A Retrospective Evaluation of Airway Anatomy in Young Children and Implications for One-Lung Ventilation.

OBJECTIVE: One-lung ventilation (OLV) in children remains a niche practice with few studies to guide best practices. The objective of this study was to describe lower airway anatomy relevant to establishment of OLV in young children. DESIGN: Retrospective, observational study using pre-existing studies in the electronic health record. SETTING: Single institution, academic medical center, tertiary-care hospital. PARTICIPANTS: Pediatric patients <8 years old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Chest computed tomographic scans of 111 children 4 days to 8 years of age were reviewed. Measurements were taken from the thyroid isthmus to the carina, carina to first lobar branch on the left and right, diameter of the trachea at the carina, and diameter of the left and right mainstem bronchi. Dimensions were correlated with the outer diameter of endotracheal tubes and bronchial blockers. The left mainstem bronchus is consistently smaller than the right. Lung isolation using a mainstem technique on the left should use an endotracheal tube a half size smaller than would be used for tracheal intubation. The length from the carina to the first lobar branch on the left is consistently 3 times longer than on the right. Further, age-delineated bronchial diameters suggest that the clinician should transition from a 5F to a 7F Arndt bronchial blocker at 3-to-4 years of age. CONCLUSION: A more detailed and accurate understanding of pediatric lower airway anatomy may assist the clinician in successfully performing OLV in young children.

Necrotizing Enterocolitis and Growth in Preterm Infants Fed Predominantly Maternal Milk, Pasteurized Donor Milk, or Preterm Formula: A Retrospective Study.

Objective To evaluate the association between necrotizing enterocolitis (NEC), growth, and feeding. Methods This is a retrospective study of 551 infants (birth weight ≤ 1,500 g, ≤32 weeks' gestation). NEC, Bell's stage ≥ 2, was confirmed by independent review of sentinel radiographs. Feeding type was defined as ≥ 50% maternal milk (MM), pasteurized donor human milk (PDHM), or preterm formula (PF). Demographic and clinical characteristics including growth were compared between the three groups. Multivariable regression analysis was performed to control variables that differed in bivariate analysis. Results PDHM and PF mothers were more likely to be African-American, be enrolled in Medicaid, and have chorioamnionitis. PF mothers received antenatal steroids less frequently. NEC rates were different by feeding group (MM: 5.3%; PHDM: 4.3%; PF: 11.4%; p = 0.04). Adjusting for group differences, lower gestational age (adjusted odds ratio [aOR]: 0.85; 95% confidence interval [CI]: 0.74-0.97; p = 0.02], and PF (aOR: 2.53; 95% CI: 1.15-5.53; p = 0.02] were associated with NEC. There were no differences in other health outcomes or growth at hospital discharge. Conclusion MM and PDHM feedings, given until 34 weeks postmenstrual age, were associated with lower rates of NEC in very low birth weight infants without interfering with growth.

Imaging of primary pediatric lymphoma of bone.

BACKGROUND: Primary pediatric bone lymphoma is a rare form of non-Hodgkin lymphoma. Unlike nodal forms of lymphoma, imaging abnormalities in lymphoma of bone do not resolve rapidly in conjunction with treatment and radiologic findings can remain abnormal for years, making it difficult to evaluate treatment response. OBJECTIVE: To evaluate the utility of imaging in assessment of patients with primary pediatric bone lymphoma. MATERIALS AND METHODS: At our institution between 2004 and 2013, six cases of pathology-proven primary pediatric bone lymphoma were diagnosed. Retrospective chart review was performed to assess imaging utilization. Our data were qualitatively compared with existing literature to construct an algorithm for imaging patients with primary lymphoma of bone. RESULTS: Imaging evaluation of patients with primary pediatric bone lymphoma was highly variable at our institution. Conventional imaging was routinely used to evaluate response to treatment, despite lack of appreciable osseous change. Imaging in the absence of symptoms did not alter clinical management. Only positron emission tomography CT (PET/CT) proved capable of demonstrating imaging changes from the pretreatment to the post-treatment scans that were consistent with the clinical response to treatment. CONCLUSION: Surveillance imaging is likely unnecessary in patients with a known diagnosis of pediatric lymphoma of bone. Pretreatment and post-treatment PET/CT is likely sufficient to assess response. There is little data to support the use of interim and surveillance PET/CT.

Imaging of the elbow in children with wrist fracture: an unnecessary source of radiation and use of resources?

BACKGROUND: Anecdotally accepted practice for evaluation of children with clinically suspected or radiographically proven wrist fracture in many urgent care and primary care settings is concurrent imaging of the forearm and elbow, despite the lack of evidence to support additional images. These additional radiographs may be an unnecessary source of radiation and use of health care resources. OBJECTIVE: Our study assesses the necessity of additional radiographs of the forearm and elbow in children with wrist injury. MATERIALS AND METHODS: We reviewed electronic medical records of children 17 and younger in whom wrist fracture was diagnosed in the emergency department. We identified the frequency with which additional radiographs of the proximal forearm and distal humerus demonstrated another site of acute injury. RESULTS: We identified 214 children with wrist fracture. Of those, 129 received additional radiographs of the elbow. Physical examination findings proximal to the wrist were documented in only 16 (12%) of these 129 children. A second injury proximal to the wrist fracture was present in 4 (3%) of these 129 children, all of whom exhibited physical examination findings at the elbow. No fractures were documented in children with a negative physical examination of the elbow. CONCLUSION: Although elbow fractures occasionally complicate distal forearm fractures in children, our findings indicate that a careful physical evaluation of the elbow is sufficient to guide further radiographic investigation. Routine radiographs of both the wrist and elbow in children with distal forearm fracture appear to be unnecessary when an appropriate physical examination is performed.

Bilateral parotitis as the initial presentation of childhood sarcoidosis.

The differential diagnosis of bilateral parotid gland enlargement in children includes infectious, inflammatory, and neoplastic disorders. We present the case of a 13-year-old male who presented with a 5-week history of bilateral parotid swelling. On exam, both parotid glands were nontender, smooth, and diffusely enlarged. He had slightly elevated inflammatory markers, but other lab results were normal. A neck CT revealed symmetric enlargement of the parotid, submandibular, and sublingual glands. A chest CT revealed scattered peripheral pulmonary nodules and bilateral hilar adenopathy. A parotid gland biopsy showed multiple noncaseating granulomas with multinucleated giant cells surrounded by lymphocytes, consistent with the diagnosis of sarcoidosis. Special stains for acid-fast and fungal organisms were negative. Using this illustrative case, we discuss the differential diagnosis of bilateral salivary gland enlargement in children and review the etiology, diagnosis, clinical manifestations, and treatment of pediatric sarcoidosis.

Adnexal masses in female pediatric patients.

OBJECTIVE: This article reviews the range of adnexal masses that present in pediatric females. The preferred imaging modalities, the appearance of the normal ovaries, and the epidemiology of ovarian diseases and abnormalities are discussed. The illustrated abnormalities include simple and complex ovarian and paraovarian cysts, neoplasms, ovarian torsion, ectopic pregnancy, and tuboovarian abscess, with attention to the imaging features and vascular flow patterns that help distinguish surgical from nonsurgical cases, malignant from benign lesions, and ovarian abnormalities from mimickers. CONCLUSION: The critical clinical questions to the radiologist in the setting of adnexal lesions are the site of origin, benign versus malignant features, and presence of infection or abscess. Pairing clinical presentation and imaging findings will direct appropriate management, whether it is reassurance, follow-up imaging, or surgery.

Deployment and testing of an automated medical equipment service communication and documentation system at a rural hospital in Kenya.

BACKGROUND: The Medical Equipment Network Documentation System (MENDS) provides a simple communication network for equipment servicing from failure to restoration. It is a text messaging-based platform, designed to use existing technologies in place in low- and middle-income settings. The system gathers and relays information about equipment service requests and reports and automatically saves them to an online database. METHODS: MENDS was deployed at a high volume, rural, charity medical facility in Kijabe, Kenya for a 3-mo pilot test. RESULTS: The results show MENDS more than tripled documentation and enhanced ease and speed of communication. CONCLUSIONS: Comprehensive data provided by MENDS created more accurate measures of equipment performance, which can be used to decrease the time that equipment is out of service and improve the efficiency of repairs, equipment quality and procurement.

Ionizing Radiation Exposure in Pediatric Patients With Intestinal Failure.

BACKGROUND: Children with intestinal failure (IF) are frequently exposed to imaging studies using ionizing radiation. Due to many advancements in care of pediatric patients with IF, the number of patients living with this condition is growing. This burden of disease as pertains to pediatric IF patients has not been previously described. METHODS AND RESULTS: 10 patients in a multidisciplinary clinic for IF were included in a retrospective review of ionizing imaging studies. Ages ranged from 2-6 years old. The average number of studies performed exposing patients to ionizing radiation was 69.1 (±41.0). A majority of the studies were plain radiographs. Fluoroscopy studies were common. The Computed tomography scans were less common. An average of 31% (±25.7%) of these studies were obtained before the first discharge from the hospital. CONCLUSIONS: While survival and outcomes of IF patients continue to improve, it is important to consider the impact of radiation-related exposure to which this population is frequently subjected. Long-term follow-up will be necessary to determine whether or not this translates to increased risks or complications in this already vulnerable patient population.

Pyomyositis due to Streptococcus pneumoniae.

Pyomyositis is an unusual but potentially serious disease in children. Staphylococcus aureus is the most commonly implicated pathogen, but pneumococcal pyomyositis is very rare. Clinical diagnosis of pyomyositis can be difficult often mimicking septic arthritis of the hip or appendicitis. We report a 12-year-old male with pyomyositis caused by Streptococcus pneumoniae who presented with fever and severe right hip and abdominal pain. Magnetic resonance imaging of the right hip revealed the diagnosis of pyomyositis. Blood cultures grew Streptococcus pneumoniae, sensitive to penicillin, ceftriaxone, and clindamycin. He was successfully treated with a 3-week course of clindamycin. Early recognition, appropriate antibiotic therapy, and if indicated, drainage of the muscle abscess is critical to reduce morbidity and mortality.

Common Pediatric Sports Injuries.

This article reviews the common acute and overuse injuries encountered in the pediatric athlete. Acute injuries are usually physeal or avulsion fractures relating to a single traumatic event. Overuse injuries are the result of repetitive stress and include the common traction apophysitis, osteochondritis dissecans, and stress fractures. Sports-related injuries most frequently involve the lower extremity with injury patterns and frequencies relative to the athlete's age, size, and type of sport. Indeed, an alternative title for this review might be Òthe adolescent athlete as the changing biomechanics and psychosocial stresses of adolescence are inherent risk factors for sports-related injuries. An estimated seven million adolescents currently play high school sports with an increasing number becoming interested in extreme sports. It is hoped that this review will assist your future encounters with the injured pediatric athlete or Òweekend warrior.

Neonatal systemic thromboembolism secondary to ductus arteriosus aneurysm and patent foramen ovale.

Ductus arteriosus aneurysm (DAA) can be associated with neonatal thromboembolism. We report a neonate with systemic thromboembolism causing acute cerebral infarction with DAA, arterial, and venous thrombosis, discovered on CT angiography. The role of DAA was suspected as a potential etiology of systemic thromboembolism in this case. CT angiography with three-dimensional reconstruction was valuable delineating the adjunctive vascular structures. Screening for presence of DAA may be considered in the neonatal thromboembolism.

Occult megarectum--a commonly unrecognized cause of enuresis.

OBJECTIVE: To determine whether occult megarectum remains a commonly unrecognized cause of enuresis and whether treating it will cure enuresis in most children. A landmark study proved constipation was a commonly unrecognized cause of enuresis in 1986 in which constipation was defined as abnormal rectal distension. However, modern recommendations have focused on signs of functional constipation, such as hard or rare stools. METHODS: A retrospective review of 30 consecutive patients seen in our clinic with a chief complaint of nocturnal enuresis was performed, with an analysis of the results of their plain abdominal radiographs. The results of the studies were determined using a novel method termed the rectal/pelvic outlet ratio and Leech criteria. These results were compared with the reported constipation history according to the International Children's Continence Society guidelines, which recommends asking parents and children whether the child's bowel movements occur less often than every other day and whether the stool consistency is hard. Patients diagnosed with megarectum were treated with laxatives, with the goal of restoring normal rectal tone. RESULTS: All patients demonstrated rectal distension according to the rectal/pelvic outlet ratio, and 80% were constipated according to the Leech criteria. Only 10% of the patient or families reported clinical symptoms of constipation. All the adolescent patients in our study and 80% of the younger patients were cured of enuresis with laxative therapy. CONCLUSION: Occult megarectum remains a commonly undiagnosed cause of nocturnal enuresis. Abdominal radiographs represent a simple, noninvasive method to diagnose megarectum and might improve the treatment of nocturnal enuresis.

Infantile orbital cellulitis secondary to community-associated methicillin-resistant Staphylococcus aureus.

Community-associated methicillin-resistant Staphylococcus aureus (MRSA) is increasingly recognized as a cause of invasive disease in children. Orbital cellulitis typically occurs in older children, but it can occasionally affect infants and neonates. We report 2 infants with sepsis and orbital cellulitis caused by community-associated MRSA and review the relevant literature.

Pediatric occupants, restraint use, and injuries in motor vehicle crashes - biomed 2011.

Pediatric occupants are vulnerable in motor vehicle crashes (MVCs), and alternative restraints have been developed for their protection. This study sought to characterize injuries in MVCs for pediatric occupants and to identify scenarios that may benefit from enhanced vehicle safety. Using the NASS-CDS database (2000-2008), pediatric occupants (< 19 yr old) were characterized by their age and injuries to look at national averages in MVCs. There were over 14 million pediatric injuries and non-injured occupants in weighted NASS-CDS (out of over 70 million total). Of these pediatric cases, 60% sustained injuries, which was comparable to the percentage of all occupants injured (65%). Six percent of NASS-CDS pediatric occupants had AIS 2+ injuries, which is the injury inclusion criteria for CIREN pediatric cases. CIREN was used to investigate pediatric occupants and injuries resulting from incorrect positioning and restraints according to NHTSA suggestions. Results indicated that many injured pediatric occupants were not properly restrained, with over 100 in the front row of the vehicle under 13 years of age. There were also over 200 CIREN pediatric occupants under 4’ 9” that were not seated in a child safety seat (CSS). The most frequently injured body region was the face, followed by the head and lower extremity. Eighty-six percent of head injuries and 82% of spinal injuries were AIS 2+. This study supports prior findings that demonstrate a need for enhanced public awareness for proper CSS use to reduce pediatric injuries in the future.

Pregnant female anthropometry from ct scans for finite element model development.

In this study, anthropometry data is collected from a CT scan of a pregnant abdomen at 32 weeks gestation. Over 1500 fetal losses occur each year in the United States due to motor vehicles crashes. Pregnant occupants involved in motor vehicle crashes are at risk for pregnancy-specific injuries. Masks of the fetus, uterus, placenta, and each of the abdominal organs are created by segmentation of the CT slices and three-dimensional volume renderings are formed. The volume and Hounsfield unit ranges for the masks of each abdominal organ are calculated. The total volume of the uterus in the 3rd trimester is measured as 3378 cm3. By measuring the length of bones on the fetal skeleton from CT slices and the 3D rendering, the gestational age of the fetus is estimated to be 32 weeks by comparison with literature values. Measurements of each of the abdominal organs are also obtained from the 3D rendering to create a blueprint of the pregnant anatomy. The masks developed and the anthropometric measurements taken will be used to develop a more accurate FE model of the pregnant female for use in the research and development in academia, industry, and government.

Spontaneous regression of langerhans cell histiocytosis in a neonate with multiple bony lesions.

We report the case of a newborn with Langerhans cell histiocytosis involving the skin and multiple bones. All lesions resolved without therapy. This case underscores the benefits of a conservative approach in the absence of risk organ involvement.