Evelyn H. Dykes

The Use of the Mitrofanoff Principle in Achieving Clean Intermittent Catheterisation and Urinary Continence in Children

The Mitrofanoff principle has been used to achieve clean intermittent catheterisation (CIC) and urinary continence in 28 children. The mean age at operation was 10.1 years (range, 1 to 19 years). A catheterisable conduit was created using the appendix (19), ureter (8), or vas deferens (1). CIC was commenced 10 to 28 days postoperatively (median, 15 days). After a mean follow-up of 13 months (range, 2 to 45 months), 24 children (86%) have achieved successful CIC and urinary continence. Use of the Mitrofanoff principle is a valuable adjunct to the treatment of urinary incontinence in children and may allow successful CIC in patients who are unable to catheterise urethrally.

Fatal bicycle accidents in children: a plea for prevention.

We reviewed the coroners records of all fatal bicycle accidents occurring in children (aged 0 to 15 years) in Ontario (pediatric population, 2,007,230) between January 1, 1985 and December 31, 1989. The injuries sustained were documented and scored with anatomical injury scores (Abbreviated Injury Score 1985 and Injury Severity Score) and categorized as unsurvivable or survivable. The causes and circumstances were documented from police accident reports. Eighty-one deaths resulted from bicycle accidents, an annual mortality rate of 1.44 deaths per 100,000 children per year. In 74 (91%) of these cases the injuries were deemed unsurvivable, 89% of which were head injuries. Seventy-eight (96%) of the deaths resulted from collisions with motor vehicles. No victim was wearing a helmet at the time of injury. In 70% of the deaths, the cyclist was considered to have caused the collision, either because of a violation of a road traffic law or poor road sense. These findings suggest that more emphasis should be placed on primary and secondary injury prevention by such methods as bicycle safety education for children and the promotion of bike helmet use. In addition, in view of the high incidence of unsurvivable head injury, the introduction of legislation requiring the use of protective helmets should be considered.

Preventable pediatric trauma deaths in a metropolitan region

All pediatric trauma deaths occurring in metropolitan Toronto (population, 2.2 million) in 1986 were analyzed from the regional coroners records. Injuries sustained were scored using the Abbreviated Injury Scale (1985; AIS) and Injury Severity Score (ISS). Victims with injuries graded AIS 6 (any region), AIS 5 head/neck (excluding acute epidural hematoma), or ISS greater than 59 were deemed unsalvageable. All other injuries were considered survivable and the deaths from them preventable. Use of these objective criteria indicated that 8/38 of the children (21%) who died from trauma had survivable injuries. Since in three cases medical aid was not sought because of social circumstances, 5/38 (13%) was considered a realistic estimate of preventable death rate (PDR). These results suggest that when objective criteria are used, the PDR in pediatric trauma may be less than that reported in adult trauma victims. Defining the PDR on the basis of objective criteria may prove useful in the conduct of further studies of this kind and permit valid comparisons to be made.

Preventable Pediatric Trauma Deaths in Ontario: A Comparative Population-based Study

INTRODUCTION Previously, we demonstrated that 21% of pediatric (<16 years) trauma deaths in the Province of Ontario during the period 1985 to 1987 were potentially preventable. Since then many trauma system changes have occurred including field triage, designation of trauma centers, and improved injury prevention. This study aims to examine the current preventable trauma death rate in our system using identical methodology to our previous study. METHOD The records of all children (<16 years) who died in Ontario from 2001 to 2003 after blunt or penetrating trauma were obtained from the Chief Coroner and compared with those in our previous report. In both series, we excluded cases where care was not sought and all deaths due to asphyxia. Deaths were considered unpreventable if the Injury Severity Score, based on Abbreviated Injury Scale 1985, was >59; or if there was a head injury that received an Abbreviated Injury Scale score of 5 with the exception of isolated extra-axial hematomas. RESULTS Eleven preventable deaths were identified. The preventable death rate was 7%, a significant decline from the 21% previously identified (p < 0.001; relative risk reduction for preventable death, 68% [95% confidence interval, 42-83%]; number needed to treat, 7). CONCLUSION There has been a threefold decline in the preventable death rate, which we believe is related to improvements in the trauma system. We estimated that, for every seven deaths from fatal injuries, system changes between the two study periods eliminated one preventable death.

Reduced tracheal growth after reconstruction with pericardium

Four groups of piglets were used to test the use of pericardium and periosteum as free grafts in the repair of full thickness cervical tracheal defects. Pericardium provided an airtight, rapidly healing graft, but did not give sufficient structural rigidity to prevent narrowing and growth failure at the graft site. Composite grafts of pericardium and periosteum were also unsatisfactory, in that the periosteum failed to produce enough bone to prevent collapse of the graft. Since previous studies have shown that periosteal grafts result in good bone formation when applied alone or as an extramucosal support, it is concluded that the osteogenic potential is dependent on the available blood supply and speed of revascularization. It appears that the presence of pericardium in the composite grafts may have inhibited this property.

Pediatric blunt and penetrating trauma deaths in Ontario: a population-based study

PURPOSE The purpose of the study was to describe the mechanisms of injury and causes of death in children dying in a modern, integrated trauma system. METHOD Records of all children (<16 years of age) who died in Ontario from 2001 through 2003 after blunt or penetrating trauma were obtained from the Chief Coroner. Demographics and the nature and causes of injury and the causes of death were recorded. Estimates of the mortality rate were determined using census data. RESULTS There were 234 injury deaths (222 blunt, 12 penetrating) over the 3 years. Thirty (13%) resulted from intentional injury. The median age was 10 (range, 0-15.9) years; 62% were male. Sixty-eight percent resulted from incidents involving motor vehicles (passenger, pedestrian, or cyclist). Most (74%) died at the scene; only 5% survived for more than 24 hours. Devastating craniocervical injury (Abbreviated Injury Scale 5 or 6) was present in 84% and was the only life-threatening injury in 40%. The annual mortality rate averaged 3.2 per 100,000 children. CONCLUSIONS In a modern, integrated trauma system, most pediatric injury deaths occur at the scene from severe head injuries. In this population, strategies to reduce the death rate from pediatric trauma must focus on primary and secondary injury prevention.

Thoracic vascular injuries : a post mortem study

We reviewed the coroners records for all pediatric (less than 16 years of age) trauma fatalities in Ontario (population, 9.5 million) for the period January 1, 1985, through December 31, 1987. Twenty-six (8%) of the 322 cases for which complete autopsy data were available had major thoracic vascular injuries. Twenty-five deaths occurred within 6 hours of injury. The majority of patients had at least one AIS 6 injury. The aorta was the most frequently injured vessel. Major thoracic vascular injuries are more common among children than previous reports suggest, probably because they are rapidly fatal. Many deaths occur in the field, at local hospitals, or in transit before the patient can reach a trauma center. Efforts to reduce the number of total thoracic vascular injuries should focus on primary and secondary prevention.

Immune competence in necrotizing enterocolitis

It has been suggested that defective immune competence may be an etiological factor in neonatal necrotizing enterocolitis (NEC). In the present study eight infants with NEC underwent in vitro studies of cellular and humoral defense mechanisms. No significant abnormalities in immune competence were identified between children with NEC and age-matched patients with and without infection. The results do not support the hypothesis that NEC is due to defective immune mechanisms.