A classification of end-of-life decisions in neonates and infants.

AIM: Valid and reliable data are needed to gain insight into the decisions of paediatricians concerning the end of life of newborns and infants. Such data could throw light on the poorly documented aspects of medical practice regarding these end-of-life decisions (ELDs). In this article a classification of ELDs is developed. METHODS: The classification is developed from knowledge generated from large-scale epidemiological studies on ELDs. RESULTS: This classification sets out from considerations of the various possible medical end-of-life procedures for newborns and infants and from important ethical aspects of the decision-making process. From both ethical and legal viewpoints the life-shortening intention of the physician is a significant factor for the qualification of ELDs. Furthermore, the consultation of the parents is an important factor in absence of the possibility of the patient's self-determination. CONCLUSION: This classification has been devised with the aim of making reliable and valid descriptions of both the incidence and nature of ELDs in this specific population of newborns and infants.

Sacrococcygeal teratoma: results of a retrospective multicentric study in Belgium and Luxembourg.

Eighteen patients, operated upon for sacrococcygeal teratoma in 7 different centres in Belgium and Luxembourg between 1992 and 1996, were reviewed. From an epidemiological point of view, this series compares very well to others. Although excellent results were obtained, with all patients surviving, some imperfection in diagnosis, timing of delivery and of operation, and in operative technique was observed. Therefore, it is stated that for optimal treatment of sacrococcygeal teratoma to be achieved, these cases should be treated in just a very few centres of neonatal surgery.

[Prevalence of Rhinoestrus usbekistanicus (Gan 1947) in donkeys (Equus asinus) in Senegal]. / Prévalence de Rhinoestrus usbekistanicus (Gan 1947) chez l'âne (Equus asinus) au Sénégal.

A survey performed in Dakar (Senegal) showed, for the first time, the presence of Rhinoestrus usbekistanicus in donkeys in the South of the Sahara desert. Out of the 138 heads examined between November and June, 84% were infected by a mean burden of 15.9 larvae (9.7 L1, 1.8 L2 and 4.1 L3). There is a hypobiotic period starting in March during the dry season.

[Human external ophthalmomyiasis: a bibliographic review apropos of cases in the Republic of Djibouti]. / L'ophtalmomyiase externe humaine: revue bibliographique à propos de cas en République de Djibouti.

Ophtalmomyiasis externa was observed in Djibouti Republic. A literature survey of agents indicates that sheep nasal bot fly larvae, Oestrus ovis, are frequent in many countries. Unusual case of oral or nasal infections are indicated.

Contribution of endoscopy to early diagnosis of hypertrophic pyloric stenosis.

The diagnostic accuracy of ultrasonography and gastrointestinal endoscopy was compared in 63 infants who were operated on for infantile hypertrophic pyloric stenosis. Endoscopy was far more accurate than ultrasonography, the diagnosis being made in 97 and 81% of the cases, respectively. The difference between the techniques was even more obvious in the younger patients and in those with a short history of vomiting. The ability to detect coexistent or other causes of vomiting with endoscopy appeared advantageous. The endoscopic procedure is easily done without general anesthesia and was without complications in our series. We recommend endoscopy as an important tool in very young patients with few clinical signs other than vomiting, allowing for appropriate treatment without delay.

Simultaneous laparotomy and intraoperative endoscopy for the treatment of high jejunal membranous stenosis in a 1-year-old boy.

A 1-year-old boy with high jejunal membranous stenosis was successfully treated "a minima" by antimesenteric longitudinal enterotomy over the diaphragm, excision of the latter, and transverse closure of the bowel. This was made possible by use of simultaneous peroperative endoscopy, which allowed exact localization of the diaphragm. Peroperative endoscopy is a useful and accurate method for this purpose and should be considered in similar cases.

Totally implantable central venous access devices in pediatric oncology--our experience in 46 patients.

Between 1986 and 1990, 50 venous access devices have been implanted in 45 children with various types of cancer and in one patient with Langerhans cell histiocytosis. Twenty-five devices were of the so-called "pediatric" type (Port-A-Cath: 24, Vascuport: 1) and 25 were "adult" ports (Port-A-Cath: 8, Vascuport: 6, Infuse-A-Port: 6, Theraport: 5). The catheters (in silicone elastomer or polyurethane) were inserted percutaneously or surgically. Cumulative total venous access was 15024 patient-days (mean: 290 days per patient, range 2-900 days). Occlusion of the system, the most frequent complication, was encountered in 5 patients (11%). Rarer complications were catheter-related infection (2 pts), pneumothorax (1 pt), skin necrosis (1 pt), catheter leakage (1 pt) and port-catheter disconnection (1 pt). No serious complication ever occurred in 35 patients (76%). Seven of the 11 complications, including all 3 port occlusions, were encountered with "pediatric" systems. All the adult access devices tested were safe and allowed long-standing access to the central venous system in this series of pediatric cancer patients. With proper placement technique and adequate nursing care, they represent a definite improvement in child cancer therapy.

[Endoscopic closure of a recurrent tracheoesophageal fistula]. / Fermeture endoscopique d'une fistule trachéo-oesophagienne récidivante.

We report a successful endoscopic obliteration of a large recurrent tracheo-esophageal fistula (diameter 0.6 cm, length 2 cm) in a 12-year old girl, using a combination of N-butyl-2-cyanoacrylate followed by polidocanol injected through a polyethylene catheter. The severe pulmonary infection, that rendered surgery potentially life-threatening, resolved after endoscopic closure. The girl remained asymptomatic for 14 months after the first obliteration. Chronic coughing was the symptom of relapse. A follow-up endoscopy revealed that most of the N-butyl-2-cyanoacrylate had disappeared from the fistula, whose endoscopic appearance was unchanged. A second obliteration with the same products was performed. The girl has again been asymptomatic for 10 months. The endoscopic obliteration is a worth-while technique, to be considered as an alternative to surgery in patients presenting with a complicated recurrent tracheo-oesophageal fistula.

Conservative treatment of 725 burned children hospitalized in 10 years.

Seven hundred and twenty-five children were hospitalized in the paediatric burn unit of Brugmann University Hospital during the past 10 years. The majority of the patients were under 5 years of age and presented with scalds on less than 10 per cent of the body surface area. As burn depth was difficult to assess on admission, a conservative form of treatment was performed including a daily bath containing chlorhexidine and silver sulphadiazine dressings. Contamination of the wounds was observed in 80 per cent of the larger than 20 per cent surface burns but only 18 cases (2.4 per cent) of the series needed administration of systemic antibiotics for repeated contamination. No lethal septicaemia was observed. Mean inpatient time ranged between 16 days for ungrafted patients to 69 days for over 20 per cent surface grafted patients. The lower iatrogenic risks (anaesthesia and donor site morbidity) seemed important enough to justify conservative treatment in children despite a slightly longer hospitalization time.

[Evaluation of medical and surgical treatment of intussusception in children apropos of a review of 100 consecutive cases]. / Evaluation du traitement médical et chirurgical de l'intussusception chez l'enfant à propos d'une revue de 100 cas consécutifs.

Evaluation of medical and surgical treatment of intussusception in children (a revue of 100 consecutive cases). The authors analysed 100 consecutive cases of intussusception hospitalized in the Department of Paediatric Surgery of the Brugmann University Hospital in Brussels. 90 baryum enemas were performed, 43 of which were curative, 57 children were operated upon. Their age varied from 3 months to 10 years, but 77% of the children were less than 2 years old. The authors paid particular attention to the observations of children who had surgical treatment. This study points out the importance of early diagnosis and treatment. After a delay of 24 hours, 81% patients needed surgery compared to 41% of those who presented earlier.

[Appendicitis in children]. / Appendicitis bij kinderen.

In 218 children of less than 16 years old appendectomy was performed. Presence of appendicitis was confirmed histologically in 199 cases. The ratio boys to girls was two to one. In one third the appendix had perforated. Administration of a combined Ampicillin-Metronidazole antimicrobial therapy, started during surgery, proved to be very efficacious in avoiding infectious complications. In this group the complication rate remained below 3%.

[Anti-infections prophylaxis of infantile burns (author's transl)]. / Prophylaxie anti-infectieuse des brûlures chez l'enfant.

Analysis of 300 consecutive hospitalized children with burns. To prevent infection, patients are given a bath with chlorhexidine (0.03%) every day and their burns covered by silver sulfadiazine (1%) and occlusive dressings. In 5.3% of the children positive swabs were obtained during hospitalization and in only 2.3% on several occasions. No case of septicemia could be documented.

[Surgical treatment of deep burns in children (author's transl)]. / Traitement chirurgical des brûlures profondes chez l'enfant.

The clinical material is described and the principles of burn wound treatment are indicated: --excision and grafting of third degree burns: early whenever possible, delayed if the diagnosis or the limits are difficult to appreciate;--local treatment with Silver-Sulfadiazine of second degree burns, and those of undetermined depth. The difficulty of diagnosing the exact depth of the burn as well as the problem of the sequelae are stressed. The treatment of the complications is mentioned, particularly of the large hypertrophic scars. More than ever, prevention seems to be essential, but also possible.