Relationship between the prenatal exposure to low-level of mercury and the size of a newborn's cerebellum.

Exposure to methylmercury at any stage of central nervous system development could induce alterations and result in severe congenital abnormalities. Total mercury level in maternal hair during pregnancy correlates well with blood levels of methylmercury and with total mercury levels in fetal brain. A prospective study has been conducted and a total of 137 childbearing women living at the coastal region with term, normal pregnancies were included and their newborns evaluated by ultrasonography. Mothers and their newborns are divided in two groups according to their hair mercury levels; examined group with high body levels of mercury (≥ 1 µg/g) and control group with low body levels of mercury (<1 µg/g). Neurosonographic examination was conducted to all newborns. Two dimensions of cerebellum in the sagital-medial plane have been measured: maximum height and width starting from the roof of the fourth chamber. Majority of mothers had hair mercury levels lower than 1 µg/g (N = 107). Mean value was 0.88 µg/g (SD 1.24), ranging from 0.02 to 8.71 µg/g. There was no significant difference between the two groups when it comes to the width of cerebellum (Mann-Whitney test: Z = 1471; p = 0.141). However, comparison related to the length of cerebellum shows statistically significant smaller cerebellum in newborns whose mother had hair mercury levels higher than 1 µg/g (Mann-Whitney test: Z = 2329; p = 0.019). Our results lead to a conclusion that prenatal exposure to, what we consider to be, low-levels of methylmercury does influence fetal brain development detected as decreased size of newborn's cerebellum. From a clinical point of view, a question related to the influence of prenatal low-level methylmercury exposure on fetal neurodevelopment remains open. Our further objectives are to direct the research towards performing detailed neuropshychological tests on children at the age of 18 months. Such tests could indicate the presence of subtle neurological or neuropsychological deficits.

Analysis of antiepileptic drugs use at a university hospital in Croatia.

To analyse the consumption rate of new generation antiepileptic drugs (AEDs) compared with traditional AEDs at a university hospital in Croatia. Antiepileptic drugs use was analysed retrospectively for two consecutive years, 2001 and 2002 at Departments of Neurology, Paediatrics, Psychiatry and Neurosurgery at the University Hospital Centre (UHC) Rijeka. The results obtained are expressed as number of defined daily doses (DDDs) per 100 bed days, as proposed by the WHO. The use of new generation AEDs was represented by 2% in 2001 and 5% in 2002. Majority of AEDs administered was taken by the barbiturates in both years. A wide spectrum of AEDs has been used at the Department of Paediatrics. At the Department of Neurology and Psychiatry use of barbiturates and carbamazepine predominated. The use of new AEDs at UHC has increased during the investigation period but it is still rather low compared with traditional AEDs. The similarity of our results with the result of the leading Croatian university hospitals might represent general routine AED prescription in country. Nationally based guidelines may bring more appropriate and rational approach for usage of modern AED. This task should be supported and promoted by international and national neurology associations.

Triple A syndrome: genotype-phenotype assessment.

The triple A or Allgrove syndrome is an autosomal-recessive disease (MIM*231550) characterized by the triad of achalasia, alacrima and adrenocorticotropic hormone (ACTH)-resistant adrenal insufficiency. Associated features of the syndrome are neurological and dermatological abnormalities. Until the discovery of the AAAS gene as the responsible gene in triple A syndrome, the diagnosis was based on characteristic clinical features. Here we present the clinical and molecular genetic data which demonstrated the marked phenotypic variability in three unrelated patients with triple A syndrome. The final diagnosis of triple A syndrome was confirmed by molecular analysis. In one patient with isolated achalasia, the diagnosis of triple A syndrome could only be made on the basis of the molecular genetic analysis of the AAAS gene. We therefore suggest that the diagnosis of triple A syndrome should be considered in patients who exhibit only one or two of the main symptoms (i.e. alacrima, achalasia or adrenal insufficiency). These patients require careful neurological investigation, and mutation analysis of the AAAS gene should be performed.

Teachers' opinions about capabilities and behavior of children with epilepsy.

The purpose of this study was to investigate primary school teachers' opinions or knowledge about children with epilepsy. Two hundred and sixteen teachers were involved. The results reveal that teachers do not have an accurate conception of the capabilities of children with epilepsy and that those beliefs differ from teacher to teacher. Nearly half of the teachers believe that children with epilepsy differ from healthy children in their behavior. The majority of teachers (60%) receive information on the child's disease not from the parents, but from other sources. One-third of teachers do not feel confident in their work in children with epilepsy. A great majority (91.2%) of teachers desire additional information and education about epilepsy. Primary school teachers who work with children with epilepsy have inconsistent knowledge of the capabilities and behavior of, and an inadequate way of working with, children with epilepsy. Therefore, they are eager to get more information on epilepsy. It is the duty of the medical team to offer teachers the necessary information, so that the approach to work with, and life quality of children with epilepsy can be improved. Our results are concordant with similar studies performed in various countries within the last 30 years. It is proved that epilepsy as a disease has a very similar social effect on the affected person with no regard for cultural or social background, implying that the stigma of epilepsy is still a very powerful factor in the formation of general opinions about the disease.

Transorbital penetrating brain injury caused by a toy arrow: a case report.

A case of a 9-year-old boy with a transorbital toy-arrow injury to the brain is presented. At admission he was in coma (Glasgow Coma Scale of 6) with right hemiparesis and had a completely prolapsed left eye. Computerized tomography revealed intracranial haemorrhage and fracture of the orbital wall, which were treated conservatively. His left eye was enucleated due to massive injury. At the 6-month check-up the boy still show neurological signs of latent right hemiparesis. Disturbances, mostly cognitive, were noted on his psychological tests. A survey of the literature reveals no report of this nature in the paediatric age group. The necessity of continuous monitoring of new environmental risks as they occur, and the requirement for the prevention of recreational brain injuries in children, is stressed.

[Therapeutic dilemmas in children with esophageal achalasia]. / Terapijske dileme u djece s ahalazijom jednjaka.

Two patients with oesophageal achalasia are presented. The first patient, a 22-month-old girl, had medical, endoscopic and surgical treatment. The effectiveness of drug therapy with nifedipine was good but short in duration. Endoscopic bougienage dilatation has not been definitely successful. Operative treatment, two years after the first symptoms, permanently resolved the problem of spastic lower oesophageal sphincter. The second girl, 13.5 years old, responded very well to nifedipine therapy during hospitalisation. Because of inadequate drug usage, oesophageal myotomy was performed relatively soon. In follow-up both girls were in good health condition. The treatment of oesophageal achalasia in children is still controversial. Therapeutic approach and decision on the treatment strategy depend primarily on patient's age, duration and severity of clinical signs and symptoms Etiology, pathogenesis, and possibilities of achalasia treatment are discussed.

Mohr syndrome (oro-facial-digital syndrome II)--a familial case with different phenotypic findings.

We report on two male siblings with an oro-facial-digital syndrome. The parents and two other siblings, a boy and a girl, are unaffected. The clinical findings on the reported brothers were different. Patient 1 had typical oral, facial and digital anomalies plus hypoplastic genitalia and short limbs. Clinically he had marked hypotonia, convulsions and apneic episodes. He died shortly after birth. His brother, Patient 2, had OFD features with conductive hearing loss and normal psychomental development. He did not have syndactylous reduplication of the great toes, although the toes were disproportionately large. These two patients are classified as OFD type II-Mohr syndrome. Involvement of the central nervous system in OFD type II is noted. Different phenotypic findings could be explained as variable gene expressivity. The patients described here support the hypothesis that the clinical variability of the Mohr syndrome is even wider than previously thought.

The management of war wounds to the extremities.

We present our experience in the treatment of war wounds in 174 patients treated in the Institute of Plastic and Reconstructive Surgery, Department of Surgery, Clinical Hospital Center in Zagreb. The wounds were divided into four categories depending on the type of injury and the extension of the soft tissue defect which showed the differences in primary excision and reconstruction of wounds. Patients were placed in one of two groups depending on their primary treatment and time of definitive reconstruction. Group A comprised 79 patients who were initially treated by plastic surgeons and whose reconstructive procedure was done within five days. Group B comprised 95 patients who were initially treated in a field hospital and referred later to the plastic surgery unit for definitive reconstruction more than five days after the injury. Sixty-nine (87%) of the patients in group A had only one or two debridements before definitive closure and stayed in hospital 20 days or less. In group B, 59 (62%) of the patients required three or more debridements before definitive closure and remained in hospital more than 21 days (p < 0.001). Proper primary treatment and early reconstruction result in significantly shorter duration of hospital stay and lead to more effective rehabilitation and recovery of the patients. A knowledge in terminal ballistics is important in the understanding of the pathophysiology of war wounds.

[Surgical management of war injuries involving soft tissue defects]. / Kirurski postupak kod ratne rane s manjkom mekog tkiva.

In this article, the authors emphasize that the knowledge of terminal ballistics is important for understanding of the pathophysiology of war wounds. They present their own experiences in the treatment of war wounds in 126 casualties, treated in the Institute of Plastic and Reconstructive Surgery, Department of Surgery, Clinical Hospital Center, Zagreb. About 96% of the wounded sustained extremity injuries, while head, neck and thoracoabdominal injuries appeared in a significantly smaller number of cases. War wound were divided into four main categories with regard to type of injury and extension of soft-tissue defect, thus showing the differences in primary excision and in reconstruction of the wounds; 78.6% of head and neck injuries were treated by primary or early primary reconstruction (within three to five days after the injuries have been sustained), while 45.4% of thoracoabdominal injuries were treated by a secondary closure. The greatest number of sophisticated reconstructions were used in extremity injuries (15 wound were reconstructed by local flaps, while free flaps were used in 8 cases). The authors emphasize the importance of proper primary treatment which enables an early reconstruction. This results in significantly shorter hospitalization, so that 87.5% of patients were treated within 20 days and then transferred to early rehabilitation.

High-energy war wounds: flap reconstruction.

In this article, we emphasize that knowledge of terminal ballistics is essential for understanding the pathophysiology of war wounds. We present our own experiences in treatment of high-energy war wounds in 75 patients treated in the Institute of Plastic and Reconstructive Surgery, Department of Surgery, Clinical Hospital Center in Zagreb. Patients were divided into three groups with regard to the time of definite reconstruction, using local or free microvascular flaps. About 12% of patients underwent flap reconstruction in the acute phase, associated with low complication rate and the shortest hospital stay. Group II was comprised by 18% of the patients and, considering the number of complications, presented the most unfavorable time for reconstruction. Flap reconstruction in the chronic phase resulted in a substantial prolongation of the hospital stay in 82% of patients. Therefore, we advocate proper primary treatment of wounds aimed at early flap closure. This type of management results in a significantly shorter hospitalization and leads to more effective rehabilitation and recovery of patients.

[Early predictors of outcome in children with head injuries]. / Rani prediktori ishoda trauma glave u djece.

In an attempt to determine whether the clinical data obtained by primary survey may be used as early outcome predictors in children who had sustained head trauma, children aged 0-14 with clinical diagnoses of coma, contusion, comotio, skull fracture or a combination of these diagnoses or who had been hospitalized for at least 3 days, between 1987 and 1990, were reviewed retrospectively. The outcome was defined by the clinical condition of children 6 months following head trauma using a Glasgow outcome scale (GOS), and was classified: good (good recovery and moderate disability) and poor (severe disability, persistent vegetative state, death). Of 70 children with trauma, 43 patients (61.4%) were separated by this method. The pupillary appearance and reactivity, Glasgow coma scale (GCS) and motor response graded by GCS were compared with the outcome. The analysis demonstrated that the early significant predictors of outcome of head trauma are the pupillary appearance and reactivity as well as Glasgow coma scale. Motor response graded by GCS did not achieve statistical significance (z = 1.5, P > 0.05) as a predictor of outcome. In this analysis, we have graded motor response according to the GCS criteria, thus it is not excluded that the use of different criteria could demonstrate the importance of motor response as an outcome predictor. In order to ascertain the significance of predictors in early outcome prognosis of head trauma, a relative risk for poor outcome was calculated. Our results showed that the significant predictors in descending order of preference are: pupillary reactivity, pupillary appearance and GCS.(ABSTRACT TRUNCATED AT 250 WORDS)

[Microdochectomy with perioperative dye localization of ducts in patients with nipple secretion]. / Mikrodohektomija s perioperativnim bojenjem izvodnih kanala kod sekrecije iz dojke.

A series of 1321 women having a discharge from the nipple were examined at the outpatient clinic. Of seven basic types of discharge: milky, multicolored, purulent, watery, yellow (serous), serosanguineous and bloody, only the last four represent and indication for surgery. Galactography was performed in 55 patients as a necessary element in the surgical plan of management. In 36 women, the operation of microdochectomy was indicated, but only 24 accepted to be subjected to that procedure. The authors describe a new technique of colour mammary ductal localization which identifies the duct from which the discharge is emerging and assures its complete excision. The procedure combines preoperative methylen blue dye injection followed by periareolar incision of the involved duct using a pair of binocular loops for magnification of the nipple. In all tissue specimens, the cause of a pathological discharge was found: 15 (62.5%) cases presented with fibrocystic disease, and in 6 carcinoma was present. This technique provides a safe and effective method of complete excision of the pathologically involved mammary duct with good cosmetic results.

[Developmental and involutional breast disorders]. / Razvojna i involucijska poremecenja dojke.

The majority of benign breast disorders may be classified as developmental and involutive. Mastalgia and breast nodularity represent the greatest groups of these disorders, while epithelial hyperplasia is a complex benign disorder which is most difficult to be evaluated. Sixty women with diagnosis of cyclic mastalgia and 30 with noncyclic breast pain were followed-up. Patients were administered bromocryptine, danazol or a local progestogel. Better treatment results were achieved in cyclic mastalgia than in women with noncyclic mastalgia. One hundred and forty-five biopsies of the benign breast tissue were examined histologically. Nonproliferative forms were found in 66.9% of the women, proliferative without atypia in 29.65%, and proliferative with atypia in 3.45% of the patients. Atypical ductal hyperplasia and atypical lobular hyperplasia increase four-to fivefold the risk for breast cancer. Prophylactic subcutaneous or total mastectomy is not as a rule indicated in atypical epithelial hyperplasia, only regular follow-up is required.

[An anatomic study of the septofascial layer in the forearm]. / Anatomsko istrazivanje septofascijalnog sloja podlaktice.

In the anatomical investigation the authors dissected 20 fresh cadaveric forearms to study septofascial layers. It's vascularization was based on radial artery and concomitant veins. We perfused those flaps with methylene blue in the proximal part of radial artery. In 10 cases we found fine vascular network colored in blue. In the second group we isolated free septofascial tissue which was perfused with radiopaque contrast Hexabrix. Five flaps were perfused in the proximal part of vascular pedicle and five in the distal part. Afterwards the radiographs confirmed good vascular network, independent of flow direction. Fascia dimension in the proximal part of the forearm varied from 7-15 cm and in the distal part from 6-10 cm, depending on the forearm size. Fascia length varied from 21-27 cm. The authors found thicker and stronger fascia in the ulnar part of the forearm. The length of vascular pedicle was reversely proportional with the flap dimension. This anatomical investigation may find it's greatest application in plastic and reconstructive surgery.

Reconstruction of the breast after mastectomy for carcinoma.

During the last 5 years, 80 patients underwent reconstruction of the breast as a primary or secondary procedure after mastectomy for carcinoma. Breast mounds were reconstructed with the silicone breast implant. A Silastic implant corrected the infraclavicular axillary deformity after radical mastectomy. The nipple-areolar complex was created either with a nipple-areolar graft from the contralateral breast or with a labial free graft in a bilateral breast reconstruction. If the contralateral breast was large or ptotic, reduction mammoplasty or mastopexy was performed. Subcutaneous mastectomy or total mastectomy of the other breast with insertion of the silicone breast implant was the method of choice for a group of high-risk patients.