Applications of contrast-enhanced ultrasound in the pediatric abdomen

Contrast-enhanced ultrasound (CEUS) is a radiation-free, safe, and in specific clinical settings, highly sensitive imaging modality. Over the recent decades, there is cumulating experience and a large volume of published safety and efficacy data on pediatric CEUS applications. Many of these applications have been directly translated from adults, while others are unique to the pediatric population. The most frequently reported intravenous abdominal applications of CEUS in children are the characterization of focal liver lesions, monitoring of solid abdominal tumor response to treatment, and the evaluation of intra-abdominal parenchymal injuries in selected cases of blunt abdominal trauma. The intravesical CEUS application, namely contrast-enhanced voiding urosonography (ceVUS), is a well-established, pediatric-specific imaging technique entailing the intravesical administration of ultrasound contrast agents for detection and grading of vesicoureteral reflux. In Europe, all pediatric CEUS applications remain off-label. In 2016, the United States Food and Drug Administration (FDA) approved the most commonly used worldwide second-generation ultrasound contrast SonoVue®/Lumason® for pediatric liver and intravesical applications, giving new impetus to pediatric CEUS worldwide.

Long-Term Influence of C1-C2 Pedicle Screw Fixation on Occipitoatlantal Angle and Subaxial Cervical Spine in the Pediatric Population

OBJECTIVE

The goal of this study was to evaluate the impact of C1-C2 pedicle screw fixation on the occipitoatlantal angle and subaxial cervical spine for a pediatric population, and the clinical efficacy and adjacent-segment degeneration after C1-C2 pedicle screw fixation with a minimum of 2 years of follow-up.

METHODS

Twenty-two pediatric patients with atlantoaxial dislocation who were enrolled in this study underwent atlantoaxial pedicle screw fixation. The correlation between C0-C1, C2-C7, and C1-C2 pre- and postoperative sagittal angles was assessed using plain radiographs, and adjacent-segment degeneration (ASD) and JOA scores (Japanese Orthopaedic Association scores) were evaluated after atlantoaxial pedicle screw fixation.

RESULTS

The C1-C2 angle increased from 16.1 ± 13.37 to 28.1 ± 5.1° (p < 0.01). The pre- and postoperative C1-C2 angles were negatively correlated with the pre- and postoperative C0-C1 and C2-C7 angles, respectively. In accordance with the optimal atlantoaxial fusion angle (25-30°) obtained from the literature, postoperative JOA scores were greater in the groups with angles of more than 30° and less than 25°, although the difference in ASD was not statistically significant. Postoperative JOA scores were not relevant to the postoperative C1-C2 angle; however, there was a positive correlation between JOA improvement rate and the change of the C1-C2 angle postoperatively.

CONCLUSION

Atlantoaxial pedicle screw fixation can be used easily to reduce atlantoaxial dislocation in the pediatric population; however, outside the range of the optimal atlantoaxial fusion angle it can change the occipitoatlantal angle and subaxial alignment, which induces ASD and influences the clinical efficacy. It is necessary to achieve an optimal atlantoaxial angle when using atlantoaxial pedicle screw fixation.

Pharmacoeconomic Analysis of Drugs Used in the Treatment of Pneumonia in Paediatric Population in a Tertiary Care Hospital in India-A Cost-of-Illness Study

AIMS AND OBJECTIVES

The cost of antibiotic therapy for the treatment of pneumonia in the inpatient paediatric population can have a major impact on the healthcare expenditure. We planned to assess the direct and indirect costs of diagnosis and medical treatment of paediatric patients with community acquired pneumonia who are hospitalized in a tertiary care hospital in India.

METHODS

125 children with a diagnosis of pneumonia who were admitted to the inpatient department of a paediatric hospital receiving antibiotic treatment were observed. Data on clinical presentation and resources consumed were collected and the costs of pneumonia treatment were calculated. Descriptive statistics (mean ± standard deviation (SD)) were used to evaluate data regarding demographics, drugs prescribed and cost (direct and indirect cost). Multivariate regression analysis was used to find out predictors of direct and indirect cost.

RESULTS

Among all pneumonia admissions, mild-to-moderate pneumonia constitutes 76.8%, and 23.2% children were admitted with severe pneumonia; 105 children out of 125 (84%) were suffering from associated disorders along with pneumonia. The majority of antibiotics prescribed belonged to beta lactams (52%) followed by aminoglycosides (19%), macrolides (13%) and peptides (11%). Parenteral routes of administration were used in a majority of patients as compared to oral. The average cost per patient in management of pneumonia was 12245 ± 593 INR ($187.34 ± 9.07).

Sporadic desmoid tumors in the pediatric population: A single center experience and review of the literature

BACKGROUND/PURPOSE

We present our long experience with desmoid tumors in children.

METHODS

Data were retrospectively collected from 17 children/adolescents treated for sporadic desmoid tumors at a tertiary pediatric hospital in 1988-2016. There were 10 girls and 7 boys aged 1-17years. Tumor sites included head and neck, trunk, extremity, and groin. Eight patients underwent radical resection, with complete remission in 7 and local relapse in one which was treated with chemotherapy. Four patients underwent incomplete surgical resection, three with adjuvant chemotherapy. Five patients underwent biopsy only and chemotherapy. Two of the 9 chemotherapy-treated patients also had intraarterial chemoembolization. Chemotherapy usually consisted of vincristine and actinomycin-D with or without cyclophosphamide or low-dose vinblastine and methotrexate. Two patients also received tamoxifen.

RESULTS

After a median follow-up of 3.3years, 10 patients were alive in complete remission, 5 had stable disease, and 2 had reduced tumor size. Five-year overall survival was 100%, and event-free survival, 87.5%. Ten were screened for CTNNB1 mutations. CTNNB1 gene sequencing yielded mutations in 5/10 samples tested: 3 T41A, 2 S45F. There was no association of CTNNB1 mutation with clinical outcome or prognosis.

CONCLUSION

Pediatric desmoid tumors are rare, with variable biologic behavior and morbidity. Treatment requires a multidisciplinary approach.

LEVEL OF EVIDENCE

LEVEL IV, treatment study.

Multivariate trajectories across multiple domains of health-related quality of life in children with new-onset epilepsy

The diagnosis of epilepsy in children is known to impact the trajectory of their health-related quality of life (HRQOL) over time. However, there is limited knowledge about variations in longitudinal trajectories across multiple domains of HRQOL. This study aims to characterize the heterogeneity in HRQOL trajectories across multiple HRQOL domains and to evaluate predictors of differences among the identified trajectory groups in children with new-onset epilepsy. Data were obtained from the Health Related Quality of Life in Children with Epilepsy Study (HERQULES), a prospective multi-center study of 373 children newly diagnosed with new-onset epilepsy who were followed up over 2years. Child HRQOL and family factors were reported by parents, and clinical characteristics were reported by neurologists. Group-based multi-trajectory modeling was adopted to characterize longitudinal trajectories of HRQOL as measured by the individual domains of cognitive, emotional, physical, and social functioning in the 55-item Quality of Life in Childhood Epilepsy Questionnaire (QOLCE-55). Multinomial logistic regression was used to assess potential factors that explain differences among the identified latent trajectory groups. Three distinct HRQOL trajectory subgroups were identified in children with new-onset epilepsy based on HRQOL scores: "High" (44.7%), "Intermediate" (37.0%), and "Low" (18.3%). While most trajectory groups exhibited increasing scores over time on physical and social domains, both flat and declining trajectories were noted on emotional and cognitive domains. Less severe epilepsy, an absence of cognitive and behavioral problems, lower parental depression scores, better family functioning, and fewer family demands were associated with a "Higher" or "Intermediate" HRQOL trajectory. The course of HRQOL over time in children with new-onset epilepsy appears to follow one of three different trajectories. Addressing the clinical and psychosocial determinants identified for each pattern can help clinicians provide more targeted care to these children and their families.

Relationship between body weight and postmenstrual age in a Korean pediatric population

Weight is a covariate representative of body size and is known to influence drug disposition. Recently, with increased use of allometric scaling, this variable has become more significant in accounting for variability in pharmacokinetic parameters. In adults, weight can be considered as a time invariant covariate because physical development is complete. As a result, when weight is missing in data, the typical or median value (say, 70 kg) could be imputed. On the contrary, weight continuously changes with age in the pediatric population. In this case, it is more appropriate to consider different median weight for each age group. We constructed a prediction model for weight using postmenstrual age (PMA) with the data consisting of 83,014 Korean pediatric patients. Weight, PMA, and gender information were collected from electronic medical records. Sigmoid models multiplied by exponential or logistic function were tested for basic model structure. Covariate effects on model parameters were then investigated using selection criteria of p < 0.001. All analyses were performed using NONMEM 7.3.0 and R3.2.0. The sigmoid model multiplied by logistic function best described the data and there was a significant difference between boys and girls in model parameters. It is expected that the results obtained in this work can be used for imputation of missing weights in pediatrics when PMA is available. In addition, the developed model can be used for clinical studies in children under 12 years old whose weight change rapidly with age and for model building in dealing with time varying body weight as a covariate.

Social economic costs of type 1 diabetes mellitus in pediatric patients in Spain: CHRYSTAL observational study

AIMS

To estimate the social-economic costs of Type 1 Diabetes Mellitus (T1DM) in patients aged 0-17years in Spain from a social perspective.

METHODS

We conducted a cross-sectional observational study in 2014 of 275 T1DM pediatric outpatients distributed across 12 public health centers in Spain. Data on demographic and clinical characteristics, healthcare utilization and informal care were collected from medical records and questionnaires completed by clinicians and patients' caregivers.

RESULTS

A valid sample of 249 individuals was analyzed. The average annual cost for a T1DM patient was €27,274. Direct healthcare costs were €4070 and direct non-healthcare cost were €23,204. Informal (familial) care represented 83% of total cost, followed by medical material (8%), outpatient and primary care visits (3.1%) and insulin (2.1%). Direct healthcare cost per patient statistically differed by glycated haemoglobin (HbA1c) level [mean cost €4704 in HbA1c ≥7.5% (≥58mmol/mol) group vs. €3616 in HbA1c<7.5% (<58mmol/mol) group)]; and by the presence or absence of complications and comorbidities (mean cost €5713 in group with complications or comorbidities vs. €3636 in group without complications or comorbidities).

CONCLUSIONS

T1DM amongst pediatric patients incurs in considerable societal costs. Informal care represents the largest cost category.

The role of upper airway obstruction and snoring in the etiology of monosymptomatic nocturnal enuresis in children

This study evaluated the necessity of examining the upper airway in children with nocturnal enuresis. 225 children (aged 5-16 years), who were referred from the urology outpatient clinic between May 2015 and May 2016 and who had completed toilet training, were included in this study. Participants were separated into monosymptomatic nocturnal enuresis (MNE) (group 1) and without MNE (group 2) groups. Tonsil hypertrophy, adenoid vegetation, septal deviation, turbinate hypertrophy, allergic rhinitis, upper airway obstruction, and snoring etiology were assessed. In total, 112 children with MNE (group 1) participated in addition to 113 children selected randomly without MNE (group 2). Adenoid score (p = 0.016), septal deviation (p = 0.017), and snoring (p = 0.007) were significantly different between the groups. No differences in tonsil score (p = 0.618), turbinate hypertrophy (p = 0.424), and allergic rhinitis (p = 0.544) were detected between the groups. Possible causes of upper airway obstruction and snoring which is a symptom of obstructive sleep-disordered breathing in the pediatric population, including adenoid hypertrophy and septal deviation, should be considered as possible etiological factors in children with MNE.

Exposure to phthalates is associated with lipid profile in peripubertal Mexican youth

Animal models indicate that endocrine disrupting chemicals (EDCs) affect circulating lipid concentrations by interfering with hepatic fatty acid oxidation. Little is known of the relationship between EDC exposure and lipid profile in humans. We measured bisphenol A (BPA) and 9 phthalate metabolites in maternal urine collected at up to three time points during pregnancy as a measure of in utero exposure, and in the child's urine at 8-14 years as a measure of concurrent, peripubertal exposure among 248 participants of a Mexico City pre-birth cohort. We used linear regression to examine relations of BPA and phthalate exposure with peripubertal serum lipids, while also adjusting for child age, sex, and specific gravity. While in utero EDC exposure was not associated with lipid profile, higher concurrent levels of mono-3-carboxypropyl phthalate (MCPP), monoethyl phthalate (MEP), and dibutyl phthalate metabolites (DBP) corresponded with lower total cholesterol and low-density lipoprotein (LDL-C) in boys; e.g., an interquartile range increment in MCPP corresponded with 7.4% (2.0%, 12.8%) lower total cholesterol and 12.7% (3.8%, 21.6%) lower LDL-C. In girls, higher urinary di-2-ethylhexyl phthalate metabolites (ΣDEHP) correlated with lower LDL-C (-7.9% [-15.4%, -0.4%]). Additional longitudinal research is needed to determine whether these associations persist beyond adolescence.

Health associations with meeting new 24-hour movement guidelines for Canadian children and youth

The study objective was to examine whether meeting the new Canadian 24-hour movement guidelines was associated with health indicators in a representative sample of Canadian children and youth. Cross-sectional findings are based on 4157 (1239 fasting subsample) children and youth aged 6-17years from cycles 1-3 of the Canadian Health Measures Survey (CHMS). Sleep and screen time were subjectively measured while moderate- to vigorous-intensity physical activity (MVPA) was accelerometer-determined. Health indicators in the full sample (body mass index (BMI) z-scores, waist circumference, blood pressure, behavioral strengths and difficulties score (lower=better), and aerobic fitness) and fasting subsample (triglycerides, high-density lipoprotein (HDL)-cholesterol, C-reactive protein, and insulin) were measured. Meeting the overall guidelines was defined as: 9-11 hour/night (5-13years) or 8-10 hour/day (14-17years) of sleep, ≤2 hour/day of screen time, and ≥60 minute/day of MVPA. Compared to meeting all three recommendations, meeting none, one, and two recommendations were associated with a higher BMI z-score, waist circumference, and behavioral strengths and difficulties score and lower aerobic fitness in a gradient pattern (P_trend<0.05). Additionally, compared to meeting all three recommendations, meeting none and one recommendation were associated with higher systolic blood pressure and insulin (P_trend<0.05). Finally, compared to meeting all three recommendations, meeting no recommendations was associated with higher triglycerides and lower HDL-cholesterol (P_trend<0.05). Collectively, meeting more recommendations within the 24-hour movement guidelines was associated with better overall health. Since a small proportion (17%) of this representative sample was meeting the overall guidelines, efforts to promote adoption are needed.

Conservative Management of Large Traumatic Supratentorial Epidural Hematoma in the Pediatric Population

BACKGROUND/AIMS

Conservative management of traumatic epidural hematomas is being recognized as a safe alternative to surgical treatment in asymptomatic children. There is still debate about the maximal size of epidural hematoma that should be tolerated before deciding for surgery.

METHODS

We report - through a retrospective cohort study from a single institution - a series of 16 conservatively managed traumatic epidural hematomas of more than 15 mm thickness.

RESULTS

14 patients (88%) were successfully treated using conservative management. Two patients required surgery. These 2 patients had the only 2 documented high-velocity injury mechanisms. All patients had a Glasgow Outcome Scale of 5/5 on follow-up.

CONCLUSION

Conservative management with close observation is a safe alternative even in this population of voluminous hematomas. Injury velocity may be a contributing factor for failure of conservative management in this population.

Therapy-related myeloid neoplasms in children and adolescents

BACKGROUND

This retrospective study aimed to characterize and analyze the outcome of therapy-related myeloid neoplasms (t-MNs) in children and adolescents.

METHODS

The medical records of 16 patients under 21 years of age at the time of t-MN diagnosis were reviewed.

RESULTS

The median patient age was 11.5 years (range, 1.6-20.4 yr). Twelve patients had therapy-related acute myeloid leukemia, 3 patients had myelodysplastic syndrome, and 1 patient had chronic myelomonocytic leukemia. The median latency period was 29 months (range, 11-68 mo). Fourteen patients had cytogenetic aberrations, 8 of whom had an 11q23 abnormality. Of the 13 patients treated with curative intent, 12 patients received myeloid-type induction therapy that led to complete remission (CR) in 8 patients. Nine patients underwent allogeneic transplantation; 4 patients did not undergo transplantation due to chemotherapy-related toxic death (N=3) or parental refusal (N=1). The 5-year overall survival and event-free survival of the 13 patients treated with a curative intent were 46.2% and 30.8%, respectively. For the 9 patients who underwent allogeneic transplantation, the 5-year event-free survival was 66.7%.

CONCLUSION

A significant proportion of young patients with t-MNs can experience long-term survival, and allogeneic transplantation plays a key role for attaining cure in these patients.

How do You Select an Anesthesia Method Prior to Tympanostomy Tube Insertion for a Child?

The use of general (face-mask inhalation and intravenous) anesthesia has been the method of choice for tympanostomy tube insertion in children. However, there is no exact guideline for the choice of anesthesia method and there is no evidence to support the use of one anesthesia method over another. Clinically, the anesthesia method used to be decided by old customs and the surgeon's blind faith that children cannot bear tympanostomy tube insertion under local anesthesia. Clinicians should keep in mind that pediatric anesthesia has a potential risk. Despite infrequent serious complications, their seriousness necessitates that sedation or general anesthesia should be done by an anesthesiologist and thus children requiring tympanostomy tube insertion should be referred to secondary or tertiary hospitals, even if they have been followed by a primary care physician for a long time. Previous evidence showed that local anesthesia is appropriate for tympanostomy tube insertion in selected children, especially in children older than 5 years are older. Proper choice of anesthesia method is helpful for both patient and medical service provider. Local anesthesia can give psychological relief to children and their parent. It is easier for the medical service providers to schedule the operation and allocate the medical resources in their hospital. Local anesthesia can reduce individual, social, and national burdens for the health care services.

Pulmonary Crohn's Disease in Down Syndrome: A Link or Linkage Problem

Crohn's disease (CD) is an autoimmune inflammatory disorder that primarily affects the gastrointestinal tract. It may have pulmonary involvement, which has been rarely reported in pediatric patients. Down syndrome (DS) has been associated with increased frequency of autoimmune diseases. However, associations between CD and DS have been rarely reported. We present the case of a 5-year-old girl with known DS and a history of chronic intermittent abdominal pain who presented with persistent pneumonia. Her workup included a chest computed tomography (CT) scan that showed multiple noncalcified pulmonary nodules. An extensive infectious workup was done that was negative. CT-guided needle biopsy of the lung nodules showed necrotizing granulomas. This raised concern for primary CD with extraintestinal pulmonary manifestation. An esophagogastroduodenoscopy and colonoscopy were performed, and colon biopsies showed scattered epithelioid granulomas. Based on this information, there was consensus that her lung nodules were secondary to CD. She was started on standard therapy for CD, and her abdominal and respiratory symptoms gradually improved. However, she continues to have mild residual lung calcification and fibrosis. To our knowledge, this is the first reported case of pulmonary CD in a child with DS. The natural history of pulmonary CD in the pediatric population is not very well studied. Furthermore, since DS has been well known to be associated with increased frequency of malignancies and autoimmune conditions due to immune dysregulation, it is difficult to predict the severity and possible complications in this patient.

Stunned myocardium after an anesthetic procedure in a pediatric patient - case report

Takotsubo syndrome (TTS) is an acquired transient type of systolic dysfunction which mimics myocardial infarction clinically and electrocardiographically. TTS is also known as stress cardiomyopathy, broken heart syndrome, apical ballooning, reversible acute heart failure, neurogenic stunned myocardium or acute catecholamine cardiomyopathy. This case report describes an uncommon presentation of myocardial stunning after an anesthetic procedure. A 14-year-old girl with a history of pineal cyst and hemiplegic migraine was admitted for control brain magnetic resonance imaging. During anesthesia induction with propofol she suffered bradycardia, which was reversed with atropine, followed by tachyarrhythmia, reversed with lidocaine and precordial thump. Within hours she developed pulmonary edema and global respiratory failure due to acute left ventricular dysfunction. A transthoracic echocardiogram showed a dilated left ventricle with global hypokinesia and depressed left ventricular systolic function (ejection fraction <30%). The electrocardiogram showed persistent sinus tachycardia and nonspecific ST-T wave abnormalities. Cardiac biomarkers were elevated (troponin 2.42 ng/ml, proBNP 8248 pg/ml). She was placed on diuretics, angiotensin-converting enzyme inhibitors, digoxin and dopamine. The clinical course was satisfactory with clinical, biochemical and echocardiographic improvement within four days. Subsequent echocardiograms showed no ventricular dysfunction. The patient was discharged home on carvedilol, which was discontinued after normalization of cardiac function on cardiac magnetic resonance imaging. Few cases of TTS have been described in children, some of them triggered by acute central nervous system disorders and others not fulfilling all the classical diagnostic criteria. In this case the anesthetic procedure probably triggered the TTS.

Hippocampus and amygdala volumes from magnetic resonance images in children: Assessing accuracy of FreeSurfer and FSL against manual segmentation

The volumetric quantification of brain structures is of great interest in pediatric populations because it allows the investigation of different factors influencing neurodevelopment. FreeSurfer and FSL both provide frequently used packages for automatic segmentation of brain structures. In this study, we examined the accuracy and consistency of those two automated protocols relative to manual segmentation, commonly considered as the "gold standard" technique, for estimating hippocampus and amygdala volumes in a sample of preadolescent children aged between 6 to 11 years. The volumes obtained with FreeSurfer and FSL-FIRST were evaluated and compared with manual segmentations with respect to volume difference, spatial agreement and between- and within-method correlations. Results highlighted a tendency for both automated techniques to overestimate hippocampus and amygdala volumes, in comparison to manual segmentation. This was more pronounced when using FreeSurfer than FSL-FIRST and, for both techniques, the overestimation was more marked for the amygdala than the hippocampus. Pearson correlations support moderate associations between manual tracing and FreeSurfer for hippocampus (right r=0.69, p<0.001; left r=0.77, p<0.001) and amygdala (right r=0.61, p<0.001; left r=0.67, p<0.001) volumes. Correlation coefficients between manual segmentation and FSL-FIRST were statistically significant (right hippocampus r=0.59, p<0.001; left hippocampus r=0.51, p<0.001; right amygdala r=0.35, p<0.001; left amygdala r=0.31, p<0.001) but were significantly weaker, for all investigated structures. When computing intraclass correlation coefficients between manual tracing and automatic segmentation, all comparisons, except for left hippocampus volume estimated with FreeSurfer, failed to reach 0.70. When looking at each method separately, correlations between left and right hemispheric volumes showed strong associations between bilateral hippocampus and bilateral amygdala volumes when assessed using manual segmentation or FreeSurfer. These correlations were significantly weaker when volumes were assessed with FSL-FIRST. Finally, Bland-Altman plots suggest that the difference between manual and automatic segmentation might be influenced by the volume of the structure, because smaller volumes were associated with larger volume differences between techniques. These results demonstrate that, at least in a pediatric population, the agreement between amygdala and hippocampus volumes obtained with automated FSL-FIRST and FreeSurfer protocols and those obtained with manual segmentation is not strong. Visual inspection by an informed individual and, if necessary, manual correction of automated segmentation outputs are important to ensure validity of volumetric results and interpretation of related findings.

Age as a Determinant to Select an Anesthesia Method for Tympanostomy Tube Insertion in a Pediatric Population

BACKGROUND AND OBJECTIVES

To evaluate the relationship between age and anesthesia method used for tympanostomy tube insertion (TTI) and to provide evidence to guide the selection of an appropriate anesthesia method in children.

SUBJECTS AND METHODS

We performed a retrospective review of children under 15 years of age who underwent tympanostomy tube insertion (n=159) or myringotomy alone (n=175) under local or general anesthesia by a single surgeon at a university-based, secondary care referral hospital. Epidermiologic data between local and general anesthesia groups as well as between TTI and myringotomy were analyzed. Medical costs were compared between local and general anesthesia groups.

RESULTS

Children who received local anesthesia were significantly older than those who received general anesthesia. Unilateral tympanostomy tube insertion was performed more frequently under local anesthesia than bilateral. Logistic regression modeling showed that local anesthesia was more frequently applied in older children (odds ratio=1.041) and for unilateral tympanostomy tube insertion (odds ratio=8.990). The cut-off value of age for local anesthesia was roughly 5 years.

CONCLUSIONS

In a pediatric population at a single medical center, age and whether unilateral or bilateral procedures were required were important factors in selecting an anesthesia method for tympanostomy tube insertion. Our findings suggest that local anesthesia can be preferentially considered for children 5 years of age or older, especially in those with unilateral otitis media with effusion.

Evaluation of transcutaneous electrical posterior tibial nerve stimulation for the treatment of fecal and urinary leaks in children: preliminary results

OBJECTIVE

To examine the effectiveness of posterior tibial nerve stimulation (PTNS) for the treatment of fecal and urinary incontinence in children with malformations of the bowel or neurological pathologies.

INTRODUCTION

Treatment of fecal and urinary leaks, in cases of congenital malformations remains a challenge. Recent studies in adults have shown the effectiveness of PTNS.

METHOD

Eight children: 4 with anorectal malformations, 3 with neurological causes (1 medullary lipoma, 1 Arnold Chiari malformation, 1 sacrococcygeal teratoma) and 1 with Hirschsprung's disease presenting with serious anal incontinence, despite extensive bowel management during at least 2 years, were treated with PTNS. Six children had associated urinary leaks. Jorge-Wexner score for defecation and Schurch score for urine were used before treatment and after the second and sixth months of stimulation.

RESULTS

After six months, five patients had no more fecal leakage, two patients were improved and one did not respond. Five out of the 6 patients with urinary leaks were continent at 6 months.

CONCLUSION

PTNS is a noninvasive technique and painless modality which seems to be effective for the treatment of fecal and urinary leaks in children even with congenital digestive pathologies or neurological malformations. These results will be confirmed in a prospective study.

Chronic unilateral locked facet joint with spinal cord injury in a 26-month-old child: A case report

OBJECTIVES

This study presents the successful posterior surgical reduction and fusion on a 26-month-old child with chronic unilateral locked facet joint and spinal cord injury (SCI).

METHODS

A 26-month-old child with chronic unilateral locked facet joint and SCI treated by posterior surgical reduction and fusion. Plaster external fixation was applied and rehabilitation exercise was trained post-operatively.

RESULTS

Chronic unilateral locked facet joint was reduced successfully and bone fusion of C4/5 was achieved 3 months after surgery. The function of both lower limbs was improved 1 year after surgery, aided with physical rehabilitation.

CONCLUSION

Unilateral locked facet joint in pediatric population is rare. Few clinical experiences were found in the literature. Non-surgical treatment has advantages of not being invasive and is preferred for acute patients; however, it may not be suitable for chronic unilateral locked facet joint with SCI, in which surgical intervention is needed.

Radiological prevalence of superior and posterior semicircular canal dehiscence in children

OBJECTIVE

Establishing the prevalence of semicircular canal dehiscence in a pediatric population using temporal bone CT imaging.

STUDY DESIGN

Retrospective analysis of all temporal bone CT scans during a 5-year period (2007-2012).

METHODS

CT scan images were reformatted in the plane of the canals and assessed by two independent reviewers with a third to resolve disagreement. Detailed chart review was performed for those found to have dehiscence. Superior and posterior canals were classified as "dehiscent", "possibly dehiscent", "thin" or "normal" for each case.

RESULTS

649 temporal bones were assessed from 334 children (under 18 years of age). The prevalence rate of superior canal dehiscence (SCD) was 1.7% (3.3% of individuals). Posterior canal dehiscence (PCD) was present in 1.2% (2.1% of individuals). There were no cases of bilateral SCD, and one case of bilateral PCD. Age under 3 years was associated with a higher prevalence of thinning but not dehiscence. Congenital inner ear malformation was not related to a higher probability of dehiscence. The superior petrosal sinus was associated with the SCD in three cases (27.3%). Retrospective chart review highlighted possible vestibular symptoms in 3/11 patients with SCD (27.3%).

CONCLUSIONS

This forms the largest pediatric study of canal dehiscence to date. This study's prevalence rate is significantly lower than previous reports. The identified association with overlying venous structures may reflect the etiological process involved. The occurrence in children supports the hypothesis of a congenital predisposition for development of canal dehiscence syndrome.

Laminar screw fixation of the axis in the pediatric population: a series of eight patients

BACKGROUND CONTEXT

Instability of the atlantoaxial spine is a recognized problem in children. Safe passage of pedicle screws at C2 poses challenges because of the proximity to the vertebral artery, size of the pedicles, and variations in the location of the foramen transversarium.

PURPOSE

The C2 translaminar technique is a useful option and its stability is comparable to that offered by C2 pedicle screws. In this follow-up from our previously published study, we wanted to verify the safety and suitability of the C2 laminar screw in the treatment of cervical instability in the pediatric population.

STUDY DESIGN/SETTING

We present a case series of eight pediatric patients who underwent laminar screw fixation of the axis as part of their operative procedure.

PATIENT SAMPLE

There were five girls and three boys, with a mean age of 7 years (range 2-17 years) who underwent this procedure. Surgical indications included atlantoaxial instability, atlanto-occipital disassociation, multilevel cervical instability, and high cervical stenosis. Seven patients had underlying dysplastic syndromes.

OUTCOME MEASURES

We studied the technical feasibility of passing laminar screws at C2 in eight consecutive patients, paying attention to screw length and diameter, vascular or neurologic complications, and stability of fixation.

METHODS

This retrospective study was funded by our institution and there was no potential conflict of interest. All patients were placed prone. The posterior aspect of the cervical spine and craniocervical junction were exposed subperiosteally. We report our modification of the Wright technique, which allowed us to safely pass 3.5-mm screws into both laminae of the second cervical vertebra.

RESULTS

A total of 15 laminar screws were passed at C2. The follow-up period ranged from 1 to 24 months (mean 8 months). There were no vascular or neurologic complications, no infection, and no instances of hardware failure either by lamina fracture or screw pullout. All patients maintained stable constructs on imaging studies at the last follow-up evaluation.

CONCLUSION

Children as young as 2 years can undergo safe and rigid fixation of the axis. The technique is especially valuable in patients with dysplastic bone and distorted anatomy where more traditional methods of C2 fixation cannot be safely used. To our knowledge, this is the largest reported series of C2 laminar screw fixation in a pediatric population.

Anatomic feasibility of posterior cervical pedicle screw placement in children: computerized tomographic analysis of children under 10 years old

OBJECTIVE

To evaluate the anatomical feasibility of 3.5 mm screw into the cervical spine in the pediatric population and to establish useful guidelines for their placement.

METHODS

A total of 37 cervical spine computerized tomography scans (24 boys and 13 girls) were included in this study. All patients were younger than 10 years of age at the time of evaluation for the period of 2007-2011.

RESULTS

For the C1 screw placement, entry point height (EPH) was the most restrictive factor (47.3% patients were larger than 3.5 mm). All C2 lamina had a height larger than 3.5 mm and 68.8% (51/74) of C2 lamina had a width thicker than 3.5 mm. For C2 pedicle width, 55.4% (41/74) of cases were larger than 3.5 mm, while 58.1% (43/74) of pedicle heights were larger than 3.5 mm. For pedicle width of subaxial spine, 75.7% (C3), 73% (C4), 82.4% (C5), 89.2% (C6), and 98.1% (C7, 1/54) were greater than 3.5 mm. Mean lamina width of subaxial cervical spine was 3.1 (C3), 2.7 (C4), 2.9 (C5), 3.8 (C6), and 4.0 mm (C7), respectively. Only 34.6% (127/370) of subaxial (C3-7) lamina thickness were greater than 3.5 mm. Mean length of lateral mass for the lateral mass screw placement was 9.28 (C3), 9.08 (C4), 8.81 (C5), 8.98 (C6), and 10.38 mm (C7).

CONCLUSION

C1 lateral mass fixation could be limited by the morphometrics of lateral mass height. C2 trans-lamina approach is preferable to C2 pedicle screw fixation. In subaxial spines, pedicle screw placement was preferable to trans-lamina screw placement, except at C7.

[Type 1 Diabetes Mellitus: brief review of the main associated psychological factors]

Type 1 Diabetes Mellitus (T1DM) is a widespread chronic disease among children and adolescents. Diagnosis and evolution usually involves a significant burden on the patient, and their families must change various aspects of their lifestyle to fulfill the demands of treatment. This study aims to identify the main psychological, family, and adjustment to illness features of children and adolescents diagnosed with DM1 and, in particular to highlight the associated psychopathological factors. The methodology involved a systematic literature search in the main scientific databases. Due to the biopsychosocial impact of DM1 usually assumed in the life of the child and family, and how it may compromise the quality of life and emotional well-being of both, different studies have agreed on the importance of identifying the set of psychological factors involved in healthy adjustment to illness in the child and adolescent with DM1.

Feasibility of pediatric plasma apheresis in intensive care settings

Therapeutic plasma apheresis or exchange (TPE) in the pediatric population is technically challenging. Moreover, there is generally an apprehension in using TPE in children compared to adults. Recently, usage of TPE has evolved and is now being used in heterogenous clinical conditions. Its usefulness is classified by the American Society for Apheresis (ASFA) into various categories ranging from I to IV. The objective of this paper was to review the procedure in context of clinical indications, complications and outcomes in children. For this purpose, we retrospectively reviewed all TPE procedures performed on inpatients of 3 to 16 years of age during a 6-year period (2007-2012). A total of 130 procedures were performed on 28 patients (M : F ratio of 1:1) with median age (range) of 8.8 (4-16) years. All procedures were done using the continuous cell-separator centrifugal method. Due to organ dysfunctions, the majority of procedures (N = 26 of 28 or 92% patients) were performed in the pediatric intensive care unit. Twenty-three, four and one patient belonged to ASFA categories I, II and III, respectively. The most common indications were neurological disorders (N = 13 or 46.4%), comprised of Guillain-Barré syndrome (N = 10) and myasthenia gravis (N = 3). Hematological disorders (N = 10 or 35.7%) including thrombotic thrombocytopenic purpura-hemolytic uremic syndrome were a close second. Complete recovery was seen in 23 patients (84%). Trivial adverse effects were observed in 18/130 (13.8%) procedures. Major complications including cardiac arrest, hypotension and transfusion-related acute lung injury were observed in 5/130 or 3.8% of procedures. However, there was no procedure-related death though five patients died during treatment due to underlying pathology. In conclusion, TPE is a safe and effective option in sick children for appropriate indications. An experienced staff with sound procedural skills is imperative for successful therapy.

[Influenza vaccination coverage in children with risk conditions in Catalonia]

INTRODUCTION

Influenza vaccination is recommended in Catalonia in children older than 6 months with risk conditions for developing flu-related complications. The aim of this study is to determine influenza vaccine coverage in children with risk conditions and their association with socio-demographic factors and medical variables.

MATERIAL AND METHOD

Descriptive cross-sectional study of children with risk conditions for developing influenza complications (aged between 6months and 15years old) assigned to Primary Health Care centers in Catalonia at the beginning of the 2011-2012 influenza vaccination campaign. The information on vaccination status and study variables were obtained from data registered on electronic health records by primary care teams. The relationship between influenza vaccination and demographic and medical variables was analyzed using bivariate analysis and a multiple logistic regression model.

RESULTS

Influenza vaccination coverage was 23.9%. Variables associated with influenza vaccination were: age 2years or older (aOR: 1.6 [1.4-1.7] in children 3-5years old; 1.8 [1.7-2.0] in those 6-10 years, and 2.2 [2.0 -2.4] in children ≥11years]); male sex (aOR: 1.1 [1.0-1.1]); foreign nationality (aOR: 1.2 [1.2-1.3]); age-appropriate immunization according to the systematic immunization schedule (aOR: 3.3 [2.8-3.8]); more than one visit to the primary care physician (5 or more visits) (aOR: 4.1 [3.8-4.4]), and more than one risk condition (3 or more conditions) (aOR: 2.5 [1.6-3.9]).

DISCUSSION

Compared to other countries, influenza vaccination coverage among children with risk conditions is low in our study. Strategies to improve coverage should be implemented.

Recent management of urinary stone disease in a pediatric population

The incidence of stone disease has been increasing and the risk of recurrent stone formation is high in a pediatric population. It is crucial to use the most effective method with the primary goal of complete stone removal to prevent recurrence from residual fragments. While extracorporeal shock wave lithotripsy (ESWL) is still considered first line therapy in many clinics for urinary tract stones in children, endoscopic techniques are widely preferred due to miniaturization of instruments and evolution of surgical techniques. The standard procedures to treat urinary stone disease in children are the same as those used in an adult population. These include ESWL, ureterorenoscopy, percutaneous nephrolithotomy (standard PCNL or mini-perc), laparoscopic and open surgery. ESWL is currently the procedure of choice for treating most upper urinary tract calculi in a pediatric population. In recent years, endourological management of pediatric urinary stone disease is preferred in many centers with increasing experience in endourological techniques and decreasing sizes of surgical equipment. The management of pediatric stone disease has evolved with improvements in the technique and a decrease in the size of surgical instruments. Recently, endoscopic methods have been safely and effectively used in children with minor complications. In this review, we aim to summarize the recent management of urolithiasis in children.

Prolonged sitting and markers of cardiometabolic disease risk in children and youth: a randomized crossover study

OBJECTIVE

Recent evidence suggests that short bouts of uninterrupted sedentary behavior reduce insulin sensitivity and glucose tolerance while increasing triglyceride levels in both healthy and overweight/obese adults. To date no study has examined the acute impact of uninterrupted sitting in children and youth. The objective of the present study was to determine whether 8 h of uninterrupted sitting increases markers of cardiometabolic disease risk in healthy children and youth, in comparison to 8 h of sitting interrupted by light intensity walk breaks or structured physical activity.

MATERIALS/METHODS

11 healthy males and 8 healthy females between the ages of 10 and 14 years experienced 3 conditions in random order: (1) 8 h of uninterrupted sitting (Sedentary); (2) 8 h of sitting interrupted with a 2-min light-intensity walk break every 20 min (Breaks); and (3) 8 h of sitting interrupted with a 2-min light-intensity walk break every 20 min as well as 2×20 min of moderate-intensity physical activity (Breaks+Physical Activity). Insulin, glucose, triglyceride, HDL and LDL cholesterol area under the curve were calculated for each condition.

RESULTS

We observed no significant differences in the area under the curve for any marker of cardiometabolic disease risk across the 3 study conditions (all p>0.09).

CONCLUSIONS

These results suggest that in comparison to interrupted sitting or structured physical activity, a single bout of 8 h of uninterrupted sitting does not result in measurable changes in circulating levels of insulin, glucose, or lipids in healthy children and youth.