Hand ischemia associated with elbow trauma in children

ObjectivesPrevious observational studies suggest that children with hand ischemia following elbow trauma can be safely observed if Doppler signals are present in the wrist arteries (pink pulseless hand, PPH). Nonoperative management of PPH is predicated on the assumption that PPH results from local arterial spasm, but the mechanism of arterial compromise has not been investigated. We hypothesized that PPH signifies a brachial artery injury that requires surgical repair.MethodsRetrospective review of operations performed on children with hand ischemia following elbow trauma at a level I trauma center pediatric hospital.ResultsBetween 2003 and 2010, 12 children (seven males, mean age 7.4 years) underwent brachial artery exploration for hand ischemia following elbow trauma (11 supracondylar fractures, one elbow dislocation) due to falls (n = 10) or motor vehicle crashes (n = 2). At presentation, three subjects had normal radial pulses, eight subjects had Doppler signals but no palpable pulses, and one had weak Doppler flow with advanced hand ischemia. Six of the nine subjects without palpable pulses also had neurosensory changes. All 12 subjects underwent brachial artery exploration either initially (n = 2) or following orthopedic fixation (n = 10) due to persistent pulselessness. At operation, eight of 12 patients (67%) had focal brachial artery thrombosis due to intimal flaps, and four had brachial artery and median nerve entrapment within the pinned fracture site. At discharge, all 12 subjects had palpable radial pulses, but three with entrapment had dense median nerve deficits. One of the three subjects with dense neurologic deficit had complete recovery of neurologic function at ten months. The other two subjects had residual median nerve deficits with partial recovery at 5 and 6 months follow-up, respectively. No patient developed Volkman's contracture.ConclusionsBrachial artery injuries should be anticipated in children with hand ischemia associated with elbow trauma. Neurovascular entrapment at the fracture site is a possible complication of orthopedic fixation. Absence of palpable wrist pulses after orthopedic fixation should prompt immediate brachial artery exploration. PPH should not be considered a consequence of arterial spasm in these patients

Embodied learning: Responding to AIDS in Lesotho's education sector

This is an Author's Accepted Manuscript of an article published in Children's Geographies, 7(1), 2009. Copyright @ 2009 Taylor & Francis, available online at: http://www.tandfonline.com/doi/abs/10.1080/14733280802630981.In contrast to pre-colonial practices, education in Lesotho's formal school system has historically assumed a Cartesian separation of mind and body, the disciplining of students' bodies serving principally to facilitate cognitive learning. Lesotho has among the highest HIV-prevalence rates worldwide, and AIDS has both direct and indirect impacts on the bodies of many children. Thus, students' bodies can no longer be taken for granted but present a challenge for education. Schools are increasingly seen as a key point of intervention to reduce young people's risk of contracting the disease and also to assist them to cope with its consequences: there is growing recognition that such goals require more than cognitive learning. The approaches adopted, however, range from those that posit a linear and causal relationship between knowledge, attitudes and practices (so-called ‘KAP’ approaches, in which the role of schools is principally to inculcate the pre-requisite knowledge) to ‘life skills programmes’ that advocate a more embodied learning practice in schools. Based on interviews with policy-makers and practitioners and a variety of documentary sources, this paper examines a series of school-based AIDS interventions, arguing that they represent a less radical departure from ‘education for the mind’ than might appear to be the case. The paper concludes that most interventions serve to cast on children responsibility for averting a social risk, and to ‘normalise’ aberrant children's bodies to ensure they conform to what the cognitively-oriented education system expects

Accuracy and utility of three-dimensional contrast-enhanced magnetic resonance angiography in planning carotid stenting

BackgroundContrast-enhanced magnetic resonance angiography (CE-MRA) is a proven diagnostic tool for the evaluation of carotid stenosis; however, its utility in planning carotid artery stenting (CAS) has not been addressed. This study assessed the accuracy of three-dimensional CE-MRA as a noninvasive screening tool, compared with digital subtraction angiography (DSA), for evaluating carotid and arch morphology before CAS.MethodsIn a series of 96 CAS procedures during a 2-year period, CE-MRAs and DSAs with complete visualization from the aortic arch to the intracranial circulation were obtained before CAS in 60 patients. Four additional patients, initially considered potential candidates for CAS, were also evaluated with CE-MRA and DSA. The two-by-two table method, receiver operating characteristic curve, and Bland-Altman analyses were used to characterize the ability of CE-MRA to discriminate carotid and arch anatomy, suitability for CAS, and degree of carotid stenosis.ResultsThe sensitivity and specificity of CE-MRA were, respectively, 100% and 100% to determine CAS suitability, 87% and 100% to define aortic arch type, 93% and 100% to determine severe carotid tortuosity, and 75% and 98% to detect ulcerated plaques. CE-MRA had 87% sensitivity and 100% specificity for the detection of carotid stenosis ≥80%. The accuracy of CE MRA to determine optimal imaging angles and stent and embolic protection device sizes was >90%. The operative technique for CAS was altered because of the findings of preoperative CE-MRA in 22 procedures (38%). The most frequent change in the operative plan was the use of the telescoping technique in 11 cases (18%). CAS was aborted in four patients (5%) due to unfavorable anatomy identified on CE-MRA, including prohibitive internal carotid artery tortuosity (n = 1), long string sign of the internal carotid artery (n = 2), and concomitant intracranial disease (n = 1). Among patients considered suitable for CAS by CE-MRA, technical success was 100%, and the 30-day stroke/death rate was 1.6%.ConclusionsContrast-enhanced magnetic resonance angiography of the arch and carotid arteries is accurate in determining suitability for CAS and may alter the operative technique. Certain anatomic contraindications for CAS may be detected without DSA. Although CE-MRA is less accurate to estimate the degree of stenosis, it can accurately predict imaging angles, and stent and embolic protection device size, which may facilitate safe and expeditious CAS

Prospective, Randomized, Controlled Trial of Tissue Adhesive (2-Octylcyanoacrylate) vs Standard Wound Closure Techniques for Laceration Repair

Objective: To compare a new tissue adhesive, 2-octylcyanoacrylate, with standard wound closure techniques for the repair of traumatic lacerations. Methods: A prospective, randomized, controlled clinical trial enrolled consecutive patients >1 year of age with non-bite, non-crush-induced lacerations who presented 3 months) was assessed by physicians using a previously validated categorical cosmetic scale and by patients using a 100-mm visual analog scale. Results : There were 63 patients randomized to the octylcyanoacrylate group and 61 patients treated with standard wound closure techniques. The 2 treatment groups were similar with respect to age, gender, race, medical history, and wound characteristics. At the 5-to-10-day follow-up, only 1 wound was infected and only 2 wounds required reclosure due to dehiscence. These 3 patients received treatment with octylcyanoacrylate. At long-term follow-up, the cosmetic appearances were similar according to the patients (octylcyanoacrylate, 83.8 ± 19.4 mm vs standard techniques, 82.5 ± 17.6 mm; p = 0.72) and the physicians (optimal cosmetic appearance, 77% vs 80%; p = 0.67). Conclusions: Wounds treated with octylcyanoacrylate and standard wound closure techniques have similar cosmetic appearances 3 months later.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75580/1/j.1553-2712.1998.tb02590.x.pd

Protocol evaluating the effectiveness of a school-based group programme for parents of children at risk of ADHD: The 'PArents, Teachers and CHildren WORKing together (PATCHWORK)' cluster RCT protocol

Introduction Early intervention for childhood behavioural problems may help improve health and educational outcomes in affected children and reduce the likelihood of developing additional difficulties. The National Institute for Health and Clinical Excellence guidelines for attention deficit/hyperactivity disorder (ADHD), a common childhood behavioural disorder, recommend a stepped care approach for the identification and management of these problems. Parents of children with high levels of hyperactivity and inattention may benefit from intervention programmes involving behavioural management and educational approaches. Such interventions may be further enhanced by providing training and feedback to teachers about the strategies discussed with parents. In relation to children with high levels of hyperactivity, impulsiveness and inattention, we aim to test the feasibility and effectiveness of a parenting programme (with and without an accompanying teacher session) in primary schools. Methods and analysis This clustered (at the level of school) randomised controlled trial (RCT) focuses on children in their first four school years (ages 4–8 years) in the East Midlands area of England. Parents will complete a screening measure, the Strengths and Difficulties Questionnaire, to identify children with high levels of hyperactivity/inattention. Three approaches to reducing hyperactivity and attention problems will be compared: a group programme for parents (parent-only intervention); group programme for parents combined with feedback to teachers (combined intervention); and waiting list control (no intervention). Differences between arms on the short version of Conners’ Parent and Teacher Rating Scales Revised will be compared and also used to inform the sample size required for a future definitive cluster RCT. A preliminary cost-effectiveness analysis will also be conducted. Ethics and dissemination The outcomes of this study will inform policy makers about the feasibility, acceptability and effectiveness of delivering targeted behavioural interventions within a school setting. The study has received ethical approval from the University of Nottingham Medical School Ethics Committee

Defining the type of surgeon volume that influences the outcomes for open abdominal aortic aneurysm repair

ObjectivePrior studies have reported improved clinical outcomes with higher surgeon volume, which is assumed to be a product of the surgeon's experience with the index operation. We hypothesized that composite surgeon volume is an important determinant of outcome. We tested this hypothesis by comparing the impact of operation-specific surgeon volume versus composite surgeon volume on surgical outcomes, using open abdominal aortic aneurysm (AAA) repair as the index operation.MethodsThe Nationwide Inpatient Sample was analyzed to identify patients undergoing open AAA repairs for 2000 to 2008. Surgeons were stratified into deciles based on annual volume of open AAA repairs (“operation-specific volume”) and overall volume of open vascular operations (“composite volume”). Composite volume was defined by the sum of several open vascular operations: carotid endarterectomy, aortobifemoral bypass, femoral-popliteal bypass, and femoral-tibial bypass. Multiple logistic regression analyses were used to examine the relationship between surgeon volume and in-hospital mortality for open AAA repair, adjusting for both patient and hospital characteristics.ResultsBetween 2000 and 2008, an estimated 111,533 (95% confidence interval [CI], 102,296-121,232) elective open AAA repairs were performed nationwide by 6,857 surgeons. The crude in-hospital mortality rate over the study period was 6.1% (95% CI, 5.6%-6.5%). The mean number of open AAA repairs performed annually was 2.4 operations per surgeon. The mean composite volume was 5.3 operations annually. As expected, in-hospital mortality for open AAA repair decreased with increasing volume of open AAA repairs performed by a surgeon. Mortality rates for the lowest and highest deciles of surgeon volume were 10.2% and 4.5%, respectively (P < .0001). A similar pattern was observed for composite surgeon volume, as the mortality rates for the lowest and highest deciles of composite volume were 9.8% and 4.8%, respectively (P < .0001). After adjusting for patient and hospital characteristics, increasing composite surgeon volume remained a significant predictor of lower in-hospital mortality for open AAA repair (odds ratio, 0.994; 95% CI, .992-.996; P < .0001), whereas increasing volume of AAA repairs per surgeon did not predict in-hospital deaths.ConclusionsThe current study suggests that composite surgeon volume—not operation-specific volume—is a key determinant of in-hospital mortality for open AAA repair. This finding needs to be considered for future credentialing of surgeons

The fossil record of early tetrapods: worker effort and the end-Permian mass extinction

It is important to understand the quality of the fossil record of early tetrapods (Tetrapoda, minus Lissamphibia and Amniota) because of their key role in the transition of vertebrates from water to land, their dominance of terrestrial faunas for over 100 million years of the late Palaeozoic and earlyMesozoic, and their variable fates during the end−Permian mass extinction. The first description of an early tetrapod dates back to 1824, and since then discoveries have occurred at a rather irregular pace, with peaks and troughs corresponding to some of the vicissitudes of human history through the past two centuries. As expected, the record is dominated by the well−sampled sedimentary basins of Europe and North America, but finds from other continents are increasing rapidly. Comparisons of snapshots of knowledge in 1900, 1950, and 2000 show that discovery of new species has changed the shape of the species−level diversification curve, contrary to earlier studies of family−level taxa. There is, however, little evidence that taxon counts relate to research effort (as counted by numbers of publications), and there are no biasing effects associated with differential study of different time intervals through the late Palaeozoic and Mesozoic. In fact, levels of effort are apparently not related to geological time, with no evidence that workers have spent more time on more recent parts of the record. In particular, the end−Permian mass extinction was investigated to determine whether diversity changes through that interval might reflect worker effort: it turns out that most records of early tetrapod taxa (when corrected for duration of geological series) occur in the Lower Triassic