The vascular changes in activation of the inflammatory cascade also result in the relaxation of arteriolar smooth muscle and a reduction in systemic vascular resistance cheap eskalith amex. The reduction in systemic vascular resistance becomes a functional reduction in left ventricular afterload 300 mg eskalith free shipping, which combined with an appropriate preload resuscitation of the severely injured patient leads to an increase in cardiac index buy eskalith once a day. The hyperdynamic circulation of the multiple- trauma patients leads to the “flow” phase of the postresuscitative patient. Increased perfusion of the kidney and liver results in acceleration of excretory functions and potential enhancement Antibiotic Kinetics in the Multiple-System Trauma Patient 525 Figure 2 Illustrates the influence upon the clearance curve of the theoretical antibiotic in Figure 1 of an increase in extracellular and/or intracellular water in a trauma patient that has fever secondary to invasive infec- tion. The peak concentration [A ]* and the equilibrated peak concentration [B ] are less* than those concentrations observed under normal circumstances. Subsequent organ failure from the ravages of sustained sepsis results in impairment of drug elimination and prolongation of T1/2. Severe injury results in the infiltration of the soft tissues with neutrophils and monocytes as part of the phagocytic phase of the inflammatory response. Proinflammatory cytokine signals are released from the phagocytic cells, from activated mast cells, and from other cell populations. The circulation of these proinflammatory signals leads to a febrile response with or without infection. The febrile response is associated with systemic hypermetabolism and autonomic and neuroendocrine changes that further amplify the systemic dyshomeostasis. Pro-inflammatory signaling up-regulates the synthesis of acute-phase reactants and down- regulates the synthesis of albumen, which further impacts the restoration of oncotic pressure and predictable drug pharmacokinetics. The summed effects of injury, fever, and the sequela of systemic inflammation result in pathophysiologic alterations (Table 1) that compromise the effectiveness of antibiotic therapy because of suboptimal dosing. A review of the literature identifies a paucity of clinical studies in the 526 Fry multiple-injury patient, despite the fact that antibiotics are used for a wide array of indications in these patients. The effects of pathophysiologic changes upon antibiotic therapy will be cited among studies of critically ill and severely septic patients in the intensive care unit, and not exclusively in multiple-trauma patients. Preventive Antibiotics in the Injured Patient Preventive antibiotics have been used for over 30 years in trauma patients (1). The recognized principals of preoperative administration of an antibiotic with activity against the likely pathogens to be encountered have been the hallmark of utilization in this setting. However, trauma patients have blood loss and large volumes of resuscitation in the period of time leading up to, and during, the operative intervention. The sequestration of the resuscitation volume into injured tissue results and the obligatory expansion of the extracellular water volume all contribute to a vastly expanded Vd. In a limited number of preliminary-study patients, they noted that conventional doses of 7. The explanation for the lower antibiotic concentrations in the conventional dosing regimen was found in the larger Vd and short T1/2 that were seen in the trauma patients compared to normal controls. In a study of eight patients that averaged 37 years of age and had normal creatinine, each received between 6. Subsequent studies of an additional 28 trauma patients confirmed the impact of the increased Vd and the increased elimination rates of the drug in adversely affecting preventive antibiotic concentrations (3). A prospective study examined the wound and intra-abdominal infection rates of penetrating abdominal trauma patients who received different doses of amikacin (2). Significantly, higher doses of amikacin resulted in statistically reduced infection rates in all patients studied. Subgroup analysis indicated that lower infection rates were identified in patients with high-volume blood loss and in patients with injury severity scores >20. No improvement in rates infections was seen in patients when colon injury was present, indicating that high inocula of surgical site contamination cannot likely be overcome by preventive antibiotics. This observed uncertainty about antibiotic pharmacoki- netics in the setting of blood loss and injury has led to some experimental investigation in the use of continuous infusion of antibiotics as a means to overcome the problem. Another strategy has been to simply not use potentially toxic agents like the aminoglycosides, but rather choose Table 2 Differences in Clinical Outcomes of Infection when 7. Antibiotic Kinetics in the Multiple-System Trauma Patient 527 b-lactam alternatives where toxicity concerns are minimized and larger doses can be safely utilized. The data that evaluate other antibiotics in preventive indications in trauma patients is very limited. They identified lower antibiotic concentrations in selected patients in the recovery room, and found that lower postoperative antibiotic concentrations were predictive of postoperative infections. They identified blood loss, extensive intraoperative resuscitation, and expanded Vd as likely causes for reduced postoperative antibiotic concentrations and recommended consideration for increased preop- erative dose of preventive antibiotics. They recommended re-dosing or continuous infusion as a requirement for effective use of preventive antibiotics in this population. Aminoglycosides The aminoglycosides more than any antibiotic group have been studied most extensively in the setting of critical illness. Nephro- and ototoxicity have been the driving issues that have stimulated pharmacokinetic studies of the aminoglycosides. However, the data indicate that perhaps more patients have been underdosed than have received toxic levels of these antibiotics. Given that gentamicin and the other aminoglycosides have been demonstrated to have highly variable pharmacokinetics even with patients that appear to have normal kidney function (6), it is not surprising that physiologic changes of trauma and clinical fever will further compound an already difficult situation. All study patients received at least one aminoglycoside with the majority receiving gentamicin or tobramycin. The Vd increased approximately 50% greater than normal for this population with one patient demonstrating a threefold increase. Using individual patient pharmacokinetic parameters, adjustments in gentamicin doses ranged from 1. In this latter study, drug elimination rates were strongly influenced by the patient’s serum creatinine as a marker of clinical renal function. Despite larger doses that were required, doses of the aminoglycosides were given less frequently with patients having a creatinine above 1 mg/dL. They identified 59% of patients that had blood concentration of the antibiotic that was significantly below expected concentrations. The expanded Vd was considered to be responsible for the low blood concentrations. Dasta and Armstrong (10) studied aminoglycoside pharmacokinetics in 181 critically ill patients in a surgical intensive care unit. Additional studies have validated that the observations of increased Vd and highly variable T1/2 are applicable to all of the aminoglycosides in trauma (11) and intensive care unit patients (12). Understanding these changes of aminoglycosides under circumstances of trauma, fever, and critical illness should lead to pharmacokinetic dosing and changes in the management of these patients. Once-daily dosing of aminoglycosides has become very common at present, but again the pharmacokinetic observations have demonstrated that conventional doses will be inadequate, especially for the younger trauma patient with normal renal function. Vancomycin Like the aminoglycosides, the pharmacokinetics of vancomycin is highly variable among patients with normal renal function (14). They assumed and documented that the Vd of vancomycin was essentially that of total body water, or 0.
In northern India buy genuine eskalith, a prospective cheap eskalith 300 mg on line, hospital-based study buy cheap eskalith on-line, which lasted for a decade (1983– 1992), evaluated the epidemiology of alopecia areata, including noting associated diseases and risk factors for development of severe alopecia areata. The study evaluated 880 patients (532 men and 276 women) and 509 controls (307 men and 202 women). Onset in childhood was more frequent in females, but the incidence of severe alopecia was higher in males with onset at an earlier age. Atopy was found to be present in 18% of patients, but its reported association with younger age of onset and severe alopecia was not conﬁrmed. However, in our mobile world, an understanding of these differences may be important in discussions with patients and families. The best place to take a biopsy for diagnostic purposes is the active edge of an area of hair loss. This biopsy specimen will typically show the characteristic perib- ulbar, inﬂammatory inﬁltrate, in both horizontal and vertical sections, as well as an increased percentage of follicles in telogen. In extensive alopecia areata, examination of both vertical and horizontal scalp biopsy specimens may provide useful information in advising patients about therapy (Fig. A mean follicular count in horizontal sections which is less than one follicle per square millimeter usually indicates little likelihood for good regrowth (21). Interestingly, the major locus on chromosome 18 was found to coincide with a previously reported locus for psoriasis as well as hereditary hypotrichosis simplex, suggesting this region may harbor genes involved in a number of different skin and hair disorders (23). More recently, peripheral nerve function in the C2 and V1 dermatomes, both of which innervate scalp skin, was found to be abnormal as compared to controls (70). Stressful life events and psychiatric disorders have been studied as they relate to both the onset and the progression of alopecia areata. After hypnotherapy treatment, all patients had a signiﬁcantly lower score for anxiety and depression and scalp-hair growth of 75% to 100% was seen in 12 patients after three to eight sessions. Clearly more patients need to be studied, but the ﬁndings suggest hyp- notherapy may enhance the mental well-being of patients and may improve clinical outcome, perhaps through an effect on the peripheral nervous and immune systems (26). It is believed that the available treatments at best only suppress the under- lying process. To facilitate comparison of data and the sharing of patient-derived tissue alopecia areata, guidelines were published in 1999 and then updated in 2004 (28,29). These guidelines are now routinely used in clinical trials and can be adapted to direct patient care. The following repre- sent the guideline recommendations for data collection on the extent of scalp and body hair loss as well as nail abnormalities: _____ S0 = no scalp hair loss _____ S1 = <=25% hair loss _____ S2 = 26–50% hair loss _____ S3 = 51–75% hair loss _____ S4 = 76–99% hair loss _____ a = 76–95% hair loss _____ b = 96–99% hair loss _____ S5 = 100% hair loss S: scalp hair loss _____ B0 = no body hair loss _____ B1 = some body hair loss _____ B2 = 100% body (excluding scalp) hair loss B: body hair loss 98 Hordinsky and Caramori _____ N0 = no nail involvement _____ N1 = some nail involvement _____ 20 nail dystrophy/trachyonychia (must be all 20 nails) N: nail involvement Sacket deﬁned evidence-based medicine as “the integration of individual clinical exper- tise with the best available external clinical evidence of systematic research” (30). However, there are questions and concerns regarding the use of these chemicals as neither preparations nor shelf-life are standardized. The goal is to choose a concentration capable of producing a mild allergic contact dermatitis. Sensitization, if usually performed on the scalp, and weekly applications are targeted to produce a mild eczematous reaction. Initial hair regrowth may be visible after 8–12 weeks and may be discontinued once hair regrowth occurs; likewise, treatment can be reinsti- tuted if a relapse occurs. Desired reactions include the development of a mild eczematous der- matitis and enlargement of retroauricular lymph nodes. Undesired side effects noted in 2–5% of patients include vesicular or bullous reactions, dissemination of allergic contact dermatitis, urticarial or erythema multiforme-like reactions, as well as alterations in skin pigmentation (32,33). Primary complications from the use of topical steroids include the development of skin atrophy, folliculitis, and telangiectasias, all of which are reversible adverse experiences if drug therapy is discontinued. Little is known about adre- nal suppression with the use of topical steroids to intact scalp skin for an extended period of time. Because of these well-known side effects of topical steroid use, implementation of sham- poos containing mid or higher strength steroids is particularly appealing as direct contact is shorter and theoretically should be associated with fewer side effects. Intralesional steroids, including triamcinolone acetonide or triamcinolone hexaceton- ide are commonly used to treat patients with less than 50% scalp involvement (39). Eyebrow Alopecia Areata 99 regions may also be injected; rarely is this technique used to treat eyelash alopecia areata. In some practices, up to 40 mg will be injected intralesionally per session with sessions spaced apart by 6- to 8-week intervals. To be successful, it is important to inject just below the epidermis where the miniaturized follicles are, not into the fat, as this may lead to atrophy and a poor response. Children and adolescents and some adults may beneﬁt from application of a topical anesthetic prior to therapy. Compli- cations include atrophy, which again is reversible if treatment is discontinued. The National Alopecia Areata Foundation is currently sponsoring a clinical trial examining adrenal-gland suppression with this treatment modality. Various dosing regimens have been used successfully and reported in the literature. A six-week tapering dose of oral prednisone beginning at 40 mg/day tapering by 5 mg/day weekly over 4 weeks and then by 5 mg/day every three days resulted in 15 of 32 patients having at least 25% regrowth and 8 of the 15 experiencing more than 75% regrowth (40). An oral monthly pulse of 300 mg prednisolone for a minimum of four doses has also been reported to result in complete or cosmetically accept- able hair regrowth (41). Adverse experiences include weight gain, osteoporosis, hypertension, psychological changes, suppression of the adrenal cortical axis, striae, acne, hypertrichosis, and purpura. To counter the development of osteoporosis, calcium, vitamin D, or even drugs such as Fosamax® [adlendronate sodium (Merck & Co. Patients need to be coached in advance about potential adverse experi- ences and expectations. Patients receiving this therapy need to be on a 2-gram sodium diet, as ﬂuid retention may be an adverse experience. Anthralin Anthralin is postulated to target mitochondria and interact with the electron transport chain on the inner mitochondrial membrane, ultimately resulting in a decrease in adenosine triphophos- phate synthesis. However, just as with minoxidil, the use of this drug in published studied has not fulﬁlled the criteria of evidence-based treatment described earlier (31). Although complete hair regrowth has been achieved with 50 to 80 treatment sessions, averaging three per week, hair loss is commonly seen following discontinuation (47). Surprisingly, after 12 weeks of treatment, in a double-blind, placebo-controlled study, patients with extensive, active disease treated with efalizumab only had an approximately 8% hair regrowth response rate (71). Signiﬁ- cant hair regrowth was not demonstrated in any of the treated subjects after 8 to 24 weeks of treatment with 50 mg of etanercept given subcutaneously twice weekly (53). A clinical trial supported by the National Alopecia Areata Foundation with the bio- logic alefacept (Amevive®, Astellas Pharma U. This biologic is known to kill activated memory T cells, reversibly lowering the T-cell count. This was a 6-week study examining a tapering dose of oral prednisone (starting at 40 mg/day) followed by 2% topical minoxidil applied daily for up to 14 weeks. In this study, patients applied 5% topical minoxidil twice daily, followed 30 minutes later by 0. In this study, patients applied 1 mL 5% topical minoxi- dil twice daily, followed by an overnight application of anthralin. Anthralin was applied two hours after the evening application of topical minoxidil.
More specifcally eskalith 300 mg without a prescription, the above technique is based on a sensitive nucleic acid stain-based assay for determining numbers of cells in culture discount 300mg eskalith visa, since the cellular nucleic acid content is considered a reasonable indicator of cell number (Jones et al discount 300 mg eskalith fast delivery. The results for the maximum soluble concentration of the powders are presented in 3 Figures 1-2. There was at 5 least a 5-time reduction in the number of cells compared with the control (Figure 1). Only in the case of gingival 6 fbroblasts and in the highest dilution of the powder (100-time), differences with the control could no longer be observed (Figure 6). Regarding cell density, the reduction in numbers was less pronounced with the powder 10-time diluted, while no difference compared with con- 7 trol was observed, when the powder was diluted 100-times. When 100-time diluted, the cell density for all cells was comparable with the control (Figure 3, 5). Regarding viability, epithelial cells and fbroblasts exhibited different responses. More specifcally, both glycine-based powders resulted in a signifcant reduction in the viability of epithelial cells, irrespective of the concentration of the powder. Both glycine-based pow- ders had no effect on the viability of gingival fbroblasts, regardless the concentration of the powder (Figure 2, 4, 6). Interestingly enough, and for all concentra- tions tested, increased numbers of epithelial cells compared with the control were observed (Figure 1, 3, 5). However, the viability of the epithelial cells was signifcantly reduced, in the 3 maximum soluble concentration and 10-time dilution. No signifcant effect on the viability of both types of fbroblasts could be observed (Figure 2, 4, 6). The other two powders (sodium bicarbonate and erythritol) caused a decrease in the numbers and viability of gin- gival fbroblasts, when used in the highest concentration. The other powders in the maximum concentration caused a reduction in the number of these cells. It has been speculated, especially in the case of implants, 6 that these powder remnants may account, at some level, for changes in the biocompatibility of the implant surfaces and may, therefore, affect the biologic responses. In the present study we investigated the possible infuence of fve commercially available air-abrasive powders 7 on periodontal tissue cells. Due to their important role in wound healing both epithelial cells and fbroblasts were included. What the concentration is of the powder remaining in the 8 tissues or on the treated surfaces is not known. The results of the present study indicate that the effect of the different 9 kinds of powders on the various cell types may differ considerably depending on the cell type and the type and concentration of the powder used. The present study indicates that sodium bicarbonate powder decreases the viability and the number of human gingival fbroblasts. In their study it was shown that fbroblasts’ counts were reduced after treatment of machined titanium surfaces with a sodium bicarbonate powder. This small dif- ference in composition, for which the manufacturers provided no details, could be an expla- nation for the difference observed on the gingival fbroblasts. It has been shown that cells residing within the periodontal ligament have phenotypic 130 Influence of various air-abrasive powders on the viability… characteristic of osteoblast-like cells, exhibiting potential osteoblastic activity (Basdra et al. We observed that sodium bicarbonate powder causes a signifcant reduction in both cell density and viability of these cells. The powders used were a sodium bicarbonate powder and amino acid glycine pow- ders with different particle sizes. These cells are an important com- 7 ponent of the soft tissue seal and are the frst cells that come in contact with the powders during non-surgical treatment. According to the results of this study all powders reduce the viability of epithelial cells. The most pronounced reduction was observed with the sodium 8 bicarbonate and erythritol powders especially when respectable amounts of the powder come in contact with the epithelial cells. However, new powders are being developed based on different ingredients such as erythritol or tricalcium phosphate, which are considered to be less abrasive. In the present study we investigated the effect of this powder on three different types of cells. In the maximum soluble concentration a reduced density and viability was observed for all types of cells. To which of the compounds of the powder these results could be attrib- uted is not clear. Erythritol is a four-carbon sugar alcohol and can be found naturally in many organisms, which indicates that it is a byproduct of metabolism of sugar. However, a possible …and density of periodontal cells: an in vitro study 131 1 contribution to the abovementioned negative effect cannot be excluded. Chlorhexidine glu- conate is a cationic polybiguanide (bisbiguanide) and it is primarily used as its salts (e. A rational for using this type of powder is the less abrasive nature of the powder and its possible osteoconductive properties. More 5 specifcally, tricalcium phosphate is considered to have excellent biological properties (os- teoconduction, osteoinduction), adequate setting time, excellent moldability for surgical ap- 6 plications and the capability to deliver different bone-enhancing proteins (Ambard & Muen- inghoff 2006). A recently published study concluded that decontamination with glycine and tricalcium phosphate powder seems to be more effcient than treatment with glycine or 7 sodium bicarbonate alone (John et al. At the cellular level it has been shown that tricalcium phosphate enhances the cellular performance of osteoblast-like cells, leading to 8 the reconstruction of hard tissues (Oh et al. It has been suggested that if remnants of this powder remain on the surface or in the tissues after treatment this may have a benefcial effect on tissue responses (Tastepe et al. An important limitation of this study is that only fbroblasts from one donor have been used. Therefore, the results regarding the fbroblasts should be interpreted with caution. This is not the case for epithelial cells, as for these cells an epithelial cell line was used. The most pronounced effect was observed with the sodium bicarbonate and erythritol-containing powders and for the high- est concentration. When the glycine powder with tricalcium phosphate was tested with fbroblasts, no adverse effect on both the viability and cell density was observed. Within the limitation of this study, it seems that while some of the powders may adversely affect the 132 Influence of various air-abrasive powders on the viability… counts and viability of periodontal cells some other powders may have a benefcial effect on 1 the cells. It can thus be speculated that in clinical situations a careful selection of the powder should be done by the clinician, depending on the area that the powder is going to be used, 2 i. The clinical signifcance of this fnding in terms of tissue healing should be the subject of further investigation. Sygkounas contributed to the design, acquisition, analysis, interpretation of data, drafted the manuscript.
Subsequently generic eskalith 300mg on line, the percentage of lateral toring local treatment of children with juvenile chronic pillar involvement should be evaluated prospectively in arthritis and hemophilic arthropathy [14 cheap eskalith 300 mg, 23] buy cheap eskalith 300 mg on-line. In the knee, maxi- persistent enhancement within the revascularized zones, mal intraarticular diffusion and fluid enhancement is ob- compared to the normal hip enhancement. Transphyseal perfu- cessing techniques for a given child, for a given anatom- sion seems to be a predictor of growth arrest. Recent ad- vances in contrast-enhancement provide new informa- Evaluating Articular Structures tion, both qualitative and quantitative, on the endochon- dral growth process and on the mechanisms of neovascu- Accurate evaluation of the status of the articular carti- larization and revascularization. All of these elements are lage, joint fluid, and synovium is crucial and requires ap- important in dictating appropriate management. J Magn Reson Imaging 6:172-179 ment of disease severity and treatment response is re- 3. Magn Reson Imaging Clin N Am 6:473-495 The synovial intima lacks a tight junction or base- 4. Contrast-enhanced, fat-suppressed T1- J Roentgenol 169:183-189 weighted 3D gradient echo techniques are most effec- 6. Jaramillo D, Shapiro F (1998) Musculoskeletal trauma in chil- Bensahel H, Hassan M (1997) Dynamic Gadolinium-enhanced dren. Jaramillo D, Shapiro F (1998) Growth cartilage: normal ap- nosis of Legg-Calve-Perthes disease: preliminary results. J Pediatr magnetic resonance imaging and positron emission tomogra- Orthop 17:230-239 phy in the assessement of synovial volume and glucose me- 23. J Radiol 78:289-292 joint fluid with intravenously administered gadopentetate demeg- 16. Imaging techniques ventional radiography still remains the first step in the must be adequately chosen according to each different analysis of a bone tumor. The tumor may also be an incidental finding on a ra- diograph performed for another reason. The analysis should fol- low a systematic approach: Bone tumors in children may be benign or malignant, 1. Situation within the bone long axis: epiphysis, meta- physis, diaphysis or several: articular involvement, for example an epiphyseal lesion in a child is most likely a chondroblastoma: in the axial plane: medullary, cor- tical, juxta-cortical; Table 2 summarizes possible eti- ologies according to the axial situation. Geographic: in which there is a relatively large, well chondroma, defined hole or a few confluent holes with sharply chondroblastoma, chondromyxoid fibroma Fibrous tissue Cortical defect, Fibrosarcoma non ossifying fibroma, periosteal desmoid, fibrous dysplasia Table 2. Etiology according to axial position within the bone Hematologic Eosinophilic granuloma Metastases, lymphoma Central Bone cyst, enchondroma, osteoblastoma, Ewing Unknown Giant cell tumor, Ewing sarcoma bone cyst, aneurysmal Lateral Giant cell tumor, chondromyxoid fibroma, bone cyst aneurismal bone cyst, osteosarcoma, osteoblastoma Vascular Hemangioma Epithelioid Cortical Cortical defect, osteoid osteoma, aneurismal hemangioendothelioma bone cyst, osteosarcoma, Ewing, osteoblastoma Others Dermoid or epidermoid Chordoma, Juxta-cortical Osteochondroma, chondroma, aneurismal bone cyst adamantinoma or paraosteal cyst, osteosarcoma, Ewing Imaging the Osseous and Soft Tissue Tumors in the Child 181 defined edges (Lodwick type 1a) (Fig. The epiphyseal location suggests Mixed, lytic and Malignant tumors, osteomyelitis chondroblastoma. Cortical layer appearance: ruptured or blown out if the Magnetic Resonance Imaging tumor is aggressive, thickened in a slowly growing tu- mor. A periosteal reaction is due to reactive osteogenesis niques in the evaluation of malignant tumors. Its appearance performed before any biopsy because bleeding secondary depends on the rapidity of the abnormal process. A soft tissue mass may be due to extra-osseous devel- ization of the whole bone, including both articulations opment of some tumors, such as osteochondromas or above and below the tumor. This may be completed paraosteal sarcoma, or associated with the bone tumor, with a spin echo T1 (Fig. In this case, it the long axis of the bone (double obliquity is often is considered aggressive. The other sequences (spin echo T1 and T2) may then tion, and radiological appearance of the tumor. The tumor dysplasia, chondroma, osteochondroma, simple bone appears hypointense on T1 weighted sequences, allow- cyst, and vertebral angioma, should be recognized on ing clear delineation between infiltrated marrow and normal bright fatty marrow. A very short T1 sequence is though it may aid in visualizing the soft tissue mass. This method may be used Computerized Tomography also during follow-up, allowing evaluation of the tu- moral response to treatment. It can also be used to analyze the tumoral ma- marrow edema in the case of an osteoid osteoma, which trix (Fig. Edema has ill defined margins but not specific of aneurysmal bone cyst) or particular lo- and is faintly hypointense on T1 weighted images com- cations, such as pelvis and spine. Another point is the absence of a soft helpful in diagnosing sarcomas, but may only be per- tissue mass in the case of benign tumor. Part of the biopsy should be may assess the diagnosis of specific tumors, such as kept frozen in all cases for further analysis. Ultrasonography is very convenient as a first approach Follow-Up Under Treatment and may be sufficient in pseudotumoral lesions (adenitis, cysts, hematomas), benign tumors (hemangiomas, fibro- On plain film, the tumoral matrix calcifies during matosis colli), or vascular malformations. Doppler, using chemotherapy, soft-tissue mass should reduce and may parameters adapted to slow flows, demonstrates avascu- also calcify. The best way to appreciate tumor reduction lar or cystic lesions, and solid tumors vascularization. Fat saturation after gadolinium improves the contrast and should be performed in all cas- Soft-Tissue Tumors es. It may also help during follow-up to demon- Soft tissue tumors are frequent in children, and are most- strate residual tumor or local recurrences. Malignant tumors are rare, often misdiagnosed spectroscopy have been used recently but are still being at the beginning and inadequately treated by surgery. Diagnosis relies on pathology with immunohistochemical There is no specificity and malignant lesions may ap- analysis. Total absence of flux suggests a be- tions, such as demonstrating calcifications in cases of nign lesion. After clinical and imaging evaluation, a decision of As for bone tumors, imaging must take the following follow up only may be made if suspicion of a benign le- into account: sion is high. Hyposignal T2 treatment planning of primary malignant bone tumors in chil- area suggests a benign lesion, such as fibrous tumor, dren. Dubois J, Garel L (1999) Imaging and therapeutic approach of he- However, it is not always possible to recognize a ma- mangiomas and vascular malformations in the pediatric age group. A vascularization pattern on power Doppler netic resonance imaging with histologic correlation. Staphylococcus aureus and Streptococcus fasciitis, pyomyositis, infectious bursitis and arthritis, os- pyogenes account for the majority of the infections. Selection ma of the subcutaneous fat, showing swelling, in- of the optimal techniques for each individual patient is creased echogenicity of the subcutaneous fat with de- essential, and factors such as cost, radiation dose and creased acoustic transmission, blurring of tissue planes, need for sedation should all be considered. This appearance is non-specific infections in children because it is rapid, non-ionizing, and cannot be distinguished from non-infectious caus- and very sensitive for (infectious) fluid collections and es of soft-tissue edema . Moreover, cellulitis, especially in the vicinity of bone, Scintigraphy (three-phase bone scan with technetium- 99m) has a high sensitivity for bone disease but a low specificty. Combining bone scintigraphy with gallium-67 and indium-111 can improve diagnostic performance . Because of the variable ultrasonographic appearance, erogeneous enhancement and normal deep fascial and many diseases may simulate abscesses: seromas, muscle compartments [6, 7].