International Study of the Epidemiology of Paediatric Trauma: PAPSA Research Study.

OBJECTIVES: Trauma is a significant cause of morbidity and mortality worldwide. The literature on paediatric trauma epidemiology in low- and middle-income countries (LMICs) is limited. This study aims to gather epidemiological data on paediatric trauma. METHODS: This is a multicentre prospective cohort study of paediatric trauma admissions, over 1 month, from 15 paediatric surgery centres in 11 countries. Epidemiology, mechanism of injury, injuries sustained, management, morbidity and mortality data were recorded. Statistical analysis compared LMICs and high-income countries (HICs). RESULTS: There were 1377 paediatric trauma admissions over 31 days; 1295 admissions across ten LMIC centres and 84 admissions across five HIC centres. Median number of admissions per centre was 15 in HICs and 43 in LMICs. Mean age was 7 years, and 62% were boys. Common mechanisms included road traffic accidents (41%), falls (41%) and interpersonal violence (11%). Frequent injuries were lacerations, fractures, head injuries and burns. Intra-abdominal and intra-thoracic injuries accounted for 3 and 2% of injuries. The mechanisms and injuries sustained differed significantly between HICs and LMICs. Median length of stay was 1 day and 19% required an operative intervention; this did not differ significantly between HICs and LMICs. No mortality and morbidity was reported from HICs. In LMICs, in-hospital morbidity was 4.0% and mortality was 0.8%. CONCLUSION: The spectrum of paediatric trauma varies significantly, with different injury mechanisms and patterns in LMICs. Healthcare structure, access to paediatric surgery and trauma prevention strategies may account for these differences. Trauma registries are needed in LMICs for future research and to inform local policy.

High-definition neural visualization of rodent brain using micro-CT scanning and non-local-means processing.

BACKGROUND: Micro-CT holds promising potential for phenotyping and histological purposes. However, few have clarified the difference in the neuroimaging quality between ex vivo and in vivo micro-CT scanners. In addition, no direct comparison has been made between micro-CT scans and standard microscopy. Furthermore, while the efficacy of various stains for yielding soft-tissue contrast in CT scans have been compared in other studies for embryos, staining protocols for larger samples have yet to be clarified. Lastly, post-acquisition processing for image enhancements have not been addressed. METHODS: Comparisons of postnatal rat brain micro-CT scans obtained through custom-built ex vivo and commercially available in vivo micro-CT scanners were made. Subsequently, the scanned rat brains were then H&E stained for microscopy. Neuroanatomy on micro-CT scanning and 4× microscopy of rat brain were compared. Diffusion and perfusion staining using iodine or PTA were trialled on adult and neonatal encapsulated rat brains. Different combinations of stain concentration and staining time were trialled. Post-acquisition denoising with NLM filter was completed using a modern General-Purpose Graphic Processing Unit (GPGPU) and custom code for prompt processing. RESULTS: Ex vivo micro-CT scans of iodine-stained postnatal rat brains yields 3D images with details comparable to 4× H&E light micrographs. Neural features shown on ex vivo micro-CT scans were significantly more distinctive than those on in vivo micro-CT scans. Both ex vivo and in vivo micro-CT scans required diffusion staining through small craniotomy. Perfusion staining is ineffective. Iodine staining was more efficient than PTA in terms of time. Consistently, enhancement made by NLM denoising on in vivo micro-CT images were more pronounced than that on ex vivo micro-CT scans due to their difference in image signal-to-noise indexes. CONCLUSIONS: Micro-CT scanning is a powerful and versatile visualization tool available for qualitative and potential quantitative anatomical analysis. Simple diffusion staining via craniotomy with 1.5% iodine is an effective and minimal structural-invasive method for both in vivo and ex vivo micro-CT scanning for studying the microscopic morphology of neonatal and adult rat brains. Post-acquisition NLM filtering is an effective enhancement technique for in vivo micro-CT brain scans.

Is 14 the new 40: trends in gallstone disease and cholecystectomy in Australian children.

BACKGROUNDS: Gallstone disease and cholecystectomy have been uncommon in paediatric patients and associated with haemolytic disease and prematurity. Many countries have observed an increase in the prevalence of paediatric gallstones and cholecystectomy with increasing childhood obesity. The purpose of this study was to determine any trend in prevalence in Australian children and the role of obesity. METHODS: Chart review was conducted for patients undergoing cholecystectomy under 18 in 25 years between 1992 and 2016. Patients were grouped based on year of operation into five groups of 5 years each. Patient demographics including age and gender were noted, as were weight, height, and percentiles. Also noted were comorbidities, indication for surgery, whether elective or emergent, and procedure performed. Statistical analysis was performed using logistic regression on R-Studio®. RESULTS: Seventy-nine patients were included, 9, 15, 18, 18, and 19 in Groups 1-5, respectively. A trend was noted of increasing frequency which did not reach statistical significance. Nineteen patients had alternative explanations for gallstone disease, decreasing over time, coefficient - 10.5. A trend was also noted of increasing proportion of patients in higher percentiles for weight, which was statistically significant for those above the 98th percentile. CONCLUSIONS: The changing profile of paediatric cholecystectomy is a little recognised aspect of the 'obesity epidemic'. This has implications when considering the impact of childhood overweight and obesity, and for clinicians involved in the diagnosis and management of these children.

Long-term follow-up of paediatric anorectal anomalies and the role and efficacy of parent support groups for such conditions.

BACKGROUND/PURPOSE: There are a multitude of parent support groups for most life situations and medical conditions. The aim of this study was to discover defining characteristics and to evaluate the structure and effectiveness of parent support groups in paediatric anorectal anomalies. METHODS: Over 200 non-profit organisations and parent support groups were sent questionnaires to determine their effectiveness. Many of these were excluded as they were deemed not relevant to the final study. A final 20 groups were included for review, questions were based around origins, activities, education and evaluation, organisational structure and their affiliations with the health care team. RESULTS: Most groups had similar origins, usually an educated parent who had a child born with the condition and a zest for further knowledge and understanding and a desire to share this with others in a similar situation. Only 20% received government funding; few had paid staff and half had good relations with the local medical and paramedical fraternity. The majority had a team of long-term enthusiastic volunteers who remained with the group to support others long after their own child was no longer a concern. CONCLUSIONS: Some support groups offer a valuable service to families alongside the medical and paramedical fraternity. These groups provide families with the day-to-day lived experiences through social media, networking and meetings. Some provide more formal educational conferences designed to bring families, the medical and paramedical fraternity together to learn valuable lessons from each other.

Surgical method to prevent early death of neonatal rat pups with Hirschsprung disease, thus permitting development of long-term therapeutic approaches.

Hirschsprung disease occurs when children are born with no intrinsic nerve cells in varying lengths of the large intestine. In the most severe cases, neurons are also missing from the distal part of the small intestine. Nerve-mediated relaxation of the aganglionic bowel fails and fecal matter accumulates in the more proximal regions of the intestine. This is life threatening. Perforation of the bowel can ensue, causing sepsis and in some cases, death of the infant. Repopulation of the colon with neural stem cells is a potential therapy, but for this to be successful the patient or experimental animal needs to survive long enough for neural precursors to differentiate and make appropriate connections. We have developed a surgical procedure that can be applied to rats with Hirschsprung disease. A stoma was created to allow the normal bowel to empty and a second stoma leading to the aganglionic bowel was also created. This allowed homozygous mutants that would usually die at less than 3 weeks of age to survive into adulthood. During this time, the rats also required post-operative care of their stomas. The interventions we describe provide an animal model of Hirschsprung disease that is suited to assess the effectiveness of cell therapies in the treatment of this condition.

Congenital midline cervical cleft with an underlying bronchogenic like cyst.

Congenital midline cervical cleft (CMCC) is an uncommon malformation. We report a case of a baby girl aged 3 days with a CMCC associated with a cyst reported as a bronchogenic cyst (BC). The pathology is not specific. The association of BC and CMCC is extremely rare and only five cases have been found in the literature. We report our case and review the relevant literature.

Lymphopaenia in the diagnosis of paediatric appendicitis: a false sense of security?

BACKGROUND: Appendicitis is a common indication for emergent surgery in children; however, it is a small proportion of presentations with abdominal pain. As viral illness is a common differential diagnosis, lymphopaenia is used by some as a predictor against appendicitis. Furthermore, neutrophil-lymphocyte ratio (NLR) has been found to predict appendicitis. We aimed to verify if lymphopaenia predicted against appendicitis in children. METHODS: Retrospective review was conducted for all patients aged 15 years and under presenting with abdominal pain to our institution in 2017, and data including age, white cell count, neutrophil and lymphocyte count, NLR, C-reactive protein and diagnosis of appendicitis were recorded. Statistical analysis was performed using Stata©. Receiver operating characteristic curves for various tests were formed and areas under curve (AUC) compared using regression, P < 0.05 was considered significant. RESULTS: A total of 1263 patients were presented, of whom 546 had their blood performed and were included, 86 had appendicitis and 460 did not. Neutrophilia was the best predictor for appendicitis (AUC = 0.86), significantly higher than NLR (0.81), P < 0.05. Lymphopaenia was a poor negative predictor of appendicitis (AUC = 0.46), and while isolated lymphopaenia was more predictive (AUC = 0.23) this was inferior to the positive prediction of neutrophilia, P < 0.05. CONCLUSION: The value of isolated lymphopaenia to predict against appendicitis is largely accounted for inherently normal neutrophils, independently lymphopaenia has little value. NLR, while predictive, is a weaker predictor than neutrophilia.

Surgical Intervention to Rescue Hirschsprung Disease in a Rat Model.

BACKGROUND/AIMS: Rats with a spontaneous null mutation in endothelin receptor type B or Ednrb (sl/sl; spotting lethal) lack enteric neurons in the distal bowel and usually die within the first week after birth. This early postnatal lethality limits their use for examining the potential of cell therapy to treat Hirschsprung disease, and for studies of the influence of EDNRB on the mature CNS and vascular systems. METHODS: We have developed a surgical intervention to prolong the life of the spotting lethal sl/sl rat, in which we perform a colostomy on postnatal (P) day 4-6 rats to avoid the fatal obstruction caused by the lack of colonic enteric neurons. RESULTS: The stomas remained patent and functional and the rats matured normally following surgery. Weight gains were comparable between control and Hirschsprung phenotype (sl/sl) rats, which were followed until 4 weeks after surgery (5 weeks old). We confirmed the absence of enteric neurons in the distal colon of rats whose lives were saved by the surgical intervention. CONCLUSIONS: This study provides a novel approach for studying EDNRB signalling in multiple organ systems in mature rats, including an animal model to study the efficacy of cell therapy to treat Hirschsprung disease.

Placental mesenchymal dysplasia associated with hepatic mesenchymal hamartoma in the newborn.

Placental mesenchymal dysplasia is an uncommon disorder in which the placenta is enlarged with abnormal, large, and often cystic villi with dilated and/or thick-walled vessels. These placental changes can mimic a partial hydatidiform mole but in contrast to a partial mole can coexist with a fully viable fetus. Fetal anatomical and vascular anomalies frequently coexist with placental mesenchymal dysplasia. In this case, placental mesenchymal dysplasia was associated with preterm labor at 33 weeks' gestation, fetal compromise, and a large abdominal mass with a large hepatic cyst that was de-roofed at exploratory laparotomy. The neonate remained critically ill with hypoxic ischaemic encephalopathy and coagulopathy and died despite intensive care. Biopsy and autopsy findings showed a large cystic mesenchymal hamartoma affecting the left lobe of the liver. This appears to be the 3rd histologically confirmed association of placental mesenchymal dysplasia with mesenchymal hamartoma of the liver in the English language literature.

Successful management of congenital chyloperitoneum with fibrin glue.

Chylous ascites in children has been treated in a variety of ways, including a low-fat diet, medium chain triglycerides, diuretics, total parental nutrition, surgical exploration, and internal peritoneo-venous shunting. The authors describe a child with persistent congenital chyloperitoneum treated successfully with the application of fibrin glue and recommend this as an effective alternative to traditional approaches.