Intentional injury against children in Sub-Saharan Africa: A tertiary trauma centre experience

BackgroundIntentional injuries are the result of violence. This is an important public health issue, particularly in children, and is an unaddressed problem in sub-Saharan Africa. This study sought to describe the characteristics of intentional injury, particularly physical abuse, in children presenting to our tertiary trauma centre in Lilongwe, Malawi and how they compare to children with unintentional injuries.MethodsA retrospective analysis of children (<18 years old) with traumatic injuries presenting to Kamuzu Central Hospital (KCH) in Lilongwe, Malawi from 2009 to 2013 was performed. Children with intentional and unintentional injuries were compared with bivariate analysis and multivariate logistic regression modelling.Results67,672 patients with traumatic injuries presented to KCH of which 24,365 were children. 1976 (8.1%) patients presented with intentional injury. Intentional injury patients had a higher mean age (11.1 ± 5.0 vs. 7.1 ± 4.6, p < 0.001), a greater male preponderance (72.5 vs. 63.6%, p < 0.001), were more often injured at night (38.3 vs. 20.7%, p < 0.001), and alcohol was more often involved (7.8 vs. 1.0%, p < 0.001). Multivariate logistic regression modelling showed that increasing age, male gender, and nighttime or urban setting for injury were associated with increased odds of intentional injury. Soft tissue injuries were more common in intentional injury patients (80.5 vs. 45.4%, p < 0.001) and fist punches were the most common weapon (25.6%). Most patients were discharged in both groups (89.2 vs 80.9%, p < 0.001) and overall mortality was lower for intentional injury patients (0.9 vs. 1.2%, p = 0.001). Head injury was the most common cause of death (43.8 vs. 32.2%, p < 0.001) in both groups.ConclusionsSub-Saharan African tertiary hospitals are uniquely positioned to play a pivotal role in the identification, clinical management, and alleviation of intentional injuries to children by facilitating access to social services and through prevention efforts.     

The outcomes of pediatric femoral shaft fractures treated surgically by different types of orthopedists

BackgroundThe objective of this study was to compare the outcomes of pediatric femoral shaft fractures treated with titanium elastic nail (TEN) by pediatric orthopedists and non-pediatric orthopedists.MethodsFrom May 2006 to June 2014, 88 children with femoral shaft fractures were randomized to operative stabilization either by pediatric orthopedists (Group A, 44 cases) or by non-pediatric orthopedists (Group B, 44 cases). Demographic data and clinical characteristics (age, sex, weight, fracture side and type, cause of injury, associated injuries and interval from injury to surgery) were comparable between the two groups before surgery. Peri-operative data, clinical and functional outcomes between the two groups were recorded.ResultsThe mean follow-up period was 20.9 ± 4.5 months for Group A and 20.0 ± 3.6 months for Group B (P = 0.356). There was no significant difference in the time to union, length of hospitalization, full weight-bearing time and TEN scores between the two groups (P = 0.785, P = 0.835, P = 0.803, P = 0.940, respectively). However, the mean operating time and radiation time was longer in Group B than in Group A (P = 0.001 and P = 0.047, respectively). Also, there was a trend for patients of Group B to have a higher rate of open reduction (P = 0.047). When comparing the total complications, no significant difference existed between the groups (P = 0.978).ConclusionsThis study indicated that both pediatric and non-pediatric orthopedists provided satisfactory clinical and functional results in treating these common injuries.     

Diagnostic performance of ultra-low dose versus standard dose CT for non-traumatic abdominal emergencies

PurposeThe purpose of this study was to compare the diagnostic performance of ultra-low dose (ULD) to that of standard (STD) computed tomography (CT) for the diagnosis of non-traumatic abdominal emergencies using clinical follow-up as reference standard.Materials and methodsAll consecutive patients requiring emergency abdomen-pelvic CT examination from March 2017 to September 2017 were prospectively included. ULD and STD CTs were acquired after intravenous administration iodinated contrast medium (portal phase). CT acquisitions were performed at 125 mAs for STD and 55 mAs for ULD. Diagnostic performance was retrospectively evaluated on ULD and STD CTs using clinical follow-up as a reference diagnosis.ResultsA total of 308 CT examinations from 308 patients (145 men; mean age 59.1 ± 20.7 (SD) years; age range: 18–96 years) were included; among which 241/308 (78.2%) showed abnormal findings. The effective dose was significantly lower with the ULD protocol (1.55 ± 1.03 [SD] mSv) than with the STD (3.67 ± 2.56 [SD] mSv) (P < 0.001). Sensitivity was significantly lower for the ULD protocol (85.5% [95%CI: 80.4–89.4]) than for the STD (93.4% [95%CI: 89.4–95.9], P < 0.001) whereas specificities were similar (94.0% [95%CI: 85.1–98.0] vs. 95.5% [95%CI: 87.0–98.9], respectively). ULD sensitivity was equivalent to STD for bowel obstruction and colitis/diverticulitis (96.4% [95%CI: 87.0–99.6] and 86.5% [95%CI: 74.3–93.5] for ULD vs. 96.4% [95%CI: 87.0–99.6] and 88.5% [95%CI: 76.5–94.9] for STD, respectively) but lower for appendicitis, pyelonephritis, abscesses and renal colic (75.0% [95%CI: 57.6–86.9]; 77.3% [95%CI: 56.0–90.1]; 90.5% [95%CI: 69.6–98.4] and 85% [95%CI: 62.9–95.4] for ULD vs. 93.8% [95%CI: 78.6–99.2]; 95.5% [95%CI: 76.2–100.0]; 100.0% [95%CI: 81.4–100.0] and 100.0% [95%CI: 80.6–100.0] for STD, respectively). Sensitivities were significantly different between the two protocols only for appendicitis (P = 0.041).ConclusionIn an emergency context, for patients with non-traumatic abdominal emergencies, ULD-CT showed inferior diagnostic performance compared to STD-CT for most abdominal conditions except for bowel obstruction and colitis/diverticulitis detection.     

Computed tomography findings in young children with minor head injury presenting to the emergency department greater than 24 h post injury

BackgroundLarge studies which developed decision rules for the use of Computed tomography (CT) in children with minor head trauma excluded children with late presentation (more than 24 h).ObjectiveTo assess the prevalence of significant traumatic brain injury (TBI) on CT in infants with head trauma presenting to the emergency department (ED) more than 24 h from the injury.MethodsA retrospective chart review of infants less than 24 months old referred for head CT because of traumatic brain injury from January 2004 to December 2014 in Assaf-Harofeh medical center was conducted. We used the PECARN definitions of TBI on CT to define significant CT findings.Results344 cases were analyzed, 68 with late presentation.There was no significant difference in the age between children with late and early presentation (mean 11.4 (SD 5.6) month vs 10. 5 (SD 7.0) month, P = 0.27). There was no significant difference between the groups in the incidence of significant TBI (22% vs 19%, p = 0.61). Any TBI on CT (e.g. fracture) was found in 43 (63%) patients with late presentation compared with 116 (42%) patients with early presentation (p = 0.002, OR 2.37, 95% CI 1.37–4.1).ConclusionA similar rate of CT-identified traumatic brain injury was detected in both groups.‏ There was no significant difference in the incidence of significant TBI on CT between the groups.‏ Young children presenting to the ED more than 24 hours after the injury may have abnormal findings on CT.     

Dietary essential amino acids are highly anabolic in pediatric patients with cystic fibrosis

BackgroundCurrent nutritional approaches have been partially successful in Cystic Fibrosis (CF). Essential amino acids mixtures with high Leucine levels (EAA) have anabolic properties in catabolic conditions, however data in CF are lacking.MethodsOn two days according a randomized crossover design, 15 pediatric CF patients ingested 6.7 g EAA versus mixture of total amino acids as present in whey. Whole body protein and Arginine metabolism (as EAA lack Arginine) were assessed by stable isotope methodology.ResultsProtein synthesis (P < 0.05) but not protein breakdown was higher after EAA and 70% higher values for net anabolism (P < 0.001)were found both in patients with and without nutritional failure. Arginine turnover was lower (P < 0.001) and de novo Arginine synthesis tended lower (P = 0.09) after EAA. Nitric oxide synthesis was not different.ConclusionsCF patients are highly responsive to EAA intake independent of their nutritional status. Addition of Arginine to the EAA mixture may be warranted in CF.     

Mortality following helicopter versus ground transport of injured children

IntroductionInjured children may be transported to trauma centers by helicopter air ambulance (HAA); however, a benefit in outcomes to this expensive resource has not been consistently shown in the literature and there is concern that HAA is over-utilized. A study that adequately controls for selection biases in transport mode is needed to determine which injured children benefit from HAA. The purpose of this study was to determine if HAA impacts mortality differently in minimally and severely injured children and if there are predictors of over-triage of HAA in children that can be identified.MethodsChildren ≤18 years of age transported by HAA or ground ambulance (GA) from scene to a trauma center were identified from the 2010–2011 National Trauma Data Bank. Analysis was stratified by Injury Severity Score (ISS) into low ISS (≤15) and high ISS (>15) groups. Following propensity score matching of HAA to GA patients, conditional multivariable logistic regression was performed to determine if transport mode independently impacted mortality in each stratum. Rates and predictors of over-triage of HAA were also determined.ResultsTransport by HAA occurred in 8218 children (5574 low ISS, 2644 high ISS) and by GA in 35305 (30506 low ISS, 4799 high ISS). Overall mortality was greater in HAA patients (4.0 vs 1.4%, p < 0.001). After propensity score matching, mortality was equivalent between HAA and GA for low ISS patients (0.2 vs 0.2%, p = 0.82) but, for high ISS patients, mortality was lower in HAA (9.0 vs 11.1% p = 0.014). On multivariable analysis, HAA was associated with decreased mortality in high ISS patients (OR = 0.66, p = 0.017) but not in low ISS patients (OR = 1.13, p = 0.73). Discharge within 24 h of HAA transport occurred in 36.5% of low ISS patients versus 7.4% high ISS patients (p < 0.001).ConclusionsBased on a national cohort adjusted for nonrandom assignment of transport mode, a survival benefit to HAA transport exists only for severely injured children with ISS >15. Many children with minor injuries are transported by helicopter despite frequent dismissal within 24 h and no mortality benefit.     

Prevalence and Risk Factors for Hypertrophic Scarring of Split Thickness Autograft Donor Sites in a Pediatric Burn Population

TitlePrevalence and Risk Factors for Hypertrophic Scarring of Split Thickness Autograft Donor Sites in a Pediatric Burn Population.ObjectiveThe split-thickness autograft remains a fundamental treatment for burn injuries; however, donor sites may remain hypersensitive, hyperemic, less pliable, and develop hypertrophic scarring. This study sought to assess the long-term scarring of donor sites after pediatric burns.MethodsA retrospective review of pediatric burn patients treated at a single institution (2010–2016) was performed. Primary outcomes were prevalence of donor site hypertrophic scarring, scarring time course, and risk factor assessment.Results237 pediatric burn patients were identified. Mean age at burn was 7 yrs., mean %TBSA was 26% with 17% being Full Thickness. Mean follow-up was 2.4 yrs. Hypertrophic scarring was observed in 152 (64%) patients with 81 (34%) patients having persistent hypertrophic scarring through long-term follow-up. Patient-specific risk factors for hypertrophic scarring were Hispanic ethnicity (P = 0.03), increased %TBSA (P = 0.03), %Full Thickness burn (P = 0.02) and total autograft amount (P = 0.03). Donor site factors for hypertrophic scarring were longer time to epithelialization (P < 0.0001), increased donor site harvest depth (P < 0.0001), autografts harvested in the acute burn setting (P = 0.008), and thigh donor site location (vs. all other sites; P < 0.0001). The scalp, arm, foot, and lower leg donor sites (vs. all other sites) were less likely to develop HTS (P < 0.0001, 0.02, 0.005, 0.002, respectively), along with a history of previous donor site harvest (P = 0.04).ConclusionsHypertrophic scarring is a prominent burden in donor site wounds of pediatric burn patients. Knowledge of pertinent risk factors can assist with guiding management and expectations.     

Parada cardiaca relacionada con la anestesia en pediatría. Registro en un hospital infantil terciario

ObjectivesThe aim of this study is to analyze the cardiac arrests related to anesthesia in a tertiary children's hospital, in order to identify risk factors that would lead to opportunities for improvement.MethodsA 5-year retrospective study was conducted on anesthesia related cardiac arrest occurring in pediatric patients. All urgent and elective anesthetic procedures performed by anesthesiologists were included. Data collected included patient characteristics, the procedure, the probable cause, and outcome of the cardiac arrest. Odds ratio was calculated by univariate analysis to determine the clinical factors associated with cardiac arrest and mortality.ResultsThere were a total of 15 cardiac arrests related to anesthesia in 43,391 anesthetic procedures (3.4 per 10,000), with an incidence in children with ASA I-II versus ASA ≥III of 0.28 and 19.27 per 10,000, respectively. The main risk factors were children ASA ≥ III (P < .001), less than one month old (P < .001), less than one year old (P < .001), emergency procedures (P < .01), cardiac procedures (P < .001) and procedures performed in the catheterization laboratory (P < .05). The main causes of cardiac arrest were cardiovascular (53.3%), mainly due to hypovolemia, and cardiovascular depression associated with induction of anesthesia, followed by respiratory causes (20%), and medication causes (20%). The incidence of mortality and neurological injury within the first 24 h after the cardiac arrest was 0.92 and 1.38 per 10,000, respectively. The mortality in the first 3 months was 1.6 per 10,000. The main causes of death were ASA ≥ III, age under one year, pulmonary arterial hypertension, cardiac arrest in areas remote from the surgery area, a duration of cardiopulmonary resuscitation over 20 min, and when hypothermia was not applied after cardiac arrest.ConclusionThe main risk factors for cardiac arrest were ASA ≥ III, age under one year, emergency procedures, cardiology procedures and procedures performed in the catheterization laboratory. The main cause of the cardiac arrest was due mainly to cardiovascular hypovolemia. All patients who died or had neurological injury were ASA ≥ III. Pulmonary arterial hypertension is a risk of anesthesia-related mortality.     

Simultaneous head and facial computed tomography scans for assessing facial fractures in patients with traumatic brain injury

IntroductionPatients with traumatic brain injury (TBI) may have concomitant facial fractures. While most head injury patients receive head computed tomography (CT) scans for initial evaluation, the objective of our study was to investigate the value of simultaneous facial CT scans in assessing facial fractures in patients with TBI.MethodsFrom January 1, 2015 to December 31, 2015, 1649 consecutive patients presenting to our emergency department (ED) with a TBI who received CT scans using the protocol for head and facial bones were enrolled. The clinical data and CT images were reviewed via a standardized format.ResultsIn our cohort, 200 patients (12.1%) had at least one facial fracture shown on the CT scans. Patients with facial fractures were more likely to have initial loss of consciousness (ILOC; p < 0.001), a Glasgow coma scale of 8 or less (p < 0.001), moderate or severe degrees of head injury severity scale (p < 0.001), positive physical examination findings (p < 0.001), and positive CT cranial abnormalities (p < 0.001). A total of 166 (83.0%) patients with facial fractures required further facial CT scans instead of conventional head CT scans alone. Surgical intervention was mandatory in 73 (44.0%) of the 166 patients, who more frequently exhibited fractures of the lower third of the face (p < 0.001) and orbital fractures (p = 0.019).ConclusionsTBI patients with risk factors may have a higher probability of concomitant facial fractures. Fractures of the lower third of the face and orbit are easily overlooked in routine head CT scans but often require surgical intervention. Therefore, simultaneous head and facial CT scans are suggested in selected TBI patients.     

Profil épidémiologique et clinique,et survie à 90 jours des patients incidents en hémodialyse chronique au cours de la pandémie à SARS-CoV2 au Cameroun : expérience de l’hôpital général de Douala

BackgroundThe effect of COVID-19 pandemic on end stage renal disease patient who should initiated dialysis are limited in Sub-Saharan Africa is unknown. We sought to describe the epidemiologic and clinical profile of newly admitted patient in chronic haemodialysis during the COVID-19 pandemic in Cameroon and evaluate their survival between 90 days of dialysis initiation.Material and methodWe conducted a cohort study of 6 months from April to October 2020. End stage renal disease patients newly admitted in the haemodialysis facility of the General Hospital of Douala were included. Patients with confirmed or suspected COVID-19 were identified. Socio-demographic, clinical and biological data at dialysis initiation as well as mortality between the 90 days of dialysis initiation were registered.ResultsA total of 57 incident patients were recorded from April to October 2020 with a monthly mean of 9.5 patients. The mean age was 46.95 ± 13.12 years. Twenty-four COVID-19 were identified with a frequency of 49% among emergency admission. Pulmonary œdema (79.2% vs. 42.4%; P = 0.006) and uremic encephalopathy (83.4% vs. 53.6%; P = 0.022) were more common in COVID-19. The overall survival at 90 days was 48% with a tendency to poor survival among COVID-19 and patients with low socioeconomic level. In Cox regression, low socioeconomic level increase the risk of instant death by 3.08.ConclusionSARS-CoV2 seem to increase nephrology emergency and poor survival in haemodialysis at 90 days.     

The functional muscle–bone unit in patients with osteogenesis imperfecta type I

ContextOsteogenesis imperfecta (OI) type I is a heritable bone fragility disorder that is caused by mutations affecting collagen type I. We recently showed that patients with OI type I frequently have muscle weakness. As muscle force and bone mass are usually closely related, we hypothesized that muscle weakness in OI type I could contribute to increase bone mass deficit in the lower extremities.ObjectiveTo assess the muscle–bone relationship in the lower extremities of children and adolescents with OI type I.SettingThe study was carried out in the outpatients department of a pediatric orthopedic hospital.Patients and other participantsThirty children and adolescents with OI type I (20 females; mean age [SD]: 11.2 years [3.9]) were compared with 30 healthy age- and sex-matched controls (mean age [SD]: 11.1 years [4.5]).Main outcome measuresTibia bone mineral content (BMC; mg/mm) was measured by peripheral quantitative computed tomography to estimate bone strength at the 4% and 14% sites. Lower extremity peak force (kN) was measured by mechanography using the multiple two-legged hopping test.ResultsCompared with age- and sex-matched controls, patients with OI type I had 17% lower peak force (1.3 kN vs. 1.7 kN; p = 0.002) as well as a 22% lower BMC (128 mg/mm vs. 165 mg/mm; p < 0.001). Stepwise regression analysis showed that muscle force and tibia length were positively related to bone strength (r² = 0.90, p < 0.001) whereas there was no effect of the disease status (OI vs. control).ConclusionsThese results suggest that the muscle–bone relationship is similar between children and adolescents with OI type I and healthy age and sex-matched controls. It also suggests that muscle weakness may contribute to decreased bone strength in individuals with OI type I.     

Bone mineral density at diagnosis determines fracture rate in children with acute lymphoblastic leukemia treated according to the DCOG-ALL9 protocol

PurposeTo elucidate incidence and risk factors of bone mineral density and fracture risk in children with Acute Lymphoblastic Leukemia (ALL).MethodsProspectively, cumulative fracture incidence, calculated from diagnosis until one year after cessation of treatment, was assessed in 672 patients. This fracture incidence was compared between subgroups of treatment stratification and age subgroups (Log-Rank test). Serial measurements of bone mineral density of the lumbar spine (BMD_LS) were performed in 399 ALL patients using dual energy X-ray absorptiometry. We evaluated risk factors for a low BMD (multivariate regression analysis). Osteoporosis was defined as a BMD_LS ≤ − 2 SDS combined with clinical significant fractures.ResultsThe 3-year cumulative fracture incidence was 17.8%. At diagnosis, mean BMD_LS of ALL patients was lower than of healthy peers (mean BMD_LS = − 1.10 SDS, P < 0.001), and remained lower during/after treatment (8 months: BMD_LS = − 1.10 SDS, P < 0.001; 24 months: BMD_LS = − 1.27 SDS, P < 0.001; 36 months: BMD_LS = − 0.95 SDS, P < 0.001). Younger age, lower weight and B-cell-immunophenotype were associated with a lower BMD_LS at diagnosis. After correction for weight, height, gender and immunophenotype, stratification to the high risk (HR)-protocol arm and older age lead to a larger decline of BMD_LS (HR group: β = − 0.52, P < 0.01; age: β = − 0.16, P < 0.001). Cumulative fracture incidences were not different between ALL risk groups and age groups. Patients with fractures had a lower BMD_LS during treatment than those without fractures. Treatment-related bone loss was similar in patients with and without fractures (respectively: ΔBMD_LS = − 0.36 SDS and ΔBMD_LS = − 0.12 SDS; interaction group time, P = 0.30). Twenty of the 399 patients (5%) met the criteria of osteoporosis.ConclusionLow values of BMD_LS at diagnosis and during treatment, rather than the treatment-related decline of BMD_LS, determine the increased fracture risk of 17.8% in children with ALL.     

Annual Review Clinic improves care in children with cystic fibrosis

BackgroundIt is unclear whether annual multidisciplinary reviews in cystic fibrosis (CF) patients should be conducted in dedicated annual review (AR) clinics or during continuous assessments throughout the year. Our aim was to assess the effect of introducing an AR clinic.MethodsA retrospective written and electronic record review of CF patients was carried out for 2007 (no AR Clinic) and 2010 (established AR Clinic) calendar years. An internet-based satisfaction survey was distributed to families attending the AR clinic.ResultsIn total, 123 children (mean age 9.5 years, range 1.32–18.8 years) and 141 children (8.3 years, 1.1–18.3 years) were included in 2007 and 2010 respectively. There was a significant increase in multidisciplinary reviews (documented annual review 28% vs 85%, P < 0.001; dietary assessment 46% vs 92%, P < 0.001) and investigations (OGTT 2% vs 74%, P < 0.001; abdominal ultrasound 35% vs 85%, P < 0.001) conducted after the introduction of AR clinic. The majority of the families surveyed (85%) were satisfied or very satisfied with the AR clinic.ConclusionsCF AR clinic significantly improves the number of annual investigations and multidisciplinary reviews performed. Families were satisfied with this new process.     

Ultrasound guided transversus abdominis plane block in pediatric patients undergoing laparoscopic surgery

ObjectiveTo assess safety and effectiveness of ultrasound-guided TAP block in children undergoing laparoscopic surgery for undescended testis.Subjects and methodsThis randomized controlled trial involved 108 children, 3–7 years old, randomly allocated into one of two equal groups; TAP Group and Control Group. All children received general anesthesia using propofol 1.5–2.5 mg/kg, atracurium 0.5 mg/kg and fentanyl 2 μg/kg. TAP Group received 0.5 ml/kg of ropivacaine 0.375% bilaterally under ultrasound guidance and control group received regular analgesics. Quality of analgesia was assessed using Children’s Hospital Eastern Ontario Pain Scale (CHEOPS) and Objective behavioral pain score (OPS). The primary outcome measures were hemodynamic parameters and degree of pain. Secondary outcome measures were intraoperative fentanyl requirement, postoperative rescue analgesia (time and dose), complications, hospital stay and degree of satisfaction of patients and their parents.ResultsTAP block group had significantly lower intraoperative fentanyl dose (p < 0.001), significantly longer time to first postoperative request of analgesic (p < 0.001), lower analgesic dose during the first postoperative 24 h (p < 0.001) and lower pain scores along the whole 24 postoperative hours. Mean arterial pressure and heart rate were within the clinically accepted range in the two groups. Parents’ satisfaction was significantly higher (p < 0.001) in the TAP block group.ConclusionTAP block under ultrasound guidance was easy, safe, reliable and effective analgesic in children undergoing laparoscopic surgery for undescended testis.     

Dexmedetomidine as supplement to low-dose levobupivacaine spinal anesthesia for knee arthroscopy

AimTo evaluate efficiency of dexmedetomidine compared to fentanyl as supplements to low-dose levobupivacaine spinal anesthesia in patients undergoing knee arthroscopy.Materials and methodsSixty adult patients (ASA I or II) scheduled for knee arthroscopy were randomized to receive plain levobupivacaine (4 mg) plus dexmedetomidine (3 μg) in group D or fentanyl (10 μg) in group F.ResultsDexmedetomidine shortened time to surgery (P = 0.002), time to highest sensory level (P = 0.001), and time to highest Bromage score (P < 0.001). The highest sensory level was comparable in both groups (P = 0.969), but the duration of sensory block was significantly longer in group D (P = 0.009). The highest Bromage score was 2 in both groups. This score was attained in significant higher number of patients in group D (P = 0.038) that showed better muscular relaxation (P = 0.035). At the end of surgery, a residual motor block (Bromage score 1) was observed in significant higher number of patients (P = 0.033) and time to ambulation was significantly longer in group D (P = 0.001). There was no difference in the number of patients bypassed post-anesthesia care unit (PACU) (P = 0.761) or time to hospital discharge (P = 0.357) between groups. The pain free period was more prolonged (P < 0.001), and the visual analog scale (VAS) for pain was lower at the 2nd, 4th, 6th, and 8th postoperative hours (P < 0.001, <0.001, 0.013, 0.030 respectively) in group D.ConclusionDexmedetomidine is a good alternative to fentanyl for supplementation of low-dose levobupivacaine spinal anesthesia for knee arthroscopy.     

Effects of differential-phase remote ischemic preconditioning intervention in laparoscopic partial nephrectomy: A single blinded,randomized controlled trial in a parallel group design

Study ObjectiveThere are two windows of protection for remote ischemic preconditioning (RIPC), an early (ERIPC) and a late-phase (LRIPC). While ERIPC has been well studied, works on LRIPC are relatively scarce, especially for the kidneys. We aimed to compare the effects of early-phase versus late-phase RIPC in patients with laparoscopic partial nephrectomy (LPN).DesignA randomized controlled studySettingThe Second Affiliated Hospital of Anhui Medical University, 1 May 2012 to 30 October 2013PatientsSixty-five ASA 1 to 2 patients scheduled for LPN were located randomly to ERIPC group, LRIPC group and CON group (control).InterventionsThree five-minute cycles of right upper limb ischaemia and reperfusion were performed after induction of anesthesia in ERIPC group. Patients in LRIPC group received similar treatment 24 h before surgery, while control patients were not subjected to preconditioning.MeasurementsSerum neutrophil gelatinase-associated lipocalin (NGAL) and serum cystatin C (CysC) were evaluated before the induction of anesthesia (0h), 2 h (2 h) and 6 h (6 h) after surgery. Unilateral glomerular filtration rates (GFR) were assessed before and after surgery to evaluate overall renal function.Main ResultsSerum NGAL and CysC were significantly lower in ERIPC and LRIPC groups at 2h post-operation (P < 0.001), 6h post-operation (P < 0.001). Additionally, The GFR were significantly lower in ERIPC and LRIPC groups than in CON group at the 3rd month after surgery (P = 0.019; P < 0.001). Moreover, compared to the ERIPC group, concentration of NGAL and CysC in LRIPC group decreased to a greater extent, while GFR and the percentage of decrement was significantly less in the LRIPC group (P = 0.016; P < 0.001).ConclusionsRegardless of early-phase or late-phase intervention, limb remote ischemic preconditioning confers protection on renal ischemia-reperfusion injury in patients with laparoscopic partial nephrectomy, and the late-phase protection is more prominent.     

Prehospital use of hemostatic dressings in emergency medical services in the Netherlands: A prospective study of 66 cases

BackgroundUncontrolled haemorrhage is the leading cause of potentially preventable death in both civilian and military trauma patients. Animal studies and several case series have shown that hemostatic dressings reduce haemorrhage and might improve survival. One of these products is HemCon ChitoGauze^®. The objective of this study was to determine the effectiveness and safety of ChitoGauze in achieving hemostasis in massive traumatic bleeding in civilian emergency medical services.MethodsFrom June 2012 to December 2014, all ambulances of two emergency medical services in the Netherlands were equipped with ChitoGauze. The dressing was used according to protocol; if conventional treatment (gauze dressing with manual pressure) failed to control external traumatic bleeding or if conventional treatment was unlikely to achieve hemostasis. The ambulance personnel filled in an evaluation form after each use.ResultsA total of 66 patients were treated with ChitoGauze during the study period. Twenty-one patients were taking anticoagulants or suffered from a clotting disorder. The injuries were located in the extremities (n = 29), the head and face (n = 29), or the neck, thorax and groin (n = 8). In 46/66 patients, the use of ChitoGauze resulted in cessation of haemorrhage. In 13/66 patients, Chitogauze application reduced haemorrhage. ChitoGauze failed to control haemorrhage in 7/66 patients, whereby user error was a contributing factor in 3 of these failures. No side effects have been observed during treatment or transport of the patients and no adverse effects have been reported in discharge letters.ConclusionThis is the largest prospective study in civilian healthcare and the second largest case series with prehospital use of hemostatic dressings. It demonstrated that ChitoGauze is an effective and safe adjunct in the prehospital treatment of massive external traumatic haemorrhage.     

Ovarian tumors in children and adolescents: A series of 41 cases

ObjectivePictorial review with a detailed semiological analysis of ovarian tumors in children and adolescents to provide a relevant diagnostic approach.Patients and methodsRetrospective study (2001–2011) of 41 patients under the age of 15 who underwent surgery for an ovarian mass with a definite pathological diagnosis.ResultsSixty-two percent of the lesions were benign, 33% were malignant and 5% were borderline. Germ cell tumors were most frequent (77.5%), followed by sex cord stromal tumors (12.5%) and epithelial tumors (7.5%). Malignant tumors were more frequent in children between 0 and 2 years old. On imaging, calcifications and fat were specific for germ cell tumors; the presence of a mural nodule was predictive of a mature teratoma (P < 0.001). Predictive factors for malignancy were clinical, including abdominal distension (P < 0.01) or a palpable mass (P = 0.05), biological, including increased hCG and/or AFP levels (P < 0.001) and radiological, including tumors larger than 12 cm (P < 0.05), tumoral hypervascularity (P < 0.01) and voluminous ascites (P < 0.01).ConclusionThis semiological analysis confirms the role of imaging in diagnosing the etiology of ovarian lesions in children and adolescents and emphasizes the importance identifying tumoral hypervascularity, which, in addition to classic criteria, is highly predictive of malignancy.