Epistaxis due to Wegener's granulomatosis in a pediatric patient.

Epistaxis is a common problem in children that typically is not severe and seldom requires hospitalization. The nose is a highly vascular structure with a large surface area; subsequently, it is highly predisposed to bleeding. Childhood vasculitides are very rare and are commonly diagnosed by characteristic lesions on imaging studies along with syndrome recognition by clinicians. We present a case of recurrent epistaxis that persisted over 3 months due to Wegener's granulomatosis in an adolescent that was misdiagnosed as a benign hemorrhage from Kiesselbach's plexus.

Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma.

BACKGROUND: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS: The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third. RESULTS: Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study. CONCLUSIONS: CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

Varicose bronchiectasis and bronchopulmonary dysplasia.

As a result of improved therapies and technology, including the use of surfactant replacement, the features of bronchopulmonary dysplasia (BPD) have changed, and a "new BPD" is emerging that is substantially different from the classical form of the disease. As the pathogenesis of BPD is evolving, so are other features of the disorder, including radiologic features. We describe varicose bronchiectasis with a bulbous appearance in a 6-year-old child with a complicated course including BPD during the neonatal period.

Non-accidental Trauma Injury Patterns and Outcomes: A Single Institutional Experience.

Non-accidental trauma (NAT) victims account for a significant percentage of our pediatric trauma population. We sought to better understand the injury patterns and outcomes of NAT victims who were treated at our level I pediatric trauma center. Trauma registry data were used to identify NAT victims between January 2008 and December 2012. Demographic data, injury severity, hospital course, and outcomes were evaluated. One hundred and eighty-eight cases of suspected NAT were identified. Children were mostly male and white. The median age was 1.1 years; the median Injury Severity Score was 9. Traumatic brain injuries, lower extremity fractures, and skull fractures were the most common injuries. Twenty-seven per cent required medical procedures; most were performed by orthopedic surgery. Twenty-four per cent required admission to the pediatric intensive care unit. The median length of stay was two days. The mortality rate was 9.6 per cent. We generated a hot spot map of our catchment area and identified areas of our state where NAT occurs at increased rates. NAT victims sustain significant morbidity and mortality. Due to the severity of injuries, pediatric trauma surgeons should be involved in the evaluation and management of these children. Much work is needed to prevent the death and disability incurred by victims of child abuse.

Current Surgical Management of Empyema Thoracis in Children: A Single-center Experience.

Empyema is a morbid complication of pneumonia in children, whose gold standard of surgical treatment technique remains undefined. Historically, treatment consisted of open thoracotomy with decortication. We evaluate the effectiveness and safety of video-assisted thoracoscopic surgery (VATS) as a surgical treatment in for empyema thoracis in a pediatric population at a single institution from 2005 to 2013. After receiving Institutional Review Board approval, we performed a retrospective chart review of children surgically treated for empyema as a complication of pneumonia from 2005 to 2013. Charts were reviewed for the type of procedure performed (VATS or open thoracotomy), comorbid conditions, preoperative status, operative outcomes, and postoperative status. A total of 112 pediatric patients were treated surgically for empyema. Surgical treatment consisted of VATS in all cases; no open thoracotomy procedures were performed. The success rate of VATS in our study was 96.4 per cent. Mean total length of stay was found to be 8.8 days, whereas postoperative length of stay was 6.3 days. Mean postoperative chest tube duration was 3.4 days. Perioperative complication rate was 11.6 per cent, with respiratory failure being the most common complication. The data from our study demonstrate that the exclusive use of VATS in children for the surgical management of all stages of empyema was safe and produced results with high efficacy. We consider VATS to be the new gold standard for surgical drainage of empyema.

Intussusception clinical pathway: a survey of pediatric surgery practices.

Therapeutic reduction of intussusception by air or contrast enema may require surgery if the bowel is irreducible or perforates. There is no standard for the involvement of a pediatric surgeon in the workup of the condition. A regional survey of clinical practices was therefore undertaken to attempt to establish a consensus as to when the presence of a pediatric surgeon is required. Distributed to pediatric surgeons at 32 institutions, a questionnaire asked the process of imaging and reduction of infants with intussusception and the extent of pediatric surgical involvement. Surgeons at 29 institutions responded (91%). Ultrasound was used in diagnosis in 16 (55%), 13 (45%) requiring a positive ultrasound diagnosis of intussusception before attempting reduction. Three-fourths (22 [76%]) required surgeon notification that enema reduction was taking place, and one-fourth (seven [24%]) required prior surgical consultation. Only three (10%) required the presence of a surgery team member. Most (21 [72%]) did not demand one, and five (18%) indicated that surgical presence was desirable but not a necessity. There is no consensus for pediatric surgical involvement before and during reduction of an intussusception.

Peritoneal drainage as the initial management of intestinal perforation in premature infants.

Complicated necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are major causes of mortality. We hypothesized that peritoneal drainage (PD) is more efficacious in SIP. Newborn infants with intestinal perforation treated with PD at our institution between 2007 and 2012 were divided into two groups: Group 1, infants with complicated NEC (n = 19), and Group 2, infants with SIP (n = 15). In Group 1, median birth weight was 705 g; median gestational age was 25.9 weeks. Median age at PD was 24 days. Six required laparotomy. Median time from PD to enteral feeds was 22.5 days. In Group 2, median birth weight was 685 g; median gestational age was 25.3 weeks. Median age at PD was 5 days. Two required laparotomy. Median time from PD to enteral feeds was 16 days. In Group 1, eight patients survived to discharge; median length of hospital stay (LOS) was 104.5 days. In Group 2, eight survived; median LOS was 109.5 days. Neither outcome was statistically significant (P = 0.73 and 0.878, respectively). Management of premature infants with intestinal perforation remains challenging. Mortality is high. Between our cohorts, there were no differences in regard to PD as definitive therapy, survival, and LOS.

Sifting through course evaluations: medical student comments driving surgery curriculum changes.

OBJECTIVE: Student empowerment of curriculum changes is a double-edged sword. When examining our third-year surgery course every year, we debate where the line is between improving education through student input against allowing the students to design "an easy course." METHODS: Written student comments on end-of-course evaluations (from the academic years 2006-2007 to 2010-2011) were analyzed using the qualitative approach described by Miles and Huberman. We compared the grouped comments to the course changes that were made over these years to determine what extent were we listening to students. Finally, we took the course changes made and juxtaposed them with student grades and with student course perceptions provided by the end-of-course evaluation analysis. RESULTS: We identified 17 alterations to our curriculum since the year 2007-2008 and of those, 12 are directly related to student comments. Some examples of our changes were a grading-scale alteration, grouping of workshops, and adding a shelf examination review session. The overall course ratings by the students steadily rose over the 5-year period (2.57 to 3.39), while the percentages of A's earned by students decreased over that same time until the year 2010-2011 when the percent of A's earned increased by over 30%. CONCLUSIONS: Because of the fact that 12 of 17 course changes can be directly related back to the student comments, we feel confident that we are listening to students. The increase in perception of the course through the first 4 years did not coincide with higher grades. The changes made have been instrumental in the course winning the best clerkship award for the last 4 years.

Thoracoscopic resection of an intrathoracic accessory liver lobe: an incidental finding in the workup of a child with a respiratory infection.

A case of an intrathoracic accessory liver lobe in a five-year-old female is presented, representing an incidental finding during workup for a respiratory infection. MRI was used to identify what appeared to be an accessory intrathoracic liver lobe. Thoracoscopy confirmed the diagnosis, and removal was achieved through a minimally invasive surgical procedure. Based on an electronic literature search, this is the first known report of minimally invasive techniques to remove accessory liver from the chest in a pediatric patient.

Primary Closure without Diversion in Management of Operative Blunt Duodenal Trauma in Children.

Background. Operative blunt duodenal trauma is rare in pediatric patients. Management is controversial with some recommending pyloric exclusion for complex cases. We hypothesized that primary closure without diversion may be safe even in complex (Grade II-III) injuries. Methods. A retrospective review of the American College of Surgeons' Trauma Center database for the years 2003-2011 was performed to identify operative blunt duodenal trauma at our Level 1 Pediatric Trauma Center. Inclusion criteria included ages <14 years and duodenal injury requiring operative intervention. Duodenal hematomas not requiring intervention and other small bowel injuries were excluded. Results. A total of 3,283 hospital records were reviewed. Forty patients with operative hollow viscous injuries and seven with operative duodenal injuries were identified. The mean Injury Severity Score was 10.4, with injuries ranging from Grades I-IV and involving all duodenal segments. All injuries were closed primarily with drain placement and assessed for leakage via fluoroscopy between postoperative days 4 and 6. The average length of stay was 11 days; average time to full feeds was 7 days. No complications were encountered. Conclusion. Blunt abdominal trauma is an uncommon mechanism of pediatric duodenal injuries. Primary repair with drain placement is safe even in more complex injuries.

Small cell carcinoma of the ovary of hypercalcemic type: a case report.

The authors report a case of small cell carcinoma of the ovary, hypercalcemic type (SCCOHT), in a mother and daughter and discuss the possibility of a heritable risk. Both mother and daughter were treated at the same institution for SCCOHT. A 23-year-old woman presented with hypercalcemia 4 months after giving birth to her daughter. She was diagnosed as having SCCOHT. Despite surgery, chemotherapy, and radiation, she died of the disease 11 months after diagnosis. Eleven years later, her daughter presented with a histologically and immunophenotypically identical SCCOHT tumor. She received postoperative chemotherapy and radiation but, eventually, relapsed and died of the disease at 27 months after the initial diagnosis. Small cell carcinoma of the ovary, hypercalcemic type, is an uncommon and aggressive malignancy that occurs in young women, which is associated with a solid ovarian tumor and hypercalcemia. Despite aggressive multimodality treatment, most patients die within 2 years of diagnosis. Genetic counseling, sonographic ovarian surveillance and serum calcium monitoring at early age, and even prophylactic oophorectomy should be considered for surviving at-risk family members.

Improved survival in venovenous vs venoarterial extracorporeal membrane oxygenation for pediatric noncardiac sepsis patients: a study of the Extracorporeal Life Support Organization registry.

BACKGROUND/PURPOSE: There are few studies comparing venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) in pediatric noncardiac sepsis patients. METHODS: Following approval, we reviewed the Extracorporeal Life Support Organization registry data from 1990 to 2008 for patients 0 to 18 years with a diagnosis of sepsis and without diagnosis of congenital heart disease. Survival to discharge was compared between VA and VV ECMO using χ(2) analysis and multivariable logistic regression. RESULTS: Four thousand three hundred thirty-two ECMO runs were reviewed, 3256 VA (75%) and 1076 VV (25%). A majority of VA modality was noted in each decade studied. Overall survival was 68% and was higher in VV (79%) than in VA ECMO (64%, P < .001). Survival decreased with increasing age (73% in newborns ≤ 1 month, 40% in children 1 month to 12 years, and 32% in adolescents >12 years, P < .001). VA ECMO had increased mortality risk after adjustment for age, use of vasoactive agents, and advanced respiratory support (odds ratio, 2.06; 95% confidence interval, 1.74-2.44; P < .001). CONCLUSIONS: These data demonstrate improved survival in VV vs. VA ECMO in select pediatric septic patients without congenital heart disease. When technically feasible, physicians should consider VV ECMO as first therapeutic choice in this patient population.

A middle fidelity model is effective in teaching and retaining skill set needed to perform a laparoscopic pyloromyotomy.

INTRODUCTION: An inanimate technical skills trainer for laparoscopic pyloromyotomy (LP) has not been described. A middle fidelity model, reproducing the three consistent steps in LP, was developed as a component of a teaching module for surgical residents, and tested on medical students, residents, and pediatric surgeons. MATERIALS AND METHODS: In the first phase of the study, a cohort of 29 pediatric surgeons used the LP model and completed questionnaires about the model's realism and accuracy. Descriptive statistics were used to analyze questionnaire responses. Chi-square tests were performed to determine if level of experience influenced responses. For the second phase of the study, medical students and surgical residents individually participated in the training of cognitive knowledge about hypertrophic pyloric stenosis and skills acquisition for LP. Subject testing consisted of simulator task performance and multiple-choice quiz administration immediately after training and repeated at 8 weeks after training. Data were analyzed by using paired sample t-tests and one-way analyses of variance (ANOVA). RESULTS: The pediatric surgeons agreed that the model accurately simulated essential components of the pyloromyotomy, and that the model would be an excellent tool to introduce surgeons to LP. A total of 26 students and early surgical residents completed the training and testing. Knowledge-based test performance improved from pre- to postinstruction by 17.45 [standard error of the mean (SEM) + 3.5] (P < 0.001) and from preinstruction to 8 weeks by 4.54 (SEM = 3.2) (P = 0.17). Mean improvement in time of simulator task performance was 85.2 +/- 75.4 seconds. Based on a one-way ANOVA, higher level of training was associated with decreased mean times (P = 0.04). CONCLUSIONS: Face and content validities of the simulation were demonstrated by the pediatric surgeons. An effective training experience was demonstrated with medical students and residents. At 2 months, simulator task-completion rates and task-performance times showed technical skills were retained, whereas, based on test scores, cognitive knowledge was not as well retained.

A late result of an early operation for unilateral coronal synostosis.

An infant underwent strip craniectomy for unilateral coronal synostosis in 1967. This report presents the cosmetic, functional and psychosocial outcome at 34 years of age. Although aggressive, reconstructive treatment of the various forms of single-suture craniosynostosis is the current standard of care, neither the natural history of these conditions nor the long-term results of treatment have been documented systematically.