Dexamethasone therapy and endogenous cortisol production in severe pediatric head injury.

A prospective randomised study was performed on 25 children aged 1.4 to 15.8 years with severe head injury (Glasgow Coma Scale less than or equal to 7) to determine the clinical effectiveness and the impact on endogenous cortisol production of high-dose steroid therapy. Thirteen patients (group 1) received dexamethasone 1 mg/kg/day during the first 3 days and 12 (group 2) not. All patients were treated with a standardized regimen. Urinary free cortisol was measured by radioimmunoassay, and the clinical data were recorded at hourly intervals. Outcome was assessed 6 months later using the Glasgow Outcome Scale. We found a higher frequency of bacterial pneumonias in the dexamethasone-treated patients (7/13 versus 2/12). Group 1 showed a suppression of endogenous cortisol production from day 1 to day 6. In group 2, mean free cortisol was up to 5-fold higher than under basal conditions. The results in group 2 showed that the endogenous steroid production reacts adequately to the stress of severe head injury. It probably is sufficient to elicit maximum glucocorticoid effects. There was no other statistically significant difference in the clinical and laboratory data between the two groups. We conclude that dexamethasone in high doses suppresses endogenous cortisol production up to 6 days and may increase the risk of bacterial infection without affecting the outcome or the clinical and laboratory data.

Cranioplasty for acquired skull defects in children--a comparison between autologous material and methylmethacrylate 1974-1990.

The authors report on their experiences with 21 patients with skull defects which were closed by polymethylmethacrylated plates (PMMA) from 1974 to 1990 at the University Children's Hospital in Zurich and the "Gemeinschaftspraxis fuer Kinderchirurgie". The results were compared with 15 cases treated by autologous grafts. Because of false indication, one case of PMMA-plasty led to an infected fistula. Otherwise no adverse reactions were noted. Three of the 15 cases with autologous grafts showed resorption. Polymethylmethacrylate is an excellent agent for skull reconstruction. The simple procedure, shorter OP time, and lack of pain or disfigurement due to a donor site signify a great advantage to this method.

[Ambulatory pediatric surgery]. / Ambulante Kinderchirurgie.

The authors refer about their experience in ambulatory pediatric surgery performed in pediatric clinics or in their own practice. Indications are listed, conditions, advantages and disadvantages are discussed. 562 operations were completed from February 1991 to January 1992, 181 (32%) under practice conditions with an experienced anesthesiologist. No complications had to be reported, and no patient was hospitalized due to surgical or anesthetic complications. But indications for ambulatory surgery have to be strictly noted, and only children in excellent health should be anesthesized. The decision about operability has to be made by the anesthesiologist in charge.

Can modern therapy influence the prognosis of brain injuries in childhood?

A standard therapy and the outcome following severe head injury in 51 children are presented. The Glasgow-Coma-Scale was used for classification. Initial therapy included intubation, hyperventilation, ICP monitoring, and barbiturate coma. 14 children had a normal ICP recording, 13 showed moderate (-35 mmHg) ICP elevations, and 23 had recurrent ICP elevations above 35 mmHg. Only one patient survived in a vegetative state. Overall mortality was 21%. All but one of the survivors were controlled one year after the accident. School performance, social integration and the Glasgow-Outcome-Scale were controlled for judging the results. 82% of the surviving children were able to visit a normal school.

[Transient post-traumatic cerebral blindness]. / Die transitorische posttraumatische zerebrale Blindheit.

Over a one-year period 7 patients with transient posttraumatic cortical blindness were observed among 145 patients with trivial blunt head trauma. The symptoms and associated signs of this syndrome are outlined. The syndrome is harmless but relatively unknown, and occurs in children with slight head injury. Vision is usually regained within a few hours. The prognosis is excellent and residues in children have not been reported.

[Late results of sub-capital humerus fracture in children]. / Spätresultate der subkapitalen Humerusfraktur im Kindesalter.

From 1980 until 1984 56 children with a subcapital humeral fracture were treated at the Department of Paediatric Surgery in Zürich. 42 of them could be followed-up 5 years after the accident, all showed a good result. In 21 children a simple immobilisation was successful. 8 cases needed a reposition of the fracture in anaesthesia and immobilisation. 11 cases needed further procedures, in 7 of them an osteosynthesis was done, in 4 cases an extension was necessary to hold the fracture position. One patient was treated primarily by open reduction and pinning of the fracture, another one by an extension. Both patients had polytrauma. The paper presents our long-term results and the different modalities of treatment are discussed in the light of our own results.

[Renal calcium excretion in primary hyperparathyroidism and idiopathic hypercalciuria (author's transl)]. / Die renale Calciumausscheidung bei primärem Hyperparathyreoidismus und idiopathischer Hypercalciurie.

The tubular reabsorption of calcium is increased in primary hyperparathyroidism as compared to control subjects and patients with resorptive hypercalciuria. The mean percentage of filtered calcium being reabsorbed by the renal tubules is decreased in primary hyperparathyroidism and hypercalciuria. This might point towards a maximal tubular transport capacity being exceeded in some cases of primary hyperparathyroidism whereas a relative hypoparathyroidism with decreased stimulation of tubular calcium reabsorption might be involved in hypercalciuria.

[Non-trauma-induced hemothorax--a certain leading symptom of a malignant tumor?]. / Der nicht traumatisch bedingte Hämatothorax--sicheres Leitsymptom für einen malignen Tumor?

The haematothorax not induced by a trauma is very uncommon in childhood. Its presence may be the leading symptom of a malignant tumour that needs further investigation, but a correct diagnosis cannot always be made before thoracotomy. We report on 3 cases which had been operated on for suspected malignant disease, but in 1 case we found a diaphragmatic hernia, in another one an extralobal sequestration of the lung and only in the third patient a malignant teratoma. The diagnostic and therapeutic procedure of a spontaneous haemothorax is discussed.

Long-term therapy of second and third degree burns in children using Jobst-compression suits.

Thirteen children, aged between 2 1/2 and 14 years, with full-thickness burns are presented. These children were treated with compression suits according to the method developed by the Jobst Institute in Toledo, Ohio. The material manufactured in Switzerland is described and the advantages and disadvantages of this material are discussed. Group I comprised 8 children who were fitted out with the suit directly after the burns had healed. These were all scalds covering 11 to 30% of the body surface and necessitating Thiersch grafts. Group 2 comprised 5 children who were only fitted with this suit 3 months to 2 years after the original accident. By that time they had all developed massive, hypertrophied scars, limiting flexion and extension of the joints. In the first group the skin colour rapidly returned to normal, the development of hypertrophic scars was not marked and these scars had a definite tendency to regress. Nine of ten affected joints either became normal or showed a considerable improvement in function. In the second group, 19 of 25 affected joints had become normal one year after the suits had been fitted and four showed definite improvement. Here the scars regressed, although admittedly slower than in the first group. The children appeared to wear the suits without discomfort or trouble.

Conservative treatment using compression suits for second and third degree burns in children.

The use of compression suits since December 1976 has shown, that even in cases with hypertrophic scarring after deep second- and third-degree burns good late results can be obtained. Thirty-five patients were re-examined 18 to 20 months after the compression suits were introduced and the results were analysed.

Split skin grafts from the scalp.

In 31 patients 57 split skin grafts were taken from the scalp. The scalp proved to be a very suitable place for the taking of skin grafts. Small postoperative complications can be prevented by careful subgaleal injection of saline, prevention of the strips of split skin grafts crossing each other and good postoperative care. The cosmetic disadvantage of temporarily losing one's hair is counterbalanced by wound healing without scarring; and 90% of the parents and all the questioned children were perfectly willing to have, if necessary, a second split skin graft taken from their head and preferred the scalp to any other donor locality. If children and parents are treated with understanding and consideration no psychological problems will result.

Dexamethasone therapy and cortisol excretion in severe pediatric head injury.

Glucocorticoids are used in an attempt to reduce brain edema secondary to head injury. Nevertheless, their usefulness remains uncertain and contradictory. In a randomized study of 24 children with severe head injury, urinary free cortisol was measured by radioimmunoassay. Twelve patients (group 1) received dexamethasone and 12 (group 2) did not. All patients were treated with a standardized regimen. In group 1 there was complete suppression of endogenous cortisol production. In group 2 free cortisol was up to 20-fold higher than under basal conditions and reached maximum values on days 1-3. Since the excretion of cortisol in urine reflects the production rate closely and is not influenced by liver function and barbiturates, the results in group 2 show that the endogenous production of steroids is an adequate reaction to severe head injury. Exogenous glucocorticoids are thus unlikely to have any more beneficial effects than endogenous cortisol.

[Isolated scalds and burns of the hands in early childhood]. / Isolierte Verbrühungen und Verbrennungen an Händen im Kleinkindesalter.

Every year about a hundred children with burns and scalds are hospitalised in the Burns Unit of the University Children's Hospital in Zürich. 15% of these patients are children between 1/2 to 4 years old with isolated burns and scalds of their hands. The experience gained in the treatment of 53 such children during 4 years is described. The burn healed spontaneously in 31 patients; in 22 cases Thiersch grafts had to be used. In the follow-up treatment compression suits and special splints to prevent secondary contractures were employed. The results of this treatment using splints and compression suits are discussed.