[The management of the child with head injury: initial assessment]. / Il management del bambino con trauma cranico: gestione iniziale.

In western countries, head injury is very important in public health; infact it is the main cause of mortality after infancy and a significant cause of long term disability. The patients with severe head injury needs an intensive care unit management, but the initial approach is a critical phase, too. In fact, it is demonstrated that trauma mortality and morbility are significantly reduced by a quick and well conducted approach. This article focuses the initial management of the injured child.

[The management of the child with head injury: our experience]. / Il management del bambino con trauma cranico: nostra esperienza.

OBJECTIVES: To analyze the group of children admitted to our Pediatric Intensive Care Unit (PICU) for neurotrauma and describe the management algorithms adopted by us for pediatric head injury. METHODS: All the children affected by head injury and admitted to PICU since november 1992 to november 2000 have been examined. Injury severity has been classified using the Glasgow Coma Score (GCS), while the long term neurological outcome with the Glasgow Outcome Score (GOS). We have described the clinical presentation, the kind and dynamics of injury and the clinical outcome one month after discharge. RESULTS: 210 children with head injury have been identified. Among them: 38 were affected by mild head injury, 50 by a moderate one and 122 by a severe one. The most frequent cause of injury has been represented by car accidents and motorbike or bicycle falls. The overall outcome has resulted good (GOS 4-5) in all children affected by mild or moderate head injury; on the other side, patients with severe injury have presented the following scores: GOS 1 (dead children) 14.7%, GOS 2 (persistent vegetative state) 1.6%, GOS 3 (severe disability) 22.2%, GOS 4 (mild disability) and GOS 5 (no disability) 61.5%. CONCLUSION: A correct management of children with head injury helps clinicians to improve outcome and to reduce mortality. Therapeutics algorithms suggested by us could be useful for the management of this kind of patients, not only when they are affected by a severe head injury but, also, when they suffer from a mild one, that is the most common event in the emergency room departments.

Malignant transformation of biliary cystadenoma: a difficult diagnosis.

The case is described of a 63-year-old female with a multilocular liver cyst diagnosed as cystadenoma after imaging and fine needle aspiration. The lesion, however, proved to be an invasive cystadenocarcinoma at surgery. Cystadenoma cannot be differentiated, preoperatively, from cystadenocarcinoma and should always be considered for surgical resection.

Early post-traumatic seizures in children with head injury.

Post-traumatic seizures (PTS) can be a serious complication of head injury, because they can cause secondary brain damage through increased metabolic requirements, raised intracranial pressure, cerebral hypoxia, and/or excessive release of neurotransmitters. In children, early PTS are more frequent than late ones. In this retrospective study we conducted an epidemiological analysis and tried to identify potential risk factors for the onset of early PTS in children hospitalized for head injury in our Paediatric Intensive Care Unit. The severity of injury was assessed using the Glasgow Coma Scale (GCS), while the outcome of traumatized children was defined using the Glasgow Outcome Score (GOS). Early PTS were diagnosed in 15 out of the 125 children hospitalized (12%). Most of the children (73.3%), developed seizures within 24 h of the trauma (immediate PTS). Among the risk factors, a very important role was played by the severity of the injury; in fact, the incidence of early PTS among patients with GCS < or = 8 was ten times greater than that among children with GCS 13-15. Other risk factors that significantly influenced the onset of early PTS, were age (60% of children with early PTS were less than 3 years old) and severe cerebral edema. Overall, children with early PTS had a worse outcome than the other patients. In fact, 53% had a GOS of < or = 3 compared to 19.1% of those without early PTS (P<001). In particular, considering children with severe head injury, 80% of those with early PTS had a GOS of < or = 3, compared to 41% of those without early PTS (P<0.05). In conclusion, PTS can be a serious complication of head injury in children, because they can worsen secondary brain damage. Appropriate management of head-trauma patients must include suitable and immediate prophylaxis with anti-epileptic drugs.

Prognostic implications of hyperglycaemia in paediatric head injury.

Fifty children with head injury were evaluated in an attempt to establish a correlation between post-traumatic hyperglycaemia and long-term outcome. In all the patients, the blood glucose level was measured on admission and on the days following the trauma (threshold of normal value set at 150 mg/dl). Hyperglycaemia was seen more frequently in children with severe head injury than in those with mild and moderate head injury. It was present in 87.5% of the patients with a Glasgow Coma Score (GCS) < or =8 (the average blood glucose level on admission was 237.8+/-92 mg/dl), in 60% of the patients with a GCS of 9-12 (178+/-78.7 mg/dl) and only in 25% of those with a GCS of 13-15 (131.5+/-39 mg/dl). A close correlation was also seen between the outcome and the blood glucose level. In fact, the blood glucose on admission was higher in the patients with a poor outcome, i.e. in those having a Glasgow Outcome Score (GOS) of 2 or 3 and in those who died (GOS 1), than in the patients with a good outcome (GOS of 4 or 5). Finally, hyperglycaemia persisted beyond the first 24 h after trauma in all the children who died or who survived with a poor outcome. Hyperglycaemia, and especially its persistence over time, appears to be an important negative prognostic factor in children with head injury.

[Diffuse axonal lesions in childhood]. / La lesione Assonale Diffusa in età pediatrica.

OBJECTIVE: About 48% of all primary traumatic intracranial lesions are represented by so-called Diffuse Axonal Injury (DAI): a pathologic condition characterized by multiple microscopic lesions and hemorrhage at the level of midline cerebral structures, in the subcortical grey matter, and/or within the brainstem. The natural history of DAI is depressing: 100% of the patients deteriorate rapidly to coma and approximately 50% die, while 50% remain in a vegetative state or with severe neurological deficits. In the present report, we describe the results of a study aimed to evaluating the cerebral hemodynamics and the neuroradiological findings observed in four children (6, 8, 10 and 12 years old) affected by DAI. METHODS: All the patients had been admitted to the Pediatric Intensive Care Unit with Glasgow Coma Score (GCS) of 5. On admission, all patients underwent mechanical ventilation, antiedemigen and barbiturates therapy. Serial CT scan and Transcranial Doppler Sonography (TCD) examinations were carried out in all children. TCD of the middle cerebral arteries was performed through the temporal window. The children underwent insertion of a ventricular catheter for intracranial pressure monitoring. Follow-up time has been, respectively, 4 years, 3 years, 7 and 1 months. RESULTS: The Glasgow Outcome Score (GOS) of three children is 2 (persistent vegetative state), while the GOS of the one child is 3 (severe neurological deficits). CONCLUSION: DAI results in unfortunate prognosis and large health care costs. The proper medical management of this condition should be based on TCD and SjO2 and CEO2 evaluations, in order to monitor efficaciously the cerebral blood flow.

Evidence for a missed signal to the CD8+ cells in CSF of multiple sclerosis patients.

Peripheral blood (PB) and cerebrospinal fluid (CSF) lymphocyte subpopulations, defined by various T-cell specific monoclonal antibodies and flow cytometry, were analysed in 44 relapsing remitting multiple sclerosis (RRMS) patients (including 21 subjects in the acute phase and 23 in the stable phase), 40 chronic-progressive multiple sclerosis (CPMS) patients, and 24 patients with other neurological diseases (OND), in order to verify the presence of any abnormality in the lymphocyte subset pattern. A significant increase in the total number of T-lymphocytes and the CD4+ subpopulation was found in the PB of the MS patients in comparison with the OND group. Moreover, a not statistically significant increase in CD4+ cells was observed in the CSF of MS patients. A statistically significant increase was also found in the CD4+ Leu 8+ (suppressor inducer) cells in the CSF of all of the MS groups. Finally, the CD8+ (suppressor/cytotoxic) cell levels, were significantly lower in the CSF of CPMS and stable RMS patients than in the CSF of the OND patients. As a whole, our data suggest that the immunosuppressive deficit that seems to be a constant finding in MS is not due to a decrease in suppressor inducer cell levels, as previously suggested, but may be caused by a missed or altered signal from the suppressor inducer to CD8+ suppressor cells.

[Current status of the use of vitamins (A, E, C, D), folates and selenium in the chemoprevention and treatment of malignant tumors]. / Stato attuale dell'impiego di vitamine (A, E, C, D), folati e selenio nella chemioprevenzione e nel trattamento dei tumori maligni.

The role of vitamins A, E, C, D, folates and selenium in the chemical prevention of tumours and/or precancerous conditions is examined in the light of epidemiological studies and experimental observations. Particular mention is made of significant clinical studies that provide valuable indications about the use of vitamin A and its derivates in particular for the treatment of precancerous and cancerous conditions. Vitamin A and its derivates apparently play a fundamental role not only in the treatment of proliferating malignancies of the skin (carcinomas, severe aclinic keratosis) or involving the skin (fungoid mycosis, skin metastases of solid tumours) but also in the prevention of recurring bladder tumours and the treatment of several bronchial dysplasias.