Characteristics and Validation of Pediatric Extremity Vascular Trauma in Dedicated Pediatric and Adult Trauma Centers: A Scoping Review Protocol.

BACKGROUND: Pediatric extremity vascular injuries constitute a rare yet serious entity that can lead to serious complications especially if left untreated or become late diagnosed. In our scoping review, we sought to evaluate different characteristics and outcomes of pediatric and combined adult trauma centers (ATCs) in the management of pediatric extremity vascular injury. METHODS: We sought to analyze various characteristics and parameters that differentiate a dedicated pediatric and a combined pediatric ATC in terms of effectiveness and quality of care in the acute setting and to describe special features and characteristics of an acute vascular disease that constitute pediatric population unique from the aspect of diagnosis and management. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews guidelines to conduct the study. RESULTS: The search identified 8,815 records in title using MeSH terms from PubMed/MEDLINE database among which 12 studies reporting a total of 2,124 pediatric patients with vascular extremity injuries were included for analysis. Incidence of pediatric extremity vascular injury was 0.5%. Upper extremity injuries were the most frequent presenting in 63% of cases followed by lower extremity injuries in 37% of cases. Blunt injuries were marginally more common than penetrating injuries (58% vs. 42%). In-hospital mortality and morbidity ranged from 13.2% to 0.9% and 13% to 30%, respectively. Limb-salvage rates were high, ranging from 92% to 99%. Furthermore, there are no clearly defined clinical guidelines involving the mode of imaging and diagnosis, the surgical specialties involved and the competency of nursing or medical staff overall. CONCLUSIONS: Dedicated children trauma centers theoretically represent the optimal path for acute pediatric trauma admission, especially in complex trauma necessitating vascular reconstruction. However, in the current setting of rapidly increasing health costs and economic crisis worldwide, regional or resource-related factors make this option rather unavailable. In any case, it is imperative the clinicians have a high index of suspicion when confronting with these types of injuries because early diagnosis is highly related with reduced morbidity and superior outcomes.

Parental history of adenotonsillectomy is associated with obstructive sleep apnea severity in children with snoring.

OBJECTIVE: To test the hypothesis that history of adenoidectomy and/or tonsillectomy (AT) in at least 1 of the parents during childhood, is a risk factor for moderate-to-severe obstructive sleep apnea (OSA) (apnea-hypopnea index [AHI] >5 episodes/hour) in the offspring with snoring. STUDY DESIGN: Data of children with snoring who were referred for polysomnography over 12 years by primary care physicians were reviewed. RESULTS: Data of 798 children without history of prior AT, neuromuscular, or genetic disorders or craniofacial abnormalities were analyzed. Of these children, 69.3% had tonsillar hypertrophy, 25.8% were obese, 26.8% had at least 1 parent with history of AT, and 22.1% had AHI >5 episodes/hour. Parental history of AT was significantly associated with moderate-to-severe OSA (logit model including sex, tonsillar hypertrophy, obesity, and physician-diagnosed wheezing; OR [95% CI], 1.70 [1.18-2.46]; P < .01). When significant variables from the logit model (tonsillar hypertrophy, obesity, parental history of AT) were considered independently or in combination, tonsillar hypertrophy combined with history of AT in at least 1 of the parents had high specificity (84.4%) and the highest positive likelihood ratio (1.78) for identifying children with AHI >5 episodes/hour. CONCLUSIONS: Among children with snoring who are referred for polysomnography by primary care physicians, those with tonsillar hypertrophy and parental history of AT have increased risk of moderate-to-severe OSA and represent 1 of the subgroups that should be prioritized for a sleep study in settings with limited resources.

Nocturnal enuresis is associated with moderate-to-severe obstructive sleep apnea in children with snoring.

BACKGROUND: Conflicting data suggest that prevalence of monosymptomatic primary nocturnal enuresis (NE) increases with increasing severity of obstructive sleep apnea (OSA) in childhood and especially in girls. We hypothesized that NE is associated with increased risk of moderate-to-severe OSA (obstructive apnea-hypopnea index (AHI) >5 episodes/hour) among children with snoring. METHODS: Data of children (≥5 y old) with snoring who were referred for polysomnography over 12 y were reviewed. RESULTS: Data of 525 children with mean age (±SD) 7.5 (± 2.2) y and median obstructive AHI (10th-90th percentiles) 1.9 (0.4-7.3) episodes/hour were analyzed. Three hundred and fifty-five children (67.6%) had NE and 87 (16.6%) had moderate-to-severe OSA. There was no interaction between NE and gender regarding the association with moderate-to-severe OSA (P > 0.05). NE was associated significantly with presence of moderate-to-severe OSA after adjustment for tonsillar hypertrophy, obesity, gender, and age (adjusted odds ratio = 1.92 (1.08-3.43); P = 0.03). Presence of NE had high sensitivity (78.2%) and low positive predictive value (19.2%) for detecting moderate-to-severe OSA and low specificity (34.5%) and high negative predictive value (88.8%) for ruling it out. CONCLUSION: Children with snoring and without NE referred for polysomnography are less likely to have moderate-to-severe OSA compared to those with NE.

Low-grade albuminuria in children with obstructive sleep apnea.

Small urinary protein loss (low-grade albuminuria or microalbuminuria) may reflect altered permeability of the glomerular filtration barrier. In the present study, it was hypothesized that children with obstructive sleep apnea have an increased risk of microalbuminuria compared with control subjects without sleep-disordered breathing. Albumin-to-creatinine ratio was measured in morning spot urine specimens collected from consecutive children with or without snoring who were referred for polysomnography. Three groups were studied: (i) control subjects (no snoring, apnea-hypopnea index < 1 episode h(-1) ; n = 31); (ii) mild obstructive sleep apnea (snoring, apnea-hypopnea index = 1-5 episodes h(-1) ; n = 71); and (iii) moderate-to-severe obstructive sleep apnea (snoring, apnea-hypopnea index > 5 episodes∙h(-1) ; n = 27). Indications for polysomnography in control subjects included nightmares, somnambulism and morning headaches. An albumin-to-creatinine ratio > median value in the control group (1.85 mg of albumin per g of creatinine) was defined as elevated. Logistic regression analysis revealed that children with moderate-to-severe obstructive sleep apnea, but not those with mild obstructive sleep apnea, had increased risk of elevated albumin-to-creatinine ratio relative to controls (reference) after adjustment for age, gender and presence of obesity: odds ratio 3.8 (95% confidence interval 1.1-12.6); P = 0.04 and 1.5 (0.6-3.7); P > 0.05, respectively. Oxygen desaturation of hemoglobin and respiratory arousal indices were significant predictors of albumin-to-creatinine ratio (r = 0.31, P = 0.01; and r = 0.43, P < 0.01, respectively). In conclusion, children with moderate-to-severe obstructive sleep apnea are at significantly higher risk of increased low-grade excretion of albumin in the morning urine as compared with control subjects without obstructive sleep apnea. These findings may reflect altered permeability of the glomerular filtration barrier related to nocturnal hypoxemia and sympathetic activation which are induced by obstructive sleep apnea.

Oxidative stress and inflammatory markers in the exhaled breath condensate of children with OSA.

INTRODUCTION: Obstructive sleep apnea (OSA) in children has been associated with systemic inflammation and oxidative stress. Limited evidence indicates that pediatric OSA is associated with oxidative stress and inflammation in the airway. OBJECTIVE: The objective of this study is to assess the hypothesis that levels of oxidative stress and inflammatory markers in the exhaled breath condensate (EBC) of children with OSA are higher than those of control subjects. METHODS: Participants were children with OSA and control subjects who underwent overnight polysomnography. Morning levels of hydrogen peroxide (H(2)O(2)) and sum of nitrite and nitrate (NO(x)) in EBC of participants were measured. RESULTS: Twelve subjects with moderate-to-severe OSA (mean age ± standard deviation: 6.3 ± 1.7 years; apnea-hypopnea index--AHI, 13.6 ± 10.1 episodes/h), 22 subjects with mild OSA (6.7 ± 2.1 years; AHI, 2.8 ± 1 episodes/h) and 16 control participants (7.7 ± 2.4 years; AHI, 0.6 ± 0.3 episodes/h) were recruited. Children with moderate-to severe OSA had higher log-transformed H(2)O(2) concentrations in EBC compared to subjects with mild OSA, or to control participants: 0.4 ± 1.1 versus -0.9 ± 1.3 (p = 0.015), or versus -1.2 ± 1.2 (p = 0.003), respectively. AHI and % sleep time with oxygen saturation of hemoglobin <95% were significant predictors of log-transformed H(2)O(2) after adjustment by age and body mass index z score (p < 0.05). No significant differences were demonstrated between the three study groups in terms of EBC NO(x) levels. CONCLUSIONS: Children with moderate-to-severe OSA have increased H(2)O(2) levels in morning EBC, an indirect index of altered redox status in the respiratory tract.

Low morning serum cortisol levels in children with tonsillar hypertrophy and moderate-to-severe OSA.

BACKGROUND: Hypertrophic tonsillar tissue in children with obstructive sleep apnea (OSA) has enhanced expression of glucocorticoid receptors, which may reflect low endogenous cortisol levels. We have evaluated the effect of the interaction between tonsillar hypertrophy and OSA severity on morning serum cortisol levels. METHODS: Children with and without snoring underwent polysomnography, tonsillar size grading, and measurement of morning serum cortisol. RESULTS: Seventy children (2-13 years old) were recruited: 30 with moderate-to-severe OSA (apnea-hypopnea index [AHI] > 5 episodes/h), 26 with mild OSA (AHI > 1 and ≤ 5), and 14 controls (no snoring; AHI ≤ 1). Tonsillar hypertrophy was present in 56.7%, 53.8%, and 42.9% of participants in each group, respectively. Application of a general linear model demonstrated a significant effect of the interaction between severity of OSA and tonsillar hypertrophy on cortisol levels (P = 0.04), after adjustment for obesity, gender, and age. Among children with tonsillar hypertrophy, subjects with moderate-to-severe OSA (n = 17; AHI 14.7 ± 10.6), mild OSA (n = 14; AHI 2.3 ± 1.2), and control participants (n = 6; AHI 0.7 ± 0.2) were significantly different regarding cortisol levels (P = 0.02). Subjects with moderate-to-severe OSA had lower cortisol (16.9 ± 8.7 mcg/dL) than those with mild OSA (23.3 ± 4.2; P = 0.01) and those without OSA (controls) (23.6 ± 5.3 mcg/dL; P = 0.04). In contrast, children with normal-size tonsils and moderate-to-severe OSA, mild OSA, and controls did not differ in cortisol levels. CONCLUSIONS: Children with moderate-to-severe obstructive sleep apnea and the phenotype of hypertrophic tonsils have reduced morning serum cortisol levels and potentially decreased glucocorticoid inhibitory effects on tonsillar growth.

Effects of adenotonsillectomy on R-R interval and brain natriuretic peptide levels in children with sleep apnea: a preliminary report.

OBJECTIVES: Obstructive sleep apnea is associated with decreased R-R interval length and overall R-R interval variability in the electrocardiogram along with increased morning brain natriuretic peptide (BNP) blood levels. These findings indicate enhanced sympathetic tone and cardiac strain. In this study, it was hypothesized that adenotonsillectomy (AT) in children with sleep apnea is accompanied by improvement in polysomnography indices, increase in length and variability of R-R interval, and reduction in BNP levels. METHODS: Polysomnography and measurements of morning BNP levels were performed before and 4-6months after AT. Mean and standard deviation of R-R interval were calculated from polysomnography electrocardiogram recordings. RESULTS: Twenty-one children were studied. Apnea-hypopnea index and log-transformed BNP levels decreased postoperatively from 8.4±7.6 episodes/h and 2.2±0.7, to 1.8±1.4 episodes/h and 1.9±0.3, respectively (p<0.05). Mean R-R interval increased from 703.2±137.4ms (Stage 2), 699.3±135.8ms (Stage 3), 707.4±128.9ms (Stage 4) and 660.5±140.1ms (Stage REM), to 773.5±122.7ms (Stage 2), 765.7±73.7ms (Stage 3), 771.2±71.6ms (Stage 4), and 738.6±81.7ms (Stage REM), respectively (p<0.05 for comparisons pre- vs. post-operatively). Standard deviation of R-R in Stage 2 increased from 88.5±29.6 to 122.7±67ms (p=0.045). CONCLUSIONS: Increase in nocturnal length of R-R interval and decrease in BNP levels after AT for sleep apnea may reflect postoperative reduction in sympathetic tone and cardiac strain.

Correlation of urinary excretion of sodium with severity of sleep-disordered breathing in children: a preliminary study.

BACKGROUND: Nocturnal urinary sodium excretion is related to blood pressure (BP) levels. Elevated BP and increased nocturnal natriuresis have been demonstrated in adults with sleep apnea. Although evidence indicates increased BP in children with obstructive sleep-disordered breathing (SDB), it is unknown whether these children have also enhanced urinary sodium excretion. OBJECTIVE: To evaluate the effects of SDB and morning BP on urinary sodium excretion. METHODS: Consecutive children with snoring (n = 95) underwent polysomnography and morning BP measurement. Fractional excretion of sodium (FE(Na)) was the primary outcome measure and was calculated using sodium and creatinine concentrations in early morning serum and urine specimens. RESULTS: Subjects with moderate-to-severe SDB had similar log-transformed FE(Na) to that of children with mild SDB and higher than children with primary snoring: -0.13 ± 0.53 versus -0.28 ± 0.41 versus -0.61 ± 0.65 (P = 0.657 and P = 0.003). Obstructive apnea-hypopnea index was significantly related to FE(Na) after adjustment for age, gender and body mass index z-score (P = 0.002). Children with moderate-to-severe SDB had similar systolic BP z-scores to those of subjects with mild SDB and higher than participants with primary snoring: 0.7 ± 1.2 versus 0.1 ± 1.0 versus -0.02 ± 1.0 (P = 0.074 and P = 0.046). In addition, participants with diastolic BP z-scores in the upper quartile of measured values had higher FE(Na) than subjects with z-scores in the lower quartiles: -0.08 ± 0.39 versus -0.41 ± 0.57 (P = 0.007). CONCLUSIONS: Morning natriuresis is related to severity of SDB in children and this association may be mediated in part by elevated BP.

Uric acid excretion in North American and Southeast European children with obstructive sleep apnea.

BACKGROUND AND OBJECTIVES: Responses to nocturnal hypoxemia accompanying sleep-disordered breathing (SDB) may vary in different populations. Aims of this study were to (1) assess whether severity of SDB is related to uric acid excretion in North American and Southeast European children and (2) evaluate the interaction between nocturnal hypoxemia and country of children's origin in uric acid excretion. METHODS: Consecutive US and Greek children with snoring who were referred for polysomnography were recruited. Uric acid excretion expressed as uric acid-to-creatinine concentrations ratio in a morning urine specimen was the primary outcome measure. RESULTS: One hundred and twenty-six US children (6.8+/-0.7years old) and 123 Greek children (6.4+/-2.5years old) were recruited. Forty-three US and 53 Greek participants had moderate-to-severe nocturnal hypoxemia (SpO(2) nadir <90%). Obstructive apnea-hypopnea index and SpO(2) nadir were related to uric acid excretion in Greek (but not US) children after adjustment by age, gender and body mass index z-score (p<0.05). There was a significant interaction between severity of hypoxemia and country of children's origin in uric acid excretion after adjustment by age, gender and body mass index z-score (p=0.036). Greek children with moderate-to-severe hypoxemia had higher uric acid excretion (0.85+/-0.35) than those with mild/no hypoxemia (0.69+/-0.25) (p=0.005). US children with moderate-to-severe hypoxemia (0.41+/-0.20) did not differ in uric acid excretion from those with mild/no hypoxemia (0.42+/-0.22) (p=0.823). CONCLUSIONS: Uric acid excretion differs in children with SDB and different ethnic backgrounds or environmental exposures.