Neuroimaging in childhood arterial ischaemic stroke: evaluation of imaging modalities and aetiologies

Aim The aim of this study was to describe neuroimaging patterns associated with arterial ischaemic stroke (AIS) in childhood and to differentiate them according to stroke aetiology. Method Clinical and neuroimaging (acute and follow‐up) findings were analysed prospectively in 79 children (48 males, 31 females) aged 2 months to 15 years 8 months (median 5y 3mo) at the time of stroke by the Swiss Neuropaediatric Stroke Registry from 2000 to 2006. Results Stroke was confirmed in the acute period in 36 out of 41 children who underwent computed tomography, in 53 of 57 who underwent T2‐weighted magnetic resonance imaging (MRI) and in all 48 children who underwent diffusion‐weighted MRI. AIS occurred in the anterior cerebral artery (ACA) in 63 participants and in all cases was associated with lesions of the middle cerebral artery (MCA). The lesion was cortical–subcortical in 30 out of 63 children, cortical in 25 out of 63, and subcortical in 8 of 63 children. Among participants with AIS in the posterior circulation territory, the stroke was cortical–subcortical in 8 out of 16, cortical in 5 of 16, and thalamic in 3 out of 16 children. Interpretation AIS mainly involves the anterior circulation territory, with both the ACA and the MCA being affected. The classification of Ganesan is an appropriate population‐based classification for our Swiss cohort, but the neuroimaging pattern alone is insufficient to determine the aetiology of stroke in a paediatric population. The results show a poor correlation between lesion pattern and aetiology.     

Intranasal immunization with yeast-expressed 19 kD carboxyl-terminal fragment of Plasmodium yoelii merozoite surface protein-1 (yMSP119) induces protective immunity to blood stage malaria infection in mice

Variable protection against malaria blood-stage infection has been demonstrated in mice following parenteral immunization with the highly conserved 19 kD carboxylterminal fragment of the merozoite surface protein-1 (MSP1₁₉) using CFA/IFA and other adjuvants. Here we show that intranasal immunization of BALB/C mice with yeast expressed Plasmodium yoelii MSP1₁₉ plus a mixture of native and recombinant cholera toxin B subunit, could induce serum MSP1₁₉-specific antibodies at titres ranging from 20 000 to 2 560 000. The Ig subclass responses were predominantly G1 and G2b. Intranasal immunization led to protection following challenge (peak parasitaemia < 1%) in mice with the highest MSP1₁₉-specific titre (≥ 640 000). In two of the three protected mice, a peak parasitaemia of 0.1%–1% was followed by a boost of the antibody response whereas one of the three protected mice did not boost its antibody response after a peak parasitaemia of 0.02%. In unprotected mice, antibody levels rose, then fell, following the detection of parasites in the peripheral blood. CD4⁺ T cell-depletion abrogated the ability of the mice to boost their antibody response following challenge. These data demonstrate the potential for intranasal immunization with MSP1₁₉ to protect against malaria .     

Surgical Excision versus Curettage plus Cryosurgery in the Treatment of Basal Cell Carcinoma

BACKGROUND: Both cryosurgery, with and without prior curettage, and surgical excision (SE) are common therapeutic strategies for basal cell carcinoma (BCC). OBJECTIVE: The objective was to compare the efficacy between curettage plus cryosurgery (C&C) and SE in nonaggressive BCC of the head and neck. MATERIALS AND METHODS: A randomized controlled trial was carried out, in which tumors were assigned to either C&C (n=51) or SE (n=49). C&C was performed with a double freeze-thaw cycle after prior curettage of the tumor. SE was performed with a margin of 3 mm and with delayed histologic examination. RESULTS: Recurrences occurred 9 times after C&C (17.6%) and 4 times after SE (8.2%). The overall 5-year recurrence probability was 19.6% for C&C and 8.4% for SE (p=.10). A hazard ratio of 2.57 (95% CI, 0.79-8.34) indicated a putative, but not statistically significant, advantage of SE. CONCLUSION: These data reflect the outcome of the first randomized controlled trial with long-term follow-up in the treatment of BCC, comparing C&C with SE. Although not statistically significantly different, the observed differences could still be of clinical relevance. Owing to the trend toward lower recurrence rates, better cosmetic results, and reduced wound healing time, we believe that SE should be preferred to C&C in the treatment of primary, nonaggressive BCC of the head and neck.     

Predictors and consequences of incarceration among a sample of young Thai methamphetamine users

Introduction and Aims. Our study examined the incidence of arrest and incarceration, investigated predictors of incarceration and explored the persistence of depression, alcohol use and drug use after incarceration among young methamphetamine users from Thailand. Design and Methods. Participants were aged 18–25 years old and were a part of a 12 month randomised social network trial that aimed to reduce sexual risk and methamphetamine use. Estimates of the incidence of arrest and incarceration over 12 months were calculated. A matched case–control study (n = 73 cases; n = 223 controls) was performed to examine incarceration risk factors using conditional logistic regression. Persistence of drug‐risk behaviours were explored after incarceration. Results. Study participants (n = 950) were 72% male, with a median age of 19 years and a median of 9 years of schooling. Frequent drug and alcohol use were reported at baseline. In total, 35% of the sample reported ever having been arrested and 22% reported ever having been incarcerated at baseline. During the 12 month follow up, 16% of the sample was arrested. In univariate analyses, risk factors for incarceration included frequent drug and alcohol use, being less educated, and a history of arrest and incarceration. A high prevalence of drug and alcohol use and involvement in the drug economy persisted after arrest. Discussion and Conclusions. The study indicates a high prevalence of recidivism among this young sample, with continued involvement in drug‐risk behaviours after incarceration. Appropriate interventions are needed to address root causes of arrest, largely related to substance use.[Sherman SG, Sutcliffe CG, Srirojn B, German D, Thomson N, Aramrattana A, Celentano DD. Predictors and consequences of incarceration among a sample of young Thai methamphetamine users. Drug Alcohol Rev 2010]     

Cerebral sinus venous thrombosis in Swiss children

Aim To describe the characteristics of paediatric cerebral sinus venous thrombosis (CSVT) in Switzerland. Method Data on clinical features, neuroimaging, risk factors, and treatment were collected for all children in Switzerland younger than 16 years of age who had CSVT between January 2000 and December 2008. A follow‐up examination and a cognitive assessment were performed (mean follow‐up period 26mo). Differences between neonates and children (patients older than 28d) were assessed and predictors of outcome were determined. Results Twenty‐one neonates (14 males, seven females; mean age 9d, SD 8d) and 44 children (30 males, 14 females; mean age 8y 7mo, SD 4y 5mo) were reported. The incidence of paediatric CSVT in Switzerland was 0.558 per 100 000 per year. In neonates, the deep venous system was more often involved and parenchymal injuries were more common. The strongest predictor of poor outcome was neonatal age (odds ratio 17.8, 95% confidence interval 0.847–372.353). Most children showed global cognitive abilities within the normal range, but impairments in single cognitive subdomains were frequent. Interpretation Paediatric CSVT is rare. Its outcome is poor in neonates. Most children have good neurological outcomes, but some patients have individual neuropsychological impairments.     

Exhaled carbon monoxide screening for environmental tobacco smoke exposure in preanesthetic children

Objective:  Exposure to environmental tobacco smoke (ETS) is associated with an increased risk of perioperative adverse events in children. The purpose of this study was to evaluate exhaled carbon monoxide (CO) as a preoperative ETS screening tool in children.
Methods:  Five hundred and one children aged 6–15 years were enrolled. The child's guardian completed a questionnaire that surveyed environmental exposures to CO and ETS. A preoperative urine sample was obtained from children who assented and were able to void, and urine cotinine values were measured. Exhaled CO was measured using the EC50-Micro Smokerlyzer^® (Bedfont Scientific Ltd, UK).
Results:  Four hundred and fifty-one subjects completed the study, and urine samples were obtained from 83. 25% of subjects were classified as exposed to ETS based on questionnaire results. Exhaled CO values did not correlate with either the qualitative (questionnaire) or quantitative (urine cotinine) measurements of ETS exposure. Exhaled CO predicted a urine cotinine/creatinine ratio >10 with a sensitivity of 10% and a specificity of 85%.
Conclusion:  Exhaled CO measured by this device is not a useful preoperative screening tool for ETS exposure in children. Because exhaled CO has been used successfully to monitor ETS exposure in adolescents, we believe that its failure in our population is as a result of the limited ability of small children to perform vital capacity maneuvers in order to provide an adequate endtidal sample.     

Continuous incisional infusion of local anesthetic in pediatric patients following open heart surgery

Aim: To determine the efficacy and safety of a continuous subcutaneous local anesthetic (LA) infusion in pediatric patients following open heart surgery. Background: The use of a continuous LA infusion has been shown to be beneficial following adult cardiac surgery. To date there are no studies in the pediatric population. Methods/Materials: Using a prospective, randomized, and double blind design, we compared LA, either 0.25% levobupivacaine or bupivacaine (Treatment Group) to saline (Placebo Group) delivered subcutaneously via a continuous infusion for 72 h after open heart surgery in 72 patients. Requirements for postoperative analgesics and pain scores were recorded for 72 h and plasma levels of local anesthetic were measured. Secondary outcomes measures included time to first oral intake, time to first bowel movement, time to urinary catheter removal, length of stay, requirements for antiemetics and additional sedation. Results: Total morphine requirements over the first 24 h were less in the Treatment Group than the Placebo Group (0.05 mg·kg^?1 vs 0.2 mg·kg^?1, P = 0.007); this was true for all patient groups except those patients weighing less than 6.3 kg. The number of patients requiring no morphine was greater in the Treatment Group (7/35 vs 1/37, P = 0.02). The Treatment Group also received less midazolam, lorazepam, and ketorolac than the Placebo Group over 72 h due to the reduced clinical need for these agents in patients weighing less than 31 kg. There were no differences in secondary outcomes. Conclusions: A continuous incisional infusion of LA reduced postoperative analgesic requirement and sedative use in pediatric patients undergoing a median sternotomy incision. Dosed at a maximum rate of 0.4 mg·kg^?1·h^?1, a continuous incisional infusion of LA is effective and safe for up to 72 h, with plasma levels of local anesthetic well below the toxic threshold.     

Community participation in formal decision-making mechanisms

This article deals with the formal mechanisms of populationparticipation: with any sort of institutional form of participationaimed at decision-making concerning health in the community.A case study concerning Community Health Councils (England andWales) and the fluoridation of the water supply illustratesthe following points: (i) the defensive or protester role ofthe population in decision-making: the population may want toshare power without changing the rules of the game or may wishto change the norms and values put forward by the authorities;(ii) the lay versus the expert approaches of those professionalsmandated to represent the population; (iii) the democratic representationof a heterogeneous population within a health service. Resultsshow that a health committee may participate effectively, evenin an advisory capacity, and that conflicts may be seen as anindicator of the reality of participation. Implications forthe development of population participation include the distinctionbetween expertise and decision-making the need for the communityto develop networking of sub-groups and organizations, and theshift from a democratic representation of the population toa polyarchy system (the rule of minorities).     

Dynorphin in bovine adrenal medulla

The presence and secretion of immunoreactive dynorphin in bovine adrenal medulla and isolated adrenal chromaffin cells were examined and compared with those of immunoreactive leucine-enkephalin. Using an antiserum raised against dynorphin-(1–13), a sensitive and highly specific radioimmunoassay was developed. A nearly intact antigen was required for recognition by the antiserum since it did not react with leucine-enkephalin and reacted poorly with dynorphin-(1–12) (cross-reactivity 0.5%) and other fragments of dynorphin-(1–13). On the other hand, the antibody used for detection of leucine-enkephalin did not cross-react with dynorphin-(1–13). Adrenal medulla acid extracts contained 195 times more immunoreactive leucine-enkephalin than dynorphin. However, the concentration of immunoreactive dynorphin in acid extracts of freshly isolated adrenal chromaffin cells was only 1.4 times smaller than that of leucine-enkephalin. Incubation of the isolated chromaffin cells in the presence of acetylcholine, nicotine, high potassium, but not muscarine, induced a concomitant release of immunoreactive dynorphin (3.5–9% of total cell content) and leucine-enkephalin (6.5–11.4% of total cell content).     

Does ultrasound guidance improve the efficacy of dorsal penile nerve block in children?

Background: Penile nerve block (PNB) is a well‐established technique used for circumcision; it requires the injection of local anesthetics close to the dorsal nerve of the penis. The goal of this study was to compare the efficacy of ultrasound‐guided PNB versus the classical landmark‐based technique (LBT) in children undergoing circumcision. Methods: Forty boys, aged 1–14 years old that were scheduled for circumcision were randomly assigned to ultrasound‐guided and landmark‐based groups. All patients were placed under standard anesthesia with sevoflurane. In each group, patients received the penile block with ropivacaine, 0.75 mg·kg^?1 per side, and 0.05 mg·kg^?1 at the penis base. Groups were compared for intraoperative failure rate of the block, anesthesia time, postoperative pain scale, time of first required dose of paracetamol, time to first micturition, and average duration of stay in the postanesthesia care unit. Results: The failure rate of dorsal PNB was not statistically different between groups (P = 0.5). Ultrasound guidance improved the efficacy of the PNB compared to the LBT in terms of postoperative pain scores on arrival in the PACU (P < 0.01) and after 30 min (P < 0.01). The ultrasound‐guided technique also delayed the time to the first paracetamol dose administration (P < 0.0001), but the duration of the procedure, defined as the time between anesthesia induction and the end of surgery, was increased by 10 min in the US‐guided group (P = 0.001). Conclusion: Ultrasound‐guided PNB improved the efficacy of the block compared with the LBT in terms of the postoperative pain during the first postoperative hour and the time to the first requirement for postoperative analgesia.