Child Exploitation and the FIFA World Cup: A review of risks and protective interventions

This review was commissioned by the Child Abuse Programme (CAP) of Oak Foundation, a large international philanthropic organisation. It forms part of CAP’s effort to win societal rejection of practices such as the sexual exploitation of children and adolescents around major sporting events (MSEs), and to embed prevention and protection from exploitation as a permanent concern for global sports-related bodies. This review is intended to inform action in countries that host MSEs and to provide some suggestions on how hosting countries can avoid past pitfalls and mistakes in relation to child exploitation, especially economic and sexual exploitation. Importantly, it also acts as a call to action by those responsible for commissioning and staging MSEs, such as FIFA and the IOC, to anticipate, prepare for and adopt risk mitigation strategies and interventions. Positive leadership from these culturally powerful bodies could prove decisive in shifting hearts, minds and actions in the direction of improved safety for children

Timing of surgery for symptomatic carotid stenosis

Sir P M Rothwell and colleagues (Mar 20, p 915)1 present an important study. If the optimum timing of surgery for symptomatic carotid stenosis is 2 weeks after the patient's last symptoms, the implications for healthcare provision are enormous. To be able to offer the highest-risk patients early surgery, an attempt to stratify the risk of waiting needs to be made. Transcranial doppler can be used to assess middle cerebral artery velocity and platelet microemboli. Immediately after a carotid-territory transient ischaemic attack (TIA) or stroke, there is a rise in microemboli in the middle cerebral artery, and patients who continue to embolise are at a greater risk of a further neurological event2. A high microembolic load after carotid endarterectomy is associated with early carotid thrombosis. Control of this load by means of intravenous transcranial doppler-directed antiplatelet agents reduces the risk of early postoperative stroke3. It is possible to influence the timing of carotid surgery in patients with recurrent or crescendo TIAs. Control of both emboli and symptoms with transcranial doppler-directed dextran allows these high-risk patients to undergo carotid surgery safely on the next elective list4. Microemboli seem to be surrogate markers for future embolic events (TIAs or strokes) and the pharmacological efficacy of any therapeutic intervention can now rapidly and non-invasively be assessed. Transcranial doppler emboli detection could offer an approach to the management of patients both medically and surgically

A novel treatment for symptomatic carotid dissection

Carotid dissection is a rare but significant cause of stroke. The neurological damage in such cases is mainly attributable to thromboembolism.1 Current treatment includes supportive therapy and antiplatelet agent either alone or with anticoagulation. This is not supported by randomised trials2 but it is logical. Presence of microemboli in cerebral circulation is a risk factor for ischaemic stroke after transient ischaemic attack (TIA)3 and transcranial Doppler examination (TCD) can detect them in middle cerebral artery circulation.4 Controlling microemboli improves the outcome in recurrent TIA and after carotid endarterectomy.5,6 We found this strategy effective in the treatment of a symptomatic carotid dissection unresponsive to anticoagulation. We report a case of carotid artery dissection treated successfully by controlling microemboli from the dissected artery and discuss its validity

Control of emboli in patients with recurrent or crescendo transient ischaemic attacks using preoperative transcranial Doppler-directed Dextran therapy

Background: Transcranial Doppler (TCD)-directed Dextran 40 treatment after carotid endarterectomy reduces the rate of early postoperative thrombosis. This study assessed the efficacy of intravenous Dextran 40 at controlling symptoms and emboli before elective carotid endarterectomy in patients with recurrent or crescendo transient ischaemic attacks (TIAs). Methods: In a prospective study, patients with more than 70 per cent internal carotid artery stenosis who had two or more symptomatic episodes within 30 days and TCD-detected microemboli were studied. Dextran 40 was commenced at 20 ml/h and TCD was repeated to reassess the rate of embolization. The infusion was increased in 20-ml/h increments until symptoms and emboli were controlled. The patient then had carotid surgery on the next elective list. Results: Nineteen patients with internal carotid stenosis greater than 70 per cent, recurrent symptoms and TCD-detected emboli were studied. All patients had symptoms and emboli controlled with Dextran 40. One patient with both unstable angina (awaiting urgent operation) and crescendo TIAs died from a myocardial infarct before undergoing operation. Of the 18 patients who had an operation, one suffered a non-disabling stroke on the third postoperative day. Conclusion: TCD-directed Dextran 40 offers a safe approach to high-risk patients before elective carotid endarterectomy, and warrants further study. Copyright © 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd

Perioperative transorbital doppler flow imaging offers an alternative to transcranial doppler monitoring in those patients without a temporal bone acoustic window

Transcranial Doppler has been used to identify microembolic signals before, during and after carotid endarterectomy, but 10% to 15% of patients are reported not to have suitable temporal bone window. The aim of this study was to assess the feasibility of transorbital Doppler monitoring of patients with absent temporal bone acoustic window. Between 2005 and 2008, those patients with absent temporal bone acoustic window were assessed for a transorbital acoustic window. During the study period, 318 carotid endarterectomy were performed. In the 29 (9.1%) with absent temporal bone acoustic window, 25 (86%) had satisfactory transorbital acoustic windows, consequently only four (1.2%) of patients could not be monitored postoperatively. One patient required postoperative transorbital acoustic windows directed glycoprotein IIb/IIIa receptor antagonist infusion due to excessive carotid microembolisation to prevent stroke. This is the first description of the use of transorbital flow imaging to determine postoperative cerebral blood flow, microembolic load and to direct the use of intravenous antiplatelet agents

Prospective validation study of transorbital Doppler ultrasound imaging for the detection of transient cerebral microemboli

Background: Transient cerebral microemboli are independent biomarkers of early risk of ischaemic stroke in acute carotid syndromes. Transcranial Doppler imaging (TCD) through the temporal bone is the standard method for detection of cerebral microemboli, but an acoustic temporal bone window for TCD is not available in around one in seven patients. Transorbital Doppler imaging (TOD) has been used when TCD is not possible. The aim of this study was to validate the use of TOD against TCD for detecting cerebral microemboli. Methods: The study included patients undergoing elective carotid endarterectomy; all had confirmed temporal and orbital acoustic windows. Subjects gave written informed consent to postoperative TCD and TOD monitoring, which was performed simultaneously for 30 min by two vascular scientists. Results: The study included 100 patients (mean(s.e.m.) age 72(1) years; 65 men). Microemboli were detected by one or both methods in 40·0 per cent of patients: by TOD and TCD in 24 patients, by TOD alone in ten and by TCD alone in six. For detecting microemboli, TOD had a sensitivity of 80·0 per cent, specificity of 86·1 per cent, positive predictive value of 71·6 per cent and negative predictive value of 91·2 per cent. Bland–Altman analysis revealed no significant bias (bias 0·11 (95 per cent c.i. −0·52 to 0·74) microemboli; P = 0·810) with upper and lower limits of agreement of +6 and −6 microemboli. Conclusion: TOD appears a valid alternative to TCD for detecting microembolic signals in patients with no suitable temporal acoustic window

Registry report on kinetics of rescue antiplatelet treatment to abolish cerebral microemboli after carotid endarterectomy

Background and Purpose—Cerebral microemboli signals (MES) are associated with increased risk of acute stroke syndromes. We compared the effects on cerebral microemboli after carotid endarterectomy of tirofiban with dextran-40. Methods—We used transcranial Doppler ultrasound to study transient MES acutely after carotid endarterectomy between August 2000 and December 2010 in 128 subjects refractory to preoperative antiplatelet treatment. Antithrombotic treatment was given for MES ≥50 hour−1 (tirofiban: 40 patients [age 74 ± 1 {SEM}, males 27, and white 38]; dextran-40: 34 patients [age 69 ± 2, males 22, white 30]). In 54 patients with MES <50 hour−1 (age 71 ± 1, male 36, white 52), MES were monitored during their spontaneous resolution (controls). Data are median (interquartile range). Results—The time to 50% reduction in MES (tirofiban 23 minutes [15–28]; dextran-56 [43–83]; controls 30 [22–38]; P<0.001, Kruskal-Wallis analysis) and for complete MES resolution (tirofiban 68 minutes [53–94]; dextran-113 [79–146]; controls 53 [49–68]; P<0.001, Kruskal-Wallis analysis) were shorter with tirofiban. The early cardiovascular event rate was similar with tirofiban compared with controls but increased in patients who received dextran. Conclusions—These findings suggest that transcranial Doppler-directed tirofiban therapy is more effective than dextran-40 in suppression of cerebral microemboli after carotid endarterectomy

Effects of breathing air containing 3% carbon dioxide, 35% oxygen or a mixture of 3% carbon dioxide/35% oxygen on cerebral and peripheral oxygenation at 150 m and 3459 m.

The effects of gas mixtures comprising supplementary 3% carbon dioxide, 35% oxygen or a combination of 3% CO(2) plus 35% O(2) in ambient air have been compared on arterial blood gases, peripheral and cerebral oxygenation and middle cerebral artery velocity (MCAV) at 150 m and on acute exposure to 3459 m in 12 healthy subjects. Breathing 3% CO(2) or 35% O(2) increased arterial blood oxygen at both altitudes, and the CO(2)/O(2) combination resulted in the most marked rise. MCAV increased on ascent to 3459 m, increasing further with 3% CO(2) and decreasing with 35% O(2) at both altitudes. The CO(2)/O(2) combination resulted in an increase in MCAV at 150 m, but not at 3549 m. Cerebral regional oxygenation fell on ascent to 3459 m. Breathing 3% CO(2) or 35% O(2) increased cerebral oxygenation at both altitudes, and the CO(2)/O(2) combination resulted in the greatest rise at both altitudes. The combination also resulted in significant rises in cutaneous and muscle oxygenation at 3459 m. The key role of carbon dioxide in oxygenation at altitude is confirmed, and the importance of this gas for tissue oxygenation is demonstrated