Imaging-Associated Radiation Trends in a Puerto Rican Pediatric Surgical Population: Is Over-Radiation an Issue in Our Emergency Departments?

The increased use of CT scans has raised concerns regarding the risks of early radiation exposure in the Puerto Rico pediatric population. Available literature sustains that repeated exposure to imaging-related radiation in the pediatric population is associated with a 3-fold increase in the risk of developing pediatric hematogenous and central nervous system malignancies. It is for this reason that an international effort known as the Image Gently Campaign was created, mostly based on the "As Low As Reasonably Achievable" (ALARA) principle described by the Center for Disease Control. With this in mind, our aim was to identify whether there are any discrepancies in imaging tendencies outside our pediatric academic center in Puerto Rico and to determine whether our patients are at increased risk of over-radiation. There were 181 patients; five were excluded because of incomplete data. Our results show that children with appendicitis who are evaluated at nontertiary centers are more likely to have a CT scan performed (93%, OR: 4.054; 95% confidence interval: 2.6-6.4), as opposed to a nonradiating imaging study. In the Pediatric University Hospital, a CT scan was performed as the initial study in 23 per cent of the patients (OR: 0.09; 95% confidence interval: 0.05-0.18), favoring ultrasound as the diagnostic modality of choice. Our concern is that if this trend does not change, our pediatric population might have an increased risk of developing associated malignancies. We believe a local effort toward educational strategies should be implemented to prevent radiation overexposure in our pediatric patients.

Silent Presentation of a Solid Pseudopapillary Neoplasm of the Pancreas.

BACKGROUND Solid pseudopapillary neoplasm (SPN) is a rare tumor frequently found in the head or tail of the pancreas. It mainly presents in young women between the 2nd and 3rd decades of life. A predilection for African Americans and Asians has been observed and is rarely reported in children. Most patients are symptomatic, with abdominal pain as the most common presenting symptom. Clinical laboratory test results are usually normal and pancreatic markers are not typically elevated. Metastatic disease is very uncommon, but most often metastasizes to the liver and regional lymph nodes. Prognosis is usually excellent after surgical resection. CASE REPORT We present the case of a 14-year-old Hispanic female who presented to the emergency department after a high-speed motor vehicle accident. She suffered multiple body traumas. Specifically, the patient referred severe epigastric pain. No significant past medical or surgical history was obtained. Laboratory workup was non-contributory. Further evaluation with abdomen and pelvis contrast-enhanced computed tomography and magnetic resonance imaging revealed a pancreatic tail mass. Distal pancreatectomy followed. Pathologic diagnosis of SPN was established. CONCLUSIONS SPN is a rare exocrine tumor with excellent prognosis following resection. Imaging findings are suggestive, but a pathology evaluation is necessary to make the final diagnosis. Differential diagnosis includes entities such as mucinous cystic pancreatic tumor, pancreatic ductal carcinoma, and pancreatic serous cystadenoma. Radiologists play a vital role in the diagnosis, since many times, as in our case, it presents as an incidental finding. A small percentage of SPN neoplasms are associated with metastasis or local recurrence. Therefore, the aim of our case presentation is to review key imaging findings to guide early management and surgical planning.

Glycerin suppositories used prophylactically in premature infants (SUPP) trial: a study protocol for a pilot randomized controlled trial.

BACKGROUND: Feeding is a significant challenge for premature infants in the neonatal intensive care unit (NICU). These patients are often treated with glycerin suppositories to stimulate the passage of meconium and prevent feeding intolerance. Unfortunately, the evidence for this practice is inconclusive. METHODS/DESIGN: This protocol is for an external pilot study that will assess the feasibility of a superiority, placebo-controlled, parallel-design, multicenter randomized controlled trial. Participants are premature infants treated in a level 3 NICU with a gestational age 24 to 32 weeks and/or birth weight of 500 to 1500 g. Thirty participants will be recruited as part of this external pilot study. Participants will be randomized to glycerin suppository (250 mg) or placebo starting 48 to 72 h after birth and continuing once daily until meconium evacuation is complete or for a maximum of 12 days. The placebo consists of a 250-mg glycerin suppository placed in the diaper rather than the rectum. Study treatments are administered by the charge nurse on duty who is not otherwise involved in patient care. All other clinicians and research personnel will remain blinded. Outcomes for the pilot study are percentage of eligible participants randomized, percentage of infants reaching full enteral feeds, cost, and treatment-related adverse events (rectal bleeding, rectal perforation, and anal fissure). DISCUSSION: This external pilot study will assess the feasibility of a multicenter randomized controlled trial of glycerin suppositories in premature infants. The subsequent multicenter trial will have sufficient power to determine whether this treatment strategy is associated with decreased time to full enteral feeds. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02153606.

Recalcitrant coloanal strictures in children managed by transanal circular stapled reanastomosis.

Coloanal strictures are the narrowing of a segment of the colon leading to multiple complications. In the pediatric population they most commonly follow anastomotic procedures. Occasionally, coloanal strictures do not respond to standard dilatational management requiring operation. Transanal circular-stapled reanastomosis successfully treats dilatational resistant strictures in adults. We review four consecutive pediatric patients with benign, recalcitrant, coloanal anastomotic strictures managed successfully with this technique. To the best of our knowledge this is the first case series describing the use of this therapeutic modality for this type of strictures in pediatric patients.

Transanal circular-stapled reanastomosis as a management alternative for anastomotic colonic strictures: a novel technique in the pediatric patient.

A 12-year-old male patient with a recalcitrant rectal anastomotic stricture following two failed endorectal pull-through (Soave) procedures for Hirschsprung's disease was satisfactorily managed with transanal resection using a circular stapling device. This is the first reported case of a benign colonic anastomotic stricture treated transanally with a circular stapling device in a pediatric patient.

Spigelian hernia in children: case report and literature review.

Spigelian hernias occur through a defect in the anterior abdominal wall adjacent to the semilunar line and lateral to the abdominal rectus. Spigelian hernias are rare regardless of the patient's age and even uncommon in the pediatric population. We report a 9-year-old male patient who presented with a bulging at the left lower abdomen consistent with a Spigelian hernia. A review of the data published between 1955 and 2010 pertaining to pediatric patients with Spigelian hernias follows. Effective treatment for this condition is surgical. Repair follows general principles with layered or plicated closure of the defect with absorbable sutures. Recurrence is unlikely.