The survival time of the ventriculo-peritoneal-shunt in children with hydrocephalus is dependent on the type of valve implanted.

PURPOSE: Despite constantly improving developments in ventriculo-peritoneal shunt systems, most patients with hydrocephalus require revision or replacement at some point of time. Therefore, this study aimed to analyse parameters that are associated with shunt dysfunction. METHODS: In this retrospective study, we included 81 patients aged 0-17 who were treated at our institution. Demographic data, etiology of the hydrocephalus, type of valve implanted, reason for any revision procedures, any complications and survival time of the ventriculo-peritoneal shunts were detected. Statistical analysis was performed using SPSS. The significance level was set at p ≤ 0.05. RESULTS: Over a mean study period of 18 years, we analyzed 226 valves subjected to 146 revision operations in 81 patients. The etiology of the hydrocephalus (p = 0.874) and the age of the child at the time of VP shunt implantation (p = 0.308) did not have any impact on the shunt survival time. However, the type of the valve significantly changed the survival time of the shunt (p = 0.030). Pressure differential valves presented a longer survival time than gravitational valves. CONCLUSION: The majority of patients in this study needed at least one replacement of the initial shunt system. Pressure differential valves may be beneficial for the survival time of the shunt system.

A new parameter for the management of positional plagiocephaly: the size of the anterior fontanelle matters.

PURPOSE: The rate of positional plagiocephaly has increased since guidelines for the prevention of sudden infant death have led to the recommendation of positioning infants on their back during sleeping. Therapy includes repositioning, physiotherapy, and helmet therapy. To date, there is no consensus on the treatment of positional plagiocephaly. Therefore, it was the goal of this study to compare the results of physiotherapy and helmet therapy and to investigate if the size of the anterior fontanelle can be used as an additional parameter for the indication of the helmet therapy. METHODS: We enrolled 98 infants with a diagonal difference of 7 mm or more and plagiocephaly classified as Argenta II or more. Patients were grouped into infants with a small anterior fontanelle (< 25mm2) and infants with a large anterior fontanelle (≥ 25mm2). The patients were observed for at least 18 months. Sixty-eight patients were treated with repositioning and physiotherapy, whereas 30 infants received helmet therapy. RESULTS: The remolding rate was significantly higher with the helmet therapy than with physiotherapy. In patients with a small fontanelle, a lower spontaneous remolding rate was seen pointing to their lower correction potential. Especially in these patients, plagiocephaly was reduced significantly more quickly with the helmet treatment than with physiotherapy, so that they may benefit from the helmet due to their otherwise reduced spontaneous remolding capacity. CONCLUSION: The helmet therapy led to a faster reduction of the asymmetry than physiotherapy in this study. In patients with a small anterior fontanelle and therefore lower remolding potential, the helmet treatment was more effective than physiotherapy.

Transcriptional activation of Hedgehog pathway components in aggressive haemangioma.

Infantile hemangioma is a vascular neoplasm and is one of the most common tumors diagnosed in young children. Although most hemangiomas are harmless and involute spontaneously, some show severe progression, leading to serious complications, such as high-output cardiac failure, ulcerations, compression of the trachea or deprivation amblyopia, depending on their size and localization. However, the pathogenesis and cause of hemangioma are largely unknown to date. The goal of this study was to identify markers that could predict hemangiomas with aggressive growth and severe progression that would benefit from early intervention. By using a PCR-based screening approach, we first confirmed that previously known markers of hemangioma, namely FGF2 and GLUT1, are highly expressed in hemangioma. Nevertheless, these genes did not show any differential expression between severely progressing tumors and mild tumors. However, transcriptional upregulation of several Hedgehog signalling components, comprising the ligand Sonic Hedgehog (SHH), the transcription factor GLI2 and its target gene FOXA2 were detected in extremely aggressive hemangioma specimens during the proliferation phase. Notably, GLI2 was even overexpressed in involuting hemangiomas if they showed an aggressive growth pattern. In conclusion, our data suggest that overexpression of the Hedgehog components SHH, GLI2 and FOXA2 might be used as markers of an aggressive hemangioma that would benefit from too early intervention, while FGF2 and GLUT1 are more general markers of hemangiomas.

Ambulatory or inpatient management of mild TBI in children: a post-concussion analysis.

BACKGROUND: Diagnosis and treatment of children with mild traumatic brain injury (mTBI) remain a challenge since initial signs and symptoms do not always indicate the severity of the trauma. Therefore, guidelines regarding the decision upon imaging methods and ambulatory or hospitalized treatment are needed. The goal of our study was to investigate if the standard that was allied from the PECARN rules and is applied in this study can ensure that patients with clinically important brain injury are recognized and leads to outcomes with a low complication rate, a high patient satisfaction and minimal post-concussion syndrome incidence. METHODS: We enrolled 478 children with mTBI and contacted their families with a questionnaire. Out of these, 267 valid questionnaires were received. Patient records and questionnaires were analyzed yielding a number of 140 ambulatory and 127 hospitalized patients. RESULTS: Patients with mild TBI were admitted according to the above-mentioned guidelines or sent home for observation through their parents after thorough patient examination and information. Among ambulatory patients only 13 children (9%) underwent any imaging procedure; however, none of those showed any pathological findings. Next, in 41 of 127 hospitalized patients (32.2%) an imaging study was performed and of these only 3 according to 2.4% of hospitalized patients showed pathological findings, namely a skull fracture, two of them in combination with an intracranial hemorrhage. The duration of inpatient observation was 48 h in most cases (55.3%). Moreover, a majority of all patients (72.4%) did not seek any follow-up visit and did not need any further treatment. Of all patients in the study, only 10 patients according to 3.7% developed a post-concussion syndrome. Patient satisfaction was very high in both, the ambulatory and hospitalized patient group. CONCLUSION: This study confirms that PECARN rules as administered in this study can ensure safe decision-making regarding ambulatory or inpatient treatment.

Timing of osteosynthesis of fractures in children changes the outcome.

PURPOSE: The search for optimal treatment strategies for fractures in children that require osteosynthesis is controversial and is still being debated. A major factor that has been under discussion is the impact of the timing of surgery: the time delay between the trauma and the operation, as well as the duration of the surgical procedure, and the time of day that the operation is performed are potential factors that might influence the outcome. Therefore, the aim of our study was to investigate the influence of these factors on the outcome after osteosynthesis of diverse fractures of the extremities in children. METHODS: In a retrospective study, 387 patients aged 1-18 years who presented with fractures of the extremities that underwent surgery were included. Patient records including radiological studies were analyzed. The follow up period lasted at least 12 months or until recovery. Statistical significance was set at an alpha level of P ≤ 0.05. RESULTS: Delayed surgery, as well as a prolonged duration of surgery, and the mode of transportation of the patient significantly were related to a higher rate of complications. However, in this study, the complication rate was not found to be influenced by the mode of reduction of the fracture, or the time of day or the day of the week. A further parameter that significantly changed the outcome was the mechanism of injury. However, the rate of complications was unchanged if a resident or a consulting was the performing surgeon so that a resident can safely perform the procedure in the presence of a consultant. CONCLUSION: Timing of surgery for fractures of the extremities in children, including the time from trauma to surgery, the duration of the operation and the mode of transportation to the ER, were found to have a significant impact on the occurrence of complications in this study while the mode of reduction and the time of day did not change the outcome. Future studies with a focus on selected types of fractures are needed to further enlighten this topic. LEVEL OF EVIDENCE: Retrospective comparative study, level III.

Trauma Scores and Their Prognostic Value for the Outcome Following Pediatric Polytrauma.

Purpose: The management and prognostic assessment of pediatric polytrauma patients can pose substantial challenges. Trauma scores developed for adults are not universally applicable in children. An accurate prediction of the severity of trauma and correct assessment of the necessity of surgical procedures are important for optimal treatment. Several trauma scores are currently available, but the advantages and drawbacks for use in pediatric patients are unclear. This study examines the value of the trauma scores Injury Severity Score (ISS), Pediatric Trauma Score (PTS), National Advisory Committee for Aeronautics (NACA), and Glasgow Coma Score (GCS) for the assessment of the polytraumatized child. Methods: In a retrospective study, 97 patients aged 0-17 years who presented with polytrauma and an ISS ≥16 in the trauma bay were included in the study. Patient records including radiological studies were analyzed. Pathological imaging findings and emergency surgery were assessed as outcome variables and the predictive value of the trauma scores were analyzed using receiver operator characteristic (ROC) curves. Statistical significance was set at an alpha level of P ≤ 0.05. Results: In this study, 35 of the 97 studied children had pathological cranial computed findings. These either underwent craniectomy or trepanation or a parenchymal catheter was placed for intracranial pressure monitoring. Abdominal trauma was present in 45 patients, 16 of which were treated surgically. Forty-three patients arrived with thoracic injuries, 10 of which received a thoracic drainage. One child underwent an emergency thoracotomy. Predictive accuracy for emergency surgery calculated using receiver-operator characteristic (ROC) curves was highest for ISS and NACA scores (0,732 and 0.683, respectively), and lower for GCS (0.246) and PTS (0.261). Conclusion: In our study cohort, initial ISS and NACA scores better predicted operative interventions and outcome than PTS or GCS for polytraumatized pediatric patients.

Lateral Condyle Fracture of the Humerus in Children: Kirschner Wire or Screw Fixation?

INTRODUCTION: The treatment of the displaced fracture of the lateral condyle of the distal humerus in children aims not only to avoid nonunion, malalignment, and impairment of the range of motion of the elbow but also to prevent delayed healing and the development of any prearthrotic deformity. To date there is no agreement on what kind of osteosynthesis should be used. So far, the screw fixation and Kirschner wire fixation have both been applied. Therefore, the goal of this study was to compare the outcome of these two methods. MATERIALS AND METHODS: A retrospective cohort study was undertaken including 43 patients aged 2 to 13 years who underwent osteosynthesis for a condylar fracture of the humerus over a period of 10 years. The electronic archive, including the radiological diagnostics, was analyzed. Statistical analysis was performed using IBM SPSS Statistics 20.0. Statistical significance was set at an α level of p = 0.05. RESULTS: Kirschner wire fixation was performed in 48.9% of condylar fractures of the humerus while screw fixation (alone or in combination with a pin) was assessed with a percentage of 51.1% of the cases in this study. Screw fixation only was applied in 20.9% of fractures of the lateral condyle. The selection of the method was independent of the age of the patient (p = 0.2). The comparison of the rate of complications and an impaired range of motion after Kirschner wire osteosynthesis to the rate after screw osteosynthesis showed a significantly lower percentage for the Kirschner wire group (p = 0.046). No case of nonunion, nerve palsy, or pin migration was detected in any patient in this study. CONCLUSION: Kirschner wire fixation of condylar humeral fractures in children resulted in a lower rate of complications than screw fixation. No case of nonunion of the fracture was found in the patients that we investigated so that we conclude that Kirschner wires sufficiently adapt the fracture in these cases. LEVEL OF EVIDENCE: Level III.