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We describe a simple ultrasound (US)-guided technique for accurate anatomical right atrium localization prior to permanent hemodialysis catheter insertion. It is used in patients for whom a permanent hemodialysis catheter will be inserted through an internal jugular vein access, in order to have the functional catheter tip located at the mid-level of the right atrium. In this technique, the right atrium is localized on US via left intercostal approach prior to catheter insertion under fluoroscopic guidance.

Solitary infantile myofibroma is a benign fibrous tumor occurring in early childhood. Although rare, it is the most common benign fibrous tumor of infancy. The clinical course of the disease is almost uniformly good since most tumors regress spontaneously. When indicated, conservative surgical excision is the treatment of choice, with a low recurrence rate. We present a case of solitary infantile myofibroma that recurred after three attempts of surgical excision, questioning the reported recurrence rate and the standard of care in recurrent solitary infantile myofibroma.

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To the Editor: A retrospective analysis was conducted on 105 pediatric patients (60% males; median age at presentation 5 years) with immune thrombocytopenia (ITP) attending Rafic Hariri University and Nini Hospitals, Lebanon, between 1985 and 2012. The presenting symptom in 89% of cases was mucocutaneous bleeding; none had gastrointestinal or intracranial bleeding; 22.9% were taking medications, 24.8% had preceding infections, and 2.85% recent vaccination. Mean platelet count at presentation was 16 Â 10 9 /L. Bone marrow aspirates (BMAs) at diagnosis (60%) and after treatment failure (20%) confirmed ITP diagnosis.Main treatment modalities were steroids (61.9%), intravenous immunoglobulin (IVIG) (43.8%), and close observation (29.5%) (Supplemental Figure 1). Median time to splenectomy was 6.75 months after presentation. Patients who received platelet transfusions had platelet counts <10 Â 10 9 /L and wet purpura; none had life-threatening bleeding. Newly diagnosed, persisting, chronic, relapsing, and refractory forms were present in 40%, 16.2%, 27.7%, 1.9%, and 0.9% of patients, respectively; 13.3% were lost to followup. Urgent hospitalization was necessary in 27.6%. Life-threatening complications occurred in two patients: rituximab associated anaphylactic shock and gastrointestinal bleeding-associated hypotension. One patient developed mild systemic lupus erythematosis.Significant correlations are summarized in Table I. Positive correlations included chronicity with older age at presentation or treatment with steroids, rituximab, or splenectomy; urgent hospitalization with severe ITP and platelet transfusion; BMA at diagnosis with steroid use and platelet transfusion; BMA after treatment failure correlated with chronicity, IVIG use, and splenectomy; platelet transfusion with persistent, relapsing, and severe ITP; IVIG treatment with severe ITP, urgent hospitalization, and chronicity; both life-threatening and non-life-threatening complications with chronic ITP, treatment with rituximab, and splenectomy. We observed negative correlations of both urgent hospitalization and IVIG treatment with increased age.Time to platelet recovery and life-threatening complications were not significantly decreased by corticosteroids (P ¼ 0.1, P ¼ 0.2) or IVIG (P ¼ 0.7, P ¼ 0.