Developmental enamel defects of primary incisors in preterm infants with very low and extremely low birthweight. A case- control study.

AIM: To determine the prevalence of developmental defects of enamel (DDE) in primary incisors of preterm very low birthweight (VLBW) and extremely low birthweight (ELBW) one-year-old infants and to compare the findings with fullterm one-year-old normal birthweight (NBW) infants. MATERIALS AND METHODS: All infants were enrolled in the case-control study at birth. Personal information and medical histories were obtained through interviews with parents and from medical hospital records. The presence of DDE in primary incisors was evaluated in 82 one-year old preterm infants delivered with VLBW, in 50 ELBW and in 58 fullterm NBW infants. The data were statistically analysed by ANOVA and chi-square tests, and a statistical significance level p<0.05 was established. Results DDE were diagnosed in 19 (23.2 %) preterm VLBW infants, in 27 (54%) ELBW infants and in 4 (6.9%) infants of the control group. The most frequent DDE found in the case group was hypoplasia in 10 (12.2%) VLBW infants and in 14 (28%) ELBW infants. The opacities were found in 6 (7.3%) VLBW infants and in 8 (16%) ELBW infants. CONCLUSION: The results of the study confirmed a significantly higher prevalence of DDE in the primary incisors in preterm ELBW infants than in VLBW infants and than in full term NBW infants.

How to interpret elevated plasmatic level of high-sensitive troponin T in newborns and infants?

Research and clinical implications on novel cardiac biomarkers has intensified significantly in the past few years. The high-sensitive troponin T (hscTnT) assay plays a dominant role in diagnostic algorithm regarding myocardial injury in adults. Despite generally accepted use of hscTnT there are no data about physiological concentrations and cut-off limits in neonates and infants to date. The aim of this study is to assess hscTnT levels in healthy newborns and infants. Consecutively 454 healthy full termed newborns and 40 healthy infants were enrolled in the study. Samples of cord or venous blood were drawn and tested for hscTnT concentrations with high-sensitive TnT assay (Roche Cobas e602 immunochemical analyzer). The 97.5 percentile of hscTnT concentration was assessed and correlation analysis was performed in neonates. Two hundred and thirteen samples (47 %) were excluded due to blood hemolysis of various degrees in neonates. Finally, the group of 241 healthy newborns was statistically analyzed. The median concentration of hscTnT was 38.2 ng/ml, 97.5 percentile reached 83.0 ng/l (confidential interval 74.1 to 106.9 ng/l). HscTnT concentrations were statistically decreased in hemolytic samples when compared to non-hemolytic samples (34.3 ng/l [26.7 to 42.0 ng/l] and 37.1 ng/l [30.5 to 47.9 ng/l], respectively, p=0.003). Elevated plasma concentrations of hscTnT decreased to adult level within six months. This study has confirmed the higher reference levels of hscTnT in neonates and young infants when compared with adult population. Many extracardiac factors as hemolysis and age may affect the hscTnT level. Based on presented results, a careful clinical interpretation of hscTnT is recommended.

Loop mediated isothermal amplification (LAMP) for the detection and subtyping of human papillomaviruses (HPV) in oropharyngeal squamous cell carcinoma (OPSCC).

BACKGROUND: Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) is a growing problem that presents a significant challenge to Otolaryngologist-Head and Neck Surgeons. Knowledge of HPV status yields critical prognostic information, with potential for treatment selection based on tumour HPV status. The current gold standard of diagnosis, PCR, is expensive, demanding and time consuming. Alternatives such as p16 immunohistochemistry are subjective and potentially inaccurate. Loop-mediated isothermal amplification (LAMP) is a rapid, robust and inexpensive molecular diagnostic technique. OBJECTIVES: Our aim was to verify LAMP as a potential bedside diagnostic assay for subtyping of HPV in OPSCC. STUDY DESIGN: DNA from 72 formalin-fixed paraffin embedded (FFPE) OPSCC patient samples was tested. PCR and LAMP were then performed to specifically identify HPV 16, 18, 31, 33 and 35. RESULTS AND CONCLUSIONS: For these high-risk subtypes, LAMP had an overall sensitivity of 99.4% and specificity of 93.2% relative to PCR. LAMP is a promising technology that can accurately diagnose high-risk HPV infection.

MRI texture analysis predicts p53 status in head and neck squamous cell carcinoma.

BACKGROUND AND PURPOSE: Head and neck cancer is common, and understanding the prognosis is an important part of patient management. In addition to the Tumor, Node, Metastasis staging system, tumor biomarkers are becoming more useful in understanding prognosis and directing treatment. We assessed whether MR imaging texture analysis would correctly classify oropharyngeal squamous cell carcinoma according to p53 status. MATERIALS AND METHODS: A cohort of 16 patients with oropharyngeal squamous cell carcinoma was prospectively evaluated by using standard clinical, histopathologic, and imaging techniques. Tumors were stained for p53 and scored by an anatomic pathologist. Regions of interest on MR imaging were selected by a neuroradiologist and then analyzed by using our 2D fast time-frequency transform tool. The quantified textures were assessed by using the subset-size forward-selection algorithm in the Waikato Environment for Knowledge Analysis. Features found to be significant were used to create a statistical model to predict p53 status. The model was tested by using a Bayesian network classifier with 10-fold stratified cross-validation. RESULTS: Feature selection identified 7 significant texture variables that were used in a predictive model. The resulting model predicted p53 status with 81.3% accuracy (P < .05). Cross-validation showed a moderate level of agreement (κ = 0.625). CONCLUSIONS: This study shows that MR imaging texture analysis correctly predicts p53 status in oropharyngeal squamous cell carcinoma with ∼80% accuracy. As our knowledge of and dependence on tumor biomarkers expand, MR imaging texture analysis warrants further study in oropharyngeal squamous cell carcinoma and other head and neck tumors.

Health care delivery for head-and-neck cancer patients in Alberta: a practice guideline.

BACKGROUND: The treatment of head-and-neck cancer is complex and requires the involvement of various health care professionals with a wide range of expertise. We describe the process of developing a practice guideline with recommendations about the organization and delivery of health care services for head-and-neck cancer patients in Alberta. METHODS: Outcomes of interest included composition of the health care team, qualification requirements for team members, cancer centre and team member volumes, infrastructure needs, and wait times. A search for existing practice guidelines and a systematic review of the literature addressing the organization and delivery of health care services for head-and-neck cancer patients were conducted. The search included the Standards and Guidelines Evidence (sage) directory of cancer guidelines and PubMed. RESULTS: One practice guideline was identified for adaptation. Three additional practice guidelines provided supplementary evidence to inform guideline recommendations. Members of the Alberta Provincial Head and Neck Tumour Team (consisting of various health professionals from across the province) provided expert feedback on the adapted recommendations through an online and in-person review process. Selected experts in head-and-neck cancer from outside the province participated in an external online review. SUMMARY: The recommendations outlined in this practice guideline are based on existing guidelines that have been modified to fit the Alberta context. Although specific to Alberta, the recommendations lend credence to similar published guidelines and could be considered for use by groups lacking the resources of appointed guideline panels. The recommendations are meant to be a guide rather than a fixed protocol. The implementation of this practice guideline will depend on many factors, including but not limited to availability of trained personnel, adequate funding of infrastructure, and collaboration with other associations of health care professionals in the province.

Extremely hypotrophic newborn of mother with systemic lupus erythematosus and antiphospholipid syndrome.

The case presented describes a high-risk pregnancy of a woman with systemic lupus erythematosus (SLE) with multiple lesions of central nervous system (CNS), vasculitis, secondary epilepsy and antiphospholipid syndrome (APS). At gestational age 28 weeks and 3 days the pregnancy was urgently terminated via caesarean section and an extremely hypotrophic immature newborn with a birth weight of 580 g was born. The high disease activity in the mother at the time of conception and the histologically proven chronic placental insufficiency due to APS are presumably the causes for the extensive hypotrophy of the neonate. The significant comorbidity of the newborn, including respiratory distress syndrome, bronchopulmonary dysplasia, necrotizing enterocolitis, osteopathy of prematurity, transient hypothyroidism and hypocortisolism, vesicoureteral reflux, and hypertonic-hyperexcitation syndrome complicated his three-month stay in NICU. A positive titre of transplacentally transferred anticardiolipin and anti-ß2 glycoprotein antibody was detected in the child and persisted through the following 30 months. During the three-year follow-up, significantly delayed neuropsychological development with microcephaly (-4 SD) and short stature of the child was observed. Finally, the authors discuss possible causes of neuropsychological consequences in children of mothers with SLE and APS and emphasize the need for long-term monitoring and specialized care to improve development of these children.

The prognostic impact of a combined carbonic anhydrase IX and Ki67 signature in oral squamous cell carcinoma.

BACKGROUND: Tumour hypoxia is associated with impaired apoptosis, resistance to therapy and poor prognosis. We previously reported that high stromal expression of the endogenous marker of hypoxia, carbonic anhydrase IX (CAIX), is associated with significantly reduced survival in oral squamous cell carcinoma (OSCC). In addition to hypoxia, CAIX expression is regulated by proliferation-associated signalling. We hypothesised that incorporating Ki67, a proliferation marker, into our existing CAIX-based stratification of OSCC would identify patients with the least favourable prognosis. METHODS: Surgically resected tumours from 60 OSCC patients were analysed for CAIX, Ki67 and BAX expression using fluorescence immunohistochemistry and automated quantitative analysis (AQUA). RESULTS: In patients expressing high stromal CAIX (sCAIX), stratification by tumour Ki67 expression revealed significantly distinct survival outcomes (P=0.005). In our OSCC cohort, below-median Ki67 and top-quartile sCAIX expression (Ki67(lo)sCAIX(hi)) were associated with significantly worse disease-specific survival in univariate (HR 7.2 (2.5-20.4), P=0.001) and multivariate (HR 4.2 (1.4-12.8), P=0.011) analyses. Hypoxia is associated with decreased BAX expression; the Ki67(lo)sCAIX(hi) group was more strongly associated with low BAX expression than high sCAIX alone. CONCLUSION: These data suggest that combined analysis of tumour Ki67 and sCAIX expression may provide a more clinically relevant assessment of tumour hypoxia in OSCC.

Occurrence of selected antiphospholipid antibodies in offspring born from mothers with autoimmunity.

Autoimmune diseases can be accompanied by presence of various antiphospholipid antibodies (aPL). The laboratory criteria of antiphospholipid syndrome are based on detection of anticardiolipin, lupus anticoagulant or to antiß2- glycoprotein I but currently a significance of other multiple aPL is being discussed. Because of their vascular and neuroinflammatory effect aPL, if being transplacentally transferred, might inflict damage in developing organism. The aim of our study was to determine the occurrence of eight selected aPL in offspring of mothers with proven autoimmune disease with aPL positivity. The possible influence of aPL presence on clinical, ultrasound and laboratory outcome of children was observed as well. The prospective study included 38 women: 17 women with primary antiphospholipid syndrome and 21 women with other diagnosed autoimmune disease with detected aPL. Also included were 39 children born to the above mentioned mothers between January 2009 and April 2010 in Perinatology Centre in Pilsen, Czech Republic. The control group consisted of 30 mothers without AD and their 30 healthy singletons. Preliminary results of the study showed the presence of aPL in 42.1% neonates of aPL positive mothers with autoimmune disease, six month later aPL were present in only 37.5 % of these children. Observed occurrence of aPL positivity at 6 months of age in originally negative offspring could be attributed to vaccination or food exposure. Psychomotor development of children has proceeded without major deviations. The follow-up study continues and will evaluate both groups of children at two years of age.

[Evaluation of risk factors of retinopathy of prematurity genesis, ocular errors, and psychomotoric development in prematurely born children in West Bohemia--twelve years longitudinal study]. / Hodnocení rizikových faktoru vzniku ROP, ocní vady a psychomotorický vývoj nedonosených detí v západoceském regionu, dvanáctileté sledování.

OBJECTIVE: The retrospective study is focused on monitoring of risk factors necessary for retinopathy of prematurity genesis and monitoring children with retinopathy of prematurity and their ocular and psychomotoric morbidity. The study concerned children treated at the Faculty Hospital in Plzen (Pilsen, Czech Republic, E.U.). MATERIAL AND METHODS: Prematurely born children with ROP during the period 1. 1. 1994 - 31. 12. 2005 in Perinatological Centre in Plzen or in other 11 maternity clinics in West Bohemia were observed. Only surviving children with ROP diagnosis, gestation under 32 weeks and birth weight under 1500 grams were involved in the study. Children with ROP were divided into 2 groups according to the nation-wide methodic for early neonatological morbidity monitoring: 1) children with the low-grade ROP with spontaneous regression (1st and 2nd stage), 2) children with high-grade ROP (3rd - 5th stage) who underwent cryotherapy. Incidence of ROP was assessed in 3 categories based on the birth weight (500-749 g, 750-999 g, 1000-1499 g). Monitored risk factors of ROP genesis: number of blood transfusions, duration of necessary oxygenoterapy period, duration of artificial ventilation period, septicemia, and intraventricular bleeding. Incidence of myopia, anisometropia, strabismus, glaucoma, congenital cataract, and the retina condition were assessed in children with ROP. The General Practitioners' reports were used for observing the children's psychomotoric development. Children's school grades and enlistment to special schools were also observed. RESULTS: Eight hundred seventy children with the birth weight under 1500 g were born in West Bohemia in the referenced period and 702 of them were released home. The ROP was found in 63 living children, 40 of them with low-grade retinopathy (63.5%) and 23 of them with high-grade retinopathy (36.5%). The incidence of all stages of ROP in all living newborns with the very low birth weight in our region was 9.0% including 3.3% of high-grade ROP. The incidence of all stages of ROP in all living newborns in individual categories according to the birth weight was 40.3%, 16.0% and 2.1%, including 17.9%, 6.1% and 0.2% of the high-grade ROP respectively. The number of blood transfusions, duration of the artificial ventilation period, and septicemia are statistically very important risk factors. The duration of oxygenotherapy period is also important while intraventricular bleeding is just below the level of statistical significance. Fifty children out of 63 came for ophthalmologic examination. Only a single kid out of 50 children examined by ophthalmologist suffers from bilateral blindness (2%), 20 children suffer from myopia (40%), 18 from anisometropia (36%), 15 from strabismus (30%), and 2 from glaucoma (4%). Congenital cataract was diagnosed in none of them. Thirty-three children are scholars, 3 of them visit school for visually handicapped children, and 6 of them visit special schools. CONCLUSION: The number of prematurely born children is still slowly increasing. Despite this fact, the incidence of ROP in West Bohemia is decreasing thanks to the improving quality of neonatological care. The aim of ophthalmologists is to reveal ocular diseases as soon as possible and apply appropriate treatment.

Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy.

BACKGROUND: Pancreaticoduodenectomy is the primary treatment for periampullary cancer. Associated morbidity is high and often related to pancreatic anastomotic failure. This paper compares rates of pancreatic fistula, morbidity and mortality after pancreaticoduodenectomy in patients having reconstruction by pancreaticogastrostomy with those in patients having reconstruction by pancreaticojejunostomy. METHODS: A meta-analysis was performed of all large cohort and randomized controlled trials carried out since 1990. RESULTS: Eleven articles were identified for inclusion: one prospective randomized trial, two non-randomized prospective trials and eight observational cohort studies. The meta-analysis revealed a higher rate of pancreatic fistula associated with pancreaticojejunostomy reconstruction (relative risk (RR) 2.62 (95 per cent confidence interval (c.i.) 1.91 to 3.60)). A higher overall morbidity rate was also demonstrated in this group (RR 1.43 (95 per cent c.i. 1.26 to 1.61)), as was a higher mortality rate (RR 2.51 (95 per cent c.i. 1.61 to 3.91)). CONCLUSION: Current literature suggests that the safer means of pancreatic reconstruction after pancreaticoduodenectomy is pancreaticogastrostomy, but much of the evidence comes from observational cohort study data.

[Congenital cytomegalovirus infection]. / Kongenitální cytomegalovirová infekce.

Cytomegalovirus (CMV) belongs to the herpesvirus family. Its distribution is ubiquitous in man and many other mammals. CMV causes a typical cytopathic effect with enlargement of the cells that contain intranuclear and cytoplasmic inclusions. CMV is spread directly or by a contact with secretions. Nosocomial transmission can occur during blood transfusion or organ transplantation. Virus excretion after infection continues for a long time. CMV is the most frequent cause of congenital infections (1-2% children). A foetal infection can lead to a preterm labour. Most of CMV congenital infections are benign, only a small proportion of children develop a disease with sensorineural hearing loss or a life threatening multiorgan disease. The diagnosis can be done on the basis of identification of specific antibodies, virus cultivation and PCR from urine, saliva, blood, and cerebrospinal fluid. An antiviral drug ganciclovir can be used for treatment. Anti-CMV vaccines are under the development. Three cases of a congenital CMV infection are described in the paper.

Investigation of skeletal muscle denervation and reinnervation using magnetic resonance spectroscopy.

OBJECTIVE: To determine changes in skeletal muscle metabolism after nerve transection and repair and to correlate metabolic changes with functional recovery. STUDY DESIGN AND SETTING: Male Wistar rats were divided into 6 experimental groups plus a control group. The posterior tibial nerve was transected and reapproximated. At varying times after surgery (1, 2, 4, 6, or 8 weeks) animals were sacrificed, the gastrocnemius muscle was harvested, and proton nuclear magnetic resonance (NMR) spectroscopy was performed. Functional recovery was measured using the sciatic function index. RESULTS: Animals undergoing nerve repair all showed functional recovery whereas the nonrepaired nerve group did not. Concentration of glucose and lactate increased after denervation and then returned toward normal. Choline concentration decreased and then returned toward normal. In animals not undergoing nerve repair, the metabolic abnormalities persisted and showed no sign of recovery over the 8-week observation period. CONCLUSIONS: 1H NMR spectroscopy is a potentially useful tool to study changes in skeletal muscle metabolism after motor nerve injury. SIGNIFICANCE: NMR spectroscopy is rapidly developing into a clinically useful tool. High-field magnets have improved resolution and data acquisition. Basic experiments, such as those described here, will help guide the use of NMR spectroscopy in clinical medicine and will also lead to a better understanding of basic mechanisms of nerve injury and repair.

Intraoperative magnetic resonance imaging for skull base surgery.

OBJECTIVES/HYPOTHESIS: Skull base surgery has evolved over the past several decades. Major improvements in the imaging of skull base pathology led to better target localization and better surgical planning. The objectives of this study were to assess the use of intraoperative magnetic resonance (MR) imaging in the management of a series of patients with skull base pathology. We hypothesized that high-quality intraoperative MR imaging would have an impact on surgery in this patient group. STUDY DESIGN: Prospective, non-randomized, cohort study. METHODS: Thirty-one patients with skull base lesions underwent surgery in a 1.5-Tesla intraoperative MR suite. The concepts of a moving magnet, high magnetic field strength, and radiofrequency coil design are presented. RESULTS: Eleven of 31 patients had the course of surgery significantly altered by the information acquired from the images obtained during surgery. CONCLUSIONS: Intraoperative MR imaging is a valuable adjunct to skull base surgery. One third of patients had altered surgery as a result of this adjunct. Intraoperative MR imaging is of particular value in the treatment of pituitary adenomas and benign skull base tumors.

Screening for cerebellopontine angle tumours: conventional MRI vs T2 fast spin echo MRI.

BACKGROUND: Unilateral audiovestibular symptoms are commonly seen in clinical practice and are rarely caused by retrocochlear pathology. However, clinicians are often required to rule out potentially serious causes of these unilateral symptoms. Gadolinium enhanced magnetic resonance imaging (GdMRI) is the most accurate test for detecting small cerebellopontine angle lesions and also screens the adjacent CNS structures. Its main disadvantage is the cost of the procedure. METHODS: We studied 100 consecutive patients with both GdMRI and a newer MRI screening study utilizing unenhanced T2-weighted fast spin echo (fse) MRI. Acquired images were randomly assessed by a panel of three neuro-radiologists. RESULTS: We found that the screening (fse) MRI was as sensitive and specific when detecting cerebellopontine angle tumors. CONCLUSIONS: We conclude that T2-weighted fse MRI is a safe and cost-effective alternative to GdMRI and offers better diagnostic utility when compared to auditory brain stem response (ABR) and CT scans.

What is normal intra-abdominal pressure?

The causes and effects of increased intra-abdominal pressure and abdominal compartment syndrome have been well documented. However, there have been no large series to determine normal intra-abdominal pressure in hospitalized patients. The purpose of this study was to determine normal intra-abdominal pressure in randomly selected hospitalized patients and to identify factors that predict variation in normal intra-abdominal pressure. A total of 77 patients were prospectively enrolled between September 1998 and July 1999. Data obtained included patient demographics (i.e., age, gender, height, weight, and body mass index), reason for hospitalization and bladder catheterization, previous and current surgical status, comorbidities, and intra-abdominal pressures. Intra-abdominal pressure readings were obtained through an indwelling transurethral bladder (Foley) catheter. Data were analyzed by analysis of variance and multiple regression analysis. There were 36 females and 41 males with a mean age of 67.7 years. Average weight, height, and body mass index were 79.6 kg, 1.70 m, and 27.6 kg/m2, respectively. Mean intraabdominal pressure was 6.5 mm Hg (range 0.2-16.2 mm Hg). Body mass index was positively related to intra-abdominal pressure (P < 0.0004). Gender, age, and medical and surgical histories did not significantly affect intra-abdominal pressure. However, using multiple regression analysis, a relationship between intra-abdominal pressure, body mass index, and abdominal surgery was discovered. Intra-abdominal pressure is related to a patient's body mass index and influenced by recent abdominal surgery. Thus, the normal intra-abdominal pressure can be estimated in hospitalized patients by using the derived equation. Knowledge of the expected intra-abdominal pressure can then by used in recognizing when an abnormally high intra-abdominal pressure or abdominal compartment syndrome exists.

Braking of expiratory airflow in obese pigs during wakefulness and sleep.

Braking of expiratory airflow is a phenomenon prominently seen in neonates where it is thought to defend end-expiratory lung volume. This paper describes pronounced expiratory braking in an adult animal, the obese Vietnamese pot-bellied pig. Three obese pigs were chronically instrumented for recording of intrapleural pressure and bioelectric signals related to sleep. Airflow was measured by a pneumotachograph attached to a facemask. Expiratory airflow resistance was calculated for 10 consecutive expirations during wakefulness, NREM, and REM sleep. All animals demonstrated a biphasic expiratory flow pattern characterized by an initial plateau in flow at a low value followed by a rapid increase later in expiration. Airflow resistance during early expiration was on average four-fold higher than during late expiration. A striking observation was the maintenance of pronounced expiratory braking during NREM and REM sleep. Expiratory braking in these animals is likely due to laryngeal mechanisms and may serve to preserve end-expiratory lung volume or improve hemodynamics.

[What is the fate of our smallest patients? Follow-up of children with a birth weight less than 1000 g]. / Jaký je osud nasich nejmensích pacientu? Follow-up detí s porodní hmotností pod 1000 g.

BACKGROUND: The neurodevelopmental status of infants of birth weight lower than 1000 g born between 1994-1998 at the age of 2 years. METHODS AND RESULTS: Infants of birth weight lower than 1000 g born between January 1994 and December 1998 and discharged from NICU of the Charles University Hospital in Pilsen were followed-up longitudinally. Physical, somatometric, neurologic, ophthalmologic, psychologic (Bayley II Mental Developmental Index) and foniatric assessment was made at 24 months of the corrected age. 143 premature newborns (under 1000 g) were born during this period, 91 survived (36.3%) and were discharged home. 76 children (84%) were evaluated at the age of 2 years. Children were divided into 3 groups: normal neurodevelopmental outcome, mild and major impairment. 80% of children were normal., 9% with mild a 11% with major impairment in the whole group. According to the birth weight the impairment distribution was as follows. Birth weight 500-749 g: normal developmental outcome--71%, mild--18% and major impairment 11%. Birth weight 750-999 g: 83% normal outcome, 4% mild and 13% major impairment. CONCLUSIONS: We determined relatively high proportion (80%) of normal neurodevelopmental status among originally extremely premature children. Major developmental impairment (mainly cerebral palsy) was found in 11% of children. There was no significant outcome differences between two birth weight cohorts.

Double-blind randomized study of tramadol vs. paracetamol in analgesia after day-case tonsillectomy in children.

Fifty children (2-9 years) scheduled for tonsillectomy were enrolled in a double-blind randomized prospective study to compare postoperative analgesia provided with propacetamol/paracetamol (acetaminophen) or tramadol. A standard anaesthetic technique was used; each patient received sufentanil 0.25 microg kg(-1) intravenously followed with either i.v. propacetamol 30 mg kg(-1) or tramadol 3 mg kg(-1) before surgical incision. For postoperative analgesia, each child received either tramadol drops (2.5 mg kg(-1)) or paracetamol (acetaminophen) suppositories (15 mg kg(-1)), 6 and 12 h after surgery the first day and three times a day during postoperative days 2 and 3. This dosage of paracetamol is lower than the current recommended dosage, which is 40 mg kg(-1) loading dose followed by 20 mg kg(-1) 8 h(-1). Rescue medication consisted of i.v. diclofenac (1 mg kg(-1)) during the first six postoperative hours and oral ibuprofen (6-9 mg kg(-1)) afterwards. Postoperative pain scores (Children's Hospital of Eastern Ontario Pain Scale) in recovery, numerical pain scale in the ward and at home, and rescue analgesic use were significantly lower in the tramadol group. No serious adverse effects were observed.