Pediatric cervical spine injuries on CT: difference in accuracy of interpretations by pediatric versus non-pediatric radiologists.

PURPOSE: To retrospectively compare the accuracy of interpretation of initial cervical computerized tomography (CCT) by a non-pediatric radiologist (NPR) versus a pediatric radiologist (PR). METHODS: IRB approval and consent waiver were granted to review all injured children from 2010 to 2014 in the trauma registry with CT and magnetic resonance imaging (MRI) of the cervical spine. Patients with negative CCT who subsequently had positive MRI from a single institution comprised the study group. Patients with negative CCT and MRI, matched by age, gender, and severity scores, comprised the control group. The CCTs from both groups were initially interpreted at the time of service by a NPR. Subsequently, a single PR with 20 years of experience blinded to clinical/imaging data reinterpreted these CCT examinations. CT interpretations were then compared with MRI results and evaluated for statistical significance using SSPS software. The data analysis utilized summary statistics, two-tailed binomial test, and univariate χ2 test. Significance for all comparisons was assessed at P < 0.05. RESULTS: The study group was comprised of the 21 patients with negative CCT and positive MRI. Of the cohort included, 76% (16) were male and 24% (5) were female. The age range was 1 month-17 years, with a mean age of 9.7 years. CCT interpretation by NPR had a specificity of 91.7% (sensitivity 71.2%, positive predictive value 81.3%, and negative predictive value 86.3%) compared with results of MRI. Six of the 21 negative CCTs were interpreted by the PR as positive, mainly craniocervical junction injuries, and confirmed by MRI (28.6%, P < .001 compared with the NPR); no control CCT was interpreted by the PR as positive (sensitivity 100%, positive predictive value 100%, and negative predictive value 58.3%). CONCLUSION: In our retrospective study, a pediatric radiologist has improved recognition of pediatric cervical spine injuries on CT compared with non-pediatric radiologist.

RBC transfusions in children requiring intensive care admission after traumatic injury*.

OBJECTIVE: To describe packed RBC utilization patterns in trauma patients admitted to a PICU and study associated outcomes while controlling for severity. DESIGN: Retrospective cohort study. SETTING: The PICU of a tertiary care children's hospital. PATIENTS: All pediatric trauma patients admitted to Helen DeVos Children's Hospital PICU between June 2007 and July 2010, either directly from the emergency department or transferred from another institution. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 389 trauma patients, 107 patients (27.5%) transferred to the PICU were transfused with blood products. Of these transfusions, 81 were packed RBC transfusions and 26 were other blood products. Only 73 of the packed RBC transfusions had a documented time of transfusion: 17 (23.3%) were transfused prior to PICU admission, seven (9.5%) both before and after PICU, and 49 (67.1%) only after PICU admission. After adjusting for injury severity score, transfused patients had higher odds of needing mechanical ventilation (odds ratios, 9.2; 95% CI, 3.6-23.3) and higher risk of mortality (odds ratios, 8.6; 95% CI, 2.6-28.6), when compared with nontransfused patients. Mean age of packed RBC was 19.6 ± 9.3 days (mean ± SD). The impact of age of packed RBCs on mortality was examined as a categorical variable at 14, 21, and 28 days. Packed RBCs more than 28 days old (14/61 patients) were associated with longer lengths of stay (13 ± 12 vs 7 ± 6; p < 0.03), lower discharge Glasgow Coma Scale score (9 ± 6 vs 13 ± 4; p< 0.03), and more mortality (43% vs 13%; p < 0.02) when compared with blood less than 28 days old. CONCLUSIONS: In pediatric trauma patients, transfusion of packed RBC and use of older RBC units are associated with higher risk of adverse outcomes independent of injury severity.

Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 4: is physical exam and laboratory data sufficient to exclude intra-abdominal injury in the paediatric trauma patient?

A short-cut review was carried out to establish whether physical and laboratory data can exclude intra-abdominal injury in children. A total of 54 papers was found using the reported search, of which three represented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. The clinical bottom line is that physical and laboratory data review may decrease the need for abdominal CT in the paediatric population.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 1: Efficacy of hypothermia for traumatic brain injury in children.

A short cut review was carried out to establish whether there is any evidence for induced hypothermia in paediatric brain injury. 80 papers were found using the reported search, of which 5 represent the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. The clinical bottom line is that there is no evidence to support the use of hypothermia in brain injured children, and it may be associated with increased mortality.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: Incidence of venous thromboembolism in critically injured children.

A short cut review was carried out to establish the incidence of thrombembolic events in traumatically injured children. 75 papers were found using the reported search, of which 5 represent the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. The clinical bottom line is that the risk of VTE events in children is small. Risk factors for VTE can identify a high risk group.

UREKA: umbilical ring easy kannula access.

BACKGROUND AND OBJECTIVES: Standard techniques of laparoscopic access involve creating an abdominal wall defect and can result in complications. We describe the umbilical ring easy kannula access (UREKA) technique, evaluating safety and a decrease in complications related to port placement. METHODS: UREKA is performed via a supra- or infraumbilical incision followed by circumferential dissection of the umbilical stalk. The umbilical skin is dissected free from the fascia, exposing the umbilical ring. Pneumoperitoneum is established either before or after placement of a dilating port through the open ring. We reviewed all laparoscopic procedures performed by one pediatric surgeon over 14 months using UREKA. RESULTS: Ninety-four patients underwent laparoscopic surgery with initial port placement via UREKA. Appendectomy (n=57) was the most common procedure, followed by fundoplication (15) and cholecystectomy (10). No intestinal, solid organ, vascular, or bladder injuries related to port placement occurred. The only postoperative complication was a superficial wound infection in a 135-kg patient following cholecystectomy, treated successfully with oral antibiotics alone. CONCLUSION: The umbilical ring persists to some degree in all pediatric patients and provides a safe portal of entry for laparoscopic surgery. UREKA has few complications and is a straightforward, reproducible technique for gaining initial laparoscopic access.

Continuous hemoglobin monitoring in pediatric trauma patients with solid organ injury.

BACKGROUND/PURPOSE: Hemoglobin monitoring is required in pediatric trauma patients with solid organ injury. We hypothesized that noninvasive hemodynamic monitoring (NIHM) represents an effective, safe alternative to laboratory hemoglobin (LabHb) monitoring in clinically stable patients. METHODS: A retrospective cohort study was conducted regarding pediatric trauma patients (<18 years old) with blunt solid organ injury over six consecutive months. Continuous NIHM was initiated at the time of admission, and LabHb measurements were obtained per institutional guidelines. Measurements were correlated within two hours of assessment and patient outcomes were analyzed. RESULTS: Twenty-one patients met inclusion criteria and had evaluable data. Blunt trauma was the exclusive mechanism of injury, and mean injury severity score was 16.6 for the cohort. Bland Altman analysis showed an average deviation of 0.80 g/dL between NIHM and LabHb values for all data pairs. Measurement trends were highly correlated in patients with stable hemoglobin levels and those requiring blood transfusion. CONCLUSIONS: NIHM demonstrated clinically acceptable accuracy when following hemoglobin trends in the defined pediatric trauma patient population. Slight variances between NIHM and LabHb values were occasionally noted, but did not affect clinical management. Continuous NIHM represents a potentially valuable adjunct to traditional laboratory hemoglobin monitoring. LEVEL OF EVIDENCE RATING: IV.

Primary thoracoscopic gross total resection of neuroblastoma.

BACKGROUND: Thoracic neuroblastomas are generally less aggressive and have a better prognosis than those arising below the diaphragm. Our purpose was to study the safety and efficacy of thoracoscopic resection and to evaluate tumor data and patient outcomes. PATIENTS AND METHODS: We reviewed the records of patients who underwent primary thoracoscopic resection of neuroblastoma (NB) between 1998 and 2002. Data included demographics, symptoms, size, location, operative time, complications, hospital stay, histology, biologic markers, adjuvant therapy, and outcome. RESULTS: Five patients (age range, 9 to 44 months) underwent thoracoscopic resection of NB. Three of the patients had neurological symptoms. Tumor size ranged from 2.1 to 6.0 cm. Two tumors were apical, three supradiaphragmatic. Primary thoracoscopic gross total resection was achieved in all 5 cases, all of which were stage 1. Operative time ranged from 64 to 175 minutes. The only complications were two cases of small tumor spillage. Hospital stay was 1 to 4 days. Histology ranged from ganglioneuroma to differentiating NB, with a favorable classification in 4 of 5 cases. None of the tumors were N-Myc amplified. Chemotherapy or radiation therapy was not indicated for any patient. All are alive with no evidence of disease at 14 to 55 months' follow-up. CONCLUSION: Primary gross total resection of mediastinal NB can be achieved safely and effectively by a thoracoscopic approach. In our series, most tumors had favorable histology and biology, and all appear to be potentially treatable by primary thoracoscopic resection alone.

Benefits of transperitoneal approach to bilateral pretransplant laparoscopic nephrectomies in pediatric patients.

INTRODUCTION: Pediatric renal transplant patients may require native nephrectomy to avoid complications at the time of kidney transplantation. We have performed unilateral and bilateral transperitoneal pretransplant laparoscopic nephrectomies (PLNs), followed by living-related renal transplantation. The benefits of transperitoneal versus retroperitoneal dissection remain controversial. SUBJECTS AND METHODS: A retrospective review of patients who underwent unilateral or bilateral transperitoneal PLNs between May 1, 2001 and April 30, 2009 was performed. A transperitoneal approach was used in all patients. RESULTS: Eight patients underwent transperitoneal PLN. Four patients were female, and the average age was 91 months (range, 9-199 months). Five of the cases involved bilateral nephrectomy. Average operating times, including hemodialysis catheter placement and other procedures, was 4.93 hours (range, 4.25-5.97 hours) for bilateral PLN and 3.93 hours (range, 2.57-5.48 hours) for unilateral PLN. The average hospital stay was 5.9 days. All patients underwent successful renal transplantation following PLN without rejection at an average 2.3 years of follow-up. CONCLUSIONS: PLN appears to be an effective, safe method of removing potentially problematic, diseased kidneys prior to planned renal transplantation. A transperitoneal technique using four midline ports affords excellent access to both kidneys and, more importantly, allows for additional procedures to be completed simultaneously.

Pediatric bronchogenic cyst complicated by atypical mycobacterium infection: a case report.

INTRODUCTION: Bronchogenic cysts are lesions of congenital origin derived from the primitive foregut and are the most common primary cysts of the mediastinum. They are most frequently unilocular and contain clear fluid. Respiratory distress is the most common presentation in pediatric patients, manifested by recurring episodes of cough, stridor, wheezing and retractions. CASE PRESENTATION: We report the first pediatric case of bronchogenic cyst complicated by atypical Mycobacterium infection. This case describes a 13-year-old Caucasian American female with a large cystic lesion and extensive pulmonary involvement. Pathology studies revealed necrotizing granulomatous inflammation, multiple nodules, and acid-fast bacilli. She was successfully treated with surgical excision and a six-week course of clarithromycin, rifampin and ethambutol. Other unusual aspects of this case include multilocular intraparenchymal cyst appearance, its turbid drainage, and late symptom onset. CONCLUSION: Bronchogenic cyst should be included in the differential diagnosis of a child with cough, dyspnea, and fever. Although rare, we stress the importance of keeping mycobacterial infection in mind in cases of an infected cyst. Acid-fast culture should be done on sputum and cyst contents. Due to the frequency of negative cultures, stains should also be performed on resected cyst specimens. Antibiotic therapy should be considered and administered based on the extent of infection. All symptomatic or enlarging cysts warrant surgical excision. Prophylactic removal of asymptomatic cysts is recommended due to higher rates of perioperative complications once cysts become symptomatic.

Sigmoid irrigation tube for the management of chronic evacuation disorders.

BACKGROUND/PURPOSE: Antegrade colonic irrigation, in which the right colon is accessed via appendicostomy or cecostomy, now is an important adjunct in the management of children with chronic evacuation disorders. However, in most children, the major area of dysfunction is the left rather than the right colon. The authors developed a simple, percutaneous endoscopic, laparoscopically controlled sigmoid irrigation tube placement and evaluated the results in 4 children. METHODS: A rigid sigmoidoscope is advanced into the upper sigmoid and the loop brought in contact with the abdominal wall under laparoscopic control. A small skin incision is made and a needle pushed across the abdominal and sigmoid walls into the lumen of the sigmoidoscope. A guide wire is advanced through the needle into the scope and retrieved. After the scope is removed, a PEG-type catheter is attached to the guide wire and pulled back, securing the sigmoid loop to the abdominal wall. The tube is subsequently converted to a skin-level device by simply adding an external port valve. RESULTS: All 4 patients achieved prompt evacuation in the sitting position. CONCLUSIONS: Sigmoid tube for antegrade irrigation is an appealing alternative to conventional cecal access. The procedure is simple and may offer physiologic advantages.

Improved outcomes in the treatment of gastroschisis using a preformed silo and delayed repair approach.

BACKGROUND/PURPOSE: The aim of this study was to critically evaluate the clinical outcomes of two different surgical treatment approaches for infants born with gastroschisis. METHODS: The medical records of 65 infants with gastroschisis treated at one institution from 1991 to 2000 were available. Infants in group I (prior to December 1998) underwent attempted early repair of the gastroschisis defect on their first day of life. Infants in group II had delayed repair after the initial placement of a preformed silo. RESULTS: Group I had 39 patients; group II had 26 patients. The two groups were equal with respect to maternal age, gestational age, and birth weight. Complete reduction and fascial closure were accomplished for 32 patients (82%) in group I and 25 patients (96%) in group II (P <.02). Median time on the ventilator was significantly less for group II (P <.0001). Infants in group II had shorter times until first postoperative feeding (P <.01) and full feedings (P <.006). Group II had fewer complications than group I (23% v 56%; P <.01). There appeared to be less necrotizing enterocolitis in group II. The average length of hospital stay was 14 days less for group II. CONCLUSIONS: The use of a preformed silo initially followed by delayed fascial closure in infants with gastroschisis is associated with improved fascial closure rates, fewer ventilator days, more rapid return of bowel function, and fewer complications compared with attempts at initial early repair.

Virtual reality modeling and computer-aided design in pediatric surgery: applications in laparoscopic pyloromyotomy.

As a test of the applicability of modern bioengineering tools to pediatric surgery, we developed by computer-aided design (CAD) methods and evaluated a virtual reality (VR) model of laparoscopic pyloromyotomy (LP) and created a set of retractable hook instruments, called Pylorohooks. Our VR model of LP incorporated the infant's body wall, stomach, and hypertrophied pylorus as well as laparoscopic cannulas and two Pylorohooks. CAD software was used to design the 3-mm-diameter, retractable, double-pronged, minimally-traumatic hook instrument. A rapid prototype processor was employed to create a plastic model of the instrument. Surgical-grade stainless-steel prototypes were then manufactured and used in actual LPs. A working VR model was achieved. Following an initial correction in the angulation of the hooks, the instruments were successfully employed in nine consecutive LPs in infants weighing from 3.4 to 5.7 kg. VR and CAD thus proved instrumental in the development of a new LP approach. Because of increasing pressure to limit human and animal experimentation, computer-based bioengineering methods offer promising alternatives that are clearly applicable to pediatric surgery.

Snowmobile injuries and fatalities in children.

BACKGROUND/PURPOSE: Snowmobiling is a popular form of wintertime recreation but can be associated with significant morbidity and mortality. To better understand snowmobile trauma in children, medical records were reviewed, evaluating the relationships between demographic data, mechanisms, and resultant injuries. In addition, because prior studies of childhood snowmobile fatalities have reviewed only national databases, state and national data were combined to evaluate possible underreporting. METHODS: Medical records were reviewed of children

Diagnostic laparoscopy with planned appendectomy: an integral step in the evaluation of unexplained right lower quadrant pain.

Recurrent right lower quadrant (RLQ) abdominal pain is often difficult to diagnose and treat. We reviewed our experience with diagnostic laparoscopy with planned appendectomy for children with unexplained RLQ pain. This procedure was performed when the cause of atypical RLQ pain could not be diagnosed by comprehensive medical and radiological evaluation. Outcome data was obtained at office visits and by telephone. From 1997 to 2000, 30 children (22 female) presented with unexplained RLQ pain. Ages ranged from 5 to 16 years (mean 11 years). Symptoms had been present from 6 days to 2 years (median 6 weeks). Gross and/or histological appendiceal abnormalities were found in 26 children (87%). Incidental findings included patent processus vaginalis in one and adnexal cysts in six. Two complications occurred: pelvic fluid collection and umbilical suture reaction. At initial follow-up, 29 patients (97%) were pain-free. Long-term follow-up was continued through 2002. At a median of 19 months (range 2-47 months), 25 of 28 patients (89%) reported no recurrence of their original pain. Our results confirm that the appendix is an important source of unexplained recurrent RLQ pain in children. Diagnostic laparoscopy with planned appendectomy is highly effective and should be considered an integral step in the management of these patients.