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Surgical management of lateral neck abscesses in children: a retrospective analysis of 100 cases
(2023)
Cervical abscesses are relatively common infections in pediatric patients. There is an ongoing debate about the necessity and time point of surgical drainage. The identification of a focus of infection might play an important role in facilitating a therapeutic decision. In a retrospective study, 100 pediatric patients aged 1–18 years who underwent incision and drainage of a lateral cervical abscess at our institution were analyzed. Patients were divided into two groups based on whether a focus of infection could be identified or not. Data collection included patient characteristics, microbiological results, antibiotic regimen, and clinical course. A focus of infection was found in 29% (29/100) of the patients, most frequently in the tonsils. A causative microorganism was found in 75% (75/100) of all patients, with Staphylococcus aureus and Streptococcus pyogenes being the most common pathogens. All patients received an empiric antibiotic therapy in addition to surgery. Antibiotic medication was changed in 31% in both groups (9/29 with a focus of infection and 22/71 without a focus of infection) during therapy. Children without an identified focus of infection generally were younger and had more comorbidities reducing immune response while also showing differences in the pathogens involved. There were no complications associated to surgery or antibiotic therapy in any of the patients involved.
Conclusion: Children with an identified focus of infection show several differences compared to those with isolated lateral abscesses, especially regarding the microorganisms involved. But the focus of infection seems not to have an impact on patient’s outcome.
What is Known:
• Neck abscesses are a relatively common disease in the pediatric population and may cause serious complications.
• Therapy in general consists of intravenous antibiotics with or without surgery.
What is New:
• The focus identification has no impact on patient’s outcome.
• Children with an identified focus of infection show several differences compared to those with isolated lateral abscesses, especially regarding their medical history, age, and the microorganisms involved.
The propounded thesis investigated fear learning including fear conditioning, its generalization as well as its extinction in 133 healthy children and adolescents aged 8 to 17 years. The main goal was to analyze these processes also in the course of childhood and adolescence due to far less research in this age span compared to adults. Of note, childhood is the typical period for the onset of anxiety disorders. To achieve this, an aversive discriminative fear conditioning, generalization and extinction paradigm, which based on the “screaming lady paradigm” from Lau et al. (2008) and was adapted by Schiele & Reinhard et al. (2016), was applied. All probands traversed the pre-acquisition (4 x CS-, 4 x CS+, no US), the acquisition (12 x CS-, 12 x CS+, reinforcement rate: 83%), the generalization (12 x CS-, 12 x GS4, 12 x GS3, 12 x GS2, 12 x GS1, 12 x CS+, reinforcement rate: 50%) and the extinction (18 x CS-, 18 x CS+, no US). The generalization stimuli, i.e. GS1-GS4, were built out of CS- and CS+ in different mixtures on a percentage basis in steps of 20% from CS- to CS+. Pictures of faces of two actresses with a neutral expression were used for the discriminative conditioning, whereby the CS+ was paired with a 95-dB loud female scream at the same time together with a fearful facial expression (US). CS- and GS1-GS4 were never followed by the US. Subjective ratings (arousal, valence and US expectancy) were collected and further the psychophysiological measure of the skin conductance response (SCR). The hypotheses were 1) that underage probands show a negative correlation between age and overgeneralization and 2) that anxiety is positively correlated with overgeneralization in the same sample. ANOVAs with repeated measures were conducted for all four dependent variables with phase (pre-acquisition phase, 1. + 2. acquisition phase, 1. + 2. generalization phase, 1. - 3. extinction phase) and stimulus type
(CS-, CS+, GS1-GS4) as within-subject factors. For the analyses of the modulatory effects of age and anxiety in additional separate ANCOVAs were conducted including a) age, b) the STAIC score for trait anxiety and c) the CASI score for anxiety sensitivity as covariates. Sex was always included as covariate of no interest. On the one hand, findings indicated that the general extent of the reactions (arousal, valence and US expectancy ratings and the SCR) decreased with growing age, i.e. the older the probands the lower their reactions towards the stimuli regardless of the type of dependent variable. On the other hand, ratings of US expectancy, i.e. the likelihood that a stimulus is followed by a US (here: female scream coupled with a fearful facial expression), showed better discrimination skills the older the probands were, resulting in a smaller overgeneralization within older probands. It must be emphasized very clearly that no causality can be derived. Thus, it was only an association revealed between
15
age and generalization of conditioned fear, which is negative. Furthermore, no obvious impact of trait anxiety could be detected on the different processes of fear learning. Especially, no overgeneralization was expressed by the probands linked to higher trait anxiety. In contrast to trait anxiety, for anxiety sensitivity there was an association between its extent and the level of fear reactions. This could be described best with a kind of parallel shifts: the higher the anxiety sensitivity, the stronger the fear reactions. Likewise, for anxiety sensitivity no overgeneralization due to a stronger extent of anxiety sensitivity could be observed.
Longitudinal follow-up examinations and, furthermore, neurobiological investigations are needed for replication purposes and purposes of gaining more supporting or opposing insights, but also for the profound exploration of the impact of hormonal changes during puberty and of the maturation processes of different brain structures. Finally, the question whether enhanced generalization of conditioned fear facilitates the development of anxiety disorders or vice versa remains unsolved yet.
Objectives
To assess the impact of HIIT performed at school, i.e. both in connection with physical education (intra-PE) and extracurricular sports activities (extra-PE), on the physical fitness and health of children and adolescents.
Methods
PubMed and SPORTDiscus were searched systematically utilizing the following criteria for inclusion: (1) healthy children and adolescents (5–18 years old) of normal weight; (2) HIIT performed intra- and/or extra-PE for at least 5 days at an intensity ≥ 80% of maximal heart rate (HR\(_{max}\)) or peak oxygen uptake (VO\(_{2peak}\)) or as Functional HIIT; (3) comparison with a control (HIIT versus alternative interventions); and (4) pre- and post-analysis of parameters related to physical fitness and health. The outcomes with HIIT and the control interventions were compared utilizing Hedges’ g effect size (ES) and associated 95% confidence intervals.
Results
Eleven studies involving 707 participants who performed intra-PE and 388 participants extra-PE HIIT were included. In comparison with the control interventions, intra-PE HIIT improved mean ES for neuromuscular and anaerobic performance (ES jump performance: 5.89 ± 5.67 (range 1.88–9.90); ES number of push-ups: 6.22 (range n.a.); ES number of sit-ups: 2.66 ± 2.02 (range 1.24–4.09)), as well as ES fasting glucose levels (− 2.68 (range n.a.)) more effectively, with large effect sizes. Extra-PE HIIT improved mean ES for neuromuscular and anaerobic performance (ES jump performance: 1.81 (range n.a.); ES number of sit-ups: 2.60 (range n.a.)) to an even greater extent, again with large effect sizes. Neither form of HIIT was more beneficial for parameters related to cardiorespiratory fitness than the control interventions.
Conclusion
Compared to other forms of exercise (e.g. low-to-moderate-intensity running or walking), both intra- and extra-PE HIIT result in greater improvements in neuromuscular and anaerobic performance, as well as in fasting levels of glucose in school children.
Background
Influenza virus infections in immunologically naïve children (primary infection) may be more severe than in children with re-infections who are already immunologically primed. We compared frequency and severity of influenza virus primary and re-infections in pre-school children requiring outpatient treatment.
Methods
Influenza-unvaccinated children 1–5 years of age presenting at pediatric practices with febrile acute respiratory infection < 48 h after symptom onset were enrolled in a prospective, cross-sectional, multicenter surveillance study (2013–2015). Influenza types/subtypes were PCR-confirmed from oropharyngeal swabs. Influenza type/subtype-specific IgG antibodies serving as surrogate markers for immunological priming were determined using ELISA/hemagglutination inhibition assays. The acute influenza disease was defined as primary infection/re-infection by the absence/presence of influenza type-specific immunoglobulin G (IgG) and, in a second approach, by the absence/presence of subtype-specific IgG. Socio-demographic and clinical data were also recorded.
Results
Of 217 influenza infections, 178 were due to influenza A (87 [49%] primary infections, 91 [51%] re-infections) and 39 were due to influenza B (38 [97%] primary infections, one [3%] re-infection). Children with “influenza A primary infections” showed fever with respiratory symptoms for a shorter period than children with “influenza A re-infections” (median 3 vs. 4 days; age-adjusted p = 0.03); other disease characteristics were similar. If primary infections and re-infections were defined based on influenza A subtypes, 122 (87%) primary infections (78 “A(H3N2) primary infections”, 44 “A(H1N1)pdm09 primary infections”) and 18 (13%) re-infections could be classified (14 “A(H3N2) re-infections” and 4 “A(H1N1)pdm09 re-infections”). Per subtype, primary infections and re-infections were of similar disease severity. Children with re-infections defined on the subtype level usually had non-protective IgG titers against the subtype of their acute infection (16 of 18; 89%). Some patients infected by one of the influenza A subtypes showed protective IgG titers (≥ 1:40) against the other influenza A subtype (32/140; 23%).
Conclusions
Pre-school children with acute influenza A primary infections and re-infections presented with similar frequency in pediatric practices. Contrary to expectation, severity of acute “influenza A primary infections” and “influenza A re-infections” were similar. Most “influenza A re-infections” defined on the type level turned out to be primary infections when defined based on the subtype. On the subtype level, re-infections were rare and of similar disease severity as primary infections of the same subtype. Subtype level re-infections were usually associated with low IgG levels for the specific subtype of the acute infection, suggesting only short-time humoral immunity induced by previous infection by this subtype. Overall, the results indicated recurring influenza virus infections in this age group and no or only limited heterosubtypic antibody-mediated cross-protection.
Regular physical activity during childhood and adolescence is associated with health benefits. Consequently, numerous health promotion programs for children and adolescents emphasize the enhancement of physical activity. However, the ActivityStat hypothesis states that increases in physical activity in one domain are compensated for by decreasing physical activity in another domain. Currently, little is known about how physical activity varies in children and adolescents within intervals of one day or multiple days. This systematic review provides an overview of studies that analyzed changes in (overall) physical activity, which were assessed with objective measurements, or compensatory mechanisms caused by increases or decreases in physical activity in a specific domain in children and adolescents. A systematic search of electronic databases (PubMed, Scopus, Web of Science, SportDiscus) was performed with a priori defined inclusion criteria. Two independent researchers screened the literature and identified and rated the methodological quality of the studies. A total of 77 peer-reviewed articles were included that analyzed changes in overall physical activity with multiple methodological approaches resulting in compensation or displacement. Of 40,829 participants, 16,265 indicated compensation associated with physical activity. Subgroup analyses separated by study design, participants, measurement instrument, physical activity context, and intervention duration also showed mixed results toward an indication of compensation. Quality assessment of the included studies revealed that they were of high quality (mean = 0.866). This review provides inconclusive results about compensation in relation to physical activity. A trend toward increased compensation in interventional studies and in interventions of longer duration have been observed.
Recurrent medulloblastomas are associated with survival rates <10%. Adequate multimodal therapy is being discussed as having a major impact on survival. In this study, 93 patients with recurrent medulloblastoma treated in the German P-HIT-REZ 2005 Study were analyzed for survival (PFS, OS) dependent on patient, disease, and treatment characteristics. The median age at the first recurrence was 10.1 years (IQR: 6.9–16.1). Median PFS and OS, at first recurrence, were 7.9 months (CI: 5.7–10.0) and 18.5 months (CI: 13.6–23.5), respectively. Early relapses/progressions (<18 months, n = 30/93) found mainly in molecular subgroup 3 were associated with markedly worse median PFS (HR: 2.34) and OS (HR: 3.26) in regression analyses. A significant survival advantage was found for the use of volume-reducing surgery as well as radiotherapy. Intravenous chemotherapy with carboplatin and etoposide (ivCHT, n = 28/93) showed improved PFS and OS data and the best objective response rate (ORR) was 66.7% compared to oral temozolomide (oCHT, n = 47/93) which was 34.8%. Intraventricular (n = 43) as well as high-dose chemotherapy (n = 17) at first relapse was not related to a significant survival benefit. Although the results are limited due to a non-randomized study design, they may serve as a basis for future treatment decisions in order to improve the patients' survival.
Background
Children with different underlying malignant diseases require long-term central venous access. As for port systems in a pectoral position, peripherally implanted port systems in the forearm revealed high levels of technical and clinical success in adult cohorts.
Objective
To investigate the technical and clinical outcomes of percutaneous central venous port implantation in the forearm in adolescents.
Materials and methods
Between April 2010 and August 2020, 32 children ages 9 to 17 years with underlying malignancy received 35 totally implantable venous access ports (TIVAPs) in the forearm. All venous port systems were peripherally inserted under ultrasound guidance. Correct catheter placement was controlled by fluoroscopy. As primary endpoints, the technical success, rate of complications and catheter maintenance were analyzed. Secondary endpoints were the side of implantation, vein of catheter access, laboratory results on the day of the procedure, procedural radiation exposure, amount of contrast agent and reasons for port device removal.
Results
Percutaneous TIVAP placement under sonographic guidance was technically successful in 34 of 35 procedures (97.1%). Procedure-related complications did not occur. During the follow-up, 13,684 catheter days were analyzed, revealing 11 complications (0.8 per 1,000 catheter-duration days), Of these 11 complications, 7 were major and 10 occurred late. In seven cases, the port device had to be removed; removal-related complications did not occur.
Conclusion
Peripheral TIVAP placement in the forearms of children is a feasible, effective and safe technique with good midterm outcome. As results are comparable with standard access routes, this technique may be offered as an alternative when intermittent venous access is required.
Risperidone is commonly used to treat different psychiatric disorders worldwide. Knowledge on dose–concentration relationships of risperidone treatment in children and adolescents with schizophrenia or other psychotic disorders is, however, scarce and no age-specific therapeutic ranges have been established yet. Multicenter data of a therapeutic drug monitoring service were analyzed to evaluate the relationship between risperidone dose and serum concentration of the active moiety (risperidone (RIS) plus its main metabolite 9-hydroxyrisperidone (9-OH-RIS)) in children and adolescents with psychotic disorders. Patient characteristics, doses, serum concentrations and therapeutic outcomes were assessed by standardized measures. The study also aimed to evaluate whether the therapeutic reference range for adults (20–60 ng/ml) is applicable for minors. In the 64 patients (aged 11–18 years) included, a positive correlation between daily dose and the active moiety (RIS\(_{am}\)) concentration was found (r\(_s\) = 0.49, p = 0.001) with variation in dose explaining 24% (r\(_s\)\(^2\) = 0.240) of the variability in serum concentrations. While the RIS\(_{am}\) concentration showed no difference, RIS as well 9-OH-RIS concentrations and the parent to metabolite ratio varied significantly in patients with co-medication of a CYP2D6 inhibitor. Patients with extrapyramidal symptoms (EPS) had on average higher RIS\(_{am}\) concentrations than patients without (p = 0.05). Considering EPS, the upper threshold of the therapeutic range of RIS\(_{am}\) was determined to be 33 ng/ml. A rough estimation method also indicated a possibly decreased lower limit of the preliminary therapeutic range in minors compared to adults. These preliminary data may contribute to the definition of a therapeutic window in children and adolescents with schizophrenic disorders treated with risperidone. TDM is recommended in this vulnerable population to prevent concentration-related adverse drug reactions.
Objects which a human agent controls by efferent activities (such as real or virtual tools) can be perceived by the agent as belonging to his or her body. This suggests that what an agent counts as “body” is plastic, depending on what she or he controls. Yet there are possible limitations for such momentary plasticity. One of these limitations is that sensations stemming from the body (e.g., proprioception) and sensations stemming from objects outside the body (e.g., vision) are not integrated if they do not sufficiently “match”. What “matches” and what does not is conceivably determined by long–term experience with the perceptual changes that body movements typically produce. Children have accumulated less sensorimotor experience than adults have. Consequently, they express higher flexibility to integrate body-internal and body-external signals, independent of their “match” as suggested by rubber hand illusion studies. However, children’s motor performance in tool use is more affected by mismatching body-internal and body-external action effects than that of adults, possibly because of less developed means to overcome such mismatches. We review research on perception-action interactions, multisensory integration, and developmental psychology to build bridges between these research fields. By doing so, we account for the flexibility of the sense of body ownership for actively controlled events and its development through ontogeny. This gives us the opportunity to validate the suggested mechanisms for generating ownership by investigating their effects in still developing and incomplete stages in children. We suggest testable predictions for future studies investigating both body ownership and motor skills throughout the lifespan.
Background
Apart from biologics, no systemic drugs are approved in Europe for children with moderate-to-severe psoriasis. Retrospective observational studies have shown promising results for fumaric acid esters (FAE) in this setting.
Objectives
To show superiority of FAE over placebo in terms of treatment response after 20 weeks in children and adolescents aged 10–17 years.
Methods
In a multicentre, randomized, double-blind, placebo-controlled phase IIIb study, patients aged 10–17 years with moderate-to-severe plaque psoriasis requiring systemic therapy were randomized 2 : 1 to receive FAE (n = 91) or placebo (n = 43) over 20 weeks, followed by an open-label FAE treatment phase. The coprimary endpoints were ≥ 75% improvement in Psoriasis Area and Severity Index (PASI 75) and Physician’s Global Assessment (PGA) score of 0 or 1 (clear or almost clear) at week 20. The study was registered with EudraCT number 2012-000035-82.
Results
At week 20, 55% [95% confidence interval (CI) 0·44–0·65] of FAE-treated patients achieved a PASI 75 response vs. 19% (95% CI 0·08–0·33) in the placebo group (absolute difference 36%, 95% CI 0·20–0·53; P < 0·001). In total, 42% (95% CI 0·32–0·53) in the FAE group vs. 7% (95% CI 0·01–0·19) in the placebo group achieved a PGA score of 0 or 1 at week 20 (absolute difference 35%, 95% CI 0·21–0·49; P < 0·001). During the double-blind period, drug-related adverse events occurred more frequently in patients receiving FAE compared with placebo (76% vs. 47%). Gastrointestinal disorders were the most common adverse events.
Conclusions
FAE administered over a period of 20 weeks demonstrated a better response than placebo; the difference was statistically significant and clinically meaningful. Application up to 40 weeks was generally well tolerated. However, further studies are required.