Progressive Chronic Inflammatory Demyelinating Polyneuropathy in a Child with Central Nervous System Involvement and Myopathy

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a chronic disorder, manifesting with monophasic or relapsing course. Progressive course is rare in children. The article presents a boy with progressive generalized muscle weakness and areflexia since the age of two, developed after viral infection. Electromyoneurography showed severe neurogenic lesion, with myopathic pattern in proximal muscles. Increased serum ganglioside antibody titers (anti-GM1 and anti-GD1b) were registered. Sural nerve biopsy revealed demyelination and onion bulbs. Inflammatory perivascular CD3 positive infiltrates were present in muscle and nerve biopsies. Brain magnetic resonance imaging showed cortical atrophy, hyperintensities of the white matter and gray matter hypointensities. Improvement occurred on intravenous immune globulins and methylprednisolone treatment. Demyelination might develop in central and peripheral nervous system associated with inflammatory myopathy in patients with progressive course of CIDP

Medical thermography (digital infrared thermal imaging - DITI) in paediatric forearm fractures - a pilot study

Trauma is the most common cause of hospitalisation in children, and forearm fractures comprise 35% of all paediatric fractures. One-third of forearm fractures are distal forearm fractures, which are the most common fractures in the paediatric population. This type of fracture represents an everyday problem for the paediatric surgeon. The three phases of fracture healing in paediatric trauma are associated with skin temperature changes that can be measured and then compared with standard plain radiographs of visible callus formation, and eventually these methods can be used in everyday practice. Thermographic assessment of temperature distribution within the examined tissues enables a quick, non-contact, non-invasive measurement of their temperature. Medical thermography is used as a screening method in other parts of medicine, but the use of this method in traumatology has still not been researched

Outpatient surgery

Podloga: Dnevna bolnica (DB) je oblik organizacije, ali i način pružanja dijagnostičko-terapijskih postupaka izvanbolničkih bolesnika uz dnevni boravak u bolnici (u trajanju do 22 sata). Dnevna bolnica može se organizirati kao organizacijski dio pojedine djelatnosti u bolnici, poliklinici i trgovačkom društvu za obavljanje zdravstvene djelatnosti. Vlada Republike Hrvatske pravilnikom propisuje minimalne uvjete za rad u Dnevnoj bolnici, a Hrvatski zavod za zdravstveno osiguranje (HZZO) ugovara kirurške postelje, plaća usluge i prati iskorištenost ugovorenih kapaciteta. Metode: Autori u ovom radu dostupnom stručnom literaturom, pravilnicima i statističkim izvješćima analiziraju brojnost i iskorištenost posteljnih kapaciteta kirurških dnevnih bolnica u javnom zdravstvenom sustavu Republike Hrvatske. Analizirano je razdoblje od 2013. Do 2014. godine. Rezultati: Od ukupno 25 219 bolničkih postelja u Hrvatskoj, u 2015. godini HZZO je ugovorio 3811 postelja dječjih bolnica (278 za potrebe opće i 33 za potrebe dječje kirurgije). U 2014. godini bolnice su imale 155 ugovorenih postelja opće i 13 postelja dječje kirurgije. U 2013. godini, bilo je 20930 dana liječenja u dnevnim bolnicama opće kirurgije i 2844 dana u dječjoj kirurgiji, a u 2014. godini bilo je 22946 dana liječenja u dnevnim bolnicama opće kirurgije i 2488 dana u dječjoj kirurgiji. Zaključak: Ukupno sudjelovanje kirurških postelja dječjih bolnica u posteljnom kapacitetu naših bolnica je niska, a popunjenost tih kapaciteta na godišnjoj razini kreće se u rasponu 5487%. Postelje dječje kirurgije u dječjim bolnicama većim se postotkom koriste nego one opće kirurgije. Zakonodavac i HZZO učestalo mijenjaju pravilnike kojima propisuju okvire rada kirurške dnevne, a bolnice teško prate te zadane okvire minimalnih uvjeta.Background: Day Hospital (DH) is a type of organization for providing diagnostic and therapeutic outpatient procedures for patients who are hospitalized and discharged within one day (within 22 hours). It can be organized in a hospital, clinic or healthcare company. The government of the Republic of Croatia prescribes minimum requirements for work on an outpatient basis, and the Croatian Health Insurance Fund (HZZO) contracts the number of surgical beds, pays for the provided services and monitors the hospital bed usage. Methods: The authors, using available literature, regulations and statistical reports, analyzed the number and hospital bed usage in surgical DH units in the public health system in Croatia for the 2013/2014 period. Results: Of 25219 hospital beds in Croatia, in 2015 HZZO contracted 3811 DH beds (278 for general surgery and 33 for pediatric surgery). In 2014 there were 155 beds for general and 13 beds for pediatric surgery. In 2013 there were 20930 days of hospitalization in general day surgery and 2844 days in pediatric day surgery. In 2014 there were 22946 days of hospitalization in general day surgery and 2488 days in pediatric day surgery. Conclusion: The percentage of surgical DH beds in overall number of surgical beds in our hospitals is low, and the utilization of capacity ranges from 54 to 87%. Pediatric day surgery beds are utilized better than general surgery. The Government and HZZO often change regulations regarding DH facilities. This makes it difficult for hospitals to maintain minimal requirements for the organization of surgical DH units

Tumori jetre u dječjoj dobi

Liver tumors count for approximately 2% of all childhood tumors and almost 70% of them are malignant. Most of them present as palpable abdominal mass. Correct diagnosis considering type, size and localization of the tumor is crucial for the right treatment strategy. Although surgical resection still remains the most important factor for survival, when combined with chemotherapy, the survival rates will raise. Liver transplantation is also considered in some cases of liver tumors. From 1991 to 2008 we treated 13 children with liver tumors. Our experience together with the review of recent literature is presented here.Tumori jetre čine ukupno 2% svih tumora dječje dobi, a preko dvije trećine su zloćudni. Većina se prezentira kao palpabilna tvorba u abdomenu. Za odabir ispravnog plana liječenja nužno je postaviti točnu dijagnozu i odrediti stupanj bolesti. Iako je kirurška resekcija i dalje najbitniji faktor prognoze, u kombinaciji s kemoterapijom postotak preživljenja značajno raste. U određenim slučajevima neresektabilnih tumora transplantacija jetre daje dobre rezultate. Od 1991. godine do 2008. liječili smo 13 djece s tumorom jetre i u ovom radu prikazujemo naše rezultate uz pregled recentne literature

Primary peritonitis in a previously healthy child

Primarni peritonitis se rijetko javlja u dječjoj dobi i zahvaća uglavnom djecu s kroničnim bolestima jetre ili nefrotskim sindromom, a vrlo rijetko se javlja u prethodno zdrave djece. Cilj ovog prikaza je opisati kliničke i radiološke značajke primarnog peritonitisa kod prethodno zdravog djeteta.Primary peritonitis rarely occurs in childhood, affecting mainly children with chronic liver disease or nephrotic syndrome, but occurs very rarely in previously healthy children. The aim of this case report is to describe the clinical and radiological features of primary peritonitis in a previously healthy child

Penoplasty and vacuum-assisted closure in children with Fournier’s gangrene of the penis

Fournierova gangrena (FG) penisa vrlo rijetko nastaje u djece. Liječenje započne odstranjenjem nekrotičnog tkiva i zaustavljanjem infekcije. Penoplastikom ogoljenog penisa, koja je zahtjevan i komplikacijama opterećen postupak, treba osigurati erektilnu funkciju i estetski prihvatljiv ishod. U radu se prikazuje tehnika penoplastike i primjene vakuum terapije u troje djece s FG penisa. U periodu 2000. do 2017. godine u KBC Zagreb je liječeno troje djece s FG penisa. Gangrena se razvila tijekom snažne imunosupresije zbog kemoterapija akutne limfatične leukemije, koja je krenula kao infekcija kože skrotuma, prepucija i perineuma. Nakon nekrektomije u općoj anesteziji, postavljen je i za glans fiksiran Foley urinarni kateter. Slobodni kožni presadak je uzet s lateralne strane natkoljenice u debljini 0,5 mm. Presadak je postavljan i šavovima fiksiran u nepotpunoj erekciji. Cirkularno punim opsegom obložen je prvo vazelinskom gazom, a preko nje spužvom debljine 20 mm. Preko svega je postavljena adherentna folija i vakuum cijev. Negativni tlak je održavan aparatom kontinuirano na 75 mm Hg, kako bi penis bio u produženoj erekciji. Praćena je prokrvljenost penisa kontrolom kapilarnog pulsa na eksponiranom glansu. Sustav negativnog vakuum-tlaka (VAC, engl. Vacuum Assisted Closure) odstranjen je sedmog dana. Nije bilo poslijeoperacijskih komplikacija, a puna reepitelizacija trajala je deset dana. Petnaestogodišnji pacijent je godinu dana nakon operacije i izlječenja osnovne bolesti imao bezbolnu erekciju, a masturbacijom je postigao ejakulaciju. Kako bi se minimalizirala mogućnost naknadne kontrakcije, korišteni su nešto deblji presadci. Negativni tlak od 75 mm Hg sustavno je čitavim obujmom fiksirao presadak kože unatoč konveksitetu podloge. Druga mu je funkcija održavati kavernozna tijela penisa u nepotpunoj erekciji, kako bi se slobodni kožni presadak fiksirao punom površinom. Neki su autori koristili sličnu tehniku, s jačim negativnim tlakom, no oni bilježe značajnu razinu poslijeoperacijske boli. Izostanak komplikacija, uz zadovoljavajući estetski, ali i funkcionalni ishod, ovu metodu penoplastike i vakuum-terapije promovira kao metodu izbora u djece s Fournierovom gangrenom penisa.Fournier’s gangrene (FG) of the penis rarely occurs in boys. Initial treatment consists of debridement and infection control. Penoplasty, a complex procedure burdened with complications, should ensure good erectile function and aesthetic outcome. This article presents the vacuum-assisted penoplasty procedure that was undertaken in three children with FG of the penis from 2000 to 2017 in University Hospital Centre Zagreb. FG started at the prepuce, penile skin or scrotum due to immunosuppression caused by chemotherapy for acute lymphatic leukaemia. Necrectomy of the whole penile shaft was performed in general anaesthesia, and urinary catheter was placed and fixated to the glans. A partial thickness skin graft (0.5 6 mm) was harvested from the lateral thigh, placed on the penile shaft while artificial erection was maintained (to ensure sufficient skin for later erections) and fixated with quilting sutures. The skin graft was covered by Vaseline gauzeVaseline® Petrolatum gauze, circular 20 mm thick VAC (Vacuum Assisted Closure ) sponge and adhesive film. Negative pressure was maintained at 75 mm Hg and the penis was kept in erected state. Glans capillary refill was regularly checked. Vacuum therapy was removed on the seventh postoperative day. There were no postoperative complications and full re-epithelisation occurred on postoperative day 10. The 15-year-old patient reported painless postoperative erections and achieved ejaculation with masturbation. Thicker than usual grafts were used to minimize graft contraction. Negative pressure of 75 mm Hg and complete adherence of the sponge were achieved despite the cylindrical shape of the wound bed. The function of the vacuum system was not only to fixate the graft, but to maintain the penile shaft in the state of permanent artificial erection. The pressure of 75 mm Hg was chosen because the reports in which higher pressures were used reported a higher postoperative pain levels as well. Good functional and aesthetic outcome with no complications make this procedure the method of choice for the reconstruction of penile shaft skin defects after Fournier’s gangrene in children

Survival prediction of high-risk outborn neonates with congenital diaphragmatic hernia from capillary blood gases

BACKGROUND: The extent of lung hypoplasia in neonates with congenital diaphragmatic hernia (CDH) can be assessed from gas exchange. We examined the role of preductal capillary blood gases in prognosticating outcome in patients with CDH. ----- METHODS: We retrospectively reviewed demographic data, disease characteristics, and preductal capillary blood gases on admission and within 24 h following admission for 44 high-risk outborn neonates. All neonates were intubated after delivery due to acute respiratory distress, and were emergently transferred via ground ambulance to our unit between 1/2000 and 12/2014. The main outcome measure was survival to hospital discharge and explanatory variables of interest were preductal capillary blood gases obtained on admission and during the first 24 h following admission. ----- RESULTS: Higher ratio of preductal partial pressure of oxygen to fraction of inspired oxygen (PcO2/FIO2) on admission predicted survival (AUC = 0.69, P = 0.04). However, some neonates substantially improve PcO2/FIO2 following initiation of treatment. Among neonates who survived at least 24 h, the highest preductal PcO2/FIO2 achieved in the initial 24 h was the strongest predictor of survival (AUC = 0.87, P = 0.002). Nonsurvivors had a mean admission preductal PcCO2 higher than survivors (91 ± 31 vs. 70 ± 25 mmHg, P = 0.02), and their PcCO2 remained high during the first 24 h of treatment. ----- CONCLUSION: The inability to achieve adequate gas exchange within 24 h of initiation of intensive care treatment is an ominous sign in high-risk outborn neonates with CDH. We suggest that improvement of oxygenation during the first 24 h, along with other relevant clinical signs, should be used when making decisions regarding treatment options in these critically ill neonates

Prevalence of overweight and obesity in pediatric surgical population

Background: Obesity has become one of the most significant public health problems in the world in recent decades. It is associated with an increased incidence of postoperative complications, and there is a cause-and-effect relationship between obesity and increased prevalence of injury in children. Although there are studies in the world that indicate an increased incidence of obesity among surgically treated children, no such research has been conducted in Croatia so far. Materials and methods: This study aimed to determine the nutritional status of children treated at the Department of Pediatric Surgery at two samples in the time lag of eight years (2010 and 2018). In 2010, 1205 children were treated in hospital, 790 children fulfilled the inclusion criteria. In 2018, 1316 children were treated in hospital, and 790 children met the inclusion criteria. The collected data were compared with the existing health statistics. Results: The proportion of obese children was 29.7% in patients treated in 2010 and 29.7% in patients treated in 2018. In 2010 the highest prevalence of obese children was in pre-school age (23.8%) and overweight in school-age (16.7%). In 2018 the highest incidence of obesity in school children was 38.9%, in preschool-age 31.6%, in puberty 28.3%, and the lowest in adolescents 23.3%. Conclusion: The prevalence of obesity in children undergoing hospitalization for surgical illness is higher than in the general population. There was no trend of increasing the incidence of obesity over a 10-year time lag

Forearm fractures in children from Zadar region

Prijelomi podlaktice najčešći su prijelomi dječje dobi. Najčešći uzrok prijeloma u ovoj dobi je pad na ispruženu ruku gdje dolazi do izbijanja osovine donjeg dijela podlaktičnih kostiju. Cilj istraživanja je utvrditi načine i mjesto prijeloma u populaciji djece Zadarske županije. Provedena je retrospektivna analiza 1603-je djece liječene tijekom vremenskog razdoblja 2014. do 2018. u Općoj bolnici Zadar. Od 1476-ero ambulantno liječene djece, 940 dječaka (63,7%) i 536 djevojčica (36,3%). Od djece liječene bolnički bilo je 87 (68,5%) dječaka i 40 (31,5%) djevojčica. Prosječna dob u trenutku ozljeđivanja je 9,6 godina (dječaci 9,7, a djevojčice 9,5 godina). Od liječene djece njih 173-je (10,8%) bilo je u dobi od 0-4 godine, 633-je (39,5 %) u dobi od 5-9 godina, 656-ero (40,9 %) u dobi od 10-14 godina i 141-no (8,8%) u dobi od 15-18 godina. Na prometnicama je ozlijeđeno 18-ero (1,1%), kod kuće 49-ero (3,1%), u školi 65-ero (4,1%), a na prostorima za izvannastavne aktivnosti i slobodno vrijeme 1369-ero (86,5%) djece. Pad je uzrokovao prijelome u 468-ero (29,2%) naše djece. Ozljede u športu i rekreaciji (padovi, udarci, posrtanja, sudar sa suigračem, loptom) uzrok su prijelomima u 956-ero djece (59,6%). Ostali uzroci su odgovorni za prijelome u 92-je djece (5,7%). U športovima s loptom najveći broj ozlijeđene djece je u nogometu 411-ero (25,6%), rukometu 143-je (8,9%) i košarci njih 115-ero (7,2%). Djeca u Zadarskoj županiji rijetko zadobiju prijelom kostiju podlaktice u prometu, školi i kod kuće, a dominantan način ozljeđivanja je pad na igralištima i u parkovima. Pretežita aktivnost su šport i rekreacija.Forearm fractures are the most common fractures in children. The main mechanism of injury is falling onto an outstretched hand, when the axis of the distal forearm is axially overloaded. The aim of this study was to evaluate the circumstances in which forearm fractures occurred in Zadar region. We performed retrospective analysis of 1603 children treated for forearm fractures between 2014 and 2018 in Zadar General Hospital. Overall, 1476 children were treated as outpatients, including 940 (63.7%) boys and 536 (36.3%) girls, whereas 127 children were hospitalized (87 boys and 40 girls). The mean patient age was 9.6 (boys 9.7 and girls 9.5) years. According to age distribution, there were 173 (10.8%) patients in the 0-4-year group, 633 (39.5%) in the 5-9-year group, 656 (40.9%) in the 10-14-year group and 141 (8.8%) in the 15-18-year group. Eighteen (1.1%) children were injured in traffic, 49 (3.1%) at home, 65 (4.1%) at school, and 1369 (86.5%) in sports, playgrounds and other leisure facilities. Fractures were mostly caused by falls (n=468, 29.2%), sports injuries (n=956, 59.6%) and other mechanisms (n=92, 5.7%). Regarding injuries sustained during sports activities, 411 (25.6%) children were injured while playing football, 143 (8.9%) during handball and 115 (7.2%) while playing basketball. In Zadar region, most forearm fractures in children occurred during sports and play, and only sporadically at home, school and in traffic

RESULTS OF TREATMENT OF TIBIAL FRACTURES IN CHILDREN

Prijelomi dijafize obiju kosti potkoljenice najčešći su prijelomi donjih ekstremiteta i čine oko 15% svih prijeloma dugih kostiju u djece. To su većinom nestabilni prijelomi, teški za repoziciju i retenciju ulomaka, a postupak njihova liječenja nije posve usuglašen. U radu se analiziraju kasni rezultati liječenja 234-ero djece s prijelomima dijafize kostiju potkoljenice, ovisno o načinu liječenja (operacijska i konzervativna metoda). Otvoreni prijelom imala su 23 bolesnika, što čini 9,8% od ukupnog broja. U 194 bolesnika primijenili smo konzervativne metode, dok smo u njih 40 primijenili neke od operacijskih metoda liječenja. Najčešća korištena operacijska metoda bila je zatvorena repozicija ulomaka, na ekstenzijskom stolu i perkutana elastična stabilna intramedularna osteosinteza titanskim žicama. Za procjenu uspješnosti liječenja mjerene su zaostale kutne deformacije i razlike dužine zdrave i liječene noge. Sekundarni pomak ulomaka nakon započetoga konzervativnog liječenja, imala su 32 djeteta, što čini 15,2% od ukupnog broja konzervativno liječenih. Ukupno je 80-ero djece imalo zaostalu kutnu deformaciju liječene noge, njih 68 (35,0%) liječeno je konzervativno, a 12-ero (30,0%) operacijski. Bez razlike u dužini bolesne i zdrave noge bilo je 131 (67,5%) konzervativno liječeno dijete i 29-ero (72,5%) operacijski liječene djece. Ove razlike nisu statistički značajne. Rezultati liječenja ovih prijeloma u naše djece i autora sa sličnim serijama potvrđuju da nema statistički značajne razlike kasnih učinaka ovisno o načinu liječenja.Diaphyseal fractures of both lower leg bones are the most common fractures of lower extremities, and account for about 15% of all fractures of long bones in children. These fractures are usully unstabilae, difficult to reposition, and retention of the fragments, and the process of their treatment is not fully compliant. The paper analyzes the late results of treating 234 children with tibial fractures, depending on the method of treatment (surgical and conservative method). Twenty-three children had open fractures (9.8%). Nonsurgical method was used in the treatment of 194 children, and surgical in 40 children. The most frequent surgical method was closed reposition of the fragments, and percutaneous elastic stable intramedullary nailing with titanium wires. The success of the treatment was measured: residual angular deformities and difference in length beetwen treated and healthy leg. Secondary displacement of fragments after primary conservative treatment was found in 32 children. Angular deformities of the treated tibia was seen in 80 children, 68 (35.0%) treated conservatively and 12 (30.0%) surgically. In 131 (67.5%) conservatively treated and 29 (72.5%) surgically treated children there were no differences in the length of sick and healthy leg. Results of treatment in our children confirmed that there were no statistically significant differences in late effects depending on treatment methods