COVID-19 positive cases in a pediatric surgery department from Romania: Case series from 2 years of pandemics

RATIONALE

The COVID-19 pandemic had a dramatic effect on various health systems in terms of admissions and outcomes, including pediatric surgery activity. The aim of this paper was to analyze the outcome of SARS-CoV-2-positive patients admitted to our department during the regional COVID-19 pandemic in North-Eastern Romania. We also evaluated the changes generated in our daily practice by the COVID-19 pandemic and the dynamic response to this major challenge.

PATIENT CONCERNS

The patients presented with symptoms related to their primary diagnosis: local pain and deformity in case of fractures; pain, swelling, and erythema in case of abscess; pain and decreased range of motion (ROM) in case of intolerance to metal implants. Other specific concerns are mentioned on an individual basis.

DIAGNOSES

Eighteen patients (of which 4 had acute appendicitis and were included in a previous article), representing 1.18% of the total number of admissions, tested positive for SARS-CoV-2. There were 4 patients with fractures, 3 patients with soft tissue abscess or cellulitis, 2 patients with intolerance to metal implants, 1 patient with facial burn, 1 patient with thumb laceration, 1 patient with liver trauma, 1 patient with undescende testis, and 1 patient with symptomatic inguinal hernia, respectively. Boys represented 11/ 14 (78.57%) of the cases. The mean age of the patients was 9 years 11 months. There were only mild COVID-19 cases.

INTERVENTIONS

Surgery was performed in 13/ 14 (95.71%) of cases. The fractures were treated with open reduction internal fixation (ORIF); incision and drainage (I & D) were performed in case of soft tissue abscess; the metal implants were removed in case of local intolerance. Other conditions (burn, inguinal hernia, undescended testis, skin laceration) were treated specifically. Only 1 patient with liver laceration was treated conservatively under close hemodynamic monitoring.

OUTCOMES

The mean length of stay (LoS) was 2.71 days. The infection with the SARS-CoV-2 virus had no deleterious effect on the surgical outcome among the 14 patients included in the study. There were no surgical complications during admission and no patient returned for late complications related to their primary disease or SARS-CoV-2 infection.

LESSONS

The SARS-CoV-2 infection had no significant influence on the outcome of pediatric surgical cases included in the study. We noticed a significant (31.54%) decrease in the number of admissions compared to the previous 2-year interval before the COVID-19 pandemic. Fast and adequate adjustment of the daily activity imposed by the COVID-19 pandemic was feasible and may be used in the future should similar epidemiological emergencies occur.

Acute Appendicitis in COVID-19-Positive Children: Report of 4 Cases from an Endemic Area in Northeastern Romania

Acute appendicitis (AA) is one of the most common surgical emergencies in children. Some reports have suggested that the COVID-19 pandemic was responsible for delays in the diagnostic and proper treatment of AA in pediatric patients. The aim of our study was to perform a retrospective study of cases of AA in children with SARS-CoV-2 infection treated in a highly endemic area for COVID-19 in Romania during a 2-year time interval. The SARS-CoV-2 infection had no unfavorable impact on children who presented with AA. Further data analysis should clarify the overall influence of COVID-19 on the management of surgical pediatric patients in such endemic areas.

Effectiveness of Physiotherapy in the Treatment of Temporomandibular Joint Dysfunction and the Relationship with Cervical Spine

Temporomandibular dysfunctions are a heterogeneous group of conditions involving the temporomandibular joints (TMJs) and periarticular musculoskeletal structures. This study aimed to evaluate the effectiveness of a physiotherapy program for TMJ dysfunctions and the relationship with cervical spine. The study design was a non-randomized clinical trial with two parallel treatment groups: 33 subjects in the experimental group that underwent conservative drug treatment and physiotherapy treatment, and 31 subjects in the control group that underwent only conservative drug treatment. The participants were examined at baseline and re-examined after 3 months. In this study there was a higher incidence of female subjects. After 3 months of treatment of the TMJs and cervical spine, pain decreased in both groups (p = 0001). Muscle testing at the cervical spine and temporomandibular level showed a decrease in pain and muscles spasms. The average percentage values of the Neck Disability Index (NDI) and the Jaw Functional Limitation Scale 8 (JFLS 8) decreased significantly in both groups, but especially in the experimental group (p = 0.001). Physiotherapy treatments could maintain the functional state at the temporomandibular and cervical levels, thus contributing to increasing the quality of daily life.

The Impact of Water and Other Fluids on Pediatric Nephrolithiasis

Pediatric nephrolithiasis cases have been on the rise in the past several years, resulting in increased healthcare costs and other burdens on the juveniles with this ailment. Recent research has shown that present trends in pediatric nephrolithiasis have changed as a result of fluid intake, including water consumption, nutrition, obesity prevalence, lifestyle, and imaging procedures. A specific cause, meanwhile, is still elusive. Trends in pediatric nephrolithiasis need to be thoroughly researched. Furthermore, variables specific to pediatric nephrolithiasis that could cause greater difficulties in an affected child elevate the level of worry with cumulative prevalence. Doctors should rigorously assess patients who present with kidney stones when they have dynamics such as varied clinical presentation, high recurrence of kidney stones linked to metabolic and urinary tract problems, and the potential existence of rare genetic kidney stone illnesses. This review aims to identify adaptive risk factors and anomalies that call for specialized treatment and prescription. More specifically, the major goals of medical and surgical treatments are to eliminate kidney stone risk and stop relapse while concurrently lowering interventional barriers. A dedicated nephrolithiasis clinic run by a pediatric nephrologist, nutritionist, urologist, and clinical nurse may sometimes be beneficial for patients in serious danger. Such a clinic offers significant chances to learn more about pediatric nephrolithiasis, which has been linked to water consumption and hence fosters urgently required study in this area.

ACCIDENTAL INGESTION OF CYLINDRICAL BATTERIES IN CHILDREN – INTERVENTIONAL OR CONSERVATIVE MANAGEMENT?

Ingestion of cylindrical batteries is a rare condition in children. There are no clear guidelines regarding the appropriate management of this condition. We present 2 such cases; one patient required endoscopic removal of the battery, while in the other one the battery passed spontaneously. We recommend that such cases be admitted for monitoring and treated on an individual basis, according to the clinical picture, X-ray data and the availability of pediatric emergency endoscopy.

Fluvial landscapes of the Harappan civilization

The collapse of the Bronze Age Harappan, one of the earliest urban civilizations, remains an enigma. Urbanism flourished in the western region of the Indo-Gangetic Plain for approximately 600 y, but since approximately 3,900 y ago, the total settled area and settlement sizes declined, many sites were abandoned, and a significant shift in site numbers and density towards the east is recorded. We report morphologic and chronologic evidence indicating that fluvial landscapes in Harappan territory became remarkably stable during the late Holocene as aridification intensified in the region after approximately 5,000 BP. Upstream on the alluvial plain, the large Himalayan rivers in Punjab stopped incising, while downstream, sedimentation slowed on the distinctive mega-fluvial ridge, which the Indus built in Sindh. This fluvial quiescence suggests a gradual decrease in flood intensity that probably stimulated intensive agriculture initially and encouraged urbanization around 4,500 BP. However, further decline in monsoon precipitation led to conditions adverse to both inundation- and rain-based farming. Contrary to earlier assumptions that a large glacier-fed Himalayan river, identified by some with the mythical Sarasvati, watered the Harappan heartland on the interfluve between the Indus and Ganges basins, we show that only monsoonal-fed rivers were active there during the Holocene. As the monsoon weakened, monsoonal rivers gradually dried or became seasonal, affecting habitability along their courses. Hydroclimatic stress increased the vulnerability of agricultural production supporting Harappan urbanism, leading to settlement downsizing, diversification of crops, and a drastic increase in settlements in the moister monsoon regions of the upper Punjab, Haryana, and Uttar Pradesh.

[The importance of Dunn's procedure in the treatment of slipped femoral epiphysis]

The slipped upper femoral epiphysis (SUFE) is a condition also known as 'coxa vara' of the adolescent, in which lesions of the growth plate are responsible for the development of sudden or gradual displacement of the femoral head. The disease is most frequent in the 10-15 years' age group, usually in boys who also have endocrine disorders. Both acute and chronic presentations are described. The clinical symptoms and especially the X-Ray features are diagnostic. Treatment options include orthopedic (conservative) measures or surgery, depending on several conditions, such as: the clinical picture, the degree of the femoral displacement, and the age of the patient. The chronic, long-lasting cases are generally associated with poor results. The paper presents our experience in using the Dunn's procedure in 7 chronic cases of slipped upper femoral epiphysis in children. It appears that surgery by using Dunn's procedure is an effective treatment in patients with SUFE.

Complications following gastric tube esophagoplasty in children

Surgery in children with caustic esophageal burns, esophageal atresia or other esophageal disorders can be performed using gastric tube esophagoplasty. Between 1991 and 1999, a number of 41 such procedures have been performed in our department, using the original technique developed by Gavriliu. The results were assessed as good and very good in 83% of the cases, and fair or bad in the rest of 17%. We recorded 13 cases with significant complications, 4 of which ended with exitus. The paper present our experience in using gastric tube esophagoplasty and the management of the complications related to this procedure.

CIM explorer--intelligent tool for exploring the ICD Romanian version

The CIM Explorer software provides us with an intelligent interface for exploring the Romanian version of the International Classification of Diseases (in Romanian Clasificarea Internationala a Maladiilor-CIM). The ICD was transposed from its initial appearance as a printed document into a database. The classification can be accessed in two modes: "Navigation" and "Code" and queried in the "Key words" mode. In the last mode CIM Explorer program searches for the right content of the ICD records starting from naturally written expressions which it "understands". As a results it returns all the records containing the key words regardless their grammatical form. This program implements the specificity of the Romanian language where the words are made up from a root and a flexional termination.

[Interactions between liposomes and synaptosomes]

In continuing experiments to determine the basis of presynaptic modulation, rat cortical synaptosomes were employed and transmembrane calcium fluxes were determined with a metalocromophoric dye, Arsenazo III. The intracellular free Ca2+ concentrations show complex fluctuations in time and space in response to a variety of stimuli, acting as a pluripotent signal for many neuronal functions. Depolarisation of synaptosomes by K+ 20 mM determined calcium influx in cortical synaptosomes, mainly mediated by the Q type Ca2+ channels, with a minor participation of the N type channels. The administration protocol for the polyamines, revealed that agmatine, spermine, spermidine, putresceine and cadaverine reduce, in variable proportions, the K(+)-induced Ca2+ influx, in synaptosomal preparations. The results plead for the ability of agmatine and spermine to modulate Ca2+ fluxes in synaptosomes, both from the interior and exterior side. Moreover, rigidization of the synaptosomal membrane (by cholesterol-enriched liposomes administration) do not significantly influences K(+)-induced Ca2+ influx in synaptosomal preparations.

[EEG patterns in alcohol withdrawal syndrome]

The cerebral motor and cognitive behavior is obviously altered by chronic alcoholism, which generates significant morphological and biochemical changes. In turn, alcoholic withdrawal improves the cerebral blood supply, the psychological and motor behavior and the EEG appearance, especially in young alcoholics. Our study also underlines that alcoholic women develop a late improvement of the clinical and bioelectrical condition during the alcoholic withdrawal.

[Intestinal occlusion by persistence of the omphalo-enteric conduct in a 10-year old child]

The persistence of the omphalo-enteric conduct is a rare, but possible, cause of pathology in children. Haemorrhage and intestinal occlusion are the most frequent clinical presentations, usually in infants. We describe the case of a 10 year old boy, who was admitted in our department for what seemed first to be an acute appendicitis. During hospitalization, the clinical picture turned on to an intestinal occlusion, and the patient finally required surgery. We performed exploratory laparotomy and we discovered a mechanical occlusion by persistence of the omphalo-enteric conduct, which was treated according to standard protocols. The post-operative course was good, and the child was discharged 8 days after surgery. This case emphasizes that the persistence of the omphalo-enteric conduct should be sought as the source of symptoms in any child presenting with intestinal occlusion.

[The importance of ano-rectal manometry in irritable bowel syndrome]

Irritable Bowel Syndrome (IBS) represents a frequent cause for gastroenterological referral. 50% of all gastroenterological consultations are for functional gastrointestinal disorders (IBS included). Multiple motility abnormalities were described in IBS. The AIM of the study was to evaluate the role of ano-rectal manometry in the diagnosis of IBS.

STUDY DESIGN

24 patients with IBS (mean age 50.8 +/- 15.4) and a control group of 10 subjects with no abdominal symptoms (mean age 48.1 +/- 12.3) had each an ano-rectal manometry examination.

RESULTS

After exclusion of constipation predominant IBS subjects, the IBS patients presented lower perception threshold (22.1 +/- 10.9 ml) than the control group (60.2 +/- 11.3 ml) (p < 0.05) and than the constipation predominant group (81.3 +/- 44.0) (p < 0.05). In 44% of constipation predominant IBS concomitant pathology, revealed by manometry, was present: megarectum or hemorrhoids (spasm).

CONCLUSION

Anorectal manometry could be a useful tool for the evaluation of IBS patients.

[The electroencephalographic aspects in stress epistaxis]

The nasal haemorrhage is a symptom whose significance is seldom completely investigated. In this paper we present the results that we have obtained in two groups of patients: a pediatric population who presented for repeated episodes of nasal haemorrhage and a group of first trimester pregnant women who also have noticed the appearance of this symptom. Beside the clinical examination, a paraclinical assessment has been performed, which included a laboratory profile (hematology and biochemistry) and electroencephalography (EEG), in which we found significant changes. We conclude that EEG is a valuable investigation technique for diagnosis and monitoring purposes in nasal hemorrhage. Also, the clinical management of the stress-related nasal hemorrhage must address multiple issues for becoming efficient.

[The blood enzymatic antioxidative potential in bronchial asthma patients]

This study aims at assessing the ability of asthma patients to defend themselves against the noxious effects of oxidative stress, known being the inflammatory nature of this disorder. As the anti-radical defence ability of the body is reflected by the antioxidative potential of blood and tissues, our study was based on the determination of the activity of superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx) and CAT/SOD and GPx/SOD ratios in the blood. Except for SOD, the activity of which was lower in asthma patients by -34.08%, CAT and GPx had values increased by +32.18%, respectively, with a resulting increase of CAT/SOD and GPx/SOD ratios. Our data, demonstrating a change in per-oxidants/antioxidants balance in favour of the first ones, seem to suggest that in the treatment of bronchial asthma the association of some compounds with antioxidants effects would be beneficial.

[An update on the polysomnographic assessment of sleep-related respiratory disorders]

The paper presents a review of recent findings in the instrumental assessment of sleep-related breathing disorders. Basic concepts of definition, classification and especially medical instrumentation used for polysomnography (PSG) are introduced. The authors present standard protocols of polygraphic investigation and solutions to some practical problems, as they appear in literature.

[The role of paraclinical studies in the diagnosis of hypomagnesemia spasmophilia]

Assuming that Ca+2 and Mg+2 play an important role in the cell (especially the neuronal and muscular ones) membrane excitability, this paper presents the place that the paraclinical specific investigations have in the proper diagnose of normal calcium serum level hypo-magnesium spasmophilia. A number of 52 patients presenting significant clinical spasmophilia, of age between 21 and 55 years old, from different professions and social classes, were selected for this study. Paraclinical investigations (spectrophotometry) showed a normal serum calcium level (an average of 9.22 mg%); also, a decrease of Mg+2 serum level (an average of 1.41 mg%) and normal levels for Na+ (3.04 g/l) and K+ (0.21 g/l). The electrophysiological investigations (EMG, EEG, VCN m, EKG) performed showed, on the EMG recordings, in 85% of the cases the presence of the typical spasmophilic repetitive discharges, increased when using compression ischemia and 3 minutes hyperventilation, while on the EEG recordings, most patients demonstrated the presence of diffuse or mainly frontal lobe cortical bioelectrical activity alteration, either in spontaneous conditions or after specific stimulation (3 minutes hyperventilation or SLI). The muscle bioelectrical activity was analyzed by mean of EMG recordings--a decrease of VCN m was detected on the SPE nerve (34.4 m/s) and also on the SPI nerve (34.2 m/s) The EKG recordings performed showed in 5% of the cases the presence of the ventricular repolarization disturbances (flat T waves). After receiving a proper treatment which included oral administration of calcium and magnesium gluconolactate, magnesium gluconolactate with B6 vitamin or Trimagant, there were important changes of all the studied parameters and so, as a specific therapy, we recommend the use of Mg+2 compounds, because it demonstrates a significant improvement of the clinical symptoms in spasmophilia and has no danger to precipitate in the body as Ca+2 exceeding does.

[The results of the Ravitch-Sutherland technic for surgical correction in pectus excavatum]

The aim of our study was to assess the functional and cosmetic results after performing a modified Ravitch-Sutherland procedure in children presenting with excavatum. A series of 31 children with ages ranging between 5 and 16 years, presenting with pectus excavatum, were operated between 1986-1996 in our service. In 5 cases surgical treatment was required by the presence of respiratory and/or cardiac functional impairment due to the malformation. In the other 23 cases operation was performed mainly for cosmetic reasons. In all cases a modified Ravitch-Sutherland procedure was performed. Modification consisted in renouncing at the plicature of the perichondra and in associating a diaphragmatic elongation and Bedouelle laparoplasty in all cases. Longitudinal sternotomy was performed in 2 cases with severely impaired ventilatory capacity. Functional and cosmetic results were good in all cases. In 2 cases, in which recurrence of the condition was observed, a second identical procedure was performed, with a good result. The interval between the operation and the moment of long-term evaluation ranged between 3 months and 11 years. We conclude that the modified Ravitch-Sutherland procedure represents an effective method for the treatment of pectus excavatum cases, offering good functional and cosmetic long-term results.

[Oxidative stress in bronchial asthma]

Oxidative stress occurs when the antioxidative defence mechanism of the body are surpassed by the intra- and/or extracellular presence of reactive oxygen species (ROS). ROS were involved in the etiopathogenesis of many disorders, but it is difficult to discern whether their role is decisive--as in the production of atherosclerosis--or only aggravating, as an intermediate link, this being the case in neoplasms. Today, the participation of ROS in the progression of some respiratory diseases, such as bronchial asthma, is considered essential. Thus, since the first description of asthma by Aretaeus of Cappadocia, a huge leap in the understanding of this disease was recorded, this condition being nowadays considered a chronic inflammatory disorders with the participation of oxidative stress. For ascertaining the share of oxidative stress in the determinism of this disease and the efficacy of antioxidants on its course further investigations are needed.

An approach to establishing a health information market

The Tempus CME project "Regional Network for Healthcare Management" was aiming to perform a feasibility study for a communication network dedicated to the healthcare field. The needs assessment survey as well as the debates during the working sessions and during the conference on how communication can support a better healthcare delivery, substantiated the approach for achieving the Romanian health information market. The proposed communication network can be considered as a national information infrastructure offering good links between health, education, research and industry and a unique frame for information providers and users, for the estate and private companies. The network should also provide support and guidance for the development of new educational fields as applied informatics in healthcare.

[The results of the Ravitch-Sutherland technic for surgical correction in pectus excavatum]

The aim of our study was to asses the functional and cosmetic results after performing a modified Ravitch-Sutherland procedure in children presenting with pectus excavatum. A series of 31 children with ages ranging between 5 and 16 years, presenting with pectus excavatum, were operated between 1986-1996 in our service. In 5 cases surgical treatment was required by the presence of respiratory and/or cardiac functional impairment due to the malformation. In the other 23 cases operation was performed mainly for cosmetic reasons. In all cases a modified Ravitch-Sutherland procedure was performed. Modifications consisted in renouncing at the plication of the perichondrium and in associating a diaphragmatic elongation and Bedouelle laparoplasty in all cases. Longitudinal sternotomy was performed in 2 cases with severely impaired ventilatory capacity. Functional and cosmetic results were good in all cases. In 2 cases, in which recurrence of the condition was observed, a second identical procedure was performed, with a good result. The interval between the operation and the moment of long-term evaluation ranged between 3 months and 11 years. We conclude that the modified Ravitch-Sutherland procedure represents an effective method for the treatment of pectus excavatum cases, offering good functional and cosmetic long-term results.

[The effect of the ascorbic acid-Cu (II) couple on enzyme activity]

Ascorbic acid (AA), Cu (II) and their association affect in different ways the activity of G6P-ase and G6PDH from the rat hepatic cytoplasm enriched in microsomes. G6P-ase is inhibited at a wide range of concentrations: 200-2 mM AA and 1-0.1 mM Cu (II). The association AA-Cu in the above mentioned concentrations, proved to be a stronger inhibitor than AA or Cu (II) introduced separately in the incubation medium. The activity of G6PDH is stimulated by AA-Cu (II) association and inhibited by AA in the dialyzed and nondialyzed cytoplasm. Cu (II) inhibits the activity of G6PDH in the nondialyzed cytoplasm and stimulates it following dialysis. The compounds with recognized antiradical action prove to be inefficient in restoring the activity of G6PDH affected by the AA-Cu (II) association.