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.

Pediatric tertiary emergency care departments in Zagreb, Rijeka, and Split before and during the coronavirus disease 2019 pandemic: a Croatian national multicenter study.

AIM: To assess the number of visits to pediatric emergency departments in Croatia and reasons for visiting before and during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: We reviewed the medical records of pediatric patients visiting emergency departments of four tertiary medical centers between February 25 and April 25, 2018 and 2019, and between February 25 and April 24, 2020. Antimicrobial prescription was analyzed as well. RESULTS: There were altogether 46 544 visits - 18218 in 2018, 19699 in 2019, and 8634 in 2020. The overall number of visits in 2020 significantly decreased compared with 2018 and 2019 (52% and 56% reduction, respectively), mostly due to a decreased number of visits due to certain infectious diseases: acute gastroenteritis (89.2%), sepsis/bacteremia (81.2%), urinary tract infections (55.3%), and lower respiratory tract infections (58%). Most visits were self-referrals regardless of the analyzed period, and the majority of patients did not require hospitalization. There were no significant differences in the number of visits requiring urgent medical care, such as those due to seizures and urgent surgery. The most frequently prescribed antibiotic in all periods was amoxicillin, followed by amoxicillin/clavulanate and oral cephalosporins. CONCLUSION: A significant reduction in the number of pediatric emergency department visits and hospital admissions is indirectly related to the COVID-19 pandemic. Most of the reduction was due to a decreased number of infectious disease cases. However, the number of visits requiring urgent medical intervention did not change.

The Importance of Primary Reconstruction in the Treatment of Blast Related Hand Injuries During Childhood.

INTRODUCTION: Blast injuries are common during wartime but are also related to various holiday festivals worldwide. Despite strict legislations, these devices still cause serious injuries leaving permanent disabilities. Children are affected in numerous cases with the hand being the most affected body region. The aim of our study was to profile the blast related hand injuries and to review treatment modalities that we used. METHODS: A retrospective study of patients treated for blast-devices related hand injuries between 2006 and 2015 was performed. RESULTS: 112 patient with blast related hand injuries were treated in our department during the 10-year period. Most of the patients were male. The dominant hand was injured in 83.9% of the patients. Associated injuries were observed in 14.3% of patients. 90 children were treated on an out-patient basis, mostly due to hand burns (86.7%) or uncomplicated blast injuries (13.3%). 22 children required hospitalization due to severe blast and crush injuries and amputations. Surgery was carried out as the urgent procedure and involved debridement with primary repair. In the case of amputations debridement and sufficient skin ensuring complete wound coverage was the procedure of choice. CONCLUSION: Blast related injuries of the hand during childhood are frequent and can cause different and complex defects. Besides prevention of these injuries, primary reconstruction of the affected hand is of outmost importance in preventing long-term consequences.

Does elevated urinary 5-hydroxyindole acetic acid level predict acute appendicitis in children?

BACKGROUND: Acute appendicitis is the most common abdominal surgical emergency in children, and appendectomy is the most frequent acute abdominal operation. Prompt diagnosis and surgical treatment are required to reduce the risk of perforation and prevent complications, especially in small children. Enterochromaffin cells that contain large amounts of serotonin are mostly located in the distal appendix. Serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) could therefore be a marker for acute appendicitis. OBJECTIVE: We tested urinary 5-HIAA concentrations in spot urine samples from children with acute appendicitis. METHODS: We enrolled 93 patients who underwent surgery for suspicion of acute appendicitis. The diagnosis was made intraoperatively and confirmed histopathologically. Additionally, urine samples from 102 healthy children were collected as controls. Their 5-HIAA was measured using high-performance liquid chromatography. RESULTS: Acute appendicitis was diagnosed in 81 patients, whereas there were other explanations for abdominal pain in the remaining 12 patients in the non-appendicitis group. The control group comprised 102 healthy children. Considering the median of all measured 5-HIAA values as the cut-off, we analysed the proportions of patients with elevated values in all the groups. Our analysis showed that statistically there was no significant difference in the distribution of percentages among the groups. The area under the curve for 5-HIAA was 0.55 (95% CI 0.47 to 0.62) with sensitivity and specificity 60.4% and 48.9%, respectively. CONCLUSIONS: Urine 5-HIAA concentration measured in spot samples is not a reliable method for diagnosing acute appendicitis in children.

The evolvement of the renographic curve pattern in early childhood.

The purpose of this study was to evaluate renographic parameters obtained from healthy renal units (RUs) in newborns and infants with unilateral kidney condition. Thirty three children including twenty newborns, referred to Technetium-99m mercaptoacetyltriglycine (Tc-99m MAG3) diuretic scintigraphy due to unilateral kidney condition entered the study. Only contralateral, healthy RUs were analyzed. Since many children returned for follow up, there were altogether 78 dynamic studies included. Kidney length was compared to ultrasound measurements. Renographic curve parameters (time to maximum counts, T max and time to half maximum counts, T1/2 max) were evaluated. The results showed that the kidney length measured on Tc-99m MAG3 scintigraphy correlated well with ultrasound measurements. Regarding the renographic curve parameters, in the newborn period a significantly shorter T max (mean T max 3.65 +/- 1.2 min, p = 0.026) was found compared to the group of two months old infants (5.12 +/- 2.2 min). In older age groups mean T max gradually shortened again. On the contrary, T1/2 max was significantly longer in newborn and early infant period than in older age groups (16.7 +/- 8.2 min, p = 0.018), but generally showed variable values until the age of three years. It can be concluded that it is important to be aware of possible diversities of renographic curve pattern of healthy kidneys in early childhood, especially in the elimination part. Therefore, when interpreting a dynamic renal study, one should also consider other parameters like kidney growth, morphology and differential function, which can be reliably monitored with repeated Tc-99m MAG3 scintigraphy, to discern between normal and pathologic finding.

Bone remodeling after supracondylar humeral fracture in children.

The aim of this study was to evaluate bone remodeling in treated supracondylar humeral fractures in children. The study was carried out at the Department of Pediatric Surgery of University Hospital Rijeka on 58 patients with an average of 6.2 years, followed up during 1 to 7 years. The Baumann angle of the humerus was measured by five observers on the anteroposterior radiographs of the injured elbow right after the surgery, and on routine follow-up. The results obtained were compared with the results of the Baumann angle on the healthy arm, and statistically processed. There was a significant difference in number of cases that showed an increase of Baumann angle, when related to cases with no change of the angle or its decrease. The mean value change of Baumann angle in cases of its increase was 4.22 degrees and in cases of its decrease 2.65 degrees. Because of relatively low mean values of the angles of remodelation, we concluded that an adequate reduction is essential to prevent malunion in supracondylar humeral fractures.

Incarcerated diaphragmatic hernia--differential diagnoses.

The incarceration of diaphragmatic hernia is very rare. We present a case of a four-year-old girl who developed the incarceration of left-sided diaphragmatic hernia, who, until then, was completely asymptomatic. This incarceration of the hernia represented a surgical emergency presenting as obstructive ileus and a severe respiratory distress which developed from what appeared to be full health. During a brief pre-operative examination a number of differential diagnoses were suggested. Along with the laboratory blood analysis (complete blood count and acid-base balance) a plain thoracic and abdominal radiography was done (babygram). After that, through an inserted nasal-gastric tube, barium meal of the upper gastrointestinal tract was done, showing abdominal organs in the left half of the thorax and a significant shift of the mediastinum to the right. With an urgent upper medial laparotomy we accessed the abdominal cavity and made the correct diagnosis. An opening was shown in the rear part of the left hemi-diaphragm with thickened and edematous edges, approx. 6 cm in diameter with incarcerated content. The incarcerated abdominal organs (stomach, transversal colon, small intestine and spleen) gradually moved into the abdominal cavity. The opening was closed with nonresorptive sutures (TiCron) size 2-0 with aprevious control and ventilated expansion of the well-developed left lung. In postoperative course the acid-base balance quickly recovered, as well as the general state of the patient and radiography showed a good expansion and lucency of the lung parenchyma and a return of the mediastinum into the middle part of the thorax.

Venomous snakebites in the Croatian North Dalmatia region.

AIM: The aim of this research project is to analyze the epidemiological, clinical and laboratory attributes of venomous snakebites and to ascertain the timely and efficient treatment at the location where the incident took place or in varying clinical conditions. METHODS: Epidemiological, clinical and laboratory data were collected from people who were bitten by venomous snakes as well as treatments at Zadar General Hospital during a span of eleven years (1999-2009) which were analyzed retrospectively. RESULTS: During that period, 93 people were bitten by venomous snakes of which 57 patients (62%) were male and 36 (38%) were female. In 82 cases (90%), the bite area was localized on the limbs while in the remaining 11 cases the bite area was located elsewhere. At the time of the venomous snakebite, 31 (33%) patients were performing leisure activities and 44 (47.31%) of them were at work. The most common local snakebite signs are swelling and pain at the bite site (93 patients; 100%), hematomas and ecchymoses (87 patients; 89%). Of the affected patients, 8 suffered from compartment syndrome and one person (0.97%) expired. CONCLUSION: Antivenom treatment for preventing possible allergic reactions should take place at the medical institution where the victim was transported. However, when transport is not immediately available or in cases where the victim shows clear signs of envenomation, antivenom treatment should be used immediately because its effect is weaker if the venom is allowed to run its course.

Ganglia/nerve fibers ratio correlates with the need for surgery in patients diagnosed with Hirschsprung's disease allied disorder (HAD).

Treatment in Hirschsprung's disease allied disorder (HAD) is surgical. In HAD, surgery is always a question. We investigated the value of ganglia/nerve fibers ratio in prediction of the need for invasive procedures in HAD. Sections of full thickness bowel specimens of 14 patients were stained with antibodies marking ganglia (Anti-Neuron-Specific Enolase, Anti-NSE) and marking nerve fibers (S-100). Six out of seven patients indicated for surgery had low ganglia/nerve fibers ratio. Five out of seven patients, not showing the need for surgery, had high ganglia/nerve fibers ratio. We propose that a lower ganglia/nerve fiber ratio can be used as a predictor of increased need for surgery in HAD.

Henoch-Schönlein purpura complicated by appendicitis, intussusception and ureteritis.

Henoch-Schönlein purpura (HSP) is the most common childhood systemic small-vessel vasculitis with skin, joint, gastrointestinal (GI) and renal involvement. Uncommon GI complications are intussusception, bowel perforation and rarely reported appendicitis. HSP-associated stenosing ureteritis represents a rare and potentially serious complication. We present a 5-year-old boy with severe and prolonged course of HSP and three very rare complications that occurred sequentially: appendicitis, intussusception and ureteritis. Only three days after admission, he developed clinical signs of acute appendicitis indicating surgical intervention. Histological analysis of excised appendix showed inflammation but without signs typical for vasculitis. Two weeks later, with the reccurence of HSP he again developed clinical picture of acute abdomen. Ultrasound and radiologic evaluation demonstrated ileo-ileal intussusception and the second laparotomy was undertaken. Histological analysis of the resected bowel tissue showed typical signs of leucocytoclastic vasculitis. In the fourth week of his illness, serial urinalysis showed nephritic urinary sediment indicative of renal involvement. Unexpectedly, control abdominal ultrasound demonstrated mild hydronephrosis of the left kidney, not seen on previous ultrasound evaluations. Undertaken excretory urography and computed tomography (CT) scan showed stenosis of upper/ midureter with mild dilation of upper part of the left ureter suggesting unilateral HSP-associated stenosing ureteritis. Eventually, the patient was discharged and closely followed-up for the next two years. He had no further reccurence of HSP, the urinalysis normalized after six months, while mild unilateral hydronephrosis remained unchanged. Our search of the literature did not show reports of HSP complicated by appendicitis, intussusception and ureteritis, and to our knowledge this is the first case with three different illness events that occured sequentially. We emphasize the necessity of repeated ultrasound evaluations in the course of HSR especially in cases with severe GI and renal invovement.

Chronic intussusception in children caused by Ascaris lumbricoides.

Chronic intussusception (CI) is defined as an intussusception lasting for 14 days or more. Because the clinical manifestations are non-specific, the diagnosis is usually delayed. Symptoms include intermittent abdominal pain, sometimes an abdominal mass is palpable and there is a marked weight loss. Diagnosis is based on typical features revealed by ultrasound or barium enema and CT investigations. Therapy is surgical with obligatory exclusion of possible underlying lesions. We report a case of a 3.5-year-old girl with chronic intussusception. Laboratory blood findings revealed sideropenic anemia and stools positive for Ascaris lumbricoides. Anti-parasitic therapy with mebendazole was repeatedly administered with early improvements but soon after symptoms relapsed. During surgery an ileocolic chronic intussusception extending to hepatic flexure was found. Postoperative control examinations proved complete healing. We suspected that Ascaris lumbricoides infestation was an etiologic factor for the development of chronic intussusception in the child.

Obtaining the child testimony in the criminal proceedings.

Children fall under the special category of vulnerable witnesses. Children's vulnerability is the reason that we must approach obtaining the child's testimony in the criminal proceedings with special attention. It is important to take the child's testimony as soon as possible and to avoid the repetition of interrogation. The criminal proceedings law and the juvenile court law enable children interrogation through the professional person without the presence of other parties in the procedure and enable the recording of such interrogation by audio-video link which considerably diminish the secondary victimization. The professionals who obtain the testimony must be well acquainted with children's psychological development. Knowledge of psychological development is of major importance in order to make the quality arrangements for interrogation and to interrogate the child and to achieve positive social contact between the examiner and the examinee and it is also of great importance for the credibility evaluation of the child's testimony. The adequate way of children interrogation will enable the child to say the correct information and to recognize the perpetrator. The forensic interview is well elaborated and child adapted technique of interrogation. Respecting the rules of forensic interview will enable the child's testimony on court to be relevant evidence.

Snodgrass' urethroplasty in hypospadias surgery in Clinical Hospital Mostar--preliminary report.

Amongst the various methods of reconstructing the hypospadic urethra such as the MAGPI, Mathieu's and Preputial island flap urethroplasty method and the Snodgrass method, the latter is being used more frequently nowadays in patients with the urethral meatus located in the proximity of the penis. In the Pediatric ward at Mostar Clinical Hospital, we have recently adopted the Snodgrass method when reconstructing the hypospadic urethra. We herewith present our research regarding the successful results in adopting the aforementioned method. Success was evaluated according to the frequency of post-operative complications, as well as the patients' satisfaction with the functional and the cosmetic result of the urethra reconstruction. The conclusions relating to our research result in an addition basis from which to evaluate whether the Snodgrass method should receive privileged preference in future operative treatment of the hypospadias over others methods, as can be seen from our research.