Trends in Pediatric Mild Traumatic Brain Injury During COVID-19-Related Lockdown-A Single-Center Study.

BACKGROUND: A relevant number of visits to pediatric emergency departments (pED) are associated with mild traumatic brain injury (mTBI). On March 16, 2020, the Bavarian government declared a first full lockdown (LD) related to the coronavirus (COVID-19) pandemic. AIM: The aim of the study was to investigate the impact of LD on pediatric mTBI. METHODS: Retrospective chart review of presentations to a pED due to mTBI. Study periods covered LD (03/17/2020 through 05/05/2020) and the same time in 2017, 2018, and 2019 as reference period (RP). Comparative analyses were performed by Chi-square or Fisher's exact test. RESULTS: Numbers of mTBI cases decreased by half. Age distribution did not differ. A significantly higher proportion of mTBI were related to falls at home (p = 0.001). Further, a higher rate of hospital admissions (p = 0.03), a higher proportion of intensive care unit admissions (p = 0.001), a longer duration of hospital stay (p = 0.02), and a higher rate of intracranial pathologies on neuroimaging were observed during LD (p = 0.007). CONCLUSION: The decrease in mTBI presentations is likely due to an absolute decrease in numbers related to the LD measures, combined with a hesitation to present very minor mTBI to the hospital, because of fear of being infected or not to put additional strain on the healthcare system during this healthcare crisis. On the other hand, data of those that presented with mTBI tend to reflect the more severe spectrum of mTBI.

Habitual physical activity in patients born with oesophageal atresia: a multicenter cross-sectional study and comparison to a healthy reference cohort matched for gender and age.

Oesophageal atresia (EA) is associated with life-long gastrointestinal and respiratory morbidity and other associated malformations. The aim of this study is to compare physical activity (PA) levels of children and adolescents with and without EA. A validated questionnaire (MoMo-PAQ) was used to evaluate PA in EA patients EA (4-17 years), who were randomly matched for gender and age (1:5) with a representative sample of the Motorik-Modul Longitudinal Study (n = 6233). Sports activity per week (sports index) and minutes of moderate to vigorous physical activity per week (MVPA minutes) were calculated. Correlations between PA and medical factors were analysed. In total, 104 patients and 520 controls were included. Children with EA were significantly less active at higher intensities (mean MPVA minutes 462; 95% confidence interval (CI): 370-554) compared to controls (626; 95% CI: 576-676), although there was no statistically significant difference in the sports index (187; 95% CI: 156-220 versus 220; 95% CI: 203-237). A lower mean weight-for-age and height-for-age, additional urogenital (r = - 0.20, p = 0.04) or anorectal malformation (r = - 0.24, p = 0.01) were associated with fewer MVPA minutes. For other medical factors (prematurity, type of repair, congenital heart disease, skeletal malformation or symptom load), no statistically significant association with PA was found.  Conclusion: EA patients participated in PA at a similar level but lower intensities compared to the reference cohort. PA in EA patients was largely independent of medical factors. TRIAL REGISTRATION: German Clinical Trials Register (ID: DRKS00025276) on September 6, 2021. WHAT IS KNOWN: • Oesophageal atresia is associated with a low body weight and height, delayed development of motor skills and impaired lung function and exercise capacity. WHAT IS NEW: • Patients with oesophageal atresia have a similar amount of sports activity per week but engage significantly less in moderate to vigorous physical activities compared to peers. • Physical activity was  associated with weight-for-age and height-for-age, but largely independent of symptom load and other medical factors.

Repair of complex esophageal atresia with tracheobronchial remnant using special magnets.

Esophageal atresia (EA) repair can be complicated by associated malformations such as a tracheobronchial remnant in the distal esophagus. We describe our experience with a patient found to have long-gap EA with a distal cartilaginous ring who was managed using a combination of esophageal lengthening and magnetic compression anastomosis. A 5-month-old girl was referred to us from an outside hospital with type C EA including a very high upper pouch. She had undergone a prior thoracotomy with fistula ligation during which a clip was placed on the lower esophagus, leaving a 2-cm diverticulum on the trachea and a short lower esophageal pouch. Upon endoscopic evaluation at our center, we found a tracheobronchial remnant in the lower esophagus between the clip and the carina. An open thoracotomy was performed to approximate the esophageal pouches and a magnet anchor (Connect EA, Myka Laboratories, San Francisco, California, United States) was placed retrograde through the distal esophageal cartilaginous ring into the lower pouch. On postoperative day 8, after adequate growth and decreased pouch tension, a second magnetic anchor was placed endoscopically to the upper pouch to mate with the previously placed lower pouch anchor. The anastomosis formed within 14 days. Due to the tracheobronchial remnant, the device did not pass distally and was removed endoscopically. On postoperative day 8, balloon dilation of the anastomosis and tracheobronchial remnant was performed. Subsequently, the patient required a total of 6 dilations in an 18-month follow-up. This case report illustrates the utility of using magnets to create an esophageal anastomosis in complex cases of EA with concomitant esophageal malformations. The parents of the patient gave their written consent to publish this technical report.

Use of Barbed Sutures for Congenital Diaphragmatic Hernia Repair.

BACKGROUND: Congenital diaphragmatic hernia (CDH) repair can be challenging, particularly when a larger defect is present. Barbed sutures prevent the suture from slipping back after approximation of the tissues. Although introduced almost 2 decades ago, barbed sutures have not been widely used for CDH repair. We report our initial experience and pitfalls. METHODS: All patients presenting with CDH from 2021 onward underwent repair using barbed sutures. Demographics, operative parameters, complications, and outcomes were prospectively recorded. RESULTS: A total of 13 patients underwent CDH repair during the study interval (median age 6 days, range 3 days to 5.75 years). Median operative time was 89 min (range 46 to 288 min). Five thoracoscopic and eight open procedures were performed. Severe pulmonary hypertension and ECMO (extracorporeal membrane oxygenation) were considered contraindications for thoracoscopic repair. The included patients were compared to a historic controlled group performed without barbed sutures. The barbed suture facilitated easy and quick closure of the defects in most cases and obviated the need for knot tying. One patient in the thoracoscopic group had a patch placed due to high tension after the barbed sutures tore the diaphragm. At a median follow-up time of 15 months (range 2 to 34 months), one patient had died, and one patient with complete diaphragmatic agenesis was home-ventilated. There were no recurrences. Median operative time trended lower (89 min) than in the historic control group repaired without barbed sutures (119 min, p < 0.06) after eliminating outliers with large, complex patch repairs. CONCLUSIONS: Barbed sutures simplify congenital diaphragmatic hernia repair regardless of whether a minimal-invasive or open approach is performed. Patch repair is not a contraindication for using barbed sutures. The resulting potential time savings make them particularly useful in patients with cardiac or other severe co-morbidities in which shorter operative times are essential. In cases with high tension, though, the barbs may tear through and produce a "saw" effect on the tissue with subsequent damage.

Esophageal Magnetic Compression Anastomosis in Esophageal Atresia Repair: A PRISMA-Compliant Systematic Review and Comparison with a Novel Approach.

The use of magnet compression to endoscopically create an esophageal anastomosis is an intriguing approach to esophageal atresia repair, but published cases with an existing available device have demonstrated mixed success. One major shortcoming has been the formation of subsequent severe, recalcitrant strictures after primary repair. To address the limitations of the existing device, we recently introduced and reported success with specially designed bi-radial magnets that exhibit a novel geometry and unique tissue compression profile. The aim of this study is to compare the outcomes using our novel device (novel group, NG) with those of previous reports which utilized the historical device (historic group, HG) in a PRISMA-compliant systematic review. Seven studies were eligible for further analysis. Additionally, one of our previously unreported cases was included in the analysis. Esophageal pouch approximation prior to primary repair was performed more frequently in the NG than in the HG (100% NG vs. 21% HG; p = 0.003). There was no difference in the overall postoperative appearance of postoperative stricture (95% HG vs. 100% NG; p = 0.64). The number of postoperative dilatations trended lower in the NG (mean 4.25 NG vs. 9.5 HG; p = 0.051). In summary, magnetic compression anastomosis adds a new promising treatment option for patients with complex esophageal atresia. Prior approximation of pouches and a novel magnet design have the potential to lower the rate of stricture formation.

Telementoring in Minimally Invasive Esophageal Atresia Repair: Results of a Case-Control Study and Lessons Learned from the TIC-PEA Study (Telemedical Interdisciplinary Care for Patients with Esophageal Atresia).

Minimally invasive esophageal atresia (EA) repair is deemed one of the most demanding procedures in pediatric surgery. Open repair is considered the gold standard and learning opportunities for minimally invasive repairs remain scarce. "Telemedical Interdisciplinary Care for Patients with Esophageal Atresia (TIC-PEA)" offers free access to an interdisciplinary network of experts for telemedical consultation (telementoring). The aim of this study was to determine the frequency of minimally invasive surgery (MIS) in TIC-PEA patients compared to the general population. TIC-PEA patients were matched and compared to controls regarding the use of MIS, patient characteristics, and complications. Patients (n = 31) were included at a mean age of 62.8 days (95%-CI: 41.4-84.3, 77% after the primary esophageal repair). The odds-ratio to have MIS was 4.03 (95%-confidence interval: 0.79-20.55) for esophageal anastomosis and 4.60 (95%-confidence interval: 0.87-24.22) for tracheoesophageal fistula-repair in the TIC-PEA group. Telementoring offered the chance to select the ideal candidate for MIS, plan the procedure, and review intraoperative images and videos with the expert. Telementoring as offered is ideal to promote MIS for EA and helps to address the individual learning curve. In order to maximize benefits, patients need to be included prior to the first esophageal procedure.

Percutaneous Anorectoplasty (PARP)-An Adaptable, Minimal-Invasive Technique for Anorectal Malformation Repair.

BACKGROUND: Anorectal malformations comprise a broad spectrum of disease. We developed a percutaneous anorectoplasty (PARP) technique as a minimal-invasive option for repair of amenable types of lesions. METHODS: Patients who underwent PARP at five institutions from 2008 through 2021 were retrospectively analyzed. Demographic information, details of the operative procedure, and perioperative complications and outcomes were collected. RESULTS: A total of 10 patients underwent the PARP procedure during the study interval. Patients either had low perineal malformations or no appreciable fistula. Most procedures were guided by ultrasound, fluoroscopy, or endoscopy. Median age at PARP was 3 days (range 1 to 311) days; eight patients were male. Only one intraoperative complication occurred, prompting conversion to posterior sagittal anorectoplasty. Functional outcomes in most children were highly satisfactory in terms of continence and functionality. CONCLUSIONS: The PARP technique is an excellent minimal-invasive alternative for boys born with perineal fistulae, as well as patients of both sexes without fistulae. The optimal type of guidance (ultrasound, fluoroscopy, or endoscopy) depends on the anatomy of the lesion and the presence of a colostomy at the time of repair.

Reply to Peña, A. Comment on "Küppers et al. Percutaneous Anorectoplasty (PARP)-An Adaptable, Minimal-Invasive Technique for Anorectal Malformation Repair. Children 2022, 9, 587".

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Duodenal Atresia Repair Using a Miniature Stapler Compared to Laparoscopic Hand-Sewn and Open Technique.

Background: Laparoscopic duodenal atresia (DA) repair is a demanding procedure that requires performing a watertight anastomosis in a small working space. Drawbacks of the approach have been high leakage rates and long operative times. In this article, we evaluate our initial experience with DA repair using a laparoscopic miniature stapler (LA-MS) and compared outcomes with a historic cohort of laparoscopic hand-sewn (LA-HS) and open repairs (ORs). Materials and Methods: A retrospective analysis of all patients who underwent surgery for DA at our two centers between January 2010 and April 2018 was performed. Demographics, comorbidities, intra- and postoperative data, and outcome parameters were evaluated and statistically analyzed. Results: DA repair was performed in 44 patients. Ten patients underwent laparoscopic DA repair using an MS, 21 patients laparoscopic repair with HS anastomosis, and 13 patients underwent OR. Median age and weight at surgery was 13.5 days (range: 2-173) and 3300 g (range: 1630-5600) in the LA-MS group, 4 days (range: 2-269) and 2750 g (range: 1700-4095) in the LA-HS group and 4 days (range: 1-17) and 2222 g (range: 1520-3590) in the OR group, respectively. Mean operative time was significantly shorter in the laparoscopic stapled group compared with LA-HS group (145 ± 37 minutes (range: 97-217) versus 201 ± 47 minutes (range: 119-275), P < .004). Duodenojejunostomy was performed more frequently in the laparoscopic stapled group compared with the open procedure (P = .008). Overall complication rate was similar between groups. Time to initiation of feeds and time to full feeds were significantly shorter in the laparoscopic stapled group compared with the open approach (5 versus 11.9 days, P = .041 and 14.5 versus 24.4 days, P = .020). Conclusion: Laparoscopic DA repair using an MS is a novel, safe, and feasible technique that was associated with significantly shorter operating times than HS laparoscopic DA repair. Owing to its simplicity, this technique has the potential to become the new standard of care.

Identification of a PA-binding peptide with inhibitory activity against influenza A and B virus replication.

There is an urgent need for new drugs against influenza type A and B viruses due to incomplete protection by vaccines and the emergence of resistance to current antivirals. The influenza virus polymerase complex, consisting of the PB1, PB2 and PA subunits, represents a promising target for the development of new drugs. We have previously demonstrated the feasibility of targeting the protein-protein interaction domain between the PB1 and PA subunits of the polymerase complex of influenza A virus using a small peptide derived from the PA-binding domain of PB1. However, this influenza A virus-derived peptide did not affect influenza B virus polymerase activity. Here we report that the PA-binding domain of the polymerase subunit PB1 of influenza A and B viruses is highly conserved and that mutual amino acid exchange shows that they cannot be functionally exchanged with each other. Based on phylogenetic analysis and a novel biochemical ELISA-based screening approach, we were able to identify an influenza A-derived peptide with a single influenza B-specific amino acid substitution which efficiently binds to PA of both virus types. This dual-binding peptide blocked the viral polymerase activity and growth of both virus types. Our findings provide proof of principle that protein-protein interaction inhibitors can be generated against influenza A and B viruses. Furthermore, this dual-binding peptide, combined with our novel screening method, is a promising platform to identify new antiviral lead compounds.