Child abuse experience, training, knowledge, and attitude of healthcare professionals in sixty hospitals in Greece

OBJECTIVE

This study aims to record the overall perception of healthcare professionals on child abuse and identify potential affecting factors in a nationwide scale in Greece as well as to provide information that might be useful for future educational actions.

MATERIALS AND METHODS

A total of 1,185 healthcare professionals in 60 hospitals with pediatric departments across Greece participated in this cross-sectional study. Participants included pediatricians, pediatric surgeons, residents, nurses, psychiatrists, psychologists, and social workers. Sections under investigation involved experience and training in child abuse, knowledge of formal and judicial issues, clinical knowledge, and self-assessment.

RESULTS

Although more than half of the participants had confronted child abuse (n=712, 60.08%), only 273 (38.34% of them) submitted reports. One third of participants reported that they had received some training (n=440, 37.13%), mainly of postgraduate nature and based on personal initiative. Of those who reported child abuse, 175 (64.10%) had been trained. Each professional category was aware of topics regarding its own interest, without adequate knowledge of other disciplines. One third of psychiatrists, psychologists, and social workers felt confident in discussing with children and parents. Relevant scores were lower in the other categories. The lower scores were recorded among nurses and residents. The training deficit and reluctance to engage with judicial issues were the main causes of avoidance to deal with child abuse.

CONCLUSIONS

Focused and organized training in child abuse is crucial to create reliable professionals in the field. The internet is a considerably helpful tool. Professionalism must characterize knowledge and practice in child abuse at the same level as in other medical topics. Motivation to engage should be early inspired and developed during the graduate years.

Asphyxia-Induced Bacterial Translocation in an Animal Experimental Model in Neonatal Piglets

BACKGROUND

The term "bacterial translocation" (BT) refers to the migration of bacteria or their products from the gastrointestinal tract to tissues located outside it, and may occur after intestinal ischemia-reperfusion injury. The term "endotoxin" is synonymous, and is used interchangeably with the term lipopolysaccharide (LPS). LPS, a component of Gram-negative gut bacteria, is a potent microbial virulence factor, that can trigger production of pro-inflammatory mediators, causing localized and systemic inflammation. The aim of this study is to investigate if neonatal asphyxia provokes BT and an increased concentration of LPS in an animal model of asphyxia in piglets.

METHODS

Twenty-one (21) newborn male Landrace/Large White piglets, 1-4 days old, were randomly allocated into three groups, Control (A), Asphyxia (B) and Asphyxia-Cardiopulmonary Resuscitation (CPR) (C). All animals were instrumented, anesthetized and underwent hemodynamic monitoring. In Group A, the animals were euthanized. In Group B, the endotracheal tube was occluded to cause asphyxia leading to cardiopulmonary arrest. In Group C, the animals were resuscitated after asphyxia and further monitored for 30'. Bacterial translocation was assessed by the measurement of endotoxin in blood from the portal vein and the aorta, and also by the measurement of endotoxin in mesenteric lymph nodes (MLNs) at euthanasia. The results are given as median (IQR) with LPS concentration in EU/mL.

RESULTS

BT was observed in all groups with minimum LPS concentration in the MLN and maximum concentration in the portal vein. LPS levels in the MLNs were higher in the Group B: 6.38 EU/mL (2.69-9.34) compared to the other groups (Group A: 2.1 EU/mL (1.08-2.52), Group C: 1.66 EU/mL (1.51-2.48), p = 0.012). The aorta to MLNs LPS difference (%) was lower in Group B: 0.13% (0.04-1.17), compared to Group A: 5.08% (2.2-10.7), and Group C: 3.42% (1.5-5.1)) (p = 0.042). The same was detected for portal to MLNs LPS difference (%) which was lower in Group B: 0.94% (0.5-3) compared to Group A: 4.9% (4-15), and Group C: 3.85% (1.5-5.1)) (p = 0.044).

CONCLUSIONS

Neonatal asphyxia can provoke ΒΤ and increased LPS concentration in blood and tissue located outside the gastrointestinal system.

Clinical significance of interleukin-18 in the course of burn injured children

BACKGROUND

Burn injury (BI) is one of the most serious causes of morbidity and mortality in the pediatric population. BI triggers an initial stage of hyperinflammation, followed by hypersecretion of both pro- and anti-inflammatory cytokines. IL- 18 is a vital pro-inflammatory cytokine, the effect of which has been investigated not only in animal models but also in adult patients. No study has yet examined the association of serum IL- 18 levels and the clinical significance in the course of pediatric BI.

METHODS

We conducted a prospective study including all children with burn injuries who were hospitalized from December 2015 to December 2018 in a tertiary Children's Hospital.

RESULTS

A total of 55 children with BI were included. In the present study, we found a strong positive correlation between total body surface area (TBSA) and the levels of IL-18 at admission and on the third day postburn, respectively. The WBC count, the number of lymphocytes and the CRP levels at admission revealed a strong, positive correlation with IL-18 levels. The correlation between IL-18 levels at admission and the length of stay (LOS) was moderate.

CONCLUSIONS

This study has shown that the levels of IL-18 collected at admission correlate positively with the extent of TBSA and inflammatory indices in pediatric patients. Moreover, IL-18 levels at admission may not be the most accurate prognostic factor regarding the LOS. However, further research is needed in order to establish more accurate predictive factors for the outcome of BIs in pediatric patients.

Morphologic alterations of the genital mesentery implicated in testis non-descent in rats prenatally exposed to flutamide

BACKGROUND

There is an endless debate on whether androgens mediate testis descent through developmental changes in the gubernacular or the cranial suspensory ligament.

OBJECTIVE

To investigate the relation of any possible morphologic changes in the genital mesentery, that is, the system of genital peritoneal folds including the gubernacular and cranial suspensory ligaments, with the event of testis non-descent in rats prenatally exposed to the antiandrogen flutamide.

MATERIALS AND METHODS

Time-pregnant Sprague Dawley rats received flutamide (100 mg/kg/d) or vehicle subcutaneously on gestational days 16-17. Flutamide-treated male offspring (n = 67), and vehicle-treated male (n = 34) and female (n = 28) offspring were surgically explored under microscope on postnatal day 50. Testicular position was examined bilaterally. Dimensions of genital mesentery parts were also assessed bilaterally. Association of flutamide-induced morphologic changes with descended (n = 61) and undescended (n = 50; 33 cryptorchid and 17 ectopic) testes was investigated with logistic regression analysis.

RESULTS

The male genital mesentery comprised a cranial and a caudal fold converging on the vas deferens. Flutamide resulted in enlarged cranial and reduced caudal folds. Of all flutamide-induced alterations, the increased length of the posterior fixation of the cranial fold and the decreased length of the gubernacular ligament of the caudal fold were found to independently increase the odds of testis non-descent. Testicular ectopy, unlike cryptorchidism, was associated with a short gubernacular ligament only. The female genital mesentery consisted of a cranial fold only.

CONCLUSION

Our findings showed a combined contribution of both cranial and caudal folds of the genital mesentery to testis non-descent, through an abnormally long mesentery root and an abnormally short gubernacular ligament, respectively. Inhibition of male-specific development of the genital mesentery with flutamide did not result in a feminized architecture.

Bilateral ectopic femoral testes: A rare cause of empty scrotum

Empty scrotum is a relatively rare entity, with few cases reported in the literature, so far; if it coexists with bilateral ectopic femoral testes, it then constitutes an extremely rare congenital abnormality. We report a case of empty scrotum revealed at the first physical examination of a neonate. The scrotum appeared empty and no testes could be palpated in the scrotum or the inguinal canal. Two solitary, oval masses were palpable laterally of each hemiscrotum, close to femoral canal and the diagnosis of bilateral femoral ectopic testes was confirmed by the consultant pediatric surgeon.

Solid Pseudopapillary Tumor of the Pancreas: A Single-center Experience and Review of the Literature

BACKGROUND

Solid pseudopapillary tumors (SPTs) of the pancreas are a rare occurrence, not exceeding 1-2% of all exocrine pancreatic tumors. SPT was first described in 1959 as "papillary tumor of the pancreas, benign or malignant" and affects mainly young women, in their second or third decade of age. These tumors are of low malignant potential, unclear pathogenesis, grow gradually and become considerably large before causing symptoms. A typical clinical presentation is often described by affected patients and, in some cases, an SPT is an incidental finding during the time the patient undergoes medical imaging studies for other health issues. SPT is frequently located at the head or tail of the pancreas. Metastases are rare but, when present, affect predominantly the liver.

PATIENTS AND METHODS

We report a series of five SPT cases in female patients 13-47 years old, presenting with almost identical symptoms of upper abdominal discomfort and non-tender palpable mass. Two out of five patients also reported vomiting, nausea and poor appetite as co-existing non-diagnostic symptoms. Only one patient presented without any symptoms. Tumor location and dimensions varied. One patient underwent a pancreatoduodenectomy (Whipple's procedure), while the remaining patients underwent distal pancreatectomy with concomitant splenectomy.

RESULTS

Perioperative morbidity and mortality was zero. All five patients are disease-free at a follow-up from 3 months to 13 years. Histopathology reports supported the diagnosis of SPT and no metastatic disease was present in any of the patients.

CONCLUSION

The overall prognosis of SPT of the pancreas is excellent due to its favorable biological features, even in the presence of distal metastasis. Although surgical resection is often curative, a close follow-up is advised in order to diagnose a possible local recurrence or distal metastasis and choose the proper therapeutic option for the patients.

Stress response to ovariohysterectomy in rabbits: role of anaesthesia and surgery

The aim of this study was to evaluate the neuroendocrine and inflammation response to laparoscopic total ovariohysterectomy (TOH) in rabbits, by comparing surgical stress markers of laparoscopic group with those of conventional open ovariohysterectomy and open ovariohysterectomy with pre-incisional local anaesthesia groups. Blood was sampled from 18 rabbits, of which six underwent laparoscopic TOH, six conventional open TOH and six conventional open TOH with pre-incisional local anaesthesia, 30 min before induction of anaesthesia (T0), immediately after skin incision (T1), 90 min postoperatively (T2), and 24 h postoperatively (T3). Cortisol and C-reactive protein serum, and adrenocorticothrophic hormone, tumour necrosis factor-a (TNF-a), adrenaline, noradrenaline and IL-6 plasma concentrations were evaluated. Laparoscopic TOH in rabbits has advantages over the open surgical technique because it causes less surgical stress response in terms of serum cortisol concentrations immediately after skin incision (p = .04), as well as plasma adrenaline (p = .035) and TNF-a (p = .047) concentrations 24 h postoperatively. Impact statement What is already known on this subject? Hysterectomy is the second most common surgery performed on women after caesarean section. Research has focussed on methods to modify the stress response associated with surgery. Various studies both in humans and animals, have demonstrated the less systemic, immunological and neurohormonal response of the laparoscopic technique, which is expressed by less elevated serum enzymes' and proteins' concentrations. However, other studies have documented that the systemic stress response after open hysterectomy is similar to that following laparoscopic surgery. What do the results of this study add? Laparoscopic total ovariohysterectomy in rabbits has advantages over the open surgical technique because it causes less surgical stress response in terms of serum cortisol concentrations, as well as plasma adrenaline and TNF-a concentrations during the first 24 h postoperatively. What are the implications are of these findings for clinical practice and/or further research? There were no significant differences between the groups in number of surgical stress markers (p > .05) perioperatively. We cannot exclude the possibility that a later increase of surgical stress response might take place after the first 24 h postoperatively.

Long-term parenteral nutrition, via the azygos system, in an adolescent with cystic fibrosis

Venous access device is critically needed for long-term parenteral nutrition (PN), especially in children with chronic disease such as cystic fibrosis, short bowel syndrome, and permanent intestinal failure. When traditional sites are unavailable and venous access is very limited, alternative central routes are required. The access to the azygos system has been shown to be a safe, relatively easy solution in those special situations. We report the case of an adolescent who benefited from this central venous access for long-term PN and antibiotic treatment for >7 years with a limited number of complications.

Inflammatory myofibroblastic tumor of the small intestine mimicking acute appendicitis: a case report and review of the literature

BACKGROUND

Inflammatory myofibroblastic tumor is a rare tumor of a borderline malignancy. Although it is commonly seen in children, the number of childhood cases in the current literature is limited. The lung is the most commonly affected location. However, cases that have been documented in the mesentery-omentum have mostly been located in the mesentery of the small bowel and not in the antimesenteric edge as in our patient.

CASE PRESENTATION

A 6-year-old Greek boy was referred to our hospital with acute abdominal pain mimicking appendicitis. Ultrasound and computed tomography revealed a solid mass in the abdomen. The patient underwent laparoscopic resection of the tumor, and histopathology and immunohistochemical analysis favored an omental-mesenteric myxoid hamartoma, which is a variant of an inflammatory myofibroblastic tumor. The patient's postoperative course was uneventful, and he has been asymptomatic during follow-up.

CONCLUSIONS

Inflammatory myofibroblastic tumor of the small intestine is a rare, benign neoplasm in children that should be considered as a possible cause of acute abdomen. A precise diagnosis can be made on the basis of histologic findings. Surgical excision is the treatment of choice.

DMSA scan for revealing vesicoureteral reflux in young children with urinary tract infection

OBJECTIVES

The objective of this study was to assess the ability of acute dimercaptosuccinic acid (DMSA) scintigraphy for revealing vesicoureteral reflux (VUR) in young children after a first febrile urinary tract infection (UTI).

METHODS

Children aged<or=24 months and were admitted with a first febrile UTI during a 5-year period were evaluated. The ability of acute DMSA scintigraphy to reveal dilating (grades 3-5) or severe (grades 4-5) VUR was assessed by comparing DMSA scan findings with those of voiding cystourethrography.

RESULTS

Of the 296 children included, 46 had dilating and 25 severe VUR. Abnormal DMSA scan results were associated with an odds ratio of 4.36 for dilating and 5.50 for severe VUR. For detecting dilating VUR, the area under the curve (AUC) was 0.68, the positive likelihood ratio (LR) was 2.00, and the negative LR was 0.46; for severe VUR, those values were 0.69, 2.10, and 0.38, respectively. Children with abnormal DMSA scan results combined with abnormal ultrasonography had an odds ratio of 3.60 for dilating and 6.32 for severe VUR. Despite normal findings on both investigations, 12 children had dilating and 4 severe VUR. For dilating VUR, the area under the (AUC) was 0.65, the positive LR was 1.70, and the negative LR was 0.47; for severe VUR, the values were 0.69, 1.90, and 0.29, respectively.

CONCLUSIONS

Our data suggest that acute DMSA scintigraphy has limited overall ability in identifying VUR and should not be endorsed as replacement for voiding cystourethrography in the evaluation of young children with a first febrile UTI.

Mixed gonadal dysgenesis in a 45,X neonate with chromosome Y material in the dysgenetic gonad

We report on a neonate with a disorder of sex development, Prader 3-4 external genitalia and a palpable structure in the right inguinal canal suggestive of gonadal tissue. Chromosome studies on blood lymphocytes showed monosomy of chromosome X. Laparoscopy identified a streak-like gonad on the left side, unicorn uterus and a dysgenetic testis on the right, attached to a Fallopian tube. Because of the unilateral palpable gonad and the presence of ambiguous genitalia we investigated further for the presence of Y material. Quantitative fluorescent PCR analysis of material from the dysgenetic gonad and skin fibroblasts revealed the presence of chromosome Y-derived sequences, suggesting sex chromosome mosaicism. In 45,X/46,XY mosaicism, chromosome studies carried out on peripheral lymphocytes do not always reflect the proportion of cell lines in the gonads. The detection of Y chromosome material in a dysgenetic gonad is extremely significant, due to the high risk of malignant transformation.

Masked severe stenosing ureteritis: a rare complication of Henoch-Schönlein purpura

Henoch-Schönlein purpura (HSP)-associated stenosing ureteritis represents a rare complication of the disease, typically presenting with severe manifestations. This article reports on a 3.5-year-old boy with HSP and severe nephritis who developed a unilateral stenosing ureteritis with atypical manifestations, resulting in a nonfunctional kidney and consequent nephrectomy. The urinary tract ultrasound was normal in the first week of illness, and the diagnosis was made during follow-up 8 months after onset. The predominance of nephritic manifestations may have masked any signs of ureteritis, leading to the delay in diagnosis. To clarify the clinical spectrum of this complication, an extensive review of the literature was performed. We emphasize the necessity of repeated urinary tract ultrasound both early and later in the course of HSP, especially in cases with renal involvement, so that an early diagnosis of this complication can prevent a potentially serious renal outcome.

Double-blind ureteral duplication: a rare urologic anomaly

We present an extremely infrequent urologic entity of asymptomatic double-blind ureteral duplication in an 8-year-old girl. Contemporary imaging modalities provided major assistance in the diagnosis. Surgical management is advocated because of the potential for future complications, such as lithiasis, obstruction of the collecting system, and renal failure.

Fetal ovarian cysts: report of two cases and literature review

In the present study we report two cases of fetal ovarian cysts. In the first case the cyst was initially discovered during prenatal ultrasound examination, while in the second case the cyst was identified during autopsy examination of a stillborn fetus. Pathologic examination of both specimens revealed similar histology, which was mainly characterized by the presence of an ovarian cortex comprising several maturing and primordial follicles which were occasionally biovular, and a focal lining of luteinized theca cells. Another prominent feature was the presence of multiple deposits of dystrophic calcifications within the cyst wall. Both cysts were diagnosed as follicular in origin.

Rare combination of unilateral renal agenesis, congenital obstructive posterior urethral membrane, and enlarged prostatic utricle, with absence of hydroureteronephrosis

The existence of congenital obstructive posterior urethral membrane (COPUM), extending proximally from the verumontanum toward the bladder neck, has been widely debated. Although COPUM often leads to chronic renal disease, a milder degree of obstruction and protective pressure pop-off mechanisms have been reported. We present a male infant with a rare combination of unilateral renal agenesis, COPUM proximally from the verumontanum to the bladder neck, and enlarged prostatic utricle. The posterior urethra was dilated, without bladder abnormalities or hydroureteronephrosis, indicating milder obstruction. Moreover, the enlarged prostatic utricle could contribute in the urinary tract protection, serving as an uncommon pressure pop-off mechanism.

First urinary tract infection in neonates, infants and young children: a comparative study

In an attempt to evaluate first urinary tract infection (UTI) in neonates and infants, we estimated retrospectively in 296 patients (62 neonates and 234 infants) clinical and laboratory findings, occurrence of vesicoureteral reflux (VUR), urinary tract abnormalities and pyelonephritis. First UTI occurred more often in male than female neonates, whereas male and female infants/young children were affected at an equal rate. The pathogens isolated in urine cultures of neonates and infants did not statistically significantly differ (P>0.05); Escherichia coli predominated. Gram-negative bacteria other than E. coli affected boys more often than girls (P=0.0022). Fever was the most frequent symptom. Neonates had lower-grade fever of shorter duration than infants (P<0.05). The incidence of reflux and urinary tract abnormalities did not differ between neonates and infants, male and female neonates and infants (P>0.05). Pyelonephritis affected neonates and infants at an equal rate; it was more prevalent among female patients (P=0.038) and patients with VUR or urinary tract abnormalities other than VUR (P<0.0001). Neonates with reflux were more often affected by Gram-negative bacteria other than E. coli than were neonates without reflux (P=0.0008).

Successful bronchotracheal reconstruction in esophageal bronchus: two case reports

Esophageal bronchus is the most common congenital bronchopulmonary foregut malformation. Current surgical treatment is resection of anomalous pulmonary tissue, which is often hypoplastic and destroyed by infection. The authors report two cases of bronchotracheal reconstruction. The diagnosis was early, before 15 days of age. The anomalous pulmonary tissue had a pulmonary arterial supply and venous drainage as assessed by angiography and a good functional capacity on selective ventilation. Bronchotracheal anastomosis was successful in both cases: a right main bronchus at 25 days of age and a left main bronchus at 13 days of age. One child underwent reoperation 1 year later for bronchomalacia of the reimplanted bronchus. Both children are well with normal growth 3 and 7 years after surgery. Chest roentgenograms showed normal and symmetrical lung aeration. Tracheal reimplantation may be preferred to pulmonary resection when the anomalous pulmonary tissue is not destroyed. The pulmonary functional capacity is increased and the complications of pneumonectomy avoided.

Congenital pyloric stenosis: a modified umbilical incision for pyloromyotomy

Thirty-two patients underwent a pyloromyotomy via an umbilical incision; in 11 a modified umbilical approach was used to facilitate delivery of the pyloric mass. Incisions are made in the skin fold of the upper half of the umbilicus and at the midline, joining the two at the top. The skin incision is closed by upper umbilical translocation with a very good cosmetic result. This incision allows easy access to the pylorus and provides more convenient exposure. The absence of traction on the retractors avoids tissue ischemia, which leads to wound abscess development.

Tubular musculopleural pedicle grafting of esophageal long gaps in dogs

Direct anastomosis of the esophagus is the treatment of choice in patients with esophageal atresia. If, however, a long esophageal gap exists, the anastomosis is performed under tension or a staged procedure is anticipated. The aim of this study was to prove that a pedicle musculopleural graft can be used to bridge the two esophageal ends. In 14 dogs through a right thoracotomy, the periosteum of the fifth rib was mobilized and the rib was excised. An intercostal musculopleural flap was created leaving the muscle attached to its vascular pedicle posteriorly with the intercostal vessels and nerve carefully preserved. A tube-like portion including pleural and intercostal muscles was formed from the free part of the graft. A 5 cm segment of the esophagus was excised and the tubular graft was interimposed. Animals were studied 1 month postoperatively with a barium meal that showed free passage through the esophageal neolumen. Peristaltic activity was studied with strain gauges above, below, and at the grafted area. Histologic examination revealed good healing at both anastomotic sites, while esophageal squamous epithelium covered the lumen all over the graft. Survival of the musculopleural pedicle graft seems to be feasible providing that its vascular supply is preserved. It is, thus, suggested that this technique might offer an alternative method in bridging long gaps in esophageal surgery.