Small bowel intussusceptions: issues and controversies related to pneumatic reduction and surgical approach.

AIM: This study aims to determine the incidence, clinical presentation, management and outcome of small bowel intussusceptions (SBI) in the paediatric population managed at our centre. METHODS: Hospital charts of SBI patients from 1999 to 2006 were reviewed retrospectively. The data collected involved the clinical presentation, diagnostic examinations, management strategy as well as outcome. RESULTS: Ileocecal intussusceptions were documented in 83 patients (74.8%) and SBI in 28 (25.2%). The median age of patients with SBI was 2.5 years (range 9 weeks to 16 years). In 18/28 patients SBI reduced spontaneously. Ileoileal SBI had an incidence of 80% in the 10/28 cases requiring intervention. In seven patients, pneumatic reductions were successful in 6/7 ileoileal intussusceptions, but unsuccessful in 1/7 where the level of intussusception (jejunojejunal intraoperative findings) could not be determined by ultrasound. Surgical intervention was required in four patients with bowel resection in three cases. CONCLUSION: Pneumatic reduction is successful in ileoileal intussusceptions with signs of bowel viability. It should be attempted with caution in patients with jejunojejunal or ileoileal SBI with pathologic lead points or bowel ischaemia. Accurate interpretation of ultrasound along with judicious implementation of pneumatic reduction or surgical options can reduce morbidity. Early diagnosis is associated with better outcomes using non-surgical reduction techniques.

Circumcision in paediatric surgery using an ultrasound dissection scalpel.

In contrast to electrocautery, the ultrasound dissection scalpel allows tissue dissection and haemostasis to be performed without the danger of thermal tissue damage or burning caused by uncontrolled active current. In a clinical application study performed on 24 boys with an average age of six years, we examined whether the use of this instrument is also practical in a routine operation such as circumcision. It was possible to perform all operations with the ultrasound dissection scalpel (Ultracision, manufactured by Ethicon) by the classic technique without the additional use of electrocautery for haemostasis. Although dissecting speed is slower than with conventional instruments, the fact that simultaneous haemostasis is possible meant that operations could be carried out quickly and with minimal bleeding. There were no perioperative complications such as haemorrhaging or burning. All children were examined postoperatively over an average of 3 weeks (range 1-8 weeks). Wound healing was completely without complications for 22 patients (92%). One patient (4%) suffered a candidal infection in the first postoperative week. One further patient (4%), who was already suffering preoperatively from an extended chronic inflammation of the prepuce, developed pronounced swelling postoperatively. Heavy scarring occurred subsequently in both cases. Our results show that the advantages of the ultrasound dissection scalpel, e.g. gentle tissue dissection with simultaneous haemostasis, can also be used to advantage for a technically simple operation such as circumcision without having to fear the risks of electrocautery.

Bunk beds--a still underestimated risk for accidents in childhood?

UNLABELLED: A retrospective analysis of 218 bunk-bed accidents and a random sample survey with 991 family interviews were performed in order to establish guidelines for bunk-bed accident prevention. Falls from the top bed during sleep (35.1%) or while playing (34.4%) and falling off the ladder (23.2%) are the leading causes of bunk-bed accidents. Of the 218 children, 91 (41.7%) had sustained major injuries, including 3 polytrauma, 7 skull fractures, 44 cerebral concussions, 33 long bone fractures, 2 Lisfranc injuries, and 2 lacerations of the spleen. Of these accidents, 58.3% resulted in minor injuries with 18 fractures in other locations than the long bones or cranial vault, 89 contusions and sprains, 18 skin lacerations and 2 tooth fractures. A total of 23.8% of the accidents occurred in children under 3 years of age. The random sample survey demonstrated that in relation to age groups of children 30.8% (0%-45.8%) of families interviewed had been using bunk beds, with peaks at 3 years (29.8%), 7 years (36.5%) and 11 years (45.8%) of age. Of these bunk beds, 75.3% were equipped with side-rails, 57.3% had placed carpets alongside the bunk bed and 43.0% had used night lights. CONCLUSION: There is only one recommendation: no bunk beds!!!

Highchair accidents.

In order to establish guidelines for highchair accident prevention we investigated causes, mode and complications of highchair accidents by the following methods: The charts of 103 children attending our Accident & Emergency department for highchair related injuries were studied retrospectively. Questionnaires were sent to the parents to obtain detailed information about the mode of accident. They were also asked to suggest preventive measures. In addition, a random sample survey was performed with 163 families inquiring about the rate of highchair use and the incidence of highchair related accidents. Of the 103 infants, 15.5% had sustained a skull fracture, 13.6% a brain concussion, 2.0% limb fractures and 68.9% a simple contusion of the head or lacerations to the scalp or face. The questionnaires were fully completed by 61.2% of parents. Every second family reported that their infant had tried to stand up in the highchair before falling off (only one child had been wearing a restraint). In a further 14.3% of accidents the highchair tipped over. Eighty-seven percent of parents would appreciate a pre-installation of restraints, 54.0% requested more informative instructions for users, and 33.3% asked for products with better stability. The random sample survey revealed a highchair use rate of 92%; 18% of families used highchairs equipped with restraints, and 6% reported highchair accidents sustained by their children. We conclude that most highchair accidents occur when unrestrained infants try to stand up. Pre-installed child restraints, better manuals for users and increased highchair stability should be recommended as promising accident prevention strategies.

Structure-energy relationship inω-amino acids and related compounds.

The potential energy surfaces of variousω-amino acids,ω-hydroxy acids, andω-amino alcohols have been investigated by ab-initio RHF calculations in the recent years. In order to find a common scheme for these molecules an energy function was developed, in which the energy is defined as a function of only those dihedral angles that are essential for the description of the nuclear framework. A least square fit procedure is performed to yield the parameters. Minimum geometries with unfavourable contributions are sorted out, as long as the correlation coefficient is below a predefined threshhold. The differences between the given (quantum chemical) and the estimated energies are small for minimum geometries which were used to fit the parameters, and larger for those which have been omitted in the fit. For conformers with intramolecular hydrogen bonding these energy differences turn out to be in the range of the interaction energy predicted for the H-bond contribution. The method can therefore be used as a semi-quantitative measure of the influence of additional interactions to the conformational energy.