A cross-sectional survey to determine the ages of emergence of permanent teeth of Caucasian children of the Colchester area of the UK.

OBJECTIVE: To determine the ages of emergence of permanent teeth of Caucasian children of the Colchester area of the UK. METHODS: Emergence data for all permanent teeth except third molars was collected from 12,395 children between four and 15 years of age, in the Colchester area of the UK between April 1998 and July 2001. A simple, robust, easy-to-follow experimental protocol was devised to provide reliable data collection. RESULTS: The ages of emergence of the permanent teeth in this study which covered the period 1998-2001 in this Colchester population are later than earlier studies conducted throughout the twentieth century. CONCLUSION: If confirmed, the results of this study would suggest that contemporary children's dental development is retarded which may have implications for their general health. The type of study reported here may have long-term value in rapidly identifying trends in children's development of public health importance.

Paediatric trauma: injury pattern and mortality in the UK.

OBJECTIVE: Trauma accounts for a large proportion of childhood deaths. No data exist about injury patterns within paediatric trauma in the UK. Identification of specific high-risk injury patterns may lead to improved care and outcome. METHODS: Data from 24 218 paediatric trauma cases recorded by the Trauma Audit and Research Network (TARN) from 1990 to 2005 were analysed. Main injury, injury patterns and outcome were analysed. Mortality at 93 days' post-injury was the major outcome measure. RESULTS: Limb injuries occurred in 65.0% of patients. In infants 81.4% of head injuries were isolated, compared with 46.5% in 11-15-year-old children. Thoracic injuries were associated with other injuries in 68.4%. The overall mortality rate was 3.7% (n = 893). Mortality decreased from 4.2% to 3.1%; this was most evident in non-isolated head injuries. It was low in isolated injuries: 1.5% (n = 293). In children aged 1-15 years the highest mortalities occurred in multiple injuries including head/thoracic (47.7%) and head/abdominal injuries (49.9%). Having a Glasgow Coma Scale of <15 on presentation to hospital was associated with a mortality of 16%. CONCLUSIONS: Differences in injury patterns and mortality exist between different age groups and high-risk injury patterns can be identified. With increasing age, a decline in the proportion of children with head injury and an increase in the proportion with limb injury were observed. This information is useful for directing ongoing care of severely injured children. Future analyses of the TARN database may help to evaluate the management of high-risk children and to identify the most effective care.

An unusual midline swelling--case report of a cutaneous bronchogenic cyst.

Cutaneous bronchogenic cyst remains a very rare cause of a midline swelling in children. The authors report a case of a 14-month-old boy who presented with a sternal sinus and consequent abscess. Histopathological analysis revealed this to be a cutaneous bronchogenic cyst. This is a very rare lesion with only 65 cases reported in the literature. It is caused by an abnormal development in the distal tracheobronchial tree, and diagnosis is confirmed by ciliated and mucin-producing pseudostratified columnar epithelium of respiratory type on histopathological analysis. It is managed by resection of the cyst, as these cysts are often foci for subsequent infections and malignant potential has been reported.

Thermal energy conduction in a honey bee comb due to cell-heating bees.

Theoretical analysis and numerical calculations are performed to characterize the unsteady two-dimensional conduction of thermal energy in an idealized honey bee comb. The situation explored corresponds to a comb containing a number of brood cells occupied by pupae. These cells are surrounded by other cells containing pollen which, in turn, are surrounded (above) by cells containing honey and (below) by vacant cells containing air. Up to five vacant cells in the brood region can be occupied by cell-heating bees which, through the isometrical contraction of their flight muscles, can generate sufficient energy to raise their body temperatures by a few degrees. In this way, the cell-heating bees alter the heat flux and temperature distributions in the brood region so as to maintain conditions that benefit the pupae. The calculations show that the number of cell-heating bees significantly affects the magnitude, time rate of change, and spatial distribution of temperature throughout the comb. They also reveal a vertically aligned asymmetry in the spatial distribution of temperature that is due to the large heat capacity and thermal conductivity of honey relative to air, whereby air-filled cells experience larger temperature increases than honey-filled cells. Analysis shows that convection and radiation represent negligible modes of thermal energy transfer at all levels in the problem considered. Also, because of its small thickness, the wax wall of a comb cell simultaneously presents negligible resistance to conduction heat transfer normal to it and very large resistance along it. As a consequence the walls of a cell play no thermal role, but simply serve as mechanical supports for the materials they contain.

Patterns and risks in spinal trauma.

BACKGROUND: Spinal injury in children is rare, and poses many difficulties in management. AIMS: To ascertain the prevalence of spinal injury within the paediatric trauma population, and to assess relative risks of spinal injury according to age, conscious level, injury severity score (ISS), and associated injuries. METHODS: Spine injured children were identified from the UK Trauma Audit & Research Network Database from 1989 to 2000. Relative risks of injury were calculated against the denominator paediatric trauma population. RESULTS: Of 19 538 on the database, 527 (2.7%) suffered spinal column fracture/dislocation without cord injury and 109 had cord injury (0.56% of all children; 16.5% of spine injured children). Thirty children (0.15% of all children; 4.5% of spine injured children) sustained spinal cord injury without radiological abnormality (SCIWORA). Cord injury and SCIWORA occurred more commonly in children aged < or =8. The risk of spine fracture/dislocation without cord injury was increased with an ISS >25 and with chest injuries. The risk of cord injury was increased with reduced GCS, head injury, and chest injury. CONCLUSIONS: Spinal cord injury and SCIWORA occur more frequently in young children. Multiple injuries and chest injuries increase the risk of fracture/dislocation and of cord injury. Reduced GCS and head injuries increase the risk of cord injury.

Extraluminal migration of a coin in the oesophagus of a child misdiagnosed as asthma.

Ingestion of a foreign body, the commonest being a coin, is a common problem in children. In most cases the coin will pass uneventfully through the gastrointestinal tract. However, on rare occasions it may become lodged in the oesophagus with subsequent extraluminal migration with the potential for serious complications such as vascular fistula or chronic suppurative infection. A case is presented of extraluminal migration of a coin in the oesophageal associated with abscess formation in a 15 month old boy. This case is particularly important because the presenting symptom of wheezing led to the erroneous diagnosis of asthma, which resulted in a three month delay in investigation and treatment. In addition, it raises the issue of whether to perform chest radiography on newly diagnosed asthmatic patients to rule out the presence of a foreign body and thereby prevent serious complications.

Patterns of management of intussusception outside tertiary centres.

BACKGROUND/PURPOSE: Intussusception is a common problem in young children and should have an excellent outcome in expert hands. Many children are treated in district general hospitals (DGH), which do not have specialist paediatric surgeons. The aim of this study was to clarify current patterns of management for such patients. METHODS: The authors conducted a postal survey of DGH consultant paediatricians, radiologists, and general surgeons in a populous region of England. RESULTS: One hundred forty-one (44%) consultants who responded comprised similar proportions of consultants from each specialty. Most respondents (79%) thought that in their location paediatricians should take responsibility for resuscitation of children with suspected intussusception. Two-thirds indicated that abdominal ultrasound scan, either alone or in combination with another modality, was their investigation of choice for confirming the diagnosis. Preferences for contrast medium for radiologic reduction varied; paediatricians favoured air (46%) or saline (28%), surgeons preferred water-soluble contrast (58%), and radiologists preferred to use barium (49%). Fifty-three percent of consultants indicated they would transfer a child with confirmed intussusception to a tertiary centre before attempting reduction, 42% would attempt reduction locally, and 5% would operate locally without attempting radiologic reduction. After failed reduction, a further 23% of consultants would consider transfer, but the remainder would operate locally. Only 13% of paediatricians thought that their surgeons had appropriate facilities and support to operate on intussusception, but 36% of surgeons claimed to be doing so. Most consultants (84%) admitted seeing fewer than 5 cases per year; 98% of surgeons were in this group. Only 16% of consultants (mostly paediatricians) were aware of any written clinical policy for managing paediatric intussusception in their hospital. CONCLUSION: This study shows that the management of paediatric intussusception outside tertiary centres is not uniform or standardised, and that improvements are necessary. J Pediatr Surg 36:312-315.

Bolus intravenous infusion of amino acids or lipids does not stimulate gallbladder contraction in neonates on total parenteral nutrition.

BACKGROUND/PURPOSE: Stimulation of gallbladder contraction in patients receiving total parenteral nutrition (TPN) may be beneficial in preventing cholestatic jaundice associated with TPN. Bolus intravenous administration of either amino acids or fat promotes gallbladder contraction in normal adult volunteers after a period of starvation. This phenomenon has not been investigated in patients receiving continuous TPN. The aim of this study was to test the hypothesis that bolus intravenous infusion of amino acids or fat produces gallbladder contraction in neonates receiving TPN. METHODS: Twenty-eight studies of gallbladder contraction were performed in 18 neonates receiving continuous TPN (median weight, 2.3 kg; range, 1.3 to 7.3; gestational age, 37 weeks; range, 28 to 40; age, 6.5 days; range, 2 to 180). Different types of experiments were performed: (1) bolus intravenous infusion of amino acid or fat for 60 minutes at twice the normal infusion rate; (2) bolus intravenous infusion of amino acid or fat for 15 minutes at four times the normal infusion rate. Gallbladder volume was measured by real-time ultrasonography by a single investigator. Measurements were made before starting the bolus infusion and every 15 minutes for 1 hour. RESULTS: The volume of the gallbladder before bolus intravenous infusion was not significantly different between experiments (median, 985; range, 603 to 1,802 mm3). These volumes are consistent with an enlarged and atonic gallbladder as previously reported in infants receiving parenteral nutrition. In all experiments there was no significant decrease in gallbladder volume after bolus infusion of either amino acids or fat. CONCLUSIONS: Contrary to their effects in adults, bolus infusions of amino acids or fat did not induce gallbladder contraction in neonates on TPN. This may have been because of lack of starvation in the neonates and/or the effect of continuous glucose infusion.

A pilot study to determine the order of emergence of permanent central incisors and permanent first molars of children in the Colchester area of the U.K.

Over the period of one calendar month, 505 children in the Colchester area of England were examined. The data gathered from the 12 non-Caucasian children was not used, leaving 493 Caucasian children (255 boys and 238 girls). Their mean age was 6.48 years, with a range of 4.49-8.75 years and 164 children had no permanent teeth leaving 329 children with a total of 2,238 permanent teeth present. A permanent tooth was deemed to have emerged if any part of it was visible in the mouth. The forensic significance of the results of this pilot study are that there is no significant difference (t = 0.407, P > 0.2) between the age of emergence of permanent central incisors (mean age 6.23 years) and permanent first molars (mean age 6.29 years). On the whole, lower central incisors emerge before upper central incisors and there is no significant difference (t = 0.899, P > 0.2) in the emergence times of upper and lower permanent first molars. There is no significant difference (t = 0.876, P > 0.2) in the emergence times of permanent central incisors for boys and girls (6.22 and 6.25 years respectively) and there is no significant difference (t = 1.413, P > 0.1) in the emergence times of permanent first molars for boys and girls (6.40 and 6.08 years respectively).

Prenatal ultrasound diagnosis of gastrointestinal malformations.

Prenatal ultrasonography is commonly used to detect fetal structural abnormalities. The aim of this study was to evaluate the reliability of fetal sonography in the detection of congenital gastrointestinal malformations (GIM). From a prospective database of all major structural fetal anomalies detected by ultrasound over 3 years in a region with a population of 3.5 million and an annual birth rate of 52,000, 294 reports of GIM were identified and reviewed. There were 220 confirmed cases of GIM, of which only 35 (16%) had been correctly identified prenatally. Of 84 prenatal diagnoses of GIM, only 35 (42%) were confirmed postnatally. Prenatal ultrasound was most reliable in the detection of duodenal obstruction (55% confirmed cases identified prenatally) and least reliable in malformations of the hindgut. Of 44 cases of nonspecific sonographic bowel abnormality (eg, echogenic bowel) with adequate follow-up, only 12 (27%) had a confirmed GIM after delivery. This study demonstrates that the prenatal ultrasound scan is still unreliable in the detection or exclusion of fetal GIM, and consequently clinicians involved in prenatal sonography or counselling should exercise caution in making such diagnoses.

Prenatal diagnosis and management of abdominal wall defects.

The widespread use of fetal ultrasonography in routine antenatal care now allows the majority of abdominal wall defects to be identified prenatally, with subsequent opportunities for parental counseling, fetal intervention, and optimal perinatal management. Outcome is significantly affected by the presence of additional structural or chromosomal malformations; appropriate multidisciplinary counseling and management is dependent on the early identification of such anomalies in addition to accurate delineation of the abdominal wall defect itself. In cases with associated lethal or multiple severe abnormalities, parents may opt for elective termination of the pregnancy. Serial sonography is of particular value in gastroschisis, but there is little evidence that fetal manipulation or premature delivery confers any significant benefit. For all types of abdominal wall defect, optimal perinatal management is achieved in centers where neonatal medical, surgical, and anesthetic expertise is immediately available; cases diagnosed in units without these services should be considered for in utero transport to the nearest perinatal center.

Cystic hygroma: comparison between prenatal and postnatal diagnosis.

Antenatal diagnosis of congenital malformation often leads to opportunities for intervention in the pregnancy that may have a profound effect on the outcome of the fetus. The accuracy of the diagnostic technique is a critical factor in judging the appropriateness of such interventions. This article reports the current accuracy of prenatal ultrasound diagnosis of cystic hygroma (CH) in a region with a population of 3.5 million and an annual birth rate of 52,000. During a 32-month period (to December 1994), 113 diagnoses of CH were reported to the South East Thames Regional Congenital Malformation Registry. Eighty-nine diagnoses were made prenatally and 24 were made postnatally (at delivery or postmortem). The number of confirmed cases of CH was 52 (46% total diagnoses). The prenatal diagnoses were established at a mean gestational age of 19 weeks. Fifty-six (63%) pregnancies with a prenatal diagnosis of fetal CH were terminated; in only 25% of these was the presence of CH confirmed after termination. Overall, of the 89 prenatal diagnoses, 28 (32%) were confirmed, 45 (50%) were incorrect, and 16 (18%) could not be confirmed or refuted. Only 24% of fetuses with a prenatal diagnosis of CH were live born. The survival rate at 1 year for the live-born infants with CH in this series was 88%. The diagnosis of fetal CH has a recognised association with chromosomal abnormalities, and consequently may lead to termination of the pregnancy. A potential error rate of almost 70% in the prenatal ultrasound diagnosis of this condition requires clinicians to adopt a more cautious approach to the management of the fetus with "cystic hygroma."

Impact of antenatal diagnosis on incidence and prognosis in abdominal wall defects.

The authors review data from the Congenital Malformation Registry in South East Thames regarding fetal abdominal wall defects. Over 24 months, 80 cases were observed (40 gastroschisis, 40 exomphalos). Live-born infants with gastroschisis had few associated anomalies and an excellent prognosis (83% survival rate). Exomphalos is associated with an increased rate of life-threatening anomalies and chromosomal defects. The latter cases often are terminated prenatally. If these cases are excluded, the 1-year survival rate for liveborn infants with exomphalos is favorable (close to 80%). Fetuses in whom gastroschisis and exomphalos are identified by ultrasonography but who have no associated life-threatening chromosomal anomalies should have a favorable prognosis.

The use of a digital imaging technique to aid bite mark analysis.

Criminal cases occasionally involve the analysis of bite mark injuries. This paper presents a method of digital image enhancement of an injury and an overlay production method to improve the comparison between the dentition of a suspect and the image of the injury. A comparison method entirely within the digital image software is also illustrated. The use of digitally-produced overlays appears to provide a more objective method of comparison. The use of this method for shoe print, tyre mark and other blunt instrument injury analysis is noted.