[Early childhood caries].

ECC was defined by the American Academy of pediatric dentistry at 2003 as the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger. This is a virulent type of dental caries that start soon after the tooth erupts and progress rapidly. The prevalence is 1-12% in developed countries and 70% in developing countries, and changes in different cultures, communities, socioeconomic status, etc. The etiology of the disease is multifactorial like in any dental caries. The risk factors include high levels of SM and LB, enamel defects, oral habits, complication at pregnancy and birth, social and demographic factors and the child's age. The disease implications are: high risk of new caries defects in both permanent and deciduous dentitions, insufficient physical development, hospitalization and emergency room visits, loss of school days and increased days with restricted activity, increased treatment costs and time, diminished ability to learn, and diminished oral health-related quality of life. Due to the aggressive pattern of the disease, treatment should be specific for each individual patient, and should be given by an expert dentist with experience who could manage the young child and the process of the disease. Treatment options are: 1. Conservative approach which includes recalls and topical fluoride, 2. Aggressive restorative approach. In both we should first stop the carious habit and encourage prevention. Before choosing the type of treatment, we should consider the severity of the lesions, child's age, caries risk, child's behavior, and parents' cooperation. Prevention at home includes: 1. decreasing the mother's/primary caregiver's mutans streptococci levels, 2. avoid sharing the same utensils in the family, 3. implementing oral hygiene measures as the first primary tooth erupts, 4. dental home, 5. avoid inappropriate feeding practices of infants and toddlers. Prevention at clinic includes: 1. topical fluoride application, 2. proximal slices in appropriate cases.

Max Sandreczky: a pediatric surgeon in 19th-century Jerusalem.

Until the mid-19th century, there had not been a single resident physician in the Holy Land. However, by the first World War in 1914, 19 hospitals had been established in Jerusalem. The reasons for this unusual phenomenon were religious, political, and sectarian. This does not apply to The Marienstift Kinderhospital, which was unique in 19th century Jerusalem. The hospital was founded and operated by Dr Max Sandreczky, a German pediatric surgeon. The standards of medical and surgical practice in the hospital not only compared favorably with those in western Europe, but, in certain aspects, they were more advanced. The Marienstift Kinderhospital was an "implant" of a western institution in a society that was medieval in character. The response of this society was studied as well as the natural history of this unique institution and its medical director, the pediatric surgeon, Dr Max Sandreczky.

How conservatively can postoperative small bowel obstruction be treated?

Although postoperative adhesion ileus is the most common cause of small bowel obstruction in adults, its management remains controversial. We retrospectively studied 297 admissions of 227 patients over a period of 14 years to evaluate our conservative approach in managing adhesion ileus. We found that nonoperative therapy of up to 5 days' duration can be used safely for the majority of patients who present with postoperative intestinal obstruction, including those with complete obstruction. In those patients, who responded to conservative treatment, the obstruction resolved within a mean of 22 hours and a maximum of 5 days. A trial of more than 5 days' duration proved ineffective. The conservative approach resulted in a 73% resolution of obstruction with no significant increase in mortality or in the rate of strangulated bowel.

Nissen fundoplication in the treatment of children with familial dysautonomia.

Thirty-four children with familial dysautonomia (FD) underwent Nissen fundoplication and gastrostomy. The indications for operation were persistent cyclic vomiting that resulted in repeated aspiration pneumonia (94% of the patients), chronic dehydration (82%), failure to thrive (97%), and frequent hospitalizations (76%). There was no operative or early postoperative mortality. Long-term follow-up for up to 12 years was available. Eight patients died during this period from 7 months to 7.5 years postoperatively. In 5 patients (15% of the operated patients), the fundoplication ceased to function 16 months to 5 years postoperatively, which was attributed mainly to repeated severe dysautonomic crises with vigorous retching. Vomiting ceased in 85% of the symptomatic patients; pulmonary deterioration was halted, and the frequency of aspiration pneumonia was reduced in 68%; nutritional improvement was seen in 44%; the hydration status improved in 88%; and the frequency of hospital admissions decreased in 74%. These long-term findings resulted in a significant improvement in the quality of life for the majority of the patients. The absence of operative mortality and the low postoperative morbidity, together with the long-term beneficial results of this surgical procedure, should encourage early surgical intervention in selected FD patients.

Life Cycle and Reproductive Potential of the Nematode Heterorhabditis bacteriophora Strain HP88.

Development of the entomopathogenic nematode Heterorhabditis bacteriophora strain HP88 was studied in vivo with larvae of the greater wax moth, Galleria mellonella, as host and in vitro. At 25 C in vivo, the duration of the life cycle from egg hatch to egg hatch was 96 hours. Juvenile development took 48 hours, with the duration of each juvenile stage ranging from 8 to 12 hours. Under crowded conditions, development proceeded to the infective juvenile (IJ) stage instead of the third juvenile stage (J3). Life-cycle duration and proportion of the various developmental stages in the population were similar in in vitro and in vivo cultures. When in vivo or in vitro development was initiated from the IJ stage, only hermaphrodites developed in the first generation and males appeared only in the second generation. The average (+/-SD) number of progeny per hermaphrodite was 243 +/- 98. The ratio of males to hermaphrodites in the second generation was 1:9.4 +/- 6.8.

Phenotypic and Genetic Analysis of a Mutant of Heterorhabditis bacteriophora Strain HP88.

Induction and characterization of a morphological mutant are described for Heterorhabditis bacteriophora strain HP88. A homozygous inbred line was used as the base population for mutagenesis and genetic analysis of mutations. Mutagenesis was induced by exposing young hermaphrodites to 0.05 M ethyl methanesulfonate. A dumpy mutant (designated Hdpy-l) was isolated from the F generation of the mutagenized population. Morphological studies with light and scanning electron microscopy revealed that the head region of the adult stage was compressed. The head region of the infective juvenile was distorted and the mouth open. Backcross with the original population was successful only between mutant hermaphrodites and wild type males; 50-100 percent of the progeny of this cross maintained the dumpy phenotype, indicating that the ratio between self- and external fertilization of the eggs is > 1 and that the dumpy mutation is recessive.

Felix Wurtz: surgeon and pediatrician.

Felix Wurtz, a surgeon in Basel and Zurich, wrote a book on pediatrics, The Childrens Book, which was first published (after his death) in 1612. It is the first known book in western Europe to deal with pediatrics and surgery. The book discusses issues dealing with the care of children, also addressing problems in pediatric surgery, primarily congenital and acquired orthopedic malformations. The book, and the contribution of its writer to pediatric surgery, are reviewed. The accuracy of the first English language translation is also evaluated.

Peritonitis and empyema following the use of dextran in tubal operations.

Two patients developed severe bacterial sepsis with peritonitis and pleural empyema following tubal surgery. Intraperitoneal low-molecular dextran was used in both patients and hydrocortisone was administered perioperatively. The use of dextran in tubal surgery probably increases the risk of severe postoperative infection and should be avoided in susceptible patients. Prophylactic antibiotics may be indicated when dextran is administered.

Treatment of faecal incontinence in children with spina bifida by biofeedback and behavioural modification.

Faecal incontinence may lead to serious social and physiological disturbances. Over 90% of patients with spina bifida have varying degrees of neurogenic bowel with disturbances of faecal control. This is a serious habilitation problem in these patients. Three encopretic children with myelomeningocele were treated by Biofeedback operant conditioning and behavioural modification to self-initiate bowel movements. Their neurological levels were T-10; T-11; T-12. Each child had a mean of 10 Biofeedback sessions each of 30-45 minutes, combined with daily behavioural modification. Two patients improved and have voluntary bowel movements. Therapy failed in one patient. We conclude that Biofeedback operant conditioning combined with specific behavioural modification may become a simple technique to treat encopretic patients with meningomyelocele.

Gastrointestinal perforations in the neonatal period.

Forty-eight neonates were treated for gastrointestinal perforation during a 9-year period. In 30, perforation occurred within the first week of life. Thirty-six were preterm infants and many had a history of obstetric and postnatal complications. Perforation resulted from necrotizing enterocolitis in 26 patients, whereas in 14 neonates spontaneous perforation occurred in an apparently normal bowel, with no evident cause (idiopathic perforation). In 6 patients perforation was associated with meconium ileus. Primary closure was carried out for perforations of the duodenum and stomach. Intestinal perforations were usually treated by resection and enterostomies. The overall mortality rate in this series was 46%. The highest mortality rate was associated with necrotizing enterocolitis (62%). The mortality rate was only 14% in patients with idiopathic perforation. Despite improvement in the prognosis of neonatal gastrointestinal perforations in recent years, it is still discouraging, reflecting the difficulty in preventing and treating necrotizing enterocolitis.

Idiopathic gastrointestinal perforation in the neonate.

Spontaneous localized perforation of the gastrointestinal tract, unrelated to mechanical intestinal obstruction and with no evidence of necrotizing entrocolitis (NEC), occurred in 20 neonates. Three perforations were located in the stomach, 11 in the small intestine, and six in the colon. Maternal obstetric complications as well as prematurity and postnatal distress were common in these patients. The overall survival rate was 80%. There was no late gastrointestinal symptoms in the survivors. Whether idiopathic perforation of the gastrointestinal tract results from a localized form of NEC or from a distinct lesion of unknown etiology has not yet been ascertained. Some ideas concerning the etiology of this entity, as well as some diagnostic aspects are discussed.

The effect of meperidine on the guinea pig extrahepatic biliary tract.

The effect of meperidine on the mechanical activity of isolated guinea pig common bile duct (CBD) and gallbladder was studied in vitro. The effect was found to consist of inhibitory and excitatory phases. The inhibitory phase, characterized by a decrease in the response of the CBD and gallbladder to carbachol and electrical stimulation, was seen with concentrations of 10(-6) M or higher. The excitatory phase, seen at high concentrations of meperidine (5 X 10(-5)-10(-4) M), involved an increase in spontaneous contractions of CBD and in the tone of the gallbladder. Neither effect of meperidine was affected by 0.5 X 10(-5) M naloxone. These data indicate that meperidine acts on the biliary tract by a mechanism different from that associated with the effect of morphine.

Wide local excision as an alternative treatment for periampullary carcinoma.

Wide excision of periampullary carcinoma is associated with low operative morbidity and mortality, but its effect on long-term survival, compared with that of pancreaticoduodenal resection, is controversial. Five patients with periampullary carcinoma were treated with wide local excision as a definitive procedure. There was no operative death, and four patients survived for two or more years following the operation. These patients are presented and the literature is reviewed.

Localized pseudomembranous colitis simulating carcinoma of the cecum.

A 76-yr-old woman complained of right lower quadrant abdominal pain, nausea, and fever. There was no history of antibiotic therapy or preceding diarrhea. At laparotomy, a cecal lesion simulating a tumor was found with an otherwise normal colon. Right hemicolectomy was performed. Pathological examination showed pseudomembranous colitis confined to the cecum. It is suggested that pseudomembranous colitis unrelated to prior exposure to antimicrobial agents can occur without diarrhea, and may be a localized process mimicking colonic carcinoma.

Lung resection for bronchiectasis in children.

Twenty children with bronchiectasis underwent pulmonary resections during an 8-year period. All patients suffered from significant symptoms that did not respond to medical treatment and had localised disease. In 7 patients bronchiectasis developed following foreign body aspiration and in two the aetiology was cystic fibrosis and immune deficiency, respectively. The lower lobes were most commonly involved. Atelectasis of the remaining ipsilateral lung was the most common postoperative complication occurring in four patients. One patient required reoperation for recurrent symptoms. Fifteen out of 18 patients who underwent curative resections were asymptomatic in the longterm follow-up. It is concluded that for children with significant symptoms due to localised bronchiectasis that fails to respond to medical treatment, resection of the affected lobes is indicated.

Effect of morphine on the mechanical activity of common bile duct isolated from the guinea pig.

The contractile response of isolated guinea pigs common bile ducts (CBD) to transmural electrical stimulation and the effects of morphine and naloxone was studied. Contractile responses increased as a function of stimulus frequency. In the absence of naloxone morphine inhibited the contractile response to electrical stimulation in a dose-dependent manner. Naloxone prevented the inhibitory effect of morphine on the contractile response to electrical stimulation. We conclude that smooth muscle of the CBD in guinea pig is functional and can contribute to biliary motility, and that opiate receptors exist in nerve elements in the CBD.