Bioethics and medical/legal considerations on cochlear implants in children

Cochlear implants are the best treatment for congenital profound deafness. Pediatric candidates to implantation are seen as vulnerable citizens, and the decision of implanting cochlear devices is ultimately in the hands of their parents/guardians. The Brazilian Penal Code dictates that deaf people may enjoy diminished criminal capacity. Many are the bioethical controversies around cochlear implants, as representatives from the deaf community have seen in them a means of decimating their culture and intrinsic values. Objective: This paper aims to discuss, in bioethical terms, the validity of implanting cochlear hearing aids in children by analyzing their vulnerability and the social/cultural implications of the procedure itself, aside from looking into the medical/legal aspects connected to their criminal capacity. Materials and Methods: The topic was searched on databases Medline and Lilacs; ethical analysis was done based on principialist bioethics. Results: Cochlear implants are the best therapeutic option for people with profound deafness and are morally justified. The level of criminal capacity attributed to deaf people requires careful analysis of the subject's degree of understanding and determination when carrying out the acts for which he/she has been charged. Conclusion: Cochlear implants are morally valid. Implantations must be analyzed on an each case basis. ENT physicians bear the ethical responsibility for indicating cochlear implants and must properly inform the child's parents/guardians and get their written consent before performing the procedure.

Perimedullary arteriovenous fistulas in children: report on six cases

Background Perimedullary arteriovenous fistulas (PMAVFs) are rare spinal lesions and even more uncommon in children. Objective The aim of this study was to document rare occurrences of this type of arteriovenous malformation in six children treated at our institution. Methods The clinical data, radiological findings, and treatment in six cases of PMAVFs were reviewed. Six patients with PMAVFs were managed at our institution over a 5-year period. The patients (four girls and two boys), ranging in age from 6 to 15 years, presented with initially fluctuating, and eventually permanent and progressive, sudden-onset paraparesis, sensory disturbances, and sphincter dysfunction. The duration of symptoms before diagnosis ranged from 1 week to 13 years. Results All the patients underwent magnetic resonance imaging and spinal selective angiography, which demonstrated the characteristic imaging of an arteriovenous fistula. Embolization of the arteriovenous fistula was initially attempted in three patients with successful occlusion of the fistula in two. For the remaining cases, open surgery was performed, with complete occlusion of the fistula. There was no morbidity, regardless of the treatment performed. All the patients experienced neurological improvement after treatment. Conclusions No specific clinical or radiological characteristic of PMAVFs in the pediatric population was observed when our series was compared with a general series. Early diagnosis and timing of the therapeutic intervention seemed to avoid the development of irreversible ischemic myeloradiculopathy and prevented hemorrhage. Treatment for PMAVFs is difficult to standardize because these are extremely rare lesions with different angioarchitecture configurations.

Are mental health problems and depression associated with bruxism in children?

Renner AC, da Silva AAM, Rodriguez JDM, Simoes VMF, Barbieri MA, Bettiol H, Thomaz EBAF, Saraiva MC. Are mental health problems and depression associated with bruxism in children? Community Dent Oral Epidemiol 2011. (C) 2011 John Wiley & Sons A/S Abstract Objectives: Previous studies have found an association between bruxism and emotional and behavioral problems in children, but reported data are inconsistent. The objective of this study was to estimate the prevalence of bruxism, and of its components clenching and grinding, and its associations with mental problems and depression. Methods: Data from two Brazilian birth cohorts were analyzed: one from 869 children in Ribeirao Preto RP (Sao Paulo), a more developed city, and the other from 805 children in Sao Luis SL (Maranhao). Current bruxism evaluated by means of a questionnaire applied to the parents/persons responsible for the children was defined when the habit of tooth clenching during daytime and/or tooth grinding at night still persisted until the time of the assessment. Additionally, the lifetime prevalence of clenching during daytime only and grinding at night only was also evaluated. Mental health problems were investigated using the Strength and Difficulties Questionnaire (SDQ) and depression using the Childrens Depression Inventory (CDI). Analyses were carried out for each city: with the SDQ subscales (emotional symptoms, conduct problems, peer problems, attention/hyperactivity disorder), with the total score (sum of the subscales), and with the CDI. These analyses were performed considering different response variables: bruxism, clenching only, and grinding only. The risks were estimated using a Poisson regression model. Statistical inferences were based on 95% confidence intervals (95% CI). Results: There was a high prevalence of current bruxism: 28.7% in RP and 30.0% in SL. The prevalence of clenching was 20.3% in RP and 18.8% in SL, and grinding was found in 35.7% of the children in RP and 39.1% in SL. Multivariable analysis showed a significant association of bruxism with emotional symptoms and total SDQ score in both cities. When analyzed separately, teeth clenching was associated with emotional symptoms, peer problems, and total SDQ score; grinding was significantly associated with emotional symptoms and total SDQ score in RP and SL. Female sex appeared as a protective factor for bruxism, and for clenching and grinding in RP. Furthermore, maternal employment outside the home and white skin color of children were associated with increased prevalence of teeth clenching in SL. Conclusions: Mental health problems were associated with bruxism, with teeth clenching only and grinding at night only. No association was detected between depression and bruxism, neither clenching nor grinding. But it is necessary to be cautious regarding the inferences from some of our results.

Ambulatory blood pressure monitoring in children with obstructive sleep apnea and primary snoring

Objective: To evaluate the systemic blood pressure (BP) during daytime and nighttime in children with sleep breathing disorders (SBD) and compare parameters of BP in children with diagnosis of obstructive sleep apnea syndrome (OSA) to those one with primary snoring (PS). Methods: Children, both genders, aged from 8 to 12 years, with symptoms of SBD realized an overnight polysomnography followed by a 24 h recording of ambulatory BP. Results: All subjects presented with a history of snoring 7 nights per week. Children who have apnea/hipoapnea index >= four or a apnea index >= one presented a mean BP of 93 +/- 7 mmHg and 85 +/- 9 mmHg diurnal and nocturnal respectively whereas children who have a apnea/hipoapnea < four or a apnea index < one presented 90 +/- 7 mmHg and 77 +/- 2 mmHg. Eight children out of fourteen, from OSA group, lost the physiologic nocturnal dipping of the blood pressure. Among OSA children 57% were considered non-dippers. Two (16%) have presented absence of nocturnal dipping among children with primary snoring. The possibility of OSA children loosing physiologic blood pressure dipping was 6.66 higher than the possibilities of patients from PS group. Discussion: Our results indicate that children with sleep apnea syndrome exhibit a higher 24 h blood pressure when compared with those of primary snoring in form of decreased degree of nocturnal dipping and increased levels of diastolic and mean blood pressure, according to previous studies in literature. OSA in children seems to be associated to the development of hypertension or other cardiovascular disease. (C) 2012 Elsevier Ireland Ltd. All rights reserved.

Stethoscopes with hearing aid use: case studies

Introduction: Description for using stethoscopes adapted to hearing aids. Aim: To describe the adaptation of HAs to stethoscopes used by 2 students in the health field with bilateral hearing impairment. Case reports: Two subjects with hearing loss had their stethoscopes coupled to HAs because of the individual requirements of their professions (healthcare) to perform auscultation. Conclusion: The improvement was measured in situ, and satisfaction was evaluated using a subjective questionnaire. The use of a stethoscope coupled to an HA allowed students with hearing loss to perform auscultation.

Pharmacokinetics of cyclosporin: a microemulsion in children with idiopathic nephrotic syndrome

OBJECTIVE: We present a prospective study of a microemulsion of cyclosporin to treat idiopathic nephrotic syndrome in ten children with normal renal function who presented cyclosporin trough levels between 50 and 150 ng/ml and achieved complete remission with cyclosporin. To compare the pharmacokinetic parameters of cyclosporin in idiopathic nephrotic syndrome during remission and relapse of the nephrotic state. METHOD: The pharmacokinetic profile of cyclosporin was evaluated with the 12-hour area under the timeconcentration curve (auc0-12) using seven time-point samples. This procedure was performed on each patient during remission and relapse with the same cyclosporin dose in mg/kg/day. The 12-hour area under the timeconcentration curve was calculated using the trapezoidal rule. All of the pharmacokinetic parameters and the resumed 4-hour area under the time-concentration curve were correlated with the 12-hour area under the timeconcentration curve. ClinicalTrials.gov:NCT01616446. RESULTS: There were no significant differences in any parameters of the pharmacokinetic of cyclosporin during remission and relapse, even when the data were normalized by dose. The best correlation with the 12-hour area under the time-concentration curve was the 4-hour area under the time-concentration curve on remission and relapse of the disease, followed by the 2-hour level after cyclosporin (c2) dosing in both disease states. CONCLUSIONS: These data indicate that the same parameters used for cyclosporin therapeutic monitoring estimated during the nephrotic state can also be used during remission. Larger controlled studies are needed to confirm these findings.

Sea Level Variations from Decades to Millennia: A few Case Studies

The main goals of this Ph.D. study are to investigate the regional and global geophysical components related to present polar ice melting and to provide independent cross validation checks of GIA models using both geophysical data detected by satellite mission, and geological observations from far field sites, in order to determine a lower and upper bound of uncertainty of GIA effect. The subject of this Thesis is the sea level change from decades to millennia scale. Within ice2sea collaboration, we developed a Fortran numerical code to analyze the local short-term sea level change and vertical deformation resulting from the loss of ice mass. This method is used to investigate polar regions: Greenland and Antarctica. We have used mass balance based on ICESat data for Greenland ice sheet and a plausible mass balance for Antarctic ice sheet. We have determined the regional and global fingerprint of sea level variations, vertical deformations of the solid surface of the Earth and variations of shape of the geoid for each ice source mentioned above. The coastal areas are affected by the long wavelength component of GIA process. Hence understanding the response of the Earth to loading is crucial in various contexts. Based on the hypothesis that Earth mantle materials obey to a linear rheology, and that the physical parameters of this rheology can be only characterized by their depth dependence, we investigate the Glacial Isostatic Effect upon the far field sites of Mediterranean area using an improved SELEN program. We presented new and revised observations for archaeological fish tanks located along the Tyrrhenian and Adriatic coast of Italy and new RSL for the SE Tunisia. Spatial and temporal variations of the Holocene sea levels studied in central Italy and Tunisia, provided important constraints on the melting history of the major ice sheets.

Social housing: interventions of densification in urban regeneration (1995-2010). Critical analysis of strategies adopted in Milan, London, São Paulo

The prospect of the continuous multiplication of life styles, the obsolescence of the traditional typological diagrams, the usability of spaces on different territorial scales, imposes on contemporary architecture the search for new models of living. Limited densities in urban development have produced the erosion of territory, the increase of the harmful emissions and energy consumption. High density housing cannot refuse the social emergency to ensure high quality and low cost dwellings, to a new people target: students, temporary workers, key workers, foreign, young couples without children, large families and, in general, people who carry out public services. Social housing strategies have become particularly relevant in regenerating high density urban outskirts. The choice of this research topic derives from the desire to deal with the recent accommodation emergency, according to different perspectives, with a view to give a contribution to the current literature, by proposing some tools for a correct design of the social housing, by ensuring good quality, cost-effective, and eco-sustainable solutions, from the concept phase, through management and maintenance, until the end of the building life cycle. The purpose of the thesis is defining a framework of guidelines that become effective instruments to be used in designing the social housing. They should also integrate the existing regulations and are mainly thought for those who work in this sector. They would aim at supporting students who have to cope with this particular residential theme, and also the users themselves. The scientific evidence of either the recent specialized literature or the solutions adopted in some case studies within the selected metropolitan areas of Milan, London and São Paulo, it is possible to identify the principles of this new design approach, in which the connection between typology, morphology and technology pursues the goal of a high living standard.

Ancient Greek harbours used as geo-archives for palaeotsunami research : case studies from Krane (Cefalonia), Lechaion (Gulf of Corinth) and Kyllini (Peloponnese)

Since historical times, coastal areas throughout the eastern Mediterranean are exposed to tsunami hazard. For many decades the knowledge about palaeotsunamis was solely based on historical accounts. However, results from timeline analyses reveal different characteristics affecting the quality of the dataset (i.e. distribution of data, temporal thinning backward of events, local periodization phenomena) that emphasize the fragmentary character of the historical data. As an increasing number of geo-scientific studies give convincing examples of well dated tsunami signatures not reported in catalogues, the non-existing record is a major problem to palaeotsunami research. While the compilation of historical data allows a first approach in the identification of areas vulnerable to tsunamis, it must not be regarded as reliable for hazard assessment. Considering the increasing economic significance of coastal regions (e.g. for mass tourism) and the constantly growing coastal population, our knowledge on the local, regional and supraregional tsunami hazard along Mediterranean coasts has to be improved. For setting up a reliable tsunami risk assessment and developing risk mitigation strategies, it is of major importance (i) to identify areas under risk and (ii) to estimate the intensity and frequency of potential events. This approach is most promising when based on the analysis of palaeotsunami research seeking to detect areas of high palaeotsunami hazard, to calculate recurrence intervals and to document palaeotsunami destructiveness in terms of wave run-up, inundation and long-term coastal change. Within the past few years, geo-scientific studies on palaeotsunami events provided convincing evidence that throughout the Mediterranean ancient harbours were subject to strong tsunami-related disturbance or destruction. Constructed to protect ships from storm and wave activity, harbours provide especially sheltered and quiescent environments and thus turned out to be valuable geo-archives for tsunamigenic high-energy impacts on coastal areas. Directly exposed to the Hellenic Trench and extensive local fault systems, coastal areas in the Ionian Sea and the Gulf of Corinth hold a considerably high risk for tsunami events, respectively.Geo-scientific and geoarcheaological studies carried out in the environs of the ancient harbours of Krane (Cefalonia Island), Lechaion (Corinth, Gulf of Corinth) and Kyllini (western Peloponnese) comprised on-shore and near-shore vibracoring and subsequent sedimentological, geochemical and microfossil analyses of the recovered sediments. Geophysical methods like electrical resistivity tomography and ground penetrating radar were applied in order to detect subsurface structures and to verify stratigraphical patterns derived from vibracores over long distances. The overall geochronological framework of each study area is based on radiocarbon dating of biogenic material and age determination of diagnostic ceramic fragments. Results presented within this study provide distinct evidence of multiple palaeotsunami landfalls for the investigated areas. Tsunami signatures encountered in the environs of Krane, Lechaion and Kyllini include (i) coarse-grained allochthonous marine sediments intersecting silt-dominated quiescent harbour deposits and/or shallow marine environments, (ii) disturbed microfaunal assemblages and/or (iii) distinct geochemical fingerprints as well as (iv) geo-archaeological destruction layers and (v) extensive units of beachrock-type calcarenitic tsunamites. For Krane, geochronological data yielded termini ad or post quem (maximum ages) for tsunami event generations dated to 4150 ± 60 cal BC, ~ 3200 ± 110 cal BC, ~ 650 ± 110 cal BC, and ~ 930 ± 40 cal AD, respectively. Results for Lechaion suggest that the harbour was hit by strong tsunami impacts in the 8th-6th century BC, the 1st-2nd century AD and in the 6th century AD. At Kyllini, the harbour site was affected by tsunami impact in between the late 7th and early 4th cent. BC and between the 4th and 6th cent. AD. In case of Lechaion and Kyllini, the final destruction of the harbour facilities also seems to be related to the tsunami impact. Comparing the tsunami signals obtained for each study areas with geo-scientific data from palaeotsunami events from other sites indicates that the investigated harbour sites represent excellent geo-archives for supra-regional mega-tsunamis.

Academic and non-academic conference presentations - are they the same genre? Five case studies.

Il presente elaborato si pone l’obiettivo di determinare se il genere del discorso di conferenza non accademica coincida con il genere del discorso di conferenza accademica, nello specifico per quanto riguarda le loro introduzioni. La prima parte della tesi si concentra sulle basi teoriche. In primo luogo è stata sviluppata una panoramica della letteratura esistente riguardo ai discorsi di conferenza accademica, dalla quale si è poi ristretto il campo sugli studi che hanno preso in esame solo la loro introduzione. Alla luce dell’assenza di pubblicazioni sulle conferenze non accademiche, e di conseguenza anche sui loro discorsi, si è cercato di definire il genere del discorso di conferenza non accademica, applicando il concetto di ‘comunità discorsiva’ sia ai discorsi di conferenza accademica sia a quelli di conferenza non accademica. Una volta stabilito che il contesto non accademico differisce da quello accademico, si è passati a definire l’introduzione dei discorsi di conferenza non accademica in quanto genere. Nella seconda parte dell’elaborato è stata svolta l’analisi di cinque case study, ovvero della trascrizione delle introduzioni di cinque discorsi di conferenza non accademica. A queste è stato applicato il modello di mosse retoriche delle introduzioni dei discorsi di conferenza accademica elaborato da Rowley-Jolivet e Carter-Thomas, per determinare se fosse valido anche per le introduzioni dei discorsi di conferenza non accademica. Una volta scoperto che non lo è, e che quindi le introduzioni dei discorsi di conferenza non accademica e quelle dei discorsi di conferenza accademica sono due 'sotto-generi' diversi, è stato proposto un nuovo modello di mosse retoriche. Infine sono stati avanzati dei suggerimenti riguardo all’applicabilità del suddetto modello, non solo in altri studi nel campo dell’analisi di genere, ma anche nel settore dell’interpretazione simultanea, con particolare riferimento alla preparazione dell’interprete e alla strategia di anticipazione.

Blood glucose and prognosis in children with presumed severe malaria: is there a threshold for 'hypoglycaemia'?

OBJECTIVES: Hypoglycaemia (glucose <2.2 mmol/l) is a defining feature of severe malaria, but the significance of other levels of blood glucose has not previously been studied in children with severe malaria. METHODS: A prospective study of 437 consecutive children with presumed severe malaria was conducted in Mali. We defined hypoglycaemia as <2.2 mmol/l, low glycaemia as 2.2-4.4 mmol/l and hyperglycaemia as >8.3 mmol/l. Associations between glycaemia and case fatality were analysed for 418 children using logistic regression models and a receiver operator curve (ROC). RESULTS: There was a significant difference between blood glucose levels in children who died (median 4.6 mmol/l) and survivors (median 7.6 mmol/l, P < 0.001). Case fatality declined from 61.5% of the hypoglycaemic children to 46.2% of those with low glycaemia, 13.4% of those with normal glycaemia and 7.6% of those with hyperglycaemia (P < 0.001). Logistic regression showed an adjusted odds ratio (AOR) of 0.75 (0.64-0.88) for case fatality per 1 mmol/l increase in baseline blood glucose. Compared to a normal blood glucose, hypoglycaemia and low glycaemia both significantly increased the odds of death (AOR 11.87, 2.10-67.00; and 5.21, 1.86-14.63, respectively), whereas hyperglycaemia reduced the odds of death (AOR 0.34, 0.13-0.91). The ROC [area under the curve at 0.753 (95% CI 0.684-0.820)] indicated that glycaemia had a moderate predictive value for death and identified an optimal threshold at glycaemia <6.1 mmol/l, (sensitivity 64.5% and specificity 75.1%). CONCLUSIONS: If there is a threshold of blood glucose which defines a worse prognosis, it is at a higher level than the current definition of 2.2 mmol/l.

Overweight and obesity in children: known facts and new trends

The prevalence of overweight and obesity in children is increasing. A growing number of children are thus suffering from complications of obesity. Contributing factors can be found on an individual level as well as in the familial and social environment of affected children. Currently there is no single evidence-based treatment strategy available. Studies from family practice are scarce. Multimodal, long-term, easily accessible treatments as offered in family practice are promising and likely to be cost-effective. The sustainability of these changes in behavior still needs to be demonstrated.

Systemic therapy of atopic dermatitis in children and adults

Systemic therapy is required in patients with severe atopic dermatitis (AD) refractory to adequate topical therapy. The aim of a systemic therapy is the rapid and efficient improvement of skin symptoms and pruritus in acute exacerbation and/or the long-term control of severe chronic disease. A number of immunosuppressive and immunomodulating substances are available that may efficiently reduce skin inflammation and thus lead to a relief of symptoms including pruritus. The excellent effects of cyclosporine as short-term as well as maintenance therapy have been documented in several studies in children and adults. Furthermore, other immunosuppressive substances such as azathioprine, mycophenolate mofetil and methotrexate are effective in patients with moderate to severe AD. Intravenous immunoglobulins and γ-interferon exert immunomodulatory effects and thus may improve severe AD. Biological agents are a new approach in AD therapy since they may specifically target cells, cytokines or mediators involved in the pathogenesis of AD.

Growth hormone receptor polymorphism and growth hormone therapy response in children: a bayesian meta-analysis

Recombinant human growth hormone (rhGH) therapy is used in the long-term treatment of children with growth disorders, but there is considerable treatment response variability. The exon 3-deleted growth hormone receptor polymorphism (GHR(d3)) may account for some of this variability. The authors performed a systematic review (to April 2011), including investigator-only data, to quantify the effects of the GHR(fl-d3) and GHR(d3-d3) genotypes on rhGH therapy response and used a recently established Bayesian inheritance model-free approach to meta-analyze the data. The primary outcome was the 1-year change-in-height standard-deviation score for the 2 genotypes. Eighteen data sets from 12 studies (1,527 children) were included. After several prior assumptions were tested, the most appropriate inheritance model was codominant (posterior probability = 0.93). Compared with noncarriers, carriers had median differences in 1-year change-in-height standard-deviation score of 0.09 (95% credible interval (CrI): 0.01, 0.17) for GHR(fl-d3) and of 0.14 (95% CrI: 0.02, 0.26) for GHR(d3-d3). However, the between-study standard deviation of 0.18 (95% CrI: 0.10, 0.33) was considerable. The authors tested by meta-regression for potential modifiers and found no substantial influence. They conclude that 1) the GHR(d3) polymorphism inheritance is codominant, contrasting with previous reports; 2) GHR(d3) genotypes account for modest increases in rhGH effects in children; and 3) considerable unexplained variability in responsiveness remains.

Presentation, microsurgical therapy, and clinical outcomes in three cases of expanding melanonychia of the nail unit in children

The management of expanding melanonychia in childhood is controversial. Here, we present three cases and discuss their operating indications and reconstruction. Between January 1, 1995 and December 31, 2007, one boy and two girls, were operated for expanding melanonychia, involving the thumb, index finger or the middle finger. They were 2, 4, and 7 years at the time of surgery. A complete resection of the nail plate was performed followed by a direct finger reconstruction using a free short-pedicle vascularized nail flap of the toe. Histology showed a junctional nevus in all cases. The follow-ups were after 2, 3, and 5 years and without any complications or recurrence. Regarding reconstruction, the mean Foucher and Leclère score were, respectively, 17 and 16 points. It is concluded that for expanding melanonychia, in case of doubt, an examination of the entire lesion is necessary. Reconstruction of the nail unit after wide excision with nail plate ablation can be performed using microsurgery as discussed below. However, new guidelines on shave biopsy can make this microsurgical procedure obsolete.