The effect of the N-methyl-D-aspartate receptor antagonist dextromethorphan on perioperative brain injury in children undergoing cardiac surgery with cardiopulmonary bypass: results of a pilot study.

Experimental evidence indicates a role of the N-methyl-D-aspartate receptor in the pathogenesis of brain injury occurring during cardiac surgery with cardiopulmonary bypass (CPB). Dextromethorphan is a noncompetitive antagonist of this receptor with a favorable safety profile. Thirteen children age 3-36 months undergoing cardiac surgery with expected CPB of 60 minutes or more were randomly assigned to treatment with dextromethorphan (36-38 mg/kg/day) or placebo administered by naso-gastric tube. Dextromethorphan was absorbed well and reached putative therapeutic levels in blood and cerebrospinal fluid. Adverse effects were not observed. Mild hemiparesis developed after operation in one child of each group, and severe encephalopathy in one of the placebo group. Sharp waves were recorded in postoperative continuous electroencephalography in all placebo (n = 7) but only in 2/6 dextromethorphan treated children (p = 0.02). Pre- and postoperative cranial magnetic resonance imaging (MRI) revealed less pronounced ventricular enlargement in the dextromethorphan group (not significant). An increase of periventricular white matter lesions was visible in two placebo-treated children only. No elevations of cerebrospinal fluid enzymes were observed in either group. Although children with dextromethorphan showed less abnormalities in electroencephalography and MRI, dissimilarities of the treatment groups by chance diminished conclusions to possible protective effects of dextromethorphan at this time.

Post-traumatic mutism in children: clinical characteristics, pattern of recovery and clinicopathological correlations.

Among the numerous clinical syndromes observed after severe traumatic head injury, post-traumatic mutism is a disorder rarely reported in adults and not studied in any detail in children. We report seven children between the ages of 3 1/2 and 14 years who sustained severe head injury and developed post-traumatic mutism. We aim to give a precise clinical characterization of this disorder, discuss differential diagnosis and correlations with brain imaging and suggest its probable neurological substrate. After a coma lasting from 5 to 25 days, the seven patients who suffered from post-traumatic mutism went through a period of total absence of verbal production lasting from 5 to 94 days, associated with the recovery of non-verbal communication skills and emotional vocalization. During the first days after the recovery of speech, all patients were able to produce correct small sentences with a hypophonic and monotonous voice, moderate dysarthria, word finding difficulties but no signs of aphasia, and preserved oral comprehension. The neurological signs in the acute phase (III nerve paresis in three of seven patients, signs of autonomic dysfunctions in five of seven patients), the results of the brain imaging and the experimental animal data all suggest the involvement of mesencephalic structures as playing a key role in the aetiology of post-traumatic mutism.

Pancreatic trauma in children.

We identified two distinct groups of patients in the 91 documented cases of pancreatic trauma (median age 8.0 years, range 0.6-15.8 years; M:F 2.5:1.0): 59 had a history of abdominal trauma and elevated serum lipase but no CT or ultrasound evidence of pancreatic injury (Group A); 32 had a history of abdominal trauma, elevated serum lipase but also had CT scan and/or ultrasound evidence of pancreatic injury (Group B). Patients with "less severe" injury based on normal imaging had a lower initial lipase level [Group A, median 651 U/L (interquartile range 520-1,324) vs. Group B, 1,608 U/L (interquartile range 680-3,526); p = 0.005] and shorter admission time [Group A, 9.0 days (interquartile range 5.5-15.5) vs. Group B, 13.4 days (interquartile range 6.8-23.8); p = 0.04]. There were no differences with respect to mortality (Group A, 13.5% vs. Group B, 12.5%), but patients with evidence of injury on imaging were more likely to have surgical intervention (p = 0.0001). The single most important overall cause of pancreatic trauma was involvement in a motor vehicle accident as a passenger or pedestrian. However, in children with high-grade ductal injury, bicycle handlebar injuries were most common. Associated injuries were common in both groups.

Pancreatic Trauma in Children

Objectives and Study: To document the demographics, mechanisms and outcome of traumatic pancreatitis in children at a single large tertiary referral centre in Australia. Methods: We undertook a 10-year retrospective audit of children admitted to the Royal Children's Hospital [RCH], Melbourne, Australia with a hospital coded diagnosis which included pancreatic injury between 1993 and 2002. Data included patient demographics, source of admission, mechanism of injury, pancreatic complications, associated injuries, Intensive Care Unit [ICU] admission, results of any operative findings, results of any acute computed tomography (CT) and/or ultrasound (US) imaging of pancreas, selected laboratory findings and length of stay. Results: We identified two distinct groups of patients in the 91 documented cases of pancreatic trauma (median age 8.0 yr, range 0.6-15.8 yr; M:F 2.5:1.0). Fifty-nine had a history of abdominal trauma and elevated serum lipase but no CT or ultrasound evidence of pancreatic injury (Group A). Thirty-two had a history of abdominal trauma, elevated serum lipase but also had CT scan and/or ultrasound evidence of pancreatic injury[Group B]. Patients with ''less severe'' injury based on normal imaging had a lower initial lipase level [Group A, median 651 U/L (interquartile range 520 - 1324) vs, Group B, 1608 U/L (interquartile range 680-3526); P = 0.005] and shorter admission time [Group A, 9.0 days (interquartile range 5.5-15.5) vs Group B, 13.4 days (interquartile range 6.8 - 23.8), P = 0.04]. There were no differences with respect to mortality [Group A, 13.5 % vs Group B, 12.5 %] but patients with evidence of injury on imaging were more likely to have surgical intervention [P = 0.0001]. The single most important overall cause of pancreatic trauma was involvement in a motor vehicle accident as a passenger or pedestrian. However, in children with high-grade ductal injury, bicycle handlebar injuries were most common. Associated injuries were common in both groups. Conclusion: Significant pancreatic injury can occur in the absence of abnormality on medical imaging. Pancreatic trauma commonly occurs in the context of multiple injuries after motor vehicle accidents in children and bicycle handlebar injuries, especially in boys. Most children can be treated conservatively, with surgical intervention being limited to high-grade ductal injury.

Comparison of transhiatal laparoscopy versus blind closed-chest cervicotomy and laparotomy for esophagectomy in children.

BACKGROUND: Esophageal replacement for caustic stenosis in children poses a challenging surgical problem. Blind removal of the injured esophagus without thoracotomy through a left cervical and transhiatal approach followed by an orthotopic esophageal replacement using either the colon or the stomach is a difficult procedure and can be dangerous in children. We performed our first total laparoscopic transhiatal esophagectomy in February 2007. We aim to compare this new technique to the previously applied method of blind closed-chest esophagectomy through a cervicotomy and laparotomy. METHODS: We analyzed the surgery and follow-up of 40 children operated upon for extensive irreversible caustic burns of the esophagus. The first 20 esophageal replacements were performed following a blind dissection of the mediastinum through a cervical incision and a laparotomy for esophagectomy (Group I). The last 20 esophageal replacements were performed after laparoscopic transhiatal dissection in the mediastinum and cervicotomy in the neck for esophagectomy (Group II). All operations were performed under the supervision of the same senior surgeon. RESULTS: Average age at the time of surgery was the same in both groups. Total esophagectomy was achieved in 45.0% of cases in Group I versus in 90.0% of cases in Group II. Colon was used in 80.0% of cases in Group I and in 90.0% in Group II. The mean duration of surgery was one hour longer in the laparoscopy group. One vascular injury was reported in the blind laparotomy group. Pneumothorax was more frequent in Group II without significant consequences besides drainage. Average time of extubation was about the same in both groups (1.8days). CONCLUSION: Laparoscopic transhiatal esophagectomy for caustic burns before esophageal replacement in children is safe and effective. It could avoid vascular and bronchial mediastinal injuries as the dissection is performed under direct visual control. The routine use of laparoscopic assistance by a senior surgeon improves the safety of esophageal dissection and reduces life-threatening complications.

A prospective, randomized, and controlled study of fluid management in children with severe head injury: lactated Ringer's solution versus hypertonic saline.

OBJECTIVES: Resuscitation in severe head injury may be detrimental when given with hypotonic fluids. We evaluated the effects of lactated Ringer's solution (sodium 131 mmol/L, 277 mOsm/L) compared with hypertonic saline (sodium 268 mmol/L, 598 mOsm/L) in severely head-injured children over the first 3 days after injury. DESIGN: An open, randomized, and prospective study. SETTING: A 16-bed pediatric intensive care unit (ICU) (level III) at a university children's hospital. PATIENTS: A total of 35 consecutive children with head injury. INTERVENTIONS: Thirty-two children with Glasgow Coma Scores of <8 were randomly assigned to receive either lactated Ringer's solution (group 1) or hypertonic saline (group 2). Routine care was standardized, and included the following: head positioning at 30 degrees; normothermia (96.8 degrees to 98.6 degrees F [36 degrees to 37 degrees C]); analgesia and sedation with morphine (10 to 30 microg/kg/hr), midazolam (0.2 to 0.3 mg/kg/hr), and phenobarbital; volume-controlled ventilation (PaCO2 of 26.3 to 30 torr [3.5 to 4 kPa]); and optimal oxygenation (PaO2 of 90 to 105 torr [12 to 14 kPa], oxygen saturation of >92%, and hematocrit of >0.30). MEASUREMENTS AND MAIN RESULTS: Mean arterial pressure and intracranial pressure (ICP) were monitored continuously and documented hourly and at every intervention. The means of every 4-hr period were calculated and serum sodium concentrations were measured at the same time. An ICP of 15 mm Hg was treated with a predefined sequence of interventions, and complications were documented. There was no difference with respect to age, male/female ratio, or initial Glasgow Coma Score. In both groups, there was an inverse correlation between serum sodium concentration and ICP (group 1: r = -.13, r2 = .02, p < .03; group 2: r = -.29, r2 = .08, p < .001) that disappeared in group 1 and increased in group 2 (group 1: r = -.08, r2 = .01, NS; group 2: r = -.35, r2 =.12, p < .001). Correlation between serum sodium concentration and cerebral perfusion pressure (CPP) became significant in group 2 after 8 hrs of treatment (r = .2, r2 = .04, p = .002). Over time, ICP and CPP did not significantly differ between the groups. However, to keep ICP at <15 mm Hg, group 2 patients required significantly fewer interventions (p < .02). Group 1 patients received less sodium (8.0 +/- 4.5 vs. 11.5 +/- 5.0 mmol/kg/day, p = .05) and more fluid on day 1 (2850 +/- 1480 vs. 2180 +/- 770 mL/m2, p = .05). They also had a higher frequency of acute respiratory distress syndrome (four vs. 0 patients, p = .1) and more than two complications (six vs. 1 patient, p = .09). Group 2 patients had significantly shorter ICU stay times (11.6 +/- 6.1 vs. 8.0 +/- 2.4 days; p = .04) and shorter mechanical ventilation times (9.5 +/- 6.0 vs. 6.9 +/- 2.2 days; p = .1). The survival rate and duration of hospital stay were similar in both groups. CONCLUSIONS: Treatment of severe head injury with hypertonic saline is superior to that treatment with lactated Ringer's solution. An increase in serum sodium concentrations significantly correlates with lower ICP and higher CPP. Children treated with hypertonic saline require fewer interventions, have fewer complications, and stay a shorter time in the ICU.

Computational modeling of resting-state activity demonstrates markers of normalcy in children with prenatal or perinatal stroke.

Children who sustain a prenatal or perinatal brain injury in the form of a stroke develop remarkably normal cognitive functions in certain areas, with a particular strength in language skills. A dominant explanation for this is that brain regions from the contralesional hemisphere "take over" their functions, whereas the damaged areas and other ipsilesional regions play much less of a role. However, it is difficult to tease apart whether changes in neural activity after early brain injury are due to damage caused by the lesion or by processes related to postinjury reorganization. We sought to differentiate between these two causes by investigating the functional connectivity (FC) of brain areas during the resting state in human children with early brain injury using a computational model. We simulated a large-scale network consisting of realistic models of local brain areas coupled through anatomical connectivity information of healthy and injured participants. We then compared the resulting simulated FC values of healthy and injured participants with the empirical ones. We found that the empirical connectivity values, especially of the damaged areas, correlated better with simulated values of a healthy brain than those of an injured brain. This result indicates that the structural damage caused by an early brain injury is unlikely to have an adverse and sustained impact on the functional connections, albeit during the resting state, of damaged areas. Therefore, these areas could continue to play a role in the development of near-normal function in certain domains such as language in these children.

Prevalence of overweight and obesity in children from urban and rural Niagara

Purpose: The influence of environment in the development of overweight and obesity is an ongoing concern. This investigation examined the influence of urbanization on the rates of childhood overweight and obesity. Method: 2167 (1090M, 1077F) grade four children from 75 schools in Ontario's Niagara Region were sampled. A sophisticated algorithm overlaying electoral boundaries, population densities, and the knowledge of community members was used to classify schools into one of three location categories: urban {N= 1588), urban fringe {N= 379), and rural (A^= 234). Each subject was measured for: height, weight, and aerobic performance (Leger). Physical activity was evaluated with the self-report Participation Questionnaire (free-time and organized sport activities), and teacher's evaluations of student activity. Overweight (overweight and obesity combined) was measured both as a continuous (BMI) and categorical variable (BMI category), to evaluate the prevalence by location. A multivariate analysis was used to test for a suppression effect. Results: BMI and BMI category did not differ significantly by location or gender, and no evidence of a gender interaction existed. According to both a linear and logistic regression, physical activity or fitness levels did not suppress the influence of location on BMI and BMI category. Age, gender, free-time activity, organized sports, fitness level, and number of siblings, were all found to significantly influence overweight. Conclusions: It is plausible that the prevalence of overweight does not differ in urban and rural children from the Niagara Region. Further investigation is recommended, examining subjects by individual location of residence, in multiple regions throughout Ontario.

The influence of physical activity behaviour on the relationship between motor proficiency and body composition in children

There is an emerging awareness that children with poor motor abilities are at particular risk for overweight. This cross-sectional study examined the influence of physical activity behaviour on the relationship between motor proficiency and body composition. Participants were 1287 (646 males, 641 females) Grade 6 students in the Physical Health Activity Study project. Height, weight, waist girth, and motor proficiency (Bruininks-Oseretsky Test of Motor Performance BOTMP-SF) were assessed. Physical activity behaviours were also evaluated with a multifaceted approach and reported for school-based, non-school based physical activity, free-time play, and sedentary activities (Participation Questionnaire), and leisure time exercise (Godin-Shephard Leisure Time Exercise Questionnaire GS). Overweight was defined by BMI scores: boys :::20.6-21.2 and <25.1-26.0; girls: ::: 20.7-21.7and <25.4-26.7 and obesity was defined as: boys:::: 25.1-26.0; girls: :::25.4-26.7. Children were classified as case group (CG,::; 10% on BOTMP-SF), borderline case group (BC, > 10% to ::; 20% on BOTMP-SF) or non-case group. Analyses of variance (ANOVAs) uncovered a significant difference in overweight and obesity between the case group and non-case group. Normal-weight children reported higher participation in organized school-sports (intra-mural and inter-school teams). The CG reported significantly lower participation in school sports teams and lower GS results, with a trend towards lower participation in all active pursuits. They also reported a significantly higher duration of television watching and book reading. There were no significant differences between motor proficiency groups by gender, age, nonschool sports, or free-time activity. Multivariate ordinal logistic regression analysis showed that the case group was 10.9 times more likely to be overweight/obese than their peers. No single aspect of physical activity was able to explain the difference in odds ratios for the motor proficiency groups. However, for the entire cohort, children who participated in more organized school sports were less likely to be overweight/obese. These findings confirm that children with low motor proficiency are at significant risk of developing overweight. It is evident that these children have generally attenuated activity levels and heightened levels of sedentary pursuits. School-based activities appear particularly limited, and are the one area where children have near autonomy in their decision to pursue active opportunities. The promotion of school-based programs, specifically intramural sports may be an important aspect in increasing children's overall activity levels. It is also essential to consider the needs of those children with low motor proficiency when designing activity promotion programs. Future research should further explore motor proficiency and overweight/obesity.

Health in Brazil 5 Violence and injuries in Brazil: the effect, progress made, and challenges ahead

Although there are signs of decline, homicides and traffic-related injuries and deaths in Brazil account for almost two-thirds of all deaths from external causes. In 2007, the homicide rate was 26.8 per 100 000 people and traffic-related mortality was 23.5 per 100 000. Domestic violence might not lead to as many deaths, but its share of violence-related morbidity is large. These are important public health problems that lead to enormous individual and collective costs. Young, black, and poor men are the main victims and perpetrators of community violence, whereas poor black women and children are the main victims of domestic violence. Regional differentials are also substantial. Besides the sociocultural determinants, much of the violence in Brazil has been associated with the misuse of alcohol and illicit drugs, and the wide availability of firearms. The high traffic-related morbidity and mortality in Brazil have been linked to the chosen model for the transport system that has given priority to roads and private-car use without offering adequate infrastructure. The system is often poorly equipped to deal with violations of traffic rules. In response to the major problems of violence and injuries, Brazil has greatly advanced in terms of legislation and action plans. The main challenge is to assess these advances to identify, extend, integrate, and continue the successful ones.

Occurrence of tooth injuries in patients treated in hospital environment in the region of Aracatuba, Brazil during a 6-year period

Dental trauma has been considered as a public health problem that affects mainly children and youngsters and due to its impact on the patient's quality of life. This study presents the results of a 6-year survey of the occurrence and characteristics of dental trauma in patients admitted to the Service of Surgery and Oral and Maxillofacial Traumatology of the School of Dentistry of Aracatuba (UNESP, Brazil) after emergency care in hospital facilities in the region of Aracatuba, SP, Brazil. For such purpose, the clinical files of patients treated at the Service between 1999 and 2005 were reviewed. Information regarding gender, age, number of traumatized teeth, etiology and diagnosis of the trauma was collected from the files of patients with tooth injuries and recorded in case report forms specifically designed for this purpose. The results showed that from a total of 4112 patients admitted to the Service within the surveyed period, 266 (6.5%) had tooth injuries (172 males - 64.7%; 94 females - 35.3%). The total number of traumatized teeth was 496. Most patients belonged to the 16-20 year-old age group (20.3%) and the most frequent causes of tooth injuries were bicycle accidents (28.6%), motorcycle accidents (19.2%) and falls (18.8%). Injuries to the periodontal tissues were the most frequent type of tooth injuries (408 teeth; 82.26%), occurring in 118 primary and 290 permanent teeth. Among the injuries to the periodontal tissues, avulsion was the most common (32.86%) (29.41% for primary and 34.0% for permanent teeth), followed by extrusive luxation (19.15%) (25.21% for primary and 17.24% for permanent teeth). In conclusion, in the surveyed population, cases of tooth injuries were more frequent in males aged 16-20 years old due to cyclist accidents with predominance of injuries to the periodontal tissues, in particular, avulsions.

A Pilot Study of the Relationship of Calcium Intake and Frequency of Injuries In High School Athletes

Little information is available related to adolescent calcium intake and relationships with injuries they might suffer from sport participation. To determine calcium intake of high school athletes, to assess their self reported injury rates, and to examine the relationship between the two over a 12 month period of time. Participants received a questionnaire at their school and completed it anywhere they found convenient. Adolescent athletes in the Lincoln Public School system (n=43) that participated in at least one sport in the past year. Four age groups participated in the study with sixteen year olds having a significantly higher calcium intake at 1297 mg that of fourteen year olds. A variety of sports were represented with largest number of respondents participating in baseball/or softball at (55%). The next most played sport was basketball at (18%). Median total diet calcium was 1144.5 mg with a mean of 1182 mg + 567 mg. For the frequency of injuries that caused a missed practice or game in the past year, ankle injuries were the most common (25%). Knee injuries were the second most common (17%), followed closely by hand injuries (8%). Mean total diet calcium of athletes with five or more injuries that caused a missed practice or game was significantly higher at 1966 mg (P<.05) than athletes mean diet calcium with zero, one, two, and three injuries. Total milk calcium of those who reported three injuries that resulted in broken or fractured bones or dislocated joints was significantly higher (P<.05) at 1286 mg of total milk calcium than those who reported having zero, one, or two breaks or fractures. Athletes with higher calcium intakes have a higher number of reported injuries. This may be the result of increased vigorous activity which leads to increased calorie and calcium consumption. More importantly, this increased activity leads to an increased chance of injury. The greater calcium intake correlated with greater number of injuries may also be because of third parties advising the athletes who get injured to drink more milk and get more calcium in their diets because they have been injuries already.

Management of gallstone disease in children: a new protocol based on the experience of a single center

Background/purpose: Gallstones and cholelithiasis are being increasingly diagnosed in children owing to the widespread use of ultrasonography. The treatment of choice is cholecystectomy, and routine intraoperative cholangiography is recommended to explore the common bile duct. The objectives of this study were to describe our experience with the management of gallstone disease in childhood over the last 18 years and to propose an algorithm to guide the approach to cholelithiasis in children based on clinical and ultrasonographic findings. Methods: The data for this study were obtained by reviewing the records of all patients with gallstone disease treated between January 1994 and October 2011. The patients were divided into the following 5 groups based on their symptoms: group 1, asymptomatic; group 2, nonbiliary obstructive symptoms; group 3, acute cholecystitis symptoms; group 4, a history of biliary obstructive symptoms that were completely resolved by the time of surgery; and group 5, ongoing biliary obstructive symptoms. Patients were treated according to an algorithm based on their clinical, ultrasonographic, and endoscopic retrograde cholangiopancreatography (ERCP) findings. Results: A total of 223 patients were diagnosed with cholelithiasis, and comorbidities were present in 177 patients (79.3%). The most common comorbidities were hemolytic disorders in 139 patients (62.3%) and previous bariatric surgery in 16 (7.1%). Although symptoms were present in 134 patients (60.0%), cholecystectomy was performed for all patients with cholelithiasis, even if they were asymptomatic; the surgery was laparoscopic in 204 patients and open in 19. Fifty-six patients (25.1%) presented with complications as the first sign of cholelithiasis (eg, pancreatitis, choledocolithiasis, or acute calculous cholecystitis). Intraoperative cholangiography was indicated in 15 children, and it was positive in only 1 (0.4%) for whom ERCP was necessary to extract the stone after a laparoscopic cholecystectomy (LC). Preoperative ERCP was performed in 11 patients to extract the stones, and a hepaticojejunostomy was indicated in 2 patients. There were no injuries to the hepatic artery or common bile duct in our series. Conclusions: Based on our experience, we can propose an algorithm to guide the approach to cholelithiasis in the pediatric population. The final conclusion is that LC results in limited postoperative complications in children with gallstones. When a diagnosis of choledocolithiasis or dilation of the choledocus is made, ERCP is necessary if obstructive symptoms persist either before or after an LC. Intraoperative cholangiography and laparoscopic common bile duct exploration are not mandatory. Published by Elsevier Inc.

The impact of dental caries and trauma in children on family quality of life

Objectives: To assess the impact of childrens dental caries (DC) and traumatic dental injuries (TDI) on parents quality of life (QoL), adjusted by family income. Methods: Parents of 219 children aged 5 and 6 years answered the Family Impact Scale (FIS) on their perception of QoL and data about income. Three calibrated dentists examined the severity of DC according to decayed, missing and filled permanent teeth index, and children were categorized into: 0 = caries free; 15 = low severity; and =6 = high severity. TDI were classified into uncomplicated and complicated injuries. QoL was measured through FIS items and total score, and Poisson regression was used to associate the variables with the outcome. Results: Severity of DC showed a negative impact on the total score and subscales on parental/family activities, parental emotions and financial burden (P < 0.001). TDI showed a negative impact on total score and in some FIS items. The multivariate-adjusted model showed that only the increase in the severity of childrens DC (RR = 3.19; 95% CI = 2.36, 4.31; P < 0.001) was associated with a greater negative impact on parents QoL, while high family income was a protective factor (RR = 0.68; 95% CI = 0.48, 0.95; P < 0.001). Conclusions: The severity of childrens DC has a negative impact on parents QoL, whereas TDI do not. A lower family income might have a negative impact on parents QoL.

The association between extra-curricular sport participation and social anxiety symptoms in children

Social anxiety is a common psychological complaint that can have a significant and long-term negative impact on a child’s social and cognitive development. In the current study, the relationship between sport participation and social anxiety symptoms was investigated. Swiss primary school children (N = 201), parents, and teachers provided information about the children’s social anxiety symptoms, classroom behavior, and sport involvement. Gender differences were observed on social anxiety scores, where girls tended to report higher social anxiety symptoms, as well as on sport activity, where boys engaged in more sport involvement. MANCOVAs with gender as covariant showed no differences in social anxiety symptoms between children involved in an extracurricular sport and those not engaged in sport participation. Nevertheless, children engaged in team sports displayed fewer physical social anxiety symptoms than children involved in individual sports.