Acute stress disorder in the paediatric surgical children and adolescents injured during the Wenchuan earthquake in China

The aim of the present study was to investigate the prevalence and symptoms of acute stress disorder (ASD) in the paediatric surgical children and adolescents injured during the Wenchuan earthquake in China. One hundred eighteen children and adolescent inpatients were surveyed by the ASD scale (ASDS) within 1 month of the earthquake. Using the validated ASDS score above cut‐off threshold levels, the incidence of ASD in this sample was 54.3 per cent. The morbidity of ASD were 56.1, 24.6 and 19.3 per cent in the child, in the early adolescent and in the middle adolescent, respectively. There was no significant difference among the three age groups about the severity of ASD symptom. The proportions of ASD positive were 44.0 per cent in boys and 63.6 per cent in girls that showed significant difference. The exposure risk factors were being buried in the earthquake, injury of parent, injury of relatives, amputation and operation. These results indicated that ASD was widely prevalent among the children and adolescents wounded in the earthquake, which needed an effective psychosocial intervention. Copyright © 2009 John Wiley & Sons, Ltd.     

Studies of enuresis VIII. Detrusor and sphincter instability caused by overactivity of integral voiding reflexes

Ninety-one children with nocturnal enuresis or enuresis plus daytime urgency incontinence were studied by cystometry. Seventy-two per cent of the girls and 62 per cent of the boys had evidence of bladder instability. Sixty-eight children in whom abnormalities were found on preliminary voiding urodynamics or voiding cystourethrography also underwent calibration and endoscopic examination under anesthesia. An atropine-suppression test was also performed preoperatively in some children with a markedly unstable bladder demonstrated on preoperative cystometry. In the majority of children tested suppression of bladder instability with atropine was demonstrable. Voluntary detrusor sphincter dyssynergia was demonstrated in a majority of the children with daytime urgency incontinence. Sixty-five per cent of the boys and 81 per cent of the girls were treated for urethral obstructive lesions suspected to be of functional urodynamic significance. Postoperative cystometry showed marked improvement in bladder stability in 57 per cent of the girls and 63 per cent of the boys treated for suspected urethral obstructive pathology. The anticholinergic suppression test was found to have no significant predictive value relative to the cause or surgical curability of bladder instability. The pathophysiologic significance of overactivity of integral voiding reflexes 6 through 11 is described.     

Late results after meniscectomy in children

Seventy-five children undergoing 77 meniscectomies have been reviewed from 1 to 30 years (mean 15) after operation in order to determine the late results of meniscectomy. Arthroscopy of the patients with a poor result was performed at the follow-up. In 30 per cent osteoarthrosis was diagnosed, all with follow-up times from 19 to 25 years. Delay in operation resulted in worse results. The younger the patient the worse the result. The benefit of operation was less in girls than in boys. Bucket-handle lesions and peripheral tears produced the best results after meniscectomy. Fifty-eight per cent of men and 26 per cent of women had symptom-free knees at follow-up. Removing a meniscus is not a benign procedure. Only 44 per cent of patients in whom a damaged meniscus and 17 per cent in whom a normal meniscus had been removed were without symptoms. These results stress the need for making an accurate diagnosis by careful examination and arthroscopy before embarking on meniscectomy in children. Efforts to preserve the meniscus in children must be made whenever possible.     

The acute stress disorder in the paediatric surgical children and adolescents injured in the Wenchuan earthquake of China

The aim of the present study was to investigate the prevalence and the symptoms of acute stress disorder (ASD) in the paediatric surgical children and adolescents injured in the Wenchuan earthquake of China. One hundred and eighteen children and adolescent inpatients were surveyed by the Acute Stress Disorder Scale (ASDS) within 1 month of the earthquake. Using the validated ASDS score above cut‐off threshold levels, the incidence of ASD in this sample was 54.3 per cent. The morbidity of ASD were 56.1, 24.6 and 19.3 per cent in the child group, in the early adolescent group and in the middle adolescent group, respectively. There was no significant difference among the three age groups about the severity of ASD symptom. The proportions of ASD‐positive were 44.0 per cent in males and 63.6 per cent in females that showed significant difference. The exposure risk factors were being buried in the earthquake, injury of parent, injury of relatives, amputation and operation. These results indicated that ASD was widely prevalent among the children and adolescents wounded in the earthquake, which needed an effective psychosocial intervention. Copyright © 2009 John Wiley & Sons, Ltd.     

Growth and predictions of growth in the upper extremity

Teleroentgenograms of the upper extremity in 244 children (123 boys and 121 girls) were made at six-month intervals from the age of seven to the time of skeletal maturity. Lengths were measured to determine the growth remaining at both growth plates of the humerus, radius, and ulna. The subjects were healthy, well nourished, middle-class Americans, mostly of northwest European descent. After the age of seven, the proportion between the upper and lower arms does not change appreciably. The humerus is 18 per cent of standing height in girls at the age of seven and 19 per cent at the age of fifteen. In boys, the humerus is 18 per cent of standing height at the age of seven and 20 per cent at the age of seventeen. The length of the radius is 13 per cent of standing height in girls at the age of seven, increasing to 14 per cent by skeletal maturity. In boys, the length of the radius increases from 14 per cent of standing height at the age of seven to 15 per cent at skeletal maturity. From the age of seven to skeletal maturity, the humerus grows approximately 1.2 centimeters in girls and 1.3 centimeters in boys each year. In girls, the ulna grows approximately 1.0 centimeter and the radius, 0.9 centimeter each year after the age of seven. In boys, the ulna grows approximately 1.1 centimeters and the radius, approximately 1.0 centimeter each year from the age of seven to skeletal maturity. Based on these data, accurate predictions of growth and of growth discrepancy in the upper extremity can be made, and the time at which to perform equalization procedures can be determined more precisely.     

Comparative results of urological evaluation of children with initial and recurrent urinary tract infection.

Complete urologic evaluation was done on male and female children having initial or recurrent urinary tract infection. Of 200 girls having recurrent urinary tract infection 43 per cent showed ureterovesical reflux on the cystogram. Of 39 boys with recurrent urinary tract infection 41 per cent had reflux. Thus, the incidence of reflux is comparable in male versus female patients. Of 47 girls studied after only 1 episode of urinary tract infection 36 per cent had reflux and of 20 boys studied after initial infection 45 per cent had reflux. The data indicate that initial or recurrent urinary tract infection in boys or girls is of equal significance. All other factors being equal, failure to evaluate a patient urologically after 1 or more episodes of urinary tract infection solely because of the sex of the child could mean that a potentially severe urinary tract abnormality can be undetected and untreated.     

Post‐awakening changes in salivary cortisol in veterans with and without PTSD

Cortisol shows a well‐documented circadian rhythm with peak levels observed shortly after awakening and steadily decreasing values thereafter. This is a relatively robust diurnal pattern that is displayed by most non‐ill individuals, but recently it has been shown that in the general population some 10–15 per cent of individuals have ‘flat’ circadian cycles of cortisol. We have analyzed post‐awakening variations in levels of salivary cortisol in veterans without post‐traumatic stress disorder (PTSD), veterans with diagnosed PTSD that were not hospitalized, and hospitalized veterans with PTSD. ‘Flat’ circadian cycles of salivary cortisol were observed in 6 per cent of veterans without PTSD, 29 per cent of non‐hospitalized veterans with PTSD, and 42 per cent of veterans hospitalized for PTSD. Copyright © 2004 John Wiley & Sons, Ltd.     

Meniscectomy in children: results in 59 knees

Forty-nine children undergoing meniscectomy have been reviewed. Fifty-nine knees were examined with a mean follow-up period of 7.5 years. There was an equal number of operations in both sexes, with a high proportion of operations on the lateral meniscus. A good result was noted in 68 per cent of boys and 29 per cent of girls. Only 27 per cent of patients had normal radiographs; 19 per cent had early osteoarthrosis. The preoperative diagnosis was correct in only 65 per cent of cases. It is concluded that meniscectomy is not a benign procedure in children, and that preoperative assessment should include arthroscopy and possibly arthrography.     

Systematic review of the risk of developing a metachronous contralateral inguinal hernia in children

BACKGROUND: This study aims to establish the risk of developing a metachronous contralateral inguinal hernia (MCIH) following open repair of a unilateral inguinal hernia in children. METHODS: A systematic review was performed using a defined search strategy. Studies in which children undergoing open repair of a unilateral inguinal hernia without contralateral exploration and who were followed up for MCIH development were included. RESULTS: Of 5937 titles and abstracts screened, 154 full-text articles were identified for review; 49 papers were analysed with data on 22,846 children. The incidence of MCIH was 7.2 per cent overall, 6.9 per cent in boys and 7.3 per cent in girls (P = 0.381). Children with a left-sided inguinal hernia had a significantly higher risk of developing a MCIH than those with a right-sided hernia (10.2 versus 6.3 per cent respectively; P < 0.001). CONCLUSION: Overall, in both boys and girls, 14 contralateral explorations are required to prevent one metachronous hernia. The risk of developing a MCIH appears unchanged in early childhood, with a slight reduction after 12 years of age. Children with a left-sided hernia have the greatest risk of developing a contralateral hernia, but ten explorations are still required to prevent one metachronous hernia. Most MCIHs occur in the first 5 years after unilateral inguinal hernia repair.     

The vesical sphincter electromyogram in children with normal and abnormal voiding patterns

Recording the vesical sphincter electromyogram clarifies abnormal patterns of voiding in children. Since the electromyogram patterns in children with normal voiding patterns have not yet been evaluated, we recorded the sphincter electromyograms during voiding of 39 children with normal voiding patterns. These normal electromyograms were compared to those recorded in 86 children with abnormal voiding patterns. Each of the 39 children with a normal voiding pattern demonstrated synergy of the vesical sphincter during voiding. Of the 86 children with an abnormal voiding pattern 69 per cent demonstrated synergy and 31 per cent demonstrated dyssynergia of the vesical sphincter during voiding. Of the children with dyssynergia 89 per cent were girls and only 11 per cent were boys. Sphincter dyssynergia was demonstrated only by children with an abnormal pattern of voiding and those with a history of a normal pattern of voiding demonstrated only sphincter synergy (p less than 0.005). The electromyographic diagnoses of vesical sphincter synergy and dyssynergia obtained by surface electrode recordings correlated with the clinical voiding patterns of the children.     

Influence of a 3‐year exercise intervention program on fracture risk,bone mass,and bone size in prepubertal children

Published prospective pediatric exercise intervention studies are short term and use skeletal traits as surrogate endpoints for fractures, whereas other reports infer exercise to be associated with more trauma and fractures. This prospective, controlled exercise intervention study therefore followed both skeletal traits and fracture risk for 36 months. Fractures were registered in children aged 7 to 9 years; there were 446 boys and 362 girls in the intervention group (2129 person‐years) and 807 boys and 780 girls in the control group (4430 person‐years). The intervention included school physical education of 40 minutes per day for 3 years. The control children achieved the Swedish standard of 60 minutes per week. In a subsample of 76 boys and 48 girls in the intervention group and 55 boys and 44 girls in the control group, bone mineral content (BMC, g) and bone width (cm) were followed in the lumbar spine and hip by dual‐energy X‐ray absorptiometry (DXA). The rate ratio (RR) for fractures was 1.08 (0.71, 1.62) [mean (95% confidence interval)]. In the DXA‐measured children, there were no group differences at baseline in age, anthropometrics, or bone traits. The mean annual gain in the intervention group in lumbar spine BMC was 0.9 SD higher in girls and 0.8 SD higher in boys (both p < .001) and in third lumbar vertebra width 0.4 SD higher in girls and 0.3 SD higher in boys (both p < .05) than in control children. It is concluded that a moderately intense 3‐year exercise program in 7‐ to 9‐year‐old children increases bone mass and possibly also bone size without increasing fracture risk. © 2011 American Society for Bone and Mineral Research     

Survey of 1000 admissions to a burns unit SSKM hospital,Calcutta

A series of 1000 cases treated in our Burns Unit in Calcutta is reported. Of those, 688 cases (68·8 per cent) were between the ages 11 to 50 years, 274 (27·4 per cent) were children below 10 years and the remaining 38 (3·8 per cent) were above 50 years. Out of the children, 180 were boys and 94 girls. In the adult group there were 354 males and 372 females. Mortality rate was 20·4 per cent in this series. This high figure is due to the high rate of suicide; 74 out of 204 deaths were due to suicidal burns. In these cases, burns were extensive and deep in nature and the patients have no will to live. In the remaining 130 cases, the burns were caused by domestic or industrial accidents. Overall mortality rate was much lower than when the burns cases were treated in general wards along with surgical and medical cases.This paper brings out the importance of having a separate burns unit for acute burns cases, where specially trained nursing staff and doctors look after the patients.     

The efficacy of early propranolol administration at reducing PTSD symptoms in pediatric injury patients: A pilot study

Initial research supports the use of propranolol to prevent posttraumatic stress disorder (PTSD); research has not examined pharmacological prevention for children. Twenty‐nine injury patients (ages 10–18 years old) at risk for PTSD were randomized to a double‐blind 10‐day trial of propranolol or placebo initiated within 12 hours postadmission. Six‐week PTSD symptoms and heart rate were assessed. Although intent‐to‐treat analyses revealed no group differences, findings supported a significant interaction between gender and treatment in medication‐adherent participants, ΔR² = .21. Whereas girls receiving propranolol reported more PTSD symptoms relative to girls receiving placebo, ΔR² = .44, boys receiving propranolol showed a nonsignificant trend toward fewer PTSD symptoms than boys receiving placebo, ΔR² = .32. Findings inform gender differences regarding pharmacological PTSD prevention in youth.     

Work stress and performance among financial traders

This study investigated factors associated with work stress and performance among professional decision‐makers in financial markets. Three hundred and twenty‐six financial traders completed questionnaires while supervisors provided performance ratings. Of these 32 per cent of traders reported ‘very high’ or ‘extremely high’ stress levels. Overall, traders ranked ‘profit goal’ as the highest stressor followed by ‘long working hours’. Traders' experience of occupational stress was based on four main factors: Profit Pressure, Social Pressure, Work Load, and Decision‐Processing. These factors varied systematically across different trading roles. Proprietary traders with higher performance ratings experienced less stress. Similar stress ‘profiles’ of North American and European traders indicate universal responses to job demands. Trader work stress is possibly mitigated through self‐selection and substantial latitude over trading style. Copyright © 2005 John Wiley & Sons, Ltd.     

Abnormalities of muscle metabolism and histology in malnourished patients awaiting surgery: effects of a course of intravenous nutrition

Malnourished surgical patients have metabolic and functional abnormalities of skeletal muscle and it has been suggested that these are due to reduced activities of glycolytic enzymes associated with abnormalities of muscle fibres. We have measured the activities of four key enzymes of glucose utilization and the size and distribution of muscle fibre types in vastus lateralis biopsies from 14 undernourished patients awaiting surgery (mean weight loss 24 +/- 10 per cent). These results were compared with those from 14 normally nourished controls, comparable in age, sex, race and habitual activity. Fructose bisphosphatase activity was reduced in undernourished patients by 44 per cent (P less than 0.01), phosphofructokinase by 40 per cent (P = 0.005) and hexokinase by 37 per cent (P less than 0.001). Both fibre types were smaller in patients than controls (area I, 41.4 micron2 X 10(-2) +/- 0.4 vs. 73.3 micron2 X 10(-2) +/- 0.6, less than 0.001; area II, 27.7 micron2 X 10(-2) +/- 0.4 vs. 72.5 micron2 X 10(-2) +/- 0.5, P less than 0.001), and there was a smaller proportional number of type II fibres in patients (35 per cent vs. 65 per cent, P less than 0.01). This loss of type II fibre numbers and preferential type II atrophy may account for the enzyme depression associated with it and could produce the syndrome of impaired glucose tolerance, muscle weakness and fatigue seen in undernourished patients. In a subgroup of 11 patients, biopsy was repeated after 14 days of intravenous nutrition. Only phosphofructokinase activity rose significantly (19.62 +/- 1.85 to 30.74 +/- 2.99 mumol min-1 g-1, P less than 0.01) and both type II fibre size (40.6 +/- 18.5 to 47.4 micron2 +/- 20.3 X 10(-2), P less than 0.05) and number (42 per cent +/- 6 to 56 per cent +/- 5, P less than 0.05) also rose. Intravenous nutrition may therefore increase maximum glycolytic rate and improve muscle function in undernourished surgical patients.     

Sex Differences and Growth‐Related Adaptations in Bone Microarchitecture,Geometry, Density,and Strength From Childhood to Early Adulthood: A Mixed Longitudinal HR‐pQCT Study

Sex differences in bone strength and fracture risk are well documented. However, we know little about bone strength accrual during growth and adaptations in bone microstructure, density, and geometry that accompany gains in bone strength. Thus, our objectives were to (1) describe growth related adaptations in bone microarchitecture, geometry, density, and strength at the distal tibia and radius in boys and girls; and (2) compare differences in adaptations in bone microarchitecture, geometry, density, and strength between boys and girls. We used HR‐pQCT at the distal tibia (8% site) and radius (7% site) in 184 boys and 209 girls (9 to 20 years old at baseline). We aligned boys and girls on a common maturational landmark (age at peak height velocity [APHV]) and fit a mixed effects model to these longitudinal data. Importantly, boys showed 28% to 63% greater estimated bone strength across 12 years of longitudinal growth. Boys showed 28% to 80% more porous cortices compared with girls at both sites across all biological ages, except at the radius at 9 years post‐APHV. However, cortical density was similar between boys and girls at all ages at both sites, except at 9 years post‐APHV at the tibia when girls’ values were 2% greater than boys’. Boys showed 13% to 48% greater cortical and total bone area across growth. Load‐to‐strength ratio was 26% to 27% lower in boys at all ages, indicating lower risk of distal forearm fracture compared with girls. Contrary to previous HR‐pQCT studies that did not align boys and girls at the same biological age, we did not observe sex differences in Ct.BMD. Boys’ superior bone size and strength compared with girls may confer them a protective advantage. However, boys’ consistently more porous cortices may contribute to their higher fracture incidence during adolescence. Large prospective studies using HR‐pQCT that target boys and girls who have sustained a fracture are needed to verify this. © 2016 American Society for Bone and Mineral Research.     

Short communication: Occupational stress and burnout among South African medical practitioners

The aim of this study was to identify job stress and burnout symptoms among randomly selected South African medical practitioners from a national survey. The sample included 402 doctors, 59.5 per cent male and 40.5 per cent female. The majority were Whites (59.3 per cent), followed by African Black (21.3 per cent), and Asians (14 per cent). Results showed that the overall job stress index indicated with 4.9, high job stress levels among the doctors. High severity job stress ratings included (1) fellow workers not doing their job, (2) inadequate salary and (3) covering work for another employee and high frequency of job stress, (4) working overtime, making critical on‐the‐spot decisions and dealing with crisis situations. Female doctors felt significantly more lack of support on job stress severity than male doctors. High levels of burnout (emotional exhaustion and depersonalization) were found among doctors. Job stress predicted emotional exhaustion and depersonalization but not personal accomplishment. Emotional exhaustion was associated with female doctors and personal accomplishment was significantly related to male doctors. White doctors reported more job stress and also burnout symptoms than doctors with colour. Copyright © 2003 John Wiley & Sons, Ltd.     

Content validation of a novel robotic surgical simulator

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

? To assess the content validity of an early prototype robotic simulator. Minimally invasive surgery poses challenges for training future surgeons. The Robotic Surgical Simulator (RoSS) is a novel virtual reality simulator for the da Vinci Surgical System.

PATIENTS AND METHODS

? Participants attending the 2010 International Robotic Urology Symposium were invited to experience RoSS. Afterwards, participants completed a survey regarding the appropriateness of the simulator as a teaching tool.

RESULTS

? Forty‐two subjects including surgeons experienced with robotics (n= 31) and novices (n= 11) participated in this study. ? Eighty per cent of the entire cohort had an average of 4 years of experience with robot‐assisted surgery. ? Eleven (26%) novices lacked independent robot‐assisted experience. The expert group comprised 17 (41%) surgeons averaging 881 (160–2200) robot‐assisted cases. Experts rated the ‘clutch control’ virtual simulation task as a good (71%) or excellent (29%) teaching tool. ? Seventy‐eight per cent rated the ‘ball place’ task as good or excellent but 22% rated it as poor. ? Twenty‐seven per cent rated the ‘needle removal’ task as an excellent teaching tool, 60% rated it good and 13% rated it poor. ? Ninety‐one per cent rated the ‘fourth arm tissue removal’ task as good or excellent. ? Ninety‐four per cent responded that RoSS would be useful for training purposes. ? Eighty‐eight per cent felt that RoSS would be an appropriate training and testing format before operating room experience for residents. ? Seventy‐nine per cent indicated that RoSS could be used for privileging or certifying in robotic surgery.

CONCLUSION

? Results based on expert evaluation of RoSS as a teaching modality illustrate that RoSS has appropriate content validity.     

The role of laparoscopic evaluation to detect a contralateral defect at initial presentation for inguinal hernia repair

Our objective was to determine the accuracy of laparoscopic evaluation to detect a contralateral patent processus vaginalis (CPPV) at initial presentation for inguinal hernia (IH) repair and the rate of CPPV relative to age, sex, and initial hernia side. We performed a 5-year retrospective review of 1580 pediatric patients with unilateral IH in which surgeons selectively used laparoscopy to evaluate for a CPPV. There were 1205 boys and 303 girls; 980 (65%) presented with right IH (RIH) and 528 (35%) with left IH (LIH). Laparoscopic evaluation was performed in 459 (47%) patients presenting with RIH and 225 (43%) patients presenting with LIH. Laparoscopic evaluation was positive for CPPV in 32 per cent of patients with RIH and 42 per cent of patients with LIH (P = 0.0168). CPPV was associated with prematurity (P = 0.0003) and age younger than 6 months (P = 0.0001) but not with sex (P = 0.55). The future contralateral occurrence rate was 1.6 per cent and recurrence rate 0.2 per cent. This study supports the accuracy of CPPV evaluation by laparoscopy. Although the rate of CPPV decreases after 6 months of age, girls older than 2 years of age have a significantly higher rate of CPPV than boys, supporting laparoscopic evaluation in older girls.