemboli (not clinically significant) and compartment syndrome if extravasation is not recognized upon insertion. [ , ] With increased awareness of complications and improved training, complications may be less common than previously seen. [ ] Obtaining alternative IV access soon after the emergency and subsequent removal of the IO

2014 eMedicine Pediatrics

853. Infections of the Lung, Pleura and Mediastinum: Surgical Perspective (Diagnosis)

antibiotics has markedly reduced the incidence of lung abscess. In children, aspiration is the leading cause of lung abscess particularly in those who have neurologic impairment, results from an infection of the lung parenchyma that was not or could not be effectively treated with systemic antibiotics, although necrotizing pneumonia (particularly Staphylococcus bacteria) may result in lung abscess formation. See the following images. Lateral chest radiograph of a newborn with a left lower-lobe lung (...) abscess. Note the cavity containing an air-fluid level. Chest radiograph that reveals a lung abscess, a complication of necrotizing pneumonia of the right middle lobe in an adolescent. CT scan reveals a lung abscess with an air-fluid level, a complication of necrotizing pneumonia of the right middle lobe in an adolescent. Note several small pneumatoceles throughout the consolidated lung parenchyma. Effective treatment for children with lung abscess begins with obtaining appropriate cultures so

2014 eMedicine Pediatrics

854. Disorders of the Breast (Diagnosis)

. They are treated with complete surgical excision and can recur if not completely removed. Trauma Trauma to the breast, iatrogenic or blunt, may result in a palpable mass. The trauma causes fat necrosis, or breakdown of the adipose tissue. To complicate the diagnosis, women may or may not recall the inciting event. In addition, women may examine a traumatized breast and discover a mass that was present prior to the event. On physical examination, the mass is sometimes indistinguishable from a cancer. US (...) , mammography, and even magnetic resonance imaging (MRI) of the breast may be unable to discern the difference, leading to biopsies in concerning masses. Although pathognomonic for fat necrosis, key features—including peripheral calcifications, fibrotic scar, and echogenic internal bands—may also be consistent with breast cancer. [ ] Findings of lipid cysts or US evidence of fat necrosis may assist in the decision to monitor a palpable abnormality or perform a biopsy. [ ] Fibrocystic changes Fibrocystic

2014 eMedicine Pediatrics

855. Spinal Instability and Spinal Fusion Surgery (Treatment)

beforehand. Thigh-high compression stockings (TED hose) and sequential compression devices are applied preoperatively for prophylaxis of deep vein thrombosis (DVT) and are not removed until the patient is mobilized postoperatively. In patients who are at particular risk for DVT and pulmonary embolism (PE; eg, those mwho are paraplegic, quadriplegic, or bedbound prior to surgery), subcutaneous injections of low-molecular-weight heparin (LMWH) may begin before the operation, with the individual patient's (...) exposures, care is taken to spare any neural structures that might correspond to a variant crossing of the recurrent laryngeal nerve. The prevertebral fascia is opened and the esophagus and pharynx are retracted toward the contralateral side. A transverse cervical artery, often accompanied by a vein, is usually identified over the C7 vertebral body in the superior extension of the mediastinal fat pad. This artery and the fat pad can usually be swept inferiorly and preserved. If exposed, this artery

2014 eMedicine Surgery

856. Short-Bowel Syndrome (Treatment)

mg/kg/day subcutaneously for 4 weeks, parenteral (0.16 g/kg/day) or enteral (30 g/day) glutamine supplementation, and a high-carbohydrate diet with 55-60% of calories coming from carbohydrates versus 20-25% from fat and 20% from protein. In 1997, Wilmore et al published their results on 87 patients treated with this regimen. [ ] After 4 weeks, 52% were completely off parenteral nutrition, and an additional 38% had significantly reduced parenteral nutrition requirements. The same investigators (...) of malnutrition and has been shown to benefit patient outcomes. TPN may be administered concurrently with enteral nutrition early in the clinical course of short-bowel syndrome because the ultimate goal in many of these patients is to enhance intestinal adaptation and render patients free of TPN as described by Wilmore et al in animal models. [ ] In many patients, intestinal adaptation, alone or in combination with modified and supplemented diets (eg, growth hormone, glutamine, high carbohydrate, low fat

2014 eMedicine Surgery

857. Salivary Gland Tumors, Major, Benign (Treatment)

or reconstructed to afford the best chance of maintaining tone in the muscle or muscles being innervated. Another potential complication is sacrifice of the greater auricular nerve causing loss of sensation to the ear lobule and surrounding skin. To avoid this, careful dissection through the subcutaneous plane is performed to permit identification and preservation of the nerve as the anatomy allows. The facial hollowing and loss of facial symmetry that may result from tumor and gland removal can sometimes (...) be addressed at the time of surgery by placing cadaveric human dermal matrix or even by rotating a portion of the nearby sternocleidomastoid muscle into the deficit. Other approaches using avascular fat graft (harvested from the patient’s abdominal wall) have also been described. Postoperative gustatory sweating (Frey syndrome) is rare but may occur with aberrant reinnervation of the parasympathetics after parotid surgery. Use of thick skin flaps, placement of human dermal matrix, or both may mitigate

2014 eMedicine Surgery

858. Thromboembolism (Treatment)

administration of warfarin sodium is started after anticoagulation with SC or IV anticoagulants has been achieved is because warfarin can have an initial procoagulant effect, particularly in patients with protein C or protein S deficiencies, potentially causing fat necrosis. For patients whose treatment has included thrombolysis for acute, massive PE causing hemodynamic instability, heparin infusion should be started once the thrombin time (TT) or aPTT is less than twice the baseline value. Treatment (...) been reported following UFH treatment of more than 1 month's duration. Skin necrosis Coumarin derivatives can cause skin necrosis as a consequence of widespread subcutaneous microthrombosis. This can occur in individuals who are protein C–deficient, either genetically or owing to large loading doses of a coumarin derivative. Areas usually affected include the breasts, abdominal wall, and lower extremities. [ ] Recurrence Recurrence of thromboembolism had been documented following discontinuance

2014 eMedicine Surgery

859. Wound Care (Treatment)

. These requirements can increase, however, for patients with sizeable wounds. Suspect malnutrition in patients with chronic illnesses, inadequate societal support, multisystemic trauma, or GI or neurologic problems that may impair oral intake. Protein deficiency occurs in approximately 25% of all hospitalized patients. Oftentimes, a thorough physical examination can reveal signs of malnutrition, such as temporal wasting, loss of subcutaneous fat, ankle/sacral edema, pronounced clavicles. Chronic malnutrition can (...) III Full-thickness skin loss into subcutaneous fatty tissues or fascia Distinct ulcer margin; deep crater (in general, 2.075 mm or deeper [the thickness of a nickel]) Debride; irrigate with saline; apply DuoDerm/Tegaderm 90 IV Full-thickness skin loss with extensive tissue involvement of underlying tissues Extensive necrosis; damage to underlying supporting structures, such as muscle, bone, tendon, or joint capsule Surgically debride; irrigate with saline (possibly under pressure); apply advanced

2014 eMedicine Surgery

860. Unstable Pelvic Fractures (Treatment)

. Additionally, a Morel-Lavalle lesion can be considered a contraindication to ORIF. This lesion is identified on the basis of a fluctuance under the skin of the involved area. Contusions and abrasions are often associated with the Morel-Lavalle lesion. It represents a large area of hematoma and fat necrosis under degloved skin. The lesion results from shearing of the subcutaneous tissue from the underlying fascia. Although the Morel-Lavalle lesion is a closed injury, it is associated with high rates (...) with pelvic trauma. The subcutaneous tissue is torn away from the underlying fascia, creating a cavity filled with hematoma and liquefied fat. The diagnosis is based on physical examination findings, including a soft fluctuant area that commonly occurs over the greater trochanter but may also occur in the flank and lumbodorsal region. Management is important because the presence of necrotic tissue and hematoma in the subcutaneous tissue increases the risk of infection. Open debridement is the preferred

2014 eMedicine Surgery

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