Paediatric trauma in Spain: a report from the HUGM Trauma Registry

OBJECTIVES

To analyse the characteristics of the infant population suffering trauma in our setting. To evaluate the importance of the different aetiological mechanisms. To study the pre- and intra-hospital management of these children. To describe the relative significance of the different lesions. To establish the magnitude of paediatric trauma as a social problem in terms of morbidity and mortality.

MATERIAL AND METHODS

From January 1995 to April 2002, a total of 2633 children admitted to our Centre (Hospital Universitario Gregorio Maranon) after suffering some type of injury were included in our Trauma Register. 108 variables have been analysed, including the identification of the patient, type, site and mechanism of the accident, pre-hospital care, transport, complete evaluation on admission, indices of injury severity, diagnostic tests, lesions, treatments performed and morbidity and mortality.

RESULTS

The accidents were more frequent in boys than in girls (68.5 % versus 31.5 %). The predominant age group was the 12 - 15 year old group (36.8 %). There was a higher frequency of accidents in the street (37.2 %) than at home (19.4 %) or at school (13.8 %). The most frequent mechanism was a fall (35.6 %), followed by road traffic accidents (23.7 %). On admission, 14.7 % of the children had a Paediatric Trauma Score (P.T.S.) < or = 8 (n = 388). 3.8 % were considered severe multiple trauma patients, presenting an Injury Severity Score (I.S.S.) > or = 15 (n = 101). 4.2 % of the children required intensive care. The most frequent lesions were those of the locomotor system (58.1 %) and head injuries (34.9 %). Some type of surgical or orthopaedic procedure was performed under general anaesthesia in 1522 patients (57.8 %). The mean length of stay was 4.4 days (range 1 - 214 days). Sequelae of some form were detected in 36.4 % of the patients over 3 years of age. The total mortality was 0.5 % (n = 13), being 12.8 % in the group of patients with an I.S.S. > or = 15.

CONCLUSIONS

Analysis of the data in our Registry has helped us to define the characteristics of the paediatric trauma population in our setting, to monitor the management of trauma in the different care levels and to develop prevention programmes. It has also enabled us to compare the results with those of other centres in terms of morbidity and mortality with the aim of identifying and correcting any possible deficiencies in the care system.

SLC11A1 promoter gene polymorphisms and fibrosis progression in chronic hepatitis C

BACKGROUND AND AIMS

The solute carrier family 11 member 1 (SLC11A1) gene (formerly Nramp1) encodes for the protein solute carrier family 11, member 1. It affects susceptibility and clinical outcome of autoimmune and infectious diseases. We investigated the possible role of the functional polymorphism located in the promoter region of SLC11A1 and tumour necrosis factor (TNF) genes in the progression of fibrosis in chronic hepatitis C.

METHODS

A total of 242 Caucasian Spanish patients with biopsy proven chronic hepatitis C and 194 healthy control subjects were genotyped for SLC11A1 and TNF promoter polymorphisms.

RESULTS

No significant differences in the distribution of frequencies among patient and control groups were observed. The SCL11A1 homozygous 2/2 genotype was rarely detected among patients showing advanced fibrosis (2/82; 2.4%) but was highly represented in those with mild fibrosis (29/160; 18.1%; odds ratio (OR) 8.85 (95% confidence interval (CI) 1.9-55.2, p(c) = 0.002). In patients carrying allele 3 of SLC11A1, the presence of -238 TNF A/G was associated with advanced fibrosis (14/26 (53.8%) v 68/216 (31.4%); OR 2.53 (95% CI 1.03-6.23); p = 0.02).

CONCLUSIONS

SLC11A1 gene promoter polymorphism could influence fibrosis progression in chronic hepatitis C in that the homozygous genotype 2/2 exerts a protective effect against cirrhosis development. Also, the combination of TNF -238 A/G and the presence of allele 3 is conducive to progression to pre-cirrhotic or cirrhotic stages of the disease.

[Events related with injury severity in pediatric multiple trauma]

AIMS

Epidemiological analysis of main factors affecting multiple trauma in children in our environment.

METHODS

We reviewed the data collected from the patients (n = 2.166) admitted to our hospital because of trauma and included in our Registry from January 1995 to December 2000. Among this group 79 patients were considered severely injured trauma patients according Injury Severity Score (ISS) (ISS > 15) and selected for the study. Statistical analysis was done using chi2 and Student t test, p values under 0.01 were considered significant.

RESULTS

Group gender distribution was 49 males and 30 females, age average was 9.7 years (range 0-15 years) Traffic related injuries were the leading cause of trauma in this group (77,2%). Initial triage by using the Pediatric Trauma Score allowed identifying the injury severity in 73,4% of patients (58 children obtained a PTS < or = 8). In 32,9% of the cases the patient was in coma at admission in the Emergency (Glasgow Coma Scale < or = 8, n = 26). ISS average was 23.4 (range 16-75). Most patients suffered from multiple injuries (87,3%), average of injuries number was 4,7 (range 1-9). The most frequent trauma localization was cranial trauma. Admission in the intensive care unit was necessary in 65,8% of patients, and any kind of surgical procedure was done in 35,4%. Average length of stay was 17,1 days (range 0-214 days). Injury severity was higher in automotive patients without restraining systems (I.S.S. average 27,2, mortality 16,6%). Overall mortality was 11,4% (n = 9), and 94.3% of patients presented any functional or anatomic disability.

CONCLUSIONS

Traffic related injuries are the main cause of multiple trauma in children. The severity and high mortality of these injuries make imperative polytonal education systems and the use of restraining devices.

[Impact of formation programs in initial management of injured children]

INTRODUCTION

In 1997 we developed the "Pediatric Trauma Life Support Course"applied to every one who provide care for the pediatric trauma patient. Since November 1997 until December 2000, 14 courses were imparted inside of the "Comunidad de Madrid" with total number of 289 students. Thirty-eight students have been people who worked in the prehospital area inside of our Community. The aim of this paper is to determinate the possible impact of these Courses in the prehospital management of the pediatric trauma patient.

MATERIAL AND METHODS

We reviewed the Pediatric Trauma Registry inputs of our hospital since January 1995 until December 2000. A total number of 2166 patients required admission in our hospital after the injuries. 495 patients which moved to our Institution by medical people and a special transport (ambulance/medical van) were enrolled. The patients were classified into two groups. In the first group were included the children admitted between 1995 to 1997 (group 1, n = 232), before we had applied our Courses and in the second group, the patients admitted between 1998 to 2000 (group II, n = 263), after The Pediatric Trauma Life Support Course was conducted. Both groups seems to be equal if we compare the age, sex and severity of the injuries. We analysed the infant orotracheal intubation in a coma patient, gastric intubation in the several trauma patient, vascular access and apply a semirigid cervical collar into a head injury. If we think that the application of these manouvers will be a good quality index of the management of these patients in the prehospital area, we compare the index of application of these variables according to the years before and after the Courses were imparted. For this pourpose we used the X2 test shows significant differences within both groups if p < 0.05.

RESULTS

All paramethers analyzed were better in group II than in group I (p < 0.05).

CONCLUSIONS

The results of this paper shows that the use of this program for the management of the pediatric trauma patient is going well and the assessment is doing better than few years before.

Complement component C7 deficiency in a Spanish family

Different genetic mutations have been described in complement component C7 deficiency, a molecular defect which is clinically associated with an increased susceptibility to neisserial recurrent infections, although some cases remain asymptomatic. In this work we report the genetic bases of C7 deficiency in one Spanish family. Exon-specific PCR and sequencing revealed a novel point mutation at nucleotide 615 (exon 6) leading to a stop codon (UGG to UGA) in the patient, his mother, and sister. This transversion causes the premature truncation of the C7 protein (W183X). Additionally, we detected a missense mutation at position 1135 (exon 9) located in the first nucleotide of the codon GGG (CGG), resulting in an amino acid change (G357R) in the patient, his father, as well as in his sister. This latter mutation had been previously described in individuals from Moroccan Sephardic Jewish ancestry. Since both heterozygous mutations were found in the patient as well as in his asymptomatic sister, we analyse other meningococcal defence mechanisms such as polymorphisms of the opsonin receptors on polymorphonuclear cells. Results showed that the patient and his sister bore identical combinations of FcgammaRIIA-H/R131 and FcgammaRIIIB-NA1/2 allotypes. Our results provide further evidence that the molecular pathogenesis of C7 deficiency as well as susceptibility to meningococcal disease are heterogeneous, since different families carry different molecular defects, although many of the C7 defects appear to be homogeneous in individuals from certain geographical areas. The missense mutation G357R would make an interesting topic of analysis with regard to meningococcal disease susceptibility in the Spanish population.

FcgammaRIIA, FcgammaRIIIA and FcgammaRIIIB polymorphisms in Spanish patients with systemic lupus erythematosus

Linkage studies on human families suggest that receptors for the Fc fragments of immunoglobulin G (IgG) (FcgammaRs) could be implicated in the susceptibility to, or the progression of, some autoimmune diseases. In this work we analyse the possible role of polymorphic variants of FcgammaRIIA, FcgammaRIIIA and FcgammaRIIIB genes in the susceptibility to systemic lupus erythematosus, the prototype systemic autoimmune disease. A total of 276 Spanish patients (34 male and 242 female) with systemic lupus erythematosus were included in this cross-sectional study. The FcgammaRIIA-131, FcgammaRIIIA-176 and FcgammaRIIIB-NA1/NA2 polymorphisms were investigated in the patient group as well as in 194 ethnically matched controls using polymerase chain reaction-amplification refractory mutation system (PCR-ARMS). Statistical comparisons of genotype frequencies were performed using the chi2 test. In the case of the FcgammaRIIIB-NA1/NA2 polymorphism, an increase in the frequency of homozygous NA2/NA2 in patients was found (61.2 vs. 51.0%; P = 0.03; OR = 1.5; 95% CI = 1.03-2.24), as well as a decrease in the frequency of the NA1/NA2 genotype (28 vs. 38.7%; P = 0.02; OR = 0.6; 95% CI = 0.41-0.92). These associations were independent of patient gender and HLA-DRB1 specificities. With respect to the FcgammaRIIA-131 and FcgammaRIIIA-176 polymorphisms, no differences were found between patients and controls. Patient stratification according to their lupus-related nephritis status gave similar genotypic distribution patterns in both disease categories in all the cases.

Association of NRAMP1 promoter gene polymorphism with the susceptibility and radiological severity of rheumatoid arthritis

The natural resistant-associated macrophage protein 1 (NRAMP1) has been proposed as a candidate gene for the susceptibility to autoimmune diseases. In this study, the possible role of the functional polymorphism located at the promoter region of NRAMP1 gene in the susceptibility and clinical outcome of rheumatoid arthritis (RA) was investigated. A total of 141 Spanish RA patients and 194 controls previously typed for HLA-DRB1* were genotyped for the NRAMP1 polymorphism. No significant differences in the distribution of frequencies among RA patients and controls were observed. Nevertheless, when patients and controls were stratified according to their HLA shared epitope (SE) status, an increase of 2/2 genotype among SE-negative (SE-) patients with respect to SE- controls was observed (23% vs 7%, OR = 3.74, 95% CI 1.31-10.72). In addition, the possible role of this polymorphism in the clinical course of RA was investigated in a subgroup of 82 patients who were prospectively followed during a mean of 9 years. After follow-up, an increase of patients with the homozygous 2/2 genotype was detected among those with severe small joint radiological involvement: 73% of patients 2/2 had a severe form in contrast to 37% of patients with the genotype 2/3 and 30% of patients bearing 3/3 OR = 5.45, 95% CI 1.14-34.24). In conclusion, NRAMP1 gene promoter polymorphism could influence the radiological severity of rheumatoid arthritis and disease susceptibility, particularly in individuals lacking HLA-linked risk factors.

[Results of using botulism toxin in the treatment of spasmodic dysphonia]

Spasmodic Dysphonia (SD) is a dystonia involving laryngeal musculature thus causing a characteristic voice disorder. Two main types of SD have been described. The adductor type is the commonest and it is characterized by a strain-strangle, choked voice. The abductor type can be distinguished from the previous one by episodes of a blown and whispering voice, interrupting speech. Botulism toxin (BTX) has demonstrated to be the most effective treatment for this condition. Thirty patients diagnosed of SD (twenty-nine adductor type/one abductor type) were included. Their degree of dysphonia was evaluated using both functional and visual-analogue scales. They were treated with BTX vocal cord injections using a percutaneous technique under EMG guidance. Improvements up to a 100% of the normal vocal function were obtained, with an average of 82% in the adductor type. The adverse effects were mild and transient. Hypophonia affected 61.3% of patients lasting an average of 11.3 days. Dysphagia was reported in 44.1% of cases lasting an average of 5.8 days.

Association of the CTLA4 3' untranslated region polymorphism with the susceptibility to rheumatoid arthritis

Cytotoxic T-lymphocyte antigen 4 (CTLA4) gene polymorphism located in the 3' untranslated region (UTR) was investigated in 141 Spanish patients (38 men and 103 women) with rheumatoid arthritis (RA) and in 194 ethnically-matched healthy controls. Twenty alleles having different numbers of (AT) repeats (from 7 to 32) were found in this population. (AT)7 and (AT)16 were the most frequent alleles, and accounted for almost two-thirds of the allelic frequency in the control population. Consequently, alleles were assigned as L (large: 16 or more AT repeats) or S (short: less than 16 AT repeats). When the L/S distribution in patients and controls were compared, an increase of L alleles was observed among patients (49.9% vs. 39.7%; p = 0.02; p(c) = 0.04, odds ratio [OR] = 1.46; 95% confidence interval [CI], 1.06-2.01). Hence, the frequency of S alleles was decreased among patients (51.1% vs. 60.3%; p = 0.02; p(c) = 0.04; OR = 0.69; 95%CI, 0.50-0.95). Moreover, a statistically significant decrease in the frequency of S/S individuals was observed among RA patients (27.7% versus 40.7%; p = 0.01; p(c) = 0.03; OR = 0.56; 95%CI, 0.34-0.91). These differences were irrespective of the HLA "shared epitope" (SE) status, and were observed similarly among SE+ as well as among SE- patients. After combining these data with other reported previously by us, from studies of CTLA4 49 (A/G) and -318 (C/T) polymorphisms, we conclude that the strongest association between CTLA4 gene polymorphisms and RA susceptibility occurs with the 3' UTR polymorphism.

MCP-1 promoter polymorphism in Spanish patients with systemic lupus erythematosus

The possible role of the functional polymorphism located in the regulatory region of the monocyte chemoattractant protein-1 (MCP-1) gene in the susceptibility to systemic lupus erythematosus (SLE) was investigated. Two hundred and seventy-six SLE patients (among them, 99 with lupus nephritis and 55 with cutaneous vasculitis) and 194 ethnically matched healthy controls were included in the study. Genotyping for -2518 (A/G) MCP-1 gene polymorphism was performed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis. No association between -2518 (A/G) MCP-1 polymorphism and susceptibility to SLE nor to lupus nephritis was found. However, a significant increase in the frequency of genotype AG and a decrease in the frequency of genotype AA were found among patients with cutaneous vasculitis (51% of AG vs. 32% in individuals without cutaneous vasculitis; P=0.008, OR=2.2, 95% CI: 1.18-4.25; and 47% of AA vs. 64%; P=0.03, OR=0.5, 95% CI: 0.27-0.96, respectively). These results indicate an association between the presence of G at position -2518 in the MCP-1 promoter region and the presence of cutaneous vasculitis among patients with SLE. This polymorphism does not seem to influence the susceptibility to SLE nor the appearance of lupus nephritis. Further studies are necessary in order to elucidate the role of this polymorphism in the pathogenesis of other inflammatory autoimmune diseases.

Effects of genitofemoral nerve transection on copulatory behavior and fertility in male rats

Selective transection of peripheral nerves that innervate the pelvic region results in the alteration of some aspects of copulatory behavior, including seminal plug weight. Both branches of the genitofemoral nerve primarily innervate the cremaster muscle although the genital branch has a wide distribution in the cremasteric sac. Thermoregulation of spermatogenesis and the mechanical event of ejaculation largely depend on cremaster contractility. In this study, we analyzed the effects of bilateral transection of the genitofemoral nerve on male copulatory behavior and on fertility. Sexually experienced adult male rats were submitted to sexual behavior tests before and after surgical transection of the genitofemoral nerve. Tests were made four times before and on Days 9, 12, 15, 18 and 21 after surgery, and seminal plug weight was also analyzed. In addition, fertility was tested using two different approaches: by allowing the male to ejaculate once in an estrous female or keeping the male with three females during 15 days. Results showed that there were no differences in any of the copulatory parameters, including seminal plug weight. Regarding fertility, both procedures showed that the ability to induce pregnancy was significantly diminished in the neurectomized males tested at different times after surgery. These results support the notion that genitofemoral nerve regulation of fertility via contraction of the male cremaster muscle is an important factor in reproduction in rats.

[Sinonasal intestinal-type adenocarcinoma: report of 7 cases]

The intestinal-type adenocarcinoma of the nasal cavity and paranasal sinuses are uncommon tumors, with less than 4% of the total of malignancies of this region. They have histological similitudes with the glandular estructure of the intestinal mucosa. In some aspects they are similar to others tumors of this area, symptoms, an etiological relation with the exposure to wood dust ... but they have differences in the local aggressivity, this is important for the tractament, evolution and survival. The authors present a revision about clinic characteristics, diagnostic and tractament of seven cases of nasosinusal intestinal type adenocarcinoma.

[New approach in the surgical treatment of the urogenital sinus]

The urogenital sinus is an embriological anomaly which consists on a common channel from the urethra and vagina. The major incidence is produced in the congenital adrenal hyperplasia's context. In certain occasions it can be associated to an imperforate anus, then the malformation is called a cloacal defect. There are multiple surgical techniques to correct this malformation and different therapeutical approaches (without surgery, surgery at one or various times, early or delayed surgery) being the newest one the total urogenital mobilization. The purpose of this work is to reflect our experience with this technique. We present seven girls with urogenital sinus (3 with congenital adrenal hyperplasia, 2 with a cloacal defect, and the other 2 associated to ambiguous genitalia). Five patients were operated in the first year of life. The outcome has been favorable, and the cosmetic and functional results have been very good. The surgical technique consists on posterior sagittal incision, it can be done transanorectal if necessary, the urethrovaginal union is achieved and both structures are mobilized together, connecting them to the perineum, as a single unit. We believe that the total urogenital mobilization is actually the surgical technique to be chosen in every of urogenital sinus, for being easier, allowing early realization (girls under 1 year old), correcting simultaneously other anomalies, reducing the complications (urethrovaginal fistula, vaginal structure, or acquired vaginal atresia); and the result is excellent.

[Ethmoidal metastasis of renal adenocarcinoma]

The sinonasal tract and, more specifically, the ethmoid sinus, are uncommon sites for metastatic tumors. Fewer than 100 cases have been reported in the world literature. We report the case of a 65-year-ol woman who underwent nephrectomy and adrenalectomy for renal cell carcinoma (hypernephroma) with adrenal metastasis. Four months later the patient was seen for repeated epistaxis and nasal obstruction, which was diagnosed as ethmoidal metastasis of renal adenocarcinoma in a second biopsy. The second metastasis was removed by lateral rhinotomy but recurred six months later. Palliative surgery was performed and the patient died eight months later from brain metastases. Therapeutic strategies for metastatic nasal tumors are reviewed.

[Otoneurological manifestations of Lyme's disease]

Infection with Borrelia burgdorferi is responsible for Lyme disease, an uncommon disorder in our country. It should be stressed that any of the neurologic manifestations of this disease may occur alone and may be the presenting manifestation of the illness. Several reports suggest that 1/4 of idiopathic Bell's palsies can be associated with this infection and in Europe is the most common cause of childhood facial nerve paresis. The same disease has been related to sudden deafness and vertigo cases. For its important therapeutic and prognostic implications the diagnosis of a Lyme disease must be taken into account in every case of peripheral facial nerve palsy, specially in children, in bilateral or recurrent cases and in those cases associated to other cranial neuritis or general manifestations.

Lack of association of MICA transmembrane region polymorphism and Behçet's disease in Spain

We have analyzed the distribution of the major histocompatibility complex (MHC) class I chain-related gene A (MICA) transmembrane alleles among 58 Spanish patients with Behçet's disease (BD) and in 194 ethnically matched healthy controls. The study included the characterization of A4, A5, A5.1, A6 "new" and "old" and A9 MICA-TM alleles using polymerase chain reaction. As previously reported, the serological B51 specificity was increased among this BD patient group (36.25% vs. 19.6% in controls; P=0.009; OR=2.33). The MICA-TM alleles A6 ("new" and "old"), in linkage disequilibrium with HLA-B51 and HLA-B14 respectively, were only slightly increased among patients (70.7% vs. 61.3% in controls; P=NS). We conclude that, in contrast to previous finding reporting a strong association of MICA-TM genes and Behçet disease in Japanese patients, in our population HLA-B51 is more closely associated to Behçet susceptibility than MICA-TM genes. Finally, our data show that in Spain, as occurs in other populations, some MICA-TM alleles exhibit strong linkage disequilibrium with certain alleles of the HLA-B locus.

[Psammomatoid ossifying fibroma. Apropos a case]

A 41-year-old woman had a left palatal tumor diagnosed as psammomatoid ossifying fibroma. This tumor is a rare subtype of benign fibro-osseous craniofacial lesion that occurs mainly in women, younger age groups, and the sinonasal tract. It has distinctive histomorphological features. The tumor is slow-growing but tends to be locally aggressive and to destroy adjacent anatomic structures. Surgical excision with broad margins is the treatment of choice.

Reflex excitability of facial motoneurons at onset of muscle reinnervation after facial nerve palsy

We studied 18 patients with complete unilateral denervation of the facial muscles after idiopathic facial nerve palsy to determine whether motoneuronal excitability is enhanced in the few motor units that are active at onset of muscle reinnervation. The study was carried out between 75 and 90 days after the facial nerve lesion. We used two needle electrodes to record simultaneously the spontaneous and voluntary activity of the orbicularis oris (OOris) and orbicularis oculi (OOculi) muscles, as well as the responses to ipsilateral and contralateral facial and supraorbital nerve stimuli. All patients showed involuntary firing of motor unit action potentials (MUAPs) in at least one of the muscles. Synkinetic activation of motor units in the OOris was induced by spontaneous blinking in all patients, and by inhalation and swallowing in some. Electrical stimulation of the ipsilateral facial nerve induced a direct M response in only 4 patients. In contrast, long-latency reflex responses were induced in both muscles by electrical stimulation of ipsilateral and contralateral facial and supraorbital nerves in all patients, at latencies ranging between 44 and 132 ms. The shape of such MUAP reflex responses was the same as that of the MUAPs seen to fire at rest. These findings provide evidence of enhanced excitability of facial motoneurons in our patients. Such hyperexcitability may be partly responsible for the postparalytic motor dysfunction syndrome that occurs after facial palsy with severe axonal damage.

The anticancer drug adriamycin interacts with the human erythrocyte membrane

Adriamycin is an aminoglycosidic anthracycline antibiotic widely used in the treatment of cancer. Increasing reports point to the involvement of cell membranes in its mechanism of action. The interaction of adriamycin with human erythrocytes was investigated in order to determine the membrane binding sites and the resultant structural perturbation. Electron microscopy revealed that red cells incubated with the therapeutical concentration of the drug in human plasma changed their discoid shape to both stomatocytes and echinocytes. According to the bilayer couple hypothesis, this means that adriamycin was incorporated into either the inner or outer leaflets of the erythrocyte membrane. To explain this unusual result, the drug was incubated with molecular models. One of them consisted of dimyristoylphosphatidylcholine (DMPC) and dimyristoylphosphatidylethanolamine (DMPE) multilayers, representative of phospholipid classes located in the outer and inner leaflets of the erythrocyte membrane, respectively. X-ray diffraction showed that adriamycin interaction perturbed the polar head and acyl chain regions of both lipids. Fluorescence spectroscopy on another model, consisting of DMPC large unilamellar vesicles (LUV), confirmed the X-ray results in that adriamycin fluidized its hydrophobic moiety. It is concluded that adriamycin incorporates into both erythrocyte leaflets affecting its membrane structure.