Objective: The pediatric Glasgow coma scale (pGCS) is a consciousness score that, although widely applied, requires skill to apply. The AVPU scale uses four simple categories (Alert; Verbal response; response to Pain; Unresponsive), but has not been studied in a large pediatric population. We compared the performance of the AVPU and pGCS scales in a large pediatric cohort in an acute, prehospital setting. Methods: In a six-month-long prospective cohort study, AVPU and pGCS scores were determined by emergency physicians in children less than 10 years of age at their first prehospital encounter. Results: We included 302 children (median age 2.3 years) with a broad spectrum of diagnoses. Data were complete for 287 children. AVPU and pGCS scores showed good a correlation in the extreme categories A and U (positive predictive values of 98% and 100%, respectively). Corresponding pGCS scores for each AVPU category were as follows: 11–15 for A; 5–15 for V; 4–12 for P; and 3–5 for U. The positive predictive value to detect patients with pGCS ≥ 8 for AVPU category V was 100%. Conclusions: We demonstrated good correlation of simple and fast consciousness AVPU scoring to the standard pGCS in a large cohort of pediatric patients in a prehospital setting. The AVPU category “V” identifies patients with a pGCS of or exceeding 8 and, therefore, identifies children at low risk requiring more invasive procedures or intensive care treatment. Key words: Glasgow coma scale (GCS); Alert-verbal-pain-unresponsive-score; AVPU-score; consciousness assessment; children, pediatric emergency

It is difficult to predict the risk of mortality in necrotizing enterocolitis (NEC). This study aimed at identifying risk factors for severe NEC (Bell stage III) and mortality in preterm children with NEC. In this multicenter retrospective study, we analyzed multiple data from 157 premature children with confirmed NEC in the period from January 2007 to October 2018. We performed univariate, multivariate, stepwise logistic regression, and receiver operator characteristics (ROC) analyses. We were able to demonstrate that low Apgar scores (notably at 1′ and 5′), low hemoglobin concentration (Hgb), and high lactate level at disease onset and during disease correlated with NEC severity and mortality (P < 0.05, respectively). Severe NEC was related to congenital heart disease (CHD — OR 2.6, CI95% 1.2–5.8, P 0.015) and patent ductus arteriosus (PDA — OR 3.3, CI95% 1.6–6.9, P 0.0012), whereas death was related to the presence of PDA (OR 5.5, CI95% 2.3–14, P < 0.001).Conclusion: Low Apgar scores, low Hgb, high lactate levels, and the presence of CHD or PDA correlated with severe NEC or mortality in children with NEC. What is Known:• It remains difficult to predict which infant that suffers from necrotizing enterocolitis at risk of death.• Several clinical and laboratory parameters tools to predict fatal outcome in NEC. What is New:• The following laboratory parameters were associated with the risk of death from NEC: Hemoglobin concentration, base excess and lactate level.• The following clinical variables were associated with the risk of death from NEC: Apgar scores, as well as the presence of congenital heart disease and patent ductus arteriosus.

In the past TIP urethroplasty became a preferred technique for distal hypospadias repair, and subsequently gained worldwide popularity and acceptance. The procedure gives good functional results and a cosmetic appearance that is superior to that obtained by flip-flap or onlay preputial flap repairs. In addition, this procedure is associated with a fairly low rate of complications. From 06/2000 to 04/2004 we performed 100 primary TIP urethroplasties in patients with distal hypospadias. The age of the patients at the time of surgical correction was 16 months to 10 years with a mean of 41.4 months. All patients underwent the procedure under general anesthesia supplemented by additional pain management with a penile block anesthesia or caudal anesthesia. The surgical technique is described. During follow-up (23.5 months) we observed 2 types of complications: formation of a urethrocutaneous fistula (5 pts., 5 %) and formation of meatal stenosis (17 pts., 17 %) with a steady decrease with no stenosis formation in the last 8 months of this series. A key point might be the length of the dorsal incision of the urethral plate which should not touch the dorsal lip of the anticipated neomeatus. There were no other complications, and the cosmetic results were good in all cases. Dans le passé l'urétroplastie de type TIP est devenue la technique de référence pour la réparation des hypospadias distaux et est devenue à travers le monde extrêmement populaire. Le procédé donne de bons résultats fonctionnels, une apparence esthétique qui est supérieure à celle obtenue par les lambeaux ou les réparations de type lambeau préputial Onlay. De plus, ce procédé est associé à un très faible taux de complications. De Juin 2000 à Avril 2004, nous avons réalisé 100 urétroplasties de type TIP chez des patients avec des hypospadias distaux. L'âge des patients au moment de la correction chirurgicale était de 16 mois à 10 ans avec une moyenne de 41,4 mois. Tous les patients ont subi l'intervention sous anesthésie générale associée à un management de la douleur par un bloc pénien ou une anesthésie caudale. La technique chirurgicale est décrite. Dans les follow-up (23,5 mois) nous avons observé deux types de complications: l'apparition d'une fistule urétro-cutanée (5 patients/5 %) et l'apparition d'une sténose du méat (17 patients/17 %) avec une diminution de ce pourcentage dans les huit derniers mois de cette série. Le point-clé doit être la longueur de l'incision dorsale de la plaque urétrale qui ne doit pas toucher la lèvre dorsale du néo-méat. Il n'y a eu aucune autre complication et les résultats esthétiques sont bons dans tous les cas. La uretroplastia TIP se ha convertido en la técnica preferida para la reparación del hipospadias distal y ha ganado una popularidad y aceptación muy amplias. El procedimiento da buenos resultados funcionales y un aspecto cosmético superior al obtenido por el flip/flap o por los colgajos prepuciales incluidos. Además este procedimiento se asocia con una baja tasa de complicaciones. Entre junio del 2000 y abril del 2004 hemos realizado 100 uretroplastias primarias TIP en pacientes con hipospadias distal. La edad de los pacientes en el momento de la operación fue de entre 16 meses y 10 años con una media de 41,4 meses. Todos los pacientes fueron operados bajo anestesia general con bloqueo peneano adicional y anestesia caudal. Se describe la técnica quirúrgica. En el seguimiento (23,5 meses) observamos dos tipos de complicaciones: fístula uretrocutánea (5 pacientes, 5 %) y estenosis meatal (17 pacientes, 17 %) con una disminución progresiva a lo largo de la serie y sin complicaciones en los últimos 8 meses. El punto clave es la longitud de la incisión dorsal de la placa uretral que no debe tocar el labio dorsal del neomeato previsto. No hubo otras complicaciones y los resultados cosméticos fueron buenos en todos los casos. Die „TIP Urethralplastik“ ist in den letzten Jahren die bevorzugte Korrekturtechnik distaler Hypospadien geworden. Mit dieser Methode sind gute funktionelle Ergebnisse zu erzielen, und der ästhetische Aspekt ist dem nach einer Mathieu-Urethralplastik oder einer Duckett-Island-Flap-Korrektur überlegen. Außerdem hat diese Technik eine relativ niedrige Komplikationsrate. Zwischen 06/2000 und 04/2004 führten wir 100 primäre TIP-Urethralplastiken bei distalen Hypospadien durch. Das Alter der Patienten zum Zeitpunkt der Korrektur lag zwischen 16 Monaten und 10 Jahren bei einem Durchschnitt von 41,4 Monaten. Alle Operationen wurden in Vollnarkose mit zusätzlicher Penisblockanästhesie oder einem zusätzlichen Kaudalblock durchgeführt. Die chirurgische Technik wird beschrieben. In der Nachbeobachtung (23,5 Monate) sahen wir 2 Arten von Komplikationen: eine Fistelbildungsrate von 5 % und die Ausbildung einer Neomeatusstenose in 17 %. In den letzten 8 Monaten haben wir keine Meatusstenose mehr beobachtet. Entscheidend zur Vermeidung der Meatusstenose ist möglicherweise die Länge der dorsalen Inzision der Urethralplatte nach distal. Sie sollte die dorsale Begrenzung des Neomeatus nicht erfassen. Andere Komplikationen sind nicht aufgetreten bei jeweils gutem kosmetischem Ergebnis.

Objectives: The aim of this study was to investigate the relationship between the pressure setting of the ventriculoperitoneal (VP) shunt valve and a magnetic resonance (MR)-based estimate of intracranial pressure (ICP) in children with shunt-treated hydrocephalus without clinical signs of shunt malfunction. Materials and Methods: Institutional review board approval was obtained before the study, and all subjects and/or their legal guardians provided written informed consent. In this prospective study, 15 consecutive patients (median age, 8.25 years; range, 2.2-18.4 years; 6 girls and 9 boys) with shunt-treated hydrocephalus without signs of shunt malfunction were examined with retrospectively gated phase contrast sequences to quantify arterial inflow, venous outflow, and cerebrospinal fluid (CSF) flow to and from the cranial vault. The ratio of the maximal intracranial volume change and the pulse pressure gradient change was used to derive MR-ICP. Spearman Q was used to test for the association of setting of the shunt valve opening pressure and MR-ICP. Results: Shunt valve opening pressure settings and MR-ICP were positively correlated (Spearman rho = 0.64, P < 0.01). Median MR-ICP was 8.67 mm Hg (interquartile range [IQR], 1.59 mm Hg) and median setting of the VP-shunt valve was 6.62 mm Hg (IQR, 1.47 mm Hg). The median MR-ICP was 1.9 mm Hg (IQR, 0.73 mm Hg) higher than the setting of the shunt valve. Conclusion: There is a positive correlation between MR-ICP and VP shunt valve opening pressure setting. The systematically higher assessment of MR-ICP is most likely a result of outflow resistance within the shunt tubing system and well within the known fluctuation rates of VP shunt systems.

Object: Over the past decade, a gravity-assisted valve (GAV) has become a standard device in many European pediatric hydrocephalus centers. Because past comparative clinical outcome studies on valve design have not included any GAV, the authors in this trial evaluated the early results of GAV applications in a pediatric population. Methods: For a minimum of 2 years the authors monitored 169 of 182 hydrocephalic children who received a pediatric GAV at their first CSF shunt insertion (61.5%) or as a substitute for any differential pressure valve (38.5%) at 1 of 7 European pediatric hydrocephalus centers. Outcomes were categorized as valve survival (primary outcome) or shunt survival (secondary outcome). The end point was defined as valve explantation. Results: Within a follow-up period of 2 years, the valve remained functional in 130 (76.9%) of 169 patients. One hundred eight of these patients (63.9%) had an uncomplicated clinical course without any subsequent surgery, and 22 (13%) were submitted to a valve-preserving catheter revision without any further complications during the follow-up period. Thirty-nine patients (23.1%) reached an end point of valve explantation: 13 valve failures from infection (7.7%), 8 (4.7%) from overdrainage, and 18 (10.6%) from underdrainage. Conclusions: Compared with nongravitational shunt designs, a GAV does not substantially affect the early complication rate. Valve-preserving shunt revisions do not increase the risk of subsequent valve failure and therefore should not be defined as an end point in studies on valve design. A significant impact of any well-established valve design on the early complication rate in shunt surgery is not supported by any current data; therefore, this correlation should be dismissed. As overdrainage-related complications have been shown to occur late, the presumed advantages of a pediatric GAV remain to be shown in a long-term study.