Comparison of Negative Pressure Wound Therapy (NPWT) and Classical Wet to Moist Dressing (WtM) in the Treatment of Complicated Extremity Wounds in Children.

Treating complicated wounds in the pediatric population using traditional wet to moist wound dressing methods is not always appropriate due to the frequent need to change dressings daily or even a number of times a day, causing distress to the patient. Topical negative pressure is a method that allows for fewer dressings and provides localized benefits, thus accelerating wound healing. The merits of this therapy have been proven in studies on adults, but research on the pediatric population is scarce. Here we intend to present the results of negative pressure wound therapy (NPWT) on 34 pediatric patients (study group) and compare them with 24 patients (control group) treated with the traditional wet to moist dressing for complicated wounds. The results show that topical negative pressure wound therapy is a safe method that downgrades a wound from a complicated to a simple one and allows definitive coverage using a simpler technique with fewer wound dressings. The scars of the patients in the study group exhibited a better result on a visual scar scale. The patients in the control group had a shorter hospital stay. Based on the recorded results, we were able to make treatment recommendations.

Profile of Children With Child Abuse From Serbia.

OBJECTIVE: To study the demographic and clinical profile of children with suspected physical or sexual abuse. METHODS: Retrospective records of children who were admitted to hospital between January, 2015 to December, 2020 with suspected physical or sexual abuse were evaluated. RESULTS: The records of 52 children [mean (SD) age 12.24 (5.32) y, 39 boys] were retrieved. Contusions were the most common injury in 53.8% of boys and 69.2% of girls. The majority (70%) of 8-18 year-old-children were abused by peers, and parents/caregivers were the main perpetrators in 72.7% of younger children. CONCLUSION: Child abuse is often underreported, and requires a high index of suspicion and multidisciplinary approach of management.

Neglected Monteggia Fractures in Children-A Retrospective Study.

(1) Background: A Monteggia fracture is an infrequent injury in children. It can be missed during an initial consultation in 20-50% of patients. Chronic radial head dislocation may lead to several complications. Thus, surgical reconstruction of chronic Monteggia injuries is justified. The aim of this study is to analyze the single tertiary center experience in the treatment of neglected Monteggia fractures. (2) Methods: A retrospective study of patients treated for missed Monteggia fractures was conducted. Hospital records, operative charts, follow-up records and a set of X-rays were analyzed for each patient. Radiographic results were graded as good, moderate or poor. The functional status of elbows was estimated using the Mayo Elbow Performance Index. (3) Results: A total of 13 patients (8 boys and 5 girls) aged 4-12 years (mean 7.15) were treated during the study period. An angulation osteotomy of the ulna was performed in ten patients and a radial shortening osteotomy in three patients. A Bell-Tawse annular ligament reconstruction was performed in five patients, and a direct repair was performed in two patients. Eight patients had radiocapitellar trans-fixation. There were nine good radiographic results, three moderate and one poor. The functional result was excellent in nine patients, good in three and poor in one. (4) Conclusions: Our work has many limitations (only 13 patients and different types of operations), and conclusions should be drawn very carefully from such a small and diverse group. The surgical reconstruction of neglected Monteggia fractures in children should be attempted in all patients. Angulation and elongation osteotomies of the ulna are suitable for most patients. If there is a marked overgrowth of the radius, gradual ulnar lengthening and radial head reduction using the Ilizarov method may be a better option. Annular ligament reconstruction is not mandatory.

Importance of a Follow-Up Ultrasound Protocol in Monitoring Posttraumatic Spleen Complications in Children Treated with a Non-Operative Management.

Background and objectives: For the last three decades, non-operative management (NOM) has been the standard in the treatment of clinically stable patients with blunt spleen injury, with a success rate of up to 95%. However, there are no prospective issues in the literature dealing with the incidence and type of splenic complications after NOM. Materials and methods: This study analyzed 76 pediatric patients, up to the age of 18, with blunt splenic injury who were treated non-operatively. All patients were included in a posttraumatic follow-up protocol with ultrasound examinations 4 and 12 weeks after injury. Results: The mean age of the children was 9.58 ± 3.97 years (range 1.98 to 17.75 years), with no statistically significant difference between the genders. The severity of the injury was determined according to the American Association for Surgery of Trauma (AAST) classification: 7 patients had grade I injuries (89.21%), 21 patients had grade II injuries (27.63%), 33 patients had grade III injuries (43.42%), and 15 patients had grade IV injuries (19.73%). The majority of the injuries were so-called high-energy ones, which were recorded in 45 patients (59.21%). According to a previously created posttraumatic follow-up protocol, complications were detected in 16 patients (21.05%). Hematomas had the highest incidence and were detected in 11 patients (14.47%), while pseudocysts were detected in 3 (3.94%), and a splenic abscess and pseudoaneurysm were detected in 1 patient (1.31%), respectively. The complications were in a direct correlation with injury grade: seven occurred in patients with grade IV injuries (9.21%), five occurred in children with grade III injuries (6.57%), three occurred in patients with grade II injuries (3.94%), and one occurred in a patient with a grade I injury (1.31%). Conclusion: Based on the severity of the spleen injury, it is difficult to predict the further course of developing complications, but complications are more common in high-grade injuries. The implementation of a follow-up ultrasound protocol is mandatory in all patients with NOM of spleen injuries for the early detection of potentially dangerous and fatal complications.

Interstitial Cells of Cajal and Neural Structures in the Human Fetal Appendix.

BACKGROUND/AIMS: The interstitial cells of Cajal (ICC) are located within and around the digestive tract's muscle layers. They function as intestinal muscle pacemakers and aid in the modification of enteric neurotransmission. The appendix's unique position requires an appropriate contraction pattern of its muscular wall to adequately evacuate its contents. We investigated the development and distribution of nervous structures and ICC in the human fetal appendix. METHODS: Specimens were exposed to anti-c-kit (CD117) antibodies to investigate ICC differentiation. Enteric plexuses were examined using anti-neuron-specific enolase, and the differentiation of smooth muscle cells was studied with anti-desmin antibodies. RESULTS: During weeks 13-14, numerous myenteric plexus ganglia form an almost uninterrupted sequence throughout the body and apex of the appendix. Fewer ganglia were present at the submucosal border of the circular muscle layer and within this layer. A large number of ganglia appear within the circular and longitudinal muscle layers in a later fetal period. The first ICC subtypes noted were of the myenteric plexus and the submucous plexus. In the later fetal period, the number of intramuscular ICC markedly rises, and this subtype becomes predominant. CONCLUSIONS: The ICC and nervous structure distribution in the human fetal appendix are significantly different from all other parts of the small and large intestine. The organization of ICC and the enteric nervous system provides the basis for the specific contraction pattern of the muscular wall of the appendix.

Congenital esophageal stenosis: a rare malformation of the foregut.

Congenital esophageal stenosis (CES) is a type of esophageal stenosis, and three histological subtypes (tracheobronchial remnants, fibromuscular thickening or fibromuscular stenosis, and membranous webbing or esophageal membrane) are described. Symptoms of CES usually appears with the introduction of the semisolid alimentation. Dysphagia is the most common symptom, but esophageal food impaction, respiratory distress or failure to thrive can be clinical manifestations of CES. Wide spectrum of differential diagnoses leads to delayed definitive diagnosis and appropriate treatment. Depends on hystological subtype of CES, some treatment procedures (dilation or segmental esophageal resection) are recommended, but individually approach is still important in terms of frequency and type of dilation procedures or type of the surgical treatment. Dysphagia can persist after the treatment and a long follow-up period is recommended. In 33% of patients with CES, a different malformations in the digestive system, but also in the other systems, are described.

Comparison between the effects of selenomethionine and S-adenosylmethionine in preventing cholestasis-induced rat liver damage.

We aimed to evaluate whether two methionine-related compounds, S-adenosylmethionine (SAM), and selenomethionine (SM), could lessen liver damage induced by regurgitated bile in a model of rat bile duct ligation (BDL). Hepatoprotective potentials of S-adenosylmethionine and selenomethionine were estimated based on the changes of serum liver damage parameters (aminotransferases, alkaline phosphatase, gamma-glutamyltranspeptidase and lactate dehydrogenase activity, and bilirubin concentration), tissue oxidative [xanthine oxidase (XO) and catalase activity, thiobarbituric acid reactive substances (TBARS) levels] and inflammatory [tumor necrosis factor-alfa (TNF-α) concentration] parameters, and morphological liver tissue alterations that follow cholestasis. The treatment regimens proved themselves able to prevent significant liver damage induced by cholestasis. Both SAM and SM decreased XO activity and TBARS levels and increased catalase activity, while only SM significantly reduced TNF-α concentration. Morphological changes related to bile-induced liver damage were also found to be partially diminished by SAM and SM. In view of the mechanisms of action of the two tested methionine-derived compounds, one might say that SM predominantly acted as an antioxidant, while SAM exerted its activity by potentially modulating different gene expression and protein structures. It is also worth mentioning that this is the first study (to the best of our knowledge) that dealt with the effects of SM on BDL-induced liver injury in rats and of the findings that speak favorably of this powerful antioxidant.

Child Migrant Health: The Role of Pediatric Surgery in the Migrants' Route across Balkan Countries to North-West Europe.

INTRODUCTION: Child migrants are the most vulnerable population, prone to various health conditions due to trauma and the bad living conditions that they experience during their migration. The objective of this study was to determine the pediatric surgical conditions of migrant children treated in our hospital on their way toward North-West Europe. MATERIALS AND METHODS: A retrospective analysis was performed on all admitted migrants in one tertiary and one secondary level hospital from 2016 to 2018. Only migrant children with surgical issues who had been hospitalized or treated in outpatient clinics were included in the study. RESULTS: There were 47 migrants admitted to hospitals and outpatient clinics; 32 from Afghanistan, 11 from Iraq, 1 from Syria, 2 from Iran, and 1 from Algeria. There were 27 boys and 20 girls, average age 7.96 years (range: 3 months-17 years). The average length of hospitalization was 14.1 days (range: 1-48), and average stay in the intensive care unit (ICU) was 7.4 days (range: 1-15). There were 29 migrants treated in outpatient clinics, and 18 were hospitalized. The cause of seeking surgical treatment was trauma in 33 and non-traumatic surgical problems in 14. The most common types of trauma were isolated fractures which occurred in one, followed by isolated head injury in eight. Polytrauma occurred in five. A lethal outcome occurred in one 9-year-old boy from Afghanistan due to severe polytrauma. CONCLUSION: Trauma, predominantly fractures and head injuries, was the leading cause of morbidity in migrant children treated in these two hospitals.

The effects of botulinum toxin type A on improvement and dynamic spastic equinus correction in children with cerebral palsy - preliminary results.

INTRODUCTION: We evaluated the effects of botulinum toxin type A (BTA) with physical therapy on dynamic foot equinus correction and higher motor functional outcome in children with spastic type of cerebral palsy (CP). MATERIAL AND METHODS: Ankle joint active and passive movement, gastrocnemial muscle spasticity levels (Modified Ashworth Scale (MAS)), and higher motor functional status (Gross Motor Function Classification System (GMFCS) and Gross Motor Function Measure (GMFM) (GMFM-D - standing and GMFM-E - walking) were assessed before treatment and 3, 8, 16 weeks and 6 months after BTA administration in 12 children. RESULTS: There was a significant improvement of active (initial - (-)13.07 ±5.78; 6 months - (-)10.64 ±4.77; p < 0.001) and passive (initial - 4.21 ±2.29; 6 months - 4.71 ±2.16; p < 0.05) ankle joint foot dorsiflexion. GMFM-D and GMFM-E were significantly higher after 3, 8, 16 weeks (p < 0.001) and GMFM-D after 6 months (p < 0.001). CONCLUSIONS: Botulinum toxin type A administration and physical therapy in patients with spastic CP improves the motion range of dynamic foot equinus after 3 weeks and higher motor functional outcome (standing and walking).

Scaphoid fractures in children.

INTRODUCTION: Scaphoid fractures are rare in childhood. Diagnosis is very difficult to establish because carpal bones are not fully ossified. In suspected cases comparative or delayed radiography is used, as well as computerized tomography, magnetic resonance imaging, ultrasound and bone scintigraphy. Majority of scaphoid fractures are treated conservatively with good results. In case of delayed fracture healing various types of treatment are available. OBJECTIVE: To determine the mechanism of injury, clinical healing process, types and outcome of treatment of scaphoid fractures in children. METHODS: We retrospectively analyzed patients with traumatic closed fracture of the scaphoid bone over a ten-year period (2002-2011).The outcome of the treatment of"acute"scaphoid fracture was evaluated using the Mayo Wrist Score. RESULTS: There were in total 34 patients, of mean age 13.8 years, with traumatic closed fracture of the scaphoid bone, whose bone growth was not finished yet. Most common injury mechanism was fall on outstretched arm--76% of patients. During the examined period 31 children with "acute" fracture underwent conservative treatment, with average immobilization period of 51 days. Six patients were lost to follow-up. In the remaining 25 patients, after completed rehabilitation, functional results determined by the Mayo Wrist Score were excellent. CONCLUSION: Conservative therapy of "acute" scaphoid fractures is an acceptable treatment option for pediatric patients with excellent functional results.

Esophagitis and almost complete esophageal occlusion in a girl with epidermolysis bullosa.

Epidermolysis bullosa is a genetically transmitted skin disorder that typically manifests with trauma-induced skin blistering, scarring and in some cases mucosal involvement. Esophageal webs, strictures or stenosis can be found in about a third of the patients with the recessive dystrophic type of this disease. We report a six-year-old girl with recessive dystrophic epidermolysis bullosa and progressive dysphagia. Almost complete esophageal occlusion was found on barium swallow and esophagoscopy (endoscopic signs of esophagitis were also seen). She was treated successfully with fluoroscopically guided balloon dilatation and esomeprazole. Fluoroscopically guided balloon dilatation and postdilatation use of esomeprazole is a safe and effective therapy for recessive dystrophic epidermolysis bullosa patients with almost complete esophageal occlusion and esophagitis.

[Evaluation of using Alvarado score and C-reactive protein in diagnosing acute appendicitis in children].

BACKGROUND/AIMS: Acute appendicitis (AA) remains a diagnostic challenge in children, despite ongoing researches. With an aim to facilitate making diagnosis of AA many scoring systems have been created; among them Alvarado score is the most popular. C-reactive protein (CRP) has proven significance for diagnosing AA in adults, but not in children. The aim of this study was to evaluate significance of Alvarado score, as well as CRP values, in making diagnosis of AA in children. METHODS: This prospective six-month study was performed on 257 patients under the age of 15, admitted for acute abdominal pain in the Clinic of Pediatric Surgery and Orthopedics in the Clinical Centre of Nis. Alvarado score and CRP values were determined on admission and compared with final diagnosis on discharge. The patients were divided into two groups: group I--non operated patients with abdominal pain (n=184) and group II--operated on patients for appendectomy (n=73). RESULTS: Values of Alvardo score were statistically significantly different between groups (group I: 4.9 +/- 1.21, group II: 8.55 +/- 1.32). Also, our results showed significantly high values of CRP measured in operated children (group I: 8.17 +/- 4.7 mg/L, group II: 38 +/- 26 mg/L). Values of validity parameters for Alvarado score were: sensitivity 90%, specifity 80%, positive predictive values 87%; for CRP 95%, 70% and 80%, respectively. CONCLUSION: Alvarado score and CRP are very useful adjuvant diagnostic tool for AA to a less experienced surgeon. High values of Alvarado score and CRP cannot be ignored neither at the same time, used as the sole diagnostic method for discriminating children with AA.

C-kit-immunopositive interstitial cells of Cajal in human embryonal and fetal oesophagus.

Interstitial cells of Cajal (ICC) are morphologically and functionally intercalated between the elements of the enteric nervous system and the smooth muscle cells (SMCs) in the musculature of the digestive tract. Kit immunohistochemistry reliably identifies the location of these cells and provides information on changes in ICC distribution and density. Human oesophagus specimens (7 embryos, 23 fetuses at 7-27 weeks gestational age; both sexes) were exposed to Kit antibodies to determine ICC differentiation. Enteric plexuses were examined immunohistochemically by using anti-neuron-specific enolase, whereas the differentiation of SMCs was studied with antibodies against alpha-smooth-muscle actin and desmin. By week 7, c-kit-immunopositive cells were present along the entire oesophagus in the form of an uninterrupted layer around the myenteric plexus (MP) elements. From the beginning of the 3rd month, the number of ICC progressively decreased around the MP ganglia but increased within the muscle layers. Concomitantly, differences in the number and distribution of ICC were established in the various portions of the oesophagus: specifically, ICC were abundant in the lower portion, less numerous in the middle region and rare in the upper part. By the 5th month of development, the relationship as found in later developmental stages had been established: C-kit IR ICC were present within the circular muscle layer, within the longitudinal layer and in the connective septa surrounding the muscle bundles but were completely missing around the MP ganglia.

[Peripheral nerve blocks in paediatric anaesthesia].

INTRODUCTION: Most children undergoing surgery can benefit from regional anaesthetic techniques, either as the sole anaesthetic regimen or, as usual in paediatric practice, in combination with general anaesthesia. The use of peripheral nerve blocks (PNBs) in paediatric anaesthesia is an effective way to decrease the side-effects and complications associated with central blocks. In spite of their many advantages, including easy performance end efficacy, peripheral nerve blocks are still underused. OBJECTIVE: This article discusses a general approach to PNBs in children and provides data concerning the practice of this regional technique in different age groups. METHODS: Data from 1,650 procedures were prospectively collected during the period from March 1, 2007 to February 29, 2008. The type of PNB, if any, as well as the patient age were noted. Our patients were divided into four groups: 0-3 years, 4-7 years, 8-12 years and 13-18 years. RESULTS: During the investigated period, PNBs as a sole technique or in anaesthetized children were performed in 7.45% of cases. Ilioinguinal/iliohypogastric nerve block and penile block were the most common (70% of all PNBs) distributed mainly among the children between 4-7 years of age (p < 0.05). In older children, extremity PNBs predominate in regard to other types of blocks. PNBs are most frequently performed under general anaesthesia (85%), so the perineural approach requires a safe technique to avoid nerve damage. CONCLUSION: The observed differences in PNB usage seem to be related to patient age and correlate with common pathology and also with technical availability of PNB performance.

[Acute appendicitis in the first three years of life].

Acute appendicitis is the most frequent disease in children population that requires an urgent surgical intervention. Only 2% of operated children belong to the group younger than 3 years. Yet, 77% are school children. Appendicitis in young children is characterized by: atypical clinical course, late diagnosis, high percentage of perforations, and high level of mortality and morbidity rates. The commonest symptoms are: vomiting, undefined abdominal pain, and high temperature. Abdominal distention and diffuse abdominal tenderness are the most frequent signs during examination. Our analysis (1991-2000) included all patients younger than 3 years who were hospitalized in Clinic for Pediatric Surgery Nis with diagnosis of the acute appendicitis. Out of 2533 patients with disease, 58 (2.3%) were younger than 3 years, 23 were girls (39.7%) and 35 were boys (60.3%). Perforated appendicitis was found in 55 (94.8%) of 58 children. Thirty five (60.5%) patients were previously treated. Complications developed in 36 (62.1%) cases: purulence (58.3%), dehiscence (22.3%), abdominal wall abscess (13.8%), and ileus (5.6%). Acute appendicitis is very specific condition that needs high attention by all doctors engaged in pediatric health care. Our recommendation is "to admit and observe" by using the physical examination in all suspected cases. Sometimes, even sedation may be used for better palpation results.

[Transverse testicular ectopia]. / Transverzalna ektopija testisa.

Transverse testicular ectopia is an extremely rare anomaly, characterized by migration of one testis towards the opposite inguinal canal, usually associated with inguinal hernia. Spermatic cord of the ectopic testis originates from the appropriate side. In most reported cases, the accurate diagnosis has not been made before surgery. This is a case report of transverse testicular ectopia in eleven-year-old boy who had undergone an operation for the left inguinal hernia in age of ten months. At the time of herniorrhaphy, the right testis was absent. Ten years later, during re-operation of the left inguinal hernia, both testis were found in left inguinal canal and easily brought down sequentially through the left groin into the scrotum. The right testis was fixed in the left hemiscrotum, due to shorter funicular elements, and the left was trans-septally moved to the right hemiscrotum (a modified Ombrédanne operation). Ultrasonography and voiding cystoureterography showed no associated genitourinary anomalies and no Mülerian duct remnants. The rupture of gubernaculum and dysfunction of the genitofemoral nerve could explain the etiology of crossed testis ectopia. Although ectopic testis could be localized preoperatively by ultrasonography, CT, MRI, arteriography and venography, correct diagnosis was made intraoperatively in the majority of cases. Treatment modalities include laparoscopic and surgical procedures. Atrophic testis should be removed. If testes are fused, they have to be brought into one hemiscrotum. In cases where testes are completely separated with individual funicular elements and vas deferens, an ipsilateral or contralateral orchiopexy should be performed depending on the length of funicular elements.