Just my luck: How children's causal attributions contribute to injury prevention.

PURPOSE: Traumatic injury in children, particularly adolescents, is both frequently and costly. In this study, we directly examined children's causal attributions for the recent traumas and asked them to propose prevention strategies of their own. We predict that children who attribute their injuries to their own actions, rather than an external force such as luck, will be more likely to develop strategies to avoid trauma in the future. METHODS: All children aged 10 -18 years who presented to a Level 1 pediatric trauma center at an urban children's hospital over a ten-month period were identified and presented with a series of structured interview questions. They were asked to describe the cause of their injuries, whether they believed them to be avoidable, and what strategies, if any, they thought might have prevented their trauma. RESULTS: 46 children with an average age of 13.4 years were surveyed and the responses of 44 children were analyzed. Most injuries resulted from sports (24) or motor vehicle accidents (14). The remaining injuries were due to burns (4) and falls (2). Twelve (27%) children believed that their own behavior was to blame for their injuries. 32 children ascribed their injuries to circumstances outside of their control with the majority (30, 94%) viewing themselves as "unlucky." Children who accepted fault for injury and children who thought their accident was avoidable were more likely to be able to formulate a strategy for preventing future injury. Children who thought their accident was avoidable were also more likely to accept fault for it. CONCLUSION: Children surveyed denied their own culpability and preferred to attribute their injuries to bad luck. Moreover, children who believed themselves to be simply unlucky were less able than others to propose strategies that might prevent further injury.

A systematic review of capacity assessment tools in pediatric surgery: Global Assessment in Pediatric Surgery (GAPS) Phase I.

BACKGROUND: The Lancet Commission on Global Surgery highlighted global surgical need but offered little insight into the specific surgical challenges of children in low-resource settings. Efforts to strengthen the quality of global pediatric surgical care have resulted in a proliferation of partnerships between low-and middle-income countries (LMICs) and high-income countries (HICs). Standardized tools able to reliably measure gaps in delivery and quality of care are important aids for these partnerships. We undertook a systematic review (SR) of capacity assessment tools (CATs) focused on needs assessment in pediatric surgery. METHODS: A comprehensive search strategy of multiple electronic databases was conducted per PRISMA guidelines without linguistic or temporal restrictions. CATs were selected according to pre-defined inclusion criteria. Articles were assessed by two independent reviewers. Methodological quality of studies was appraised using the COSMIN checklist with 4-point scale. RESULTS: The search strategy generated 16,641 original publications, of which three CATs were deemed eligible. Eligible tools were either excessively detailed or oversimplified. None used weighted scores to identify finer granularity between institutions. No CATs comprehensively included measures of resources, outcomes, accessibility/impact and training. DISCUSSION: The results of this study identify the need for a CAT capable of objectively measuring key aspects of surgical capacity and performance in a weighted tool designed for pediatric surgical centers in LMICs. TYPE OF STUDY: Systematic Review. LEVEL OF EVIDENCE: II.

Pediatric thyroidectomy: Favorable outcomes can be achieved by a multidisciplinary team of pediatric providers.

AIM OF THE STUDY: Recent publications suggest pediatric surgeons may not be well suited to perform thyroid surgeries unless considered high volume. We sought to assess the outcome of thyroidectomies performed by pediatric surgeons in an academic setting. METHODS: We reviewed charts of patients younger than 18 years who underwent thyroid surgeries at a free standing children's hospital between April 2006 and October 2015. MAIN RESULTS: The analysis included 118 surgeries in 98 patients (mean age 11.8 years). Most surgeries were performed by a single pediatric surgeon (average 10 thyroidectomies per year). The commonest indication for resection was thyroid nodule (64%). 80% of patients had a single surgery; the remainder had two, including 13 completion hemithyroidectomies. Cancer was found in 37% of specimens, with papillary subtype being most common (72%). Seven patients had locoregional metastases and one had pulmonary metastases. Among the 17 malignant cases that had a second intervention, 6 had malignancy in the resected specimen. There were no deaths in the follow up period (mean 2.7 years). Two patients had permanent hypocalcemia, and three had persistent unilateral recurrent laryngeal nerve injuries causing dysphonia for a total permanent complication rate of 4.2%. CONCLUSIONS: We conclude that pediatric thyroidectomy is a safe procedure when performed by pediatric surgeons. Our rate of complications is comparable to those reported in the literature. Our data highlight the need for a vigilant and multidisciplinary approach for children with thyroid pathology. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: IV.

Interventions in the operating room for children near end of life: A multidisciplinary approach.

INTRODUCTION: Pediatric surgeons are often involved in the management of severely or terminally ill patients. However, articles addressing their specific roles in the context of palliative care are almost inexistent. We sought to characterize the involvement of pediatric surgeons caring for children near end of life. METHODS: Chart review of children who had a procedure under general anesthesia within 6months of their death over a five-year period at a tertiary children's hospital (excluding traumas and neonatology cases). In addition to demographic and clinical data, we recorded the aim of the procedures performed, the involvement of the palliative care service, and presence of DNAR orders. RESULTS: The analysis included 83 patients (mean age: 8years). Forty-four children had more than one procedure (range 2-10). Pediatric palliative care service was involved in 66 cases (80%). A majority of patients had cancer (50%), and the most frequent cause of death was oncologic progression (46%). Ten patients died of a complication following their intervention. The aim of the procedure was palliative in 48 cases (29 for symptoms control and 19 to facilitate care), diagnostic in 16, and curative in 19. Forty-five procedures were performed urgently and 14 despite DNAR orders. CONCLUSION: Surgeon involvement with children near end of life is not infrequent. The procedures performed are varied and can be categorized according to their aim. Lack of formal palliative care training by surgeons highlights the need for increased collaboration with palliative care services to provide children optimal care when they need it most. LEVEL OF EVIDENCE: IV.

Prophylactic thyroidectomies in MEN2 syndrome: Management and outcomes.

AIM OF THE STUDY: The aim of the study was to evaluate the outcomes of prophylactic thyroidectomies performed in an academic setting in the context of multiple endocrine neoplasia type 2 (MEN2) syndrome. METHODS: A chart review of patients <18years old who underwent prophylactic thyroidectomy for a MEN2 syndrome at a children's hospital between 2006 and 2015 was performed. MAIN RESULTS: The study included 21 patients (57% female) with a mean age of 6.2±2.5years. All patients were asymptomatic at first evaluation. Nineteen had MEN2A syndrome with RET proto-oncogene mutations identified. The remaining two were RET-negative with familial medullary thyroid cancer (FMTC). One patient had a concomitant Hirschsprung disease. Of the 11 patients who had RET proto-oncogene mutations ranked as Moderate Risk for medullary thyroid cancer (MTC) (American Thyroid Association), one had a microcarcinoma on the resected specimen, and the others had C-Cell Hyperplasia. Among the 8 patients who had RET proto-oncogene mutations ranked as High Risk level for MTC, all had microcarcinoma. Of the nine patients with microcarcinoma, three underwent surgery after 5years of age. No microcarcinoma exceeded 6mm. There were no permanent complications. Six patients experienced transient hypocalcemia, of which only one was symptomatic. No patients had lymph node involvement, and no recurrence was noted during the follow-up period. CONCLUSIONS: Of 21 children with familial thyroid cancer syndrome who underwent a prophylactic thyroidectomy, nine had microcarcinoma. This study highlights the need for a complete familial history, including FMTC history and mandatory preventive surgical approach. LEVEL OF EVIDENCE: III.

Cheerleading injuries in children: What can be learned?

INTRODUCTION: Cheerleading has gradually become more popular in Canada and represents an accessible way for youth to be physically active. OBJECTIVE: To determine the differences in the injuries encountered by cheerleaders according to their age, in order to propose safety guidelines that take into account the developmental stages of children. METHOD: Retrospective database review of cheerleading injuries extracted from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) database between 1990 and 2010. The injuries were compared by age group (5 to 11 versus 12 to 19) according to their sex, mechanism of injury and injury severity. RESULTS: Overall, in 20 years, there were 1496 cases of injuries documented secondary to cheerleading (median age 15, 4 (interquartile range [IQR]=2, 2) years); mostly females (1410 [94%]). Of that number, 101 cases were 5 to 11 years old (age group [AG]1), while 1385 were 12 to 19 (AG2). Participants in AG1 were found to have a higher proportion of moderate-to-severe injury (46.5% compared with 28.2% in AG2). The odds ratio of moderate/severe injury for AG1 compared with AG2 was found to be 2.217 (95% CI [1.472; 3.339]). No fatalities were known to have occurred. CONCLUSION: Children's developmental stages affect their ability to participate in sports and the responses of their bodies to impact forces. Our findings concerning cheerleading injuries indicate that younger children (5 to 11 years old) are more likely to suffer moderate-to-severe injuries. Thus, on a local basis, the use of appropriate safety measures including appropriate flooring/safety mats and spotters to catch falling athletes should be mandatory.

Congenital paraesophageal hernia: The Montreal experience.

INTRODUCTION: Congenital paraesophageal hernia (CPEH) is the least common congenital diaphragmatic hernia. We performed an extensive review to further define this entity. METHODS: A retrospective study of children with CPEH (types II-IV hiatal hernias) treated at two children's hospitals over a 25-year period (1988-2013) was performed. RESULTS: Fourteen patients were diagnosed at a median age of 35 days (range 0-500), with one prenatal diagnosis. The most common symptoms were emesis in type II hernias (50%), and respiratory distress in types III and IV hernias (75% and 50%, respectively). Gastroesophageal reflux was concomitantly diagnosed in 50%, while concurrent congenital anomalies existed in 36%. A correct initial diagnosis was made in only 29% of cases. The diagnosis was most often established by UGI study (64%). The method of repair was laparoscopy in 21%, and laparotomy in 71%. An antireflux procedure was done in 13 (93%) patients. Long-term follow up data was available for 86% of patient. During follow-up, one patient recurred and one required sequential pneumatic esophageal dilations. There were no mortalities. CONCLUSIONS: CPEH is a rare entity often associated with gastroesophageal reflux disease and other congenital anomalies. Prognosis is excellent, but awareness of this anomaly may lead to earlier diagnosis.

Legislation in Québec for all-terrain vehicles: are we doing enough?

OBJECTIVES: All-terrain vehicle (ATV) legislation in Québec is among the most restrictive in Canada. The purpose of our study was to characterize the pediatric ATV traumas in our center and determine the impact of legislation. METHODS: Retrospective chart review of all patients seen in the emergency department after an ATV injury was done from 2005 to 2011. RESULTS: Seventy-tree patients (50 boys and 23 girls) with a mean age of 11 years (range, 3-17 years) were identified. Forty-nine percent were drivers, 40% were passengers, and 11% unknown. Forty-five percent did not reach the legal age of 16 years. Helmet use was documented in 36%. Eighty-five percent were admitted to the floor, and 15% were discharged from the emergency department. Intensive care unit stay was necessary in 21%, and 60% were operated on. Most of the surgeries were for orthopedic, either extremities, spine, or pelvic (80%). The most frequent types of trauma were extremities (30%), head (30%), and face (25%). Head trauma was severe in 23%. Hospitalization rates for ATV injuries have remained unchanged in the last years. CONCLUSIONS: Despite implementation of ATV legislation regarding helmet use and minimal legal age, a lot of our patients did not obey these rules. This study demonstrates that strong legislation did not have a real impact on ATV morbidity in children. It is essential to develop strategies to enforce ATV users to respect legislation.

Inappropriate use of infant seating devices increases risks of injury.

PURPOSE: The purpose of our study was to investigate the epidemiology and resulting injuries following falls sustained by infants seated in a variety of seating devices. METHODS: A retrospective chart review of a cohort of infants less than 12 months old who presented to our institution from 1991 to 2010 after a fall from various seating devices was performed. RESULTS: Two hundred five infants were identified, including 146 patients who were admitted to our institution (1991-2010) and 59 patients who were seen and discharged from the ED (2008-2010). Mean age of admitted infants was younger (3.5 vs. 5.3 months). Two patients (1%) required surgery for a depressed skull fracture. Overall, 18% had an intra-cranial hemorrhage. More patients requiring an admission secondary to their injuries fell from a table or counter (42% vs. 27%). CONCLUSION: Falls sustained by children seated in a variety of devices are frequent. Failure to restrain children in seating devices or improperly placing them on a table/counter is associated with more significant injuries. In order to minimize such injuries, it is important to educate caregivers of the risk in utilizing such seating devices.

Trauma association of Canada Pediatric Subcommittee National Pediatric Cervical Spine Evaluation Pathway: consensus guidelines.

BACKGROUND: The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and improve patient outcomes. In 2006, The Trauma Association of Canada Pediatric Committee set out to create an evidence-based, national pediatric cervical spine (c-spine) clearance guideline based on the literature, existing algorithms from each pediatric trauma center and from expert opinion from across Canada. METHODS: A review of the literature took place in September 2006 using the PubMed database. Search criteria were "cervical spine," "c-spine," "clearance," and "trauma." Limits that were applied were "Languages: English," "Humans," "Type of Article: Meta-Analysis, Practice Guidelines, Randomized Control Trial, Review," and "Ages: all child 0-18 years." These search criteria were repeated in December 2007, April 2009, and October 2009. A total of 248 articles were identified. Existing guidelines were identified and their practices examined as models of care. Two draft guidelines were created for discussion: one for the pediatric patient with a reliable clinical examination and the other for the pediatric patient with an unreliable clinical examination. Via email, telephone, and two national videoconferences, the content of the guidelines was reviewed, discussed, and amended. The final article was prepared and circulated for author input until consensus was reached. RESULTS: A consensus was reached on two pathways to evaluate the pediatric cervical spine: a patient with a reliable clinical examination and a patient with an unreliable examination. CONCLUSION: Presented herein are the consensus Trauma Association of Canada, National Pediatric Cervical Spine Evaluation Pathways for the patient with a reliable clinical examination, and the patient with and unreliable clinical examination.

Type A esophageal atresia: a critical review of management strategies at a single center.

PURPOSE: The purpose of was to study the short- and long-term outcomes in the management of isolated esophageal atresia with different operative strategies. METHODS: All patients undergoing type A atresia repair over a 15-year period were included. Demographic data, birth weight, gestational age, incidence of associated anomalies, management, and long-term outcomes were studied. RESULTS: Fifteen patients with type A atresia (9 male) were treated in the study period. The mean gestational age was 35.5 weeks (range, 27-39 weeks), and the mean birth weight was 2179 g (range, 670-3520 g). Eight babies had associated anomalies. Thirteen patients underwent gastrostomy as the initial procedure, and 2 underwent the Foker procedure. In the delayed management group, 9 patients underwent primary anastomosis, with 2 patients needing proximal pouch myotomy. Two patients underwent a Collis gastroplasty. Two patients underwent a cervical esophagostomy and a gastric tube replacement at 4 months and 1 year, respectively. Eight patients (60%) in this group had anastomotic leaks. All patients are currently on prokinetics and proton pump inhibitors. Seven required antireflux surgery. The median length of hospital admission was 4 months (range, 3-19 months). The native esophagus was preserved in 13 (85%) of 15 babies. All patients are alive, and 14 of 15 are capable of feeding orally. CONCLUSIONS: Type A esophageal atresia continues to be associated with significant morbidity despite advances in surgical technique and intensive care.

Predictive indicators for bowel injury in pediatric patients who present with a positive seat belt sign after motor vehicle collision.

PURPOSE: Abdominal wall bruising (AWB) is a frequent finding in children wearing seat belts involved in motor vehicle collision (MVC) and is highly suspicious but not indicative of intestinal injury. The aim of this study was to find objective clinical and radiologic predictors for the need of an abdominal exploration in these children. MATERIALS AND METHODS: A retrospective chart review of children admitted from 1998 and 2008 with AWB after MVC was conducted. Demographics, vital signs, physical examinations, radiologic investigations, associated injuries, management, and outcome were extracted. Univariate and multivariate statistical analyses were done. RESULTS: Fifty-three children with a median age of 9 years (range, 3-16 years) were included. Forty-four patients (83%) had abdominal pain on arrival, and 25 (47%) had free intraabdominal fluid on ultrasound/scan. Intraabdominal injuries were noted in 29 patients (55%), and the most common were mesenteric or bowel injuries (25%), splenic injuries (13%), and hepatic injuries (8%). Ten patients (19%) needed therapeutic laparotomy, and all were victims from collision involving 2 moving vehicles, had abdominal pain, free intraabdominal fluid, and tachycardia. Five patients (50%) operated on had lumbar fracture compared to only 4 patients (9%) in the nonoperative group. Pulse rate higher than 120 (P = .048), lumbar fracture (P = .008), and free intraabdominal fluid (P

Topical mitomycin-C for the treatment of anal stricture.

BACKGROUND: Anal stricture is a well-known and feared consequence of anorectal surgery. Daily dilatations are often prescribed in the immediate postoperative period to avoid stricture of the anus. Nonetheless, stricture may still occur and, particularly in older children, may require multiple dilatations under anesthesia. Topical mitomycin-C has been found to be effective in the treatment of strictures at various anatomical locations. In this article, we review our experience with topical mitomycin-C as an adjunct to anal dilatation for children with anal stricture. MATERIALS AND METHODS: Cases of children with anal stricture who were treated with a single application of topical mitomycin-C as an adjunct to anal dilatation between 2000 and 2008 were analyzed retrospectively. Anal diameter was measured with Hegar dilators. Cottonoid swabs soaked in mitomycin-C were placed on the anal mucosa for 5 minutes after dilatation. Treatment success was defined by sustained improvement in anal size, decrease in symptoms, parental satisfaction, and need for additional intervention. RESULTS: Ten children with anal stricture who underwent anal dilatation with application of topical mitomycin-C were identified. All children presented with severe constipation. Average increase in anal size after dilatation under sedation was 5.7 mm (+/-3.2 mm). Average improvement in anal diameter on first clinic visit after mitomycin-C application was 3.7 mm. On follow-up, only 1 child required repeated intervention for stricture after treatment with mitomycin-C. No complications were associated with the use of mitomycin-C. CONCLUSIONS: All children treated with mitomycin-C showed early improvement in their anal size after dilatation under sedation. A single application of topical mitomycin-C allowed them to retain an increased anal diameter over time and avoid additional dilatations. Furthermore, the application of mitomycin-C in our population was straightforward and safe. Therefore, we advocate its use as an adjunct to anal dilatation under sedation in the treatment of severe anal stricture.

Spindle epithelial tumor with thymus-like elements of the thyroid: a multi-institutional case series and review of the literature.

BACKGROUND/PURPOSE: Spindle epithelial tumor with thymus-like elements (SETTLE) is a rare tumor of the thyroid observed in children and adolescents. We present a case series of 3 patients with SETTLE, focusing on the clinical and pathologic features of this rare tumor. METHODS: Three male patients presented at ages 4.5, 6.5, and 7 years with a right thyroid mass. All were treated by standard hemithyroidectomy. None had evidence of distant metastases at presentation. The diagnosis of SETTLE was confirmed at the time of the initial operation in 2 of the 3 patients. RESULTS: All patients had uneventful postoperative courses. Two patients remain disease-free 4 and 7 years postresection, respectively. One patient presented 10 years after resection with shortness of breath and hemoptysis secondary to multiple bilateral parenchymal lung metastases. This patient received chemotherapy against the epithelial components of the tumor with a 25% response based on imaging studies. CONCLUSION: Spindle epithelial tumor with thymus-like elements is rare tumor that should be suspected if spindle elements are observed in the resected thyroid specimen. Because these patients may present with delayed metastases, follow-up is recommended. However, chemotherapy against specific tumor elements is only marginally effective.

Prophylactic thyroidectomy in pediatric carriers of multiple endocrine neoplasia type 2A or familial medullary thyroid carcinoma: mutation in C620 is associated with Hirschsprung's disease.

PURPOSE: Prophylactic total thyroidectomy is now recommended after having confirmed RET mutations in children of parents with multiple endocrine neoplasia type 2 or familial medullary thyroid carcinoma. We reviewed our experience to determine the incidence of medullary thyroid carcinoma with respect to age at surgery, the location of the mutation, and its association with Hirschsprung's disease (HD). METHODS: A retrospective review from 1996 to 2005 revealed 20 children with genetic screening for multiple endocrine neoplasia type 2A or familial medullary thyroid carcinoma who underwent a prophylactic total thyroidectomy with parathyroid gland preservation. RESULTS: The median age of the 20 patients (9 boys and 11 girls) included in this study was 8.2 years (range, 3.7-16.9 years) at the time of their surgery. Final pathology revealed normal thyroid tissue (n = 3; median age, 5.9 years), C-cell hyperplasia (n = 13; median age, 10 years), or medullary thyroid carcinoma (n = 4; median age, 8 years). Four children, all with mutations in C620, had a previous diagnosis of HD. At a median follow-up of 3.7 years (range, 1 month to 8.4 years), all patients were well and cancer free. CONCLUSIONS: There is no correlation between histologic findings and median age at surgery. Hirschsprung's disease was found in 50% of the patients with the RET mutation in C620. In children of C620 parents, symptoms of HD should be actively sought, and if such are found, rectal biopsies should be performed even if mutation results are not yet available. Based on the age of the earliest cancer and the safety of total thyroidectomy, children should promptly undergo surgery after genetic screening and before their fifth year of life.

The role of laparotomy for intestinal perforation in very low birth weight infants.

BACKGROUND/PURPOSE: The management of intestinal perforation in very low birth weight (VLBW) infants (less than 1500 g) is controversial. Current practice favors peritoneal drainage (PD) with or without a delayed laparotomy over primary laparotomy (PL). We compared the outcomes of PD +/- delayed laparotomy vs PL in VLBW infants using the Score for Neonatal Acute Physiology with Perinatal Extension (SNAPPE-II) as a validated predictor of mortality. METHODS: A retrospective analysis (1998-2003) of VLBW infants with intestinal perforation at 2 pediatric centers was undertaken. Data retrieval included neonatal demographics and parameters for SNAPPE-II calculation. The primary end point was 30-day mortality. Other outcome measures included in-hospital mortality, days fasting, days to extubation, and length of stay. Statistical analysis was performed with either Student's t test or chi2 analysis. Subgroup and multivariate analyses were also performed. P values < .05 were considered significant. RESULTS: Fifty-two neonates (25 PD, 27 PL) were reviewed. Overall, 10 (19.2%) infants died. Observed 30-day mortality rates in PD and PL groups were 32% and 7.4% (P = .028), respectively. Average SNAPPE-II scores for PD (42.5 +/- 20.8) and PL (25.1 +/- 14.6) groups yielded predicted mortality rates of 15.7% and 4.9% (P = .001), respectively. PD group 30-day mortality far exceeded the rate predicted by the SNAPPE-II score. Days fasting (13.7 vs 20.4; P = .0001), days to extubation (26.7 vs 51.5; P = .014), and length of stay (56.1 vs 83.6; P = .031) all favored the PL group despite incorporating SNAPPE-II score as a covariate into the multivariate analysis. Of the 25 patients receiving drainage, 9 underwent PD alone (SNAPPE-II = 46.6 +/- 27.9), whereas 16 patients underwent delayed laparotomy (SNAPPE-II = 37.8 +/- 17.6). The PD-only group had a greatly elevated mortality rate (77.8% vs 15.7% predicted), whereas the delayed laparotomy group had a reduced mortality rate (6.3% vs 9.3% predicted). CONCLUSION: Our data suggest that laparotomy, either alone or after PD, provides an improved outcome in VLBW infants with intestinal perforation. PD should be used as a temporizing measure until laparotomy can be performed.

Unilobar congenital pulmonary lymphangiectasis mimicking congenital lobar emphysema: an underestimated presentation?

BACKGROUND: Congenital lobar emphysema (CLE) is characterized by unilobar alveolar distension secondary to bronchomalacia or absent cartilage. In contrast, congenital pulmonary lymphangiectasis (CPL) is defined as distended lymphatics in the bronchovascular bundle, in the interlobular septa, and in the subpleural space. Little information is available regarding the radiologic presentation of CLE as it correlates with histological diagnosis. METHODS: In a retrospective chart review from 1995 to 2002, 8 patients (5 boys and 3 girls) with clinical and radiologic diagnosis of CLE were reviewed. RESULTS: The mean age at diagnosis was 26 months (range, 11 days to 10 years). All but one had classic respiratory symptoms of CLE. Six of 7 chest computed tomography (CT), scans were suggestive of CLE. Of 8 patients, 3 were treated without pulmonary resection with resolution of symptoms. Five patients underwent lobectomies, and histology results showed CPL in 3. CT failed to identify CPL in all cases. CONCLUSIONS: Diagnosis of CLE is not as straightforward as the literature suggests. Even retrospectively, radiologic distinction between CLE and CPL could not be achieved by an experienced pediatric radiologist. CPL, thus, mimics CLE clinically and radiologically and, therefore, should be considered in the differential radiologic diagnosis of CLE.

Spontaneous pneumomediastinum: are we overinvestigating?

BACKGROUND: Spontaneous pneumomediastinum (SPM) is uncommon in pediatrics. Because of the growing concern about the risks of radiation in children, the authors analyzed whether an extensive radiologic workup influences management and outcome. METHODS: In a retrospective study from 1991 to 2003, 53 patients were diagnosed with SPM. Charts were reviewed for demographics, predisposing factors, presentation, investigation, and evolution. Pneumomediastinum occurring in the neonatal period or related to either pneumothorax, barotrauma, or trauma were excluded. RESULTS: Of 53 cases, 26 (49%) were bronchospasm related, 11 (21%) had respiratory tract infections, and 8 (15%) were idiopathic. Four (7.5%) were caused by inhaled foreign bodies while other causes accounted for the remaining 7.5%. No esophageal perforations were identified. Presentations included dyspnea (64%), subcutaneous emphysema (60%), cough (45%), cervical or chest pain (42%), and Hamman's sign (19%). Postero-anterior chest x-rays (CXR) were diagnostic in all cases except one. Mean number of CXR per hospitalization was 3. Only 3 patients subsequently had pneumothorax, and none required pleural drainage. Of the 8 patients with idiopathic SPM, 5 underwent a barium swallow, and 2 had a chest CT scan; results of all were normal. CONCLUSIONS: More than 70% of SPMs were related to bronchospasm or respiratory tract infections. Idiopathic SPMs deserve more attention because of the concern about esophageal perforation, although most investigations will be negative. SPM usually is a self-limited condition, and prognosis is related to the underlying disorder. Consequently, with clinical improvement, aggressive investigation and follow-up x-ray rarely is warranted.

Blunt renal trauma-blessing in disguise?

PURPOSE: The purpose of this study was to quantify pathologic lesions of the kidney found incidentally during the workup of a blunt renal trauma. METHODS: A retrospective review of the medical records of 103 patients ages 0 to 18 years with blunt renal injuries admitted to a level 1 pediatric trauma center between January 1, 1991 and December 31, 1999 was performed. All patients underwent ultrasonography and Doppler of their renal vessels. Additional investigations with computed tomography (CT) scan, cystography, or nuclear medicine functional studies were performed as indicated. RESULTS: Coexisting urogenital lesions were identified in 13 of 103 (12.6%) patients reviewed, and 7 (54%) required surgical treatment. The majority of the patients (9 of 13, 69%) suffered minimal trauma. All patients presented with gross hematuria as their main symptom. Stenosis of the uretero-pelvic junction was the most frequent diagnosis (n = 7): 3 patients required uretero-pyeloplasty, and 3 required nephrectomy. Two heterogeneous renal masses were discovered in which the diagnosis of a malignant process could not be eliminated; elective resection and open biopsy were performed. The diagnoses of multicystic kidney and solitary cyst with complex hematoma, respectively, were confirmed on pathology. Grade III ureterovesical reflux with pyelonephritis (n = 1), polycystic kidney (n = 1), extrarenal pelvis without obstruction (n = 1), and horseshoe kidney (n = 1) were the other lesions discovered. CONCLUSIONS: Pathologic lesions of the urinary tract are uncommon; however, they may complicate an otherwise negligible renal trauma. The diagnostic and therapeutic approach to blunt renal trauma must be modified in these cases. A high index of suspicion must be maintained when a patient presents with gross hematuria with a minimal force blunt abdominal trauma.