Vipera berus adder bite in the water, complicated by rapid shock. A case history.

A case of a child who presented with severe and rapid shock after receiving a common adder (vipera berus berus) bite in sea water is presented. Although most poisonous snakebites in Europe tend to be relatively minor and uncomplicated, the present case highlights the need to regard all viper bites as life-threatening accidents, before proved otherwise by a medical professional.

Laparoscopic versus open appendectomy in children: a prospective randomised study.

43 children between the ages of 7 and 15 years with clinical symptoms of acute appendicitis were randomised to an open appendectomy (OA) or a laparoscopic appendectomy (LA). There were 15 acute cases of appendicitis and 5 perforated appendices in the OA group and 17 acute appendicitis, 3 cases of perforated appendices and 3 other diagnoses in the LA group. The operative time was a little shorter in the OA group. There were no differences in hospital stay or the postoperative course of the patients. In the LA group, there were two minor complications, no other complications were seen. When comparing the two surgical methods in the consistent group of patients with non-perforated acute appendicitis no statistical differences were seen in the operative time, hospital stay or in the recovery of the patients between the OA and the LA groups.We conclude that LA has no significant benefit over OA in routine use. In paediatric patients we recommend an open approach for clinically typical acute appendicitis, but there should be no hesitation to choose laparoscopic approach when the clinical diagnosis is unclear.

Surgical closure of patent ductus arteriosus in very-low-birth-weight infants.

In many very-low-birth-weight (VLBW) infants the ductus arteriosus fails to close spontaneously, and they subsequently develop signs and symptoms of poor tissue perfusion and heart failure. This study evalutes the results of early surgical closure of patent ductus arteriosus (PDA). We retrospectively reviewed the records of all 101 VLBW infants who weighed 1,500 g or less when their PDA was surgically ligated in Turku University Hospital between 1988 and 1998. The mean gestational age at birth was 27.2 weeks and mean birth weight 963+/-239 g. The operation was performed at 12+/-8 days of age; the infants' weight at operation was 969+/-231 g and they were tracheally extubated 11+/-14 days after the operation. The surgery-related mortality was 3% (3/101) and overall mortality 10% (10/101). We conclude that surgical closure of PDA is safe and effective in VLBW infants.

Infrequent isolation of multiresistant Acinetobacter baumannii from the staff tending a colonized patient with severe burns.

A patient with severe burns who was colonized by multiresistant Acinetobacter baumannii was cared for in contact isolation by staff intensively trained on hospital hygiene. Of the 1,907 postexposure cultures from the staff and 425 environmental samples, only 0.7% and 4%, respectively, yielded this microorganism. These data show that strict hygienic measures may limit staff colonization and contamination of the environment byA baumannii.

Hyaluronic acid in incision wound fluid: a clinical study with the Cellstick device in children.

When inserted into a human incision wound, the Cellstick device harvests inflammatory cells and collects wound fluid, reflecting time-related changes in cell populations and in wound fluid composition. Hyaluronic acid has been postulated to be an important factor in scar reduction in wound healing and in scarless fetal wound healing. The aim of this work was to determine the concentration and variation of hyaluronic acid and proportions of wound cells in closed surgical wounds in children at two time points. The Cellstick device was inserted subcutaneously into the wound at the end of an elective inguinal hernia operation on 37 healthy boys, and the devices were removed 3+/-1 or 24+/-3 hours after surgery. Haluronic acid concentration was measured from the wound fluid and a differential count of the wound cells was performed. There was a significant decrease in hyaluronic acid concentration from 3+/-1 to 24+/-3 hours after surgery (p<0.001, Kruskal-Wallis anova). The variance of hyaluronic acid concentration in wound fluid differed between the wounds at the two time points (p<0.01, Levene test for homogeneity of variance). A positive correlation between hyaluronic acid concentration and patient age (r=0.91, p<0.05, Spearman) at 3+/-1 hours post surgery and between HA and wound lymphocytes (r=0.38, p<0.05, Spearman) was also found. We conclude that the hyaluronic acid concentration in wound fluid peaks early in children and decreases significantly by 3 to 24 hours after surgery, and the concentrations in the wound fluid of healthy boys are more variable 3 hours than at 24 hours after surgery.

Cerebrospinal fluid flow in children with normal and dilated ventricles studied by MR imaging.

PURPOSE: . To quantify the cerebrospinal fluid (CSF) dynamics in the aqueduct of children with normal and dilated ventricles using MR phase-contrast technique. MATERIAL AND METHODS: Eighteen patients (6 months to 17 years of age) with various neurological symptoms underwent routine brain MR imaging and CSF flow measurement in the aqueduct. Nine patients had normal ventricles, 5 had dilated ventricles and 4 had a ventriculoperitoneal shunt. RESULTS: The CSF velocity and flow rates in the aqueduct in patients with normal and dilated ventricles showed marked inter-individual variation and clear overlap. In a patient with tight aqueductal stenosis and increased ventricular pressure, pronounced CSF flow in the aqueduct was measured. Absence of flow in another patient with aqueductal stenosis was detected. Measurable although low flow in the aqueduct in 4 patients with a ventriculoperitoneal shunt was found. CONCLUSION: Quantitative phase MR flow measurement in the aqueduct demonstrated aqueductal stenosis; these patients had either pronounced flow or no flow in the aqueduct.

Duration of surgery and patient age affect wound healing in children.

The migration of inflammatory cells into a wound and their subsequent changes during wound healing are essential for the complex processes of tissue repair to occur. The aim of this work was to investigate the number of wound leukocytes during early wound healing at different time periods in children. Wound cells of 184 children aged 0-15 years, operated on for a benign disease in the lower abdominal region, were harvested with the Cellstick(R) device. The device was removed from the wound at 3, 6, or 24 hours after surgery and differential cell counts were performed. The cellular patterns were significantly influenced by the age of the patient and by the duration of the surgery. The proportions of neutrophils, lymphocytes, and monocytes changed significantly from 3-24 hours. Our results suggest that there is a distinct time-related change in the pattern of inflammatory cells in the early phase of wound healing in children. This pattern is affected by the age of the child and by the duration of the surgery.

Pancreatic injuries in children.

AIMS: There are several different philosophies in the diagnostics of blunt abdominal trauma (BAT), yet none of them has been shown to be superior, although enhanced computed tomography (CT) and diagnostic ultrasonography (US) seem to be the most used methods today. Treatment of pancreatic injury (PI) in children is a matter of controversy, whether operative treatment is needed and to what extent. MATERIAL AND METHODS: Seventeen pancreatic injuries were found in a retrospective analysis of 111 paediatric patients, aged 2-14 years, who underwent a laparotomy because of BAT, between 1968 and 1995 in Turku University Central Hospital. The number of non-operated BAT patients was calculated as 287. RESULTS: During the past two decades, the number of BATs and operations diminished by more than two thirds, but the number of PIs remained the same. Twelve acute operations led to four pancreatic resections, two external drainages and two explorations. PI was present but not the main reason for operation in four cases. Five PIs were operated on later due to postraumatic pseudocyst of the pancreas. CONCLUSIONS: PI was rare (15%) in laparotomies done because of BAT, operations which have diminished by 74% during the last twenty years. When PI was found, a variety of operative procedures was needed.

Correlation between interleukin-6 and matrix metalloproteinase-9 in early wound healing in children.

Interleukin-6 and matrix metalloproteinase-9 concentrations in the wound fluid and their associations to cellular changes were determined in early wound healing. Wound healing of 75 children who underwent elective operations was studied with the Cellstick(R) device, which was inserted into the wound at the end of the operation and removed 3 or 24 hours post-wounding. Differential counts of the wound cells and interleukin-6 and matrix metalloproteinase-9 concentrations in the wound fluid were analyzed. Interleukin-6 and the matrix metalloproteinase-9 concentrations increased in parallel (r = 0.81). The proportion of wound neutrophils increased (p < 0.0001) and lymphocytes decreased (p < 0. 0001) between the observation times. The number of wound neutrophils had a strong correlation with both interleukin-6 (adjusted R2 = 0.41, p < 0.0001) and matrix metalloproteinase-9 concentrations (adjusted R2 = 0.37, p < 0.0001). The extracellular matrix degradation process of the early wound healing seems to be closely linked to the inflammatory response. Both of these measured markers are associated significantly with the neutrophil proportion in the wound.

Lung compliance during laparoscopic surgery in paediatric patients.

Insufflation of CO2 and positioning of patients induces changes in cardiovascular and respiratory function during laparoscopic procedures. This study was initiated to assess respiratory mechanics such as lung compliance and peak airway pressure (PIP) during laparoscopic surgery in paediatric patients. Ten consecutive patients (age 1-15 years) scheduled for laparoscopic procedure were included in this open prospective single-group study. Anaesthesia was induced and maintained with intravenous infusions of propofol and alfentanil. Vecuronium was administered to maintain muscle relaxation. Head down tilt induced a mean decrease of 17% in lung compliance, which was further decreased by 27% from the baseline during insufflation of intraabdominal CO2 (intraabdominal pressure 12 mmHg). Coincidently, PIP increased by 19% and 32% from the baseline during Trendelenburg position and peritoneal insufflation. Lung compliance and PIP returned to their respective baseline values after removal of CO2 from the peritoneal cavity. Endtidal CO2 increased from a baseline value of 4.3 kPa to 5.4 kPa (33-42 mmHg) during surgery when ventilator settings were not altered. We conclude that insufflation of CO2 induces significant increases in peak airway pressure with simultaneous decreases in lung compliance.

Salivary flow rate, buffer effect, sodium, and amylase in adolescents: a longitudinal study.

The study aimed to provide information on salivary secretion rate, buffer effect, sodium, total protein, and amylase in adolescence. Paraffin-wax-stimulated saliva was collected annually in 69 initially 10-yr-olds and in 98 initially 15-yr-olds. During the 5-yr follow-up, the rate of flow increased in both sexes in the younger age group. In the older age group there was only a slight increase in the flow within the 2-yr follow-up. In both age groups, girls tended to have lower secretion than boys. In cross-sectional analyses, the rate of flow correlated positively with buffer effect and sodium, and negatively with proteins. These findings are in line with earlier observations. However, with age, the buffer effect did not parallel the flow. At the base-line examination the buffer effect was lower in the 15-yr-old than in the younger age group. In line with that, a decrease was found at the final examination in the initially 10-yr-olds. This decrease was stronger in girls than in boys. The observed change in the buffer effect was not related to a parallel change in the flow rate or total protein and amylase content of saliva. In girls the change was, however, associated with a small, but statistically significant drop in the salivary sodium level. The variation in the buffer effect increased from the age of 12 to 15, especially in girls. This effect could not be demonstrated for the other flow-rate-associated variables used to monitor the functioning of the salivary glands.

Preoperative tissue characterization with chemical shift imaging: a case report of an epidermal cyst.

We introduce here a case of an epidermal cyst, which was preoperatively examined with chemical shift MR imaging at 0.1-T magnetic field. The case shows that fat/water separation method can be successfully used in tissue characterization.

Twenty-six early operations in brachial birth palsy.

26 babies with brachial birth palsy were operated on at the age of 12-275 days (mean 75 days) in paediatric surgical departments of Helsinki (12 cases) and Turku (14 cases) University Central Hospitals during years 1970-1985 using microsurgical techniques. Epineuroraphy was used in 9, interfascicular nerve grafting in 7, neurolysis in 7, and intercostal neurotisation in 3 cases. The functional status of the upper extremity was recorded 1 to 14 years after the operation using a modified Mallet's classification: 6 were good, 17 fair and 3 poor. The outcome after epineuroraphy was similar to interfascicular grafting. One intercostal neurotisation resulted in fair function and 2 in poor, but the result in target function, i.g. in the peripheral neurotised nerve, was good.

Early surgical exploration and epineural repair in birth brachial palsy.

The management of birth brachial palsy (Erb-Duchenne, Klumpke) has been traditionally conservative, and that is why the condition leaves some patients with impaired upper limb function for life. Development of anaesthesiology and microsurgical techniques have made safe early surgical repair of selected palsies possible. A 12 years' experience of early exploration of 11 patients aged from 2 weeks to 7 months is evaluated. The technique of direct epineural repair of ruptured roots has been successful in the early treatment of birth palsy. In the follow-up of 1 to 13 years after operation 7/11 patients regained good to excellent hand function.