Esophago-gastric junction findings on high resolution impedance manometry in children with esophageal atresia

OBJECTIVES

Using high resolution impedance manometry (HRIM), this study characterized the esophago-gastric junction (EGJ) dynamics in children with esophageal atresia (EA).

METHOD

Esophageal HRIM was performed in patients with EA aged less than 18 years. Objective motility patterns were analyzed, and EGJ data reported. Controls were pediatric patients without EA undergoing investigations for consideration of fundoplication surgery.

RESULTS

Seventy-five patients (M:F = 43:32, median age 1 year 3 months [3 months-17 years 4 months]) completed 133 HRIM studies. The majority (64/75, 85.3%) had EA with distal tracheo-esophageal fistula. Compared with controls, liquid swallows were poorer in patients with EA, as evident by significant differences in distension pressure emptying and bolus flow time (BFT). The integrated relaxation pressure for thin liquid swallows was significantly different between EA types, as well as when comparing patients with EA with and without previous esophageal dilatations. The BFT for solid swallows was significantly different when compared with EA types.

CONCLUSIONS

We have utilized HRIM in patients with EA to demonstrate abnormalities in their long-term EGJ function. These abnormalities correlate with poorer esophageal compliance and reduced esophageal peristalsis across the EGJ. Understanding the EGJ function in patients with EA will allow us to tailor long-term management to specific patients.

Developing a core outcome set for the health outcomes for children and adults with congenital oesophageal atresia and/or tracheo-oesophageal fistula: OCELOT task group study protocol

INTRODUCTION

Heterogeneity in reported outcomes of infants with oesophageal atresia (OA) with or without tracheo-oesophageal fistula (TOF) prevents effective data pooling. Core outcome sets (COS) have been developed for many conditions to standardise outcome reporting, facilitate meta-analysis and improve the relevance of research for patients and families. Our aim is to develop an internationally-agreed, comprehensive COS for OA-TOF, relevant from birth through to transition and adulthood.

METHODS AND ANALYSIS

A long list of outcomes will be generated using (1) a systematic review of existing studies on OA-TOF and (2) qualitative research with children (patients), adults (patients) and families involving focus groups, semistructured interviews and self-reported outcome activity packs. A two-phase Delphi survey will then be completed by four key stakeholder groups: (1) patients (paediatric and adult); (2) families; (3) healthcare professionals; and (4) researchers. Phase I will include stakeholders individually rating the importance and relevance of each long-listed outcome using a 9-point Likert scale, with the option to suggest additional outcomes not already included. During phase II, stakeholders will review summarised results from phase I relative to their own initial score and then will be asked to rescore the outcome based on this information. Responses from phase II will be summarised using descriptive statistics and a predefined definition of consensus for inclusion or exclusion of outcomes. Following the Delphi process, stakeholder experts will be invited to review data at a consensus meeting and agree on a COS for OA-TOF.

ETHICS AND DISSEMINATION

Ethical approval was sought through the Health Research Authority via the Integrated Research Application System, registration no. 297026. However, approval was deemed not to be required, so study sponsorship and oversight were provided by Alder Hey Children's NHS Foundation Trust. The study has been prospectively registered with the COMET Initiative. The study will be published in an open access forum.

Craniofacial anomalies in a murine model of heterozygous fibroblast growth factor 10 gene mutation

OBJECTIVE

Dysregulation of Fibroblast Growth Factor 10 (FGF10), a member of the family of Fibroblast Growth Factor (FGF) proteins, has been implicated in craniofacial and dental anomalies, including craniosynostosis, cleft palate, and Lacrimo-Auriculo-Dento-Digital Syndrome. The aim of this murine study was to assess the craniofacial and dental phenotypes associated with a heterozygous FGF10 gene (FGF10+/- ) mutation at skeletal maturity.

METHODS

Skulls of 40 skeletally mature mice, comprising two genotypes (heterozygous FGF10+/- mutation, n = 22; wildtype, n = 18) and two sexes (male, n = 23; female, n = 17), were subjected to micro-computed tomography. Landmark-based linear dimensions were measured for the cranial vault, maxilla, mandible, and first molar teeth. Multivariate analysis of variance was performed to assess whether there were significant differences in the craniofacial and dental structures between genotypes and sexes.

RESULTS

The craniomaxillary skeleton and the first molar teeth were smaller in the FGF10+/- mice (P < .05), but the mandible was unaffected. Sex did not have a significant effect on these structures (P > .05). Cranial sutural defects were noted in 5/22 (22.7%) mutant versus 2/18 (11.1%) wildtype mice, and cleft palate in only one (4.5%) mutant mouse. None of the mice displayed craniosynostosis, expansive bony lesions, bifid condyles, or impacted teeth.

CONCLUSION

The FGF10+/- mutation was associated with craniomaxillary skeletal hypoplasia that probably arose from deficient (delayed) intramembranous ossification of the sutured bones. Overall, the skeletal and dental data suggest that the FGF10 gene plays an important role in the aetiology of craniofacial dysmorphology and malocclusion.

Trampoline Park Injury Trends

OBJECTIVES

Trampolines are an important cause of childhood injury and focus of injury prevention. Understanding and prevention of trampoline park injury is constrained by inadequate exposure data to estimate the at-risk population. This study aimed to measure trampoline park injury incidence and time trends using industry data.

METHODS

Cross-sectional study to retrospectively analyze reported injuries and exposure in 18 trampoline parks operating in Australia and the Middle East, from 2017 to 2019. Exposure was derived from ticket sales and expressed as jumper hours. Exposure-adjusted incidence was measured using marginalized 0-inflated Poisson modeling and time trends using Joinpoint regression.

RESULTS

There were 13 256 injured trampoline park users reported from 8 387 178 jumper hours; 11% sustained significant injury. Overall, trampoline park injuries occurred at a rate of 1.14 injuries per 1000 jumper hours (95% confidence intervals 1.00 to 1.28), with rates highest for high-performance (2.11/1000 jumper hours, 1.66 to 2.56) and inflatable bag or foam pit (1.91/1000 jumper hours, 1.35 to 2.50) jumping. Significant injuries occurred at a rate of 0.11 injuries per 1000 jumper hours (0.10 to 0.13), with rates highest for high-performance (0.29/1000 jumper hours, 0.23 to 0.36), and parkour (0.22/1000 jumper hours, 0.15 to 0.28) jumping. Overall, injury rates decreased by 0.72%/month (-1.05 to -0.40) over the study period.

CONCLUSIONS

Trampoline park injuries occur in important numbers with sometimes serious consequences. However, within these safety standard-compliant parks, exposure-adjusted estimates show injuries to be uncommon and injury rates to be declining. Further reductions are required, especially severe injuries, and this study can enhance injury prevention initiatives.

Playground injury prevention: the need for consistent and national implementation of Australian safety standards

OBJECTIVES

Hospitalisation rates for injury, including at playgrounds, have not changed in the past decade. There are nine Australian Standards specific to playgrounds. The impact (if any) of these standards on playground injury resulting in hospitalisation is unknown.

METHODS

Retrospective data for patients under 18 years presenting to emergency departments and/or admitted between October 2015 and December 2019 due to an injury documented as occurring at a playground were retrieved by the Illawarra Shoalhaven Local Health District Planning, Information and Performance Department. Maintenance and Australian Standard (AS) compliance data for the 401 local playgrounds were requested from the four Local Governments in Illawarra Shoalhaven Local Health District. Descriptive statistics were used.

RESULTS

A total of 548 children were treated in emergency departments and/or admitted following playground injury. There was an overall increase of 39.3% in playground injury across the study period, and expenditure rose from $43,478 in 2011 to $367,259 in 2019 (a 744.7% increase).

CONCLUSIONS

Playground injury has not decreased in the Illawarra Shoalhaven. Data regarding maintenance and AS compliance are lacking. This is not unique to our region.

IMPLICATIONS FOR PUBLIC HEALTH

Without a national approach to adequately resource and monitor playground injury, it is not possible to assess the impact of Australian Standards or any injury prevention program.

Workflow Improvement of Electronic Health Record Usage in a Tertiary Pediatric Burns Clinic

BACKGROUND

As a high patient-throughput clinic, the Royal Children's Hospital's multidisciplinary burns clinic's efficiency of clinic workflow and streamlined patient assessment is crucial. The clinic has been using a customized "burns assessment tool" (BAT) as part of its integrated electronic health record (EHR) since 2016.

OBJECTIVES

The aim was to assess the usage patterns of the BAT at baseline, followed by re-evaluation following interventions to improve efficiency and utilization of the BAT.

METHODS

This study was a prospective observational time-motion quality improvement study. Observations of 19 clinicians in the pediatric burns clinic by five trained observers using a validated time-motion capture tool (TimeCaT 3.9) to map clinician workflow, with specific reference to time spent on a list of predetermined tasks, were conducted. Baseline data were collected for 7 weeks followed by three cycles of interventions and observations over 5 months.

RESULTS

At baseline, the median time for a patient visit was 24.56 minutes (range: 2.78-73.72 minutes, interquartile range: 14.17-27 minutes), with most of the time spent on documentation (34.6%) and patient contact tasks (26.0%). In each of the study cycles, the median time spent on documentation within the EHR was significantly reduced compared with baseline (cycle 1 29.8%, p = 0.08; cycle 2 20.4%, p ≤ 0.01; cycle 3 27.32%, p = 0.04). The time spent on patient contact increased when comparing baseline to data of cycles 1, 2, and 3 (25.96 vs. 33.27% of visit, p = 0.04). There was no significant change in absolute time spent on the BAT during the study.

CONCLUSION

The study findings of clear, significant, and sustained improvement in documentation efficiency and the corresponding increase in patient contact time after interventions were introduced reinforce the importance of integration of an EHR with clinical workflow.

Screening for VACTERL anomalies in children with anorectal malformations: Outcomes of a standardized approach

PURPOSE

The majority of patients with an anorectal malformation (ARM) have associated congenital anomalies. It is well established that all patients diagnosed with an ARM should undergo systematic screening, including renal, spinal, and cardiac imaging. This study aimed to evaluate the findings and completeness of screening, following local implementation of standardized protocols.

METHODS

A retrospective cohort study was performed assessing all patients with an ARM managed at our tertiary pediatric surgical center, following a standardized protocol implementation for VACTERL screening (January 2016-December 2021). Cohort demographics, medical characteristics, and screening investigations were analyzed. Findings were compared with our previously published data (2000-2015), conducted prior to protocol implementation.

RESULTS

One hundred twenty-seven (64 male, 50.4%) children were eligible for inclusion. Complete screening was performed in 107/127 (84.3%) children. Of these, one or more associated anomalies were diagnosed in 85/107 (79.4%), whilst the VACTERL association was demonstrated in 57/107 (53.3%). The proportion of children that underwent complete screening increased significantly in comparison with those assessed prior to protocol implementation (RR 0.43 [CI 0.27-0.66]; p < 0.001). Children with less complex ARM types were significantly less likely to receive complete screening (p = 0.028). Neither presence of an associated anomaly, nor prevalence of the VACTERL association, differed significantly by ARM type complexity.

CONCLUSION

Screening for associated VACTERL anomalies in children with ARM was significantly improved following standardized protocol implementation. The prevalence of associated anomalies in our cohort supports the value of routine VACTERL screening in all children with ARM, regardless of malformation type.

LEVEL OF EVIDENCE

II.

Preexisting neural factors that contribute to dysmotility in esophageal atresia: a systematic review

Esophageal dysmotility in esophageal atresia (EA) relates to abnormal development of esophageal innervation and musculature and to the esophageal repair. Few studies have investigated the preexisting dysmotility in EA, present prior to surgery. This systematic review aims to summarize the literature on neuronal studies in EA, to understand the causative factors for esophageal dysmotility. We performed a systematic review (PubMed, EMBASE, EBM, CINAHL databases; January 1947-February 2021) in accordance with PRISMA (PROSPERO number CRD42020171014). Fourteen studies were identified (eleven human, 187 EA patients; three animal, 64 EA rat specimens). Neural factors affecting esophageal dysmotility in human and animal studies included proteins, enzymes, growth factors, and genes, which play a role in the nervous system or neuroendocrine system, some of which have functions as neuromodulators or neurotransmitters. This systematic review has identified neural factors that affect esophageal dysmotility and contributes toward our understanding of the underlying dysmotility in patients with EA. The studies identified are important and essential for successful translation of basic science knowledge to impact clinical practice and understanding. Level of evidence: III.

Patient journey mapping to investigate quality and cultural safety in burn care for Aboriginal and Torres Strait Islander children and families - development, application and implications

BACKGROUND

Quality and safety in Australian healthcare is inequitably distributed, highlighted by gaps in the provision of quality care for Aboriginal and Torres Strait Islander children. Burns have potential for long-term adverse outcomes, and quality care, including culturally safe care, is critical to recovery. This study aimed to develop and apply an Aboriginal Patient Journey Mapping (APJM) tool to investigate the quality of healthcare systems for burn care with Aboriginal and Torres Strait Islander children.

STUDY DESIGN

Interface research methodology, using biomedical and cultural evidence, informed the modification of an existing APJM tool. The tool was then applied to the journey of one family accessing a paediatric tertiary burn care site. Data were collected through yarning with the family, case note review and clinician interviews. Data were analysed using Emden's core story and thematic analysis methods. Reflexivity informed consideration of the implications of the APJM tool, including its effectiveness and efficiency in eliciting information about quality and cultural safety.

RESULTS

Through application of a modified APJM tool, gaps in quality care for Aboriginal and Torres Strait Islander children and families were identified at the individual, service and system levels. Engagement in innovative methodology incorporating more than biomedical standards of care, uncovered critical information about the experiences of culturally safe care in complex patient journeys.

CONCLUSION

Based on our application of the tool, APJM can identify and evaluate specific aspects of culturally safe care as experienced by Aboriginal and Torres Strait Islander peoples and be used for quality improvement.

Mid‐Arm Point in PAEDiatrics (MAPPAED): An effective procedural aid for safe pleural decompression in trauma

OBJECTIVE

Life-threatening thoracic trauma requires emergency pleural decompression and thoracostomy and chest drain insertion are core trauma procedures. Reliably determining a safe site for pleural decompression in children can be challenging. We assessed whether the Mid-Arm Point (MAP) technique, a procedural aid proposed for use with injured adults, would also identify a safe site for pleural decompression in children.

METHODS

Children (0-18 years) attending four EDs were prospectively recruited. The MAP technique was performed, and chest wall skin marked bilaterally at the level of the MAP; no pleural decompression was performed. Radio-opaque markers were placed over the MAP-determined skin marks and corresponding intercostal space (ICS) reported using chest X-ray.

RESULTS

A total of 392 children participated, and 712 markers sited using the MAP technique were analysed. Eighty-three percentage of markers were sited within the 'safe zone' for pleural decompression (4th to 6th ICSs). When sited outside the 'safe zone', MAP-determined markers were typically too caudal. However, if the site for pleural decompression was transposed one ICS cranially in children ≥4 years, the MAP technique performance improved significantly with 91% within the 'safe zone'.

CONCLUSIONS

The MAP technique reliably determines a safe site for pleural decompression in children, albeit with an age-based adjustment, the Mid-Arm Point in PAEDiatrics (MAPPAED) rule: 'in children aged ≥4 years, use the MAP and go up one ICS to hit the safe zone. In children <4 years, use the MAP.' When together with this rule, the MAP technique will identify a site within the 'safe zone' in 9 out of 10 children.

Review of the requirements for effective mass casualty preparedness for trauma systems. A disaster waiting to happen?

Mass casualty incidents (MCIs) are diverse, unpredictable, and increasing in frequency, but preparation is possible and necessary. The nature of MCIs requires a trauma response but also requires effective and tested disaster preparedness planning. From an international perspective, the aims of this narrative review are to describe the key components necessary for optimisation of trauma system preparedness for MCIs, whether trauma systems and centres meet these components and areas for improvement of trauma system response. Many of the principles necessary for response to MCIs are embedded in trauma system design and trauma centre function. These include robust communication networks, established triage systems, and capacity to secure centres from threats to safety and quality of care. However, evidence from the current literature indicates the need to strengthen trauma system preparedness for MCIs through greater trauma leader representation at all levels of disaster preparedness planning, enhanced training of staff and simulated disaster training, expanded surge capacity planning, improved staff management and support during the MCI and in the post-disaster recovery phase, clear provision for the treatment of paediatric patients in disaster plans, and diversified and pre-agreed systems for essential supplies and services continuity. Mass casualty preparedness is a complex, iterative process that requires an integrated, multidisciplinary, and tiered approach. Through effective preparedness planning, trauma systems should be well-placed to deliver an optimal response when faced with MCIs.

Post-operative colonic manometry in children with Hirschsprung disease: A systematic review

BACKGROUND

A significant proportion of children experience bowel dysfunction (including constipation and fecal incontinence) following surgical repair of Hirschsprung disease (HD). Persistent symptoms are thought to relate to underlying colonic and/or anorectal dysmotility. Manometry may be used to investigate the gastrointestinal motility patterns of this population.

PURPOSE

To (1) evaluate the colonic manometry equipment and protocols used in the assessment of the post-operative HD population and (2) summarize the available evidence regarding colonic motility patterns in children with HD following surgical repair.

DATA SOURCES

We performed a systematic review of the Cochrane Library, Embase, MEDLINE, and PubMed databases (January 1, 1980 and March 9, 2020). Data were extracted independently by two authors.

STUDY SELECTION

This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies reporting the post-operative assessment of children with HD using colonic manometry were considered for inclusion.

RESULTS

Five studies satisfied selection criteria, providing a combined total of 496 children. Of these, 184 children with repaired HD underwent colonic manometry. Studies assessed heterogeneous populations, utilized variable manometry equipment and protocols, and reported limited baseline symptom characteristics, thus restricting comparability. All studies used low-resolution colonic manometry.

CONCLUSIONS

This systematic review highlighted the paucity of evidence informing the understanding of colonic dysmotility in the post-operative HD cohort. Current literature is limited by variable methodologies, heterogeneous cohorts, and the lack of high-resolution manometry.

Quality of Life Outcomes in Primary Caregivers of Children with Esophageal Atresia

OBJECTIVE

To investigate the quality of life (QoL) impact on primary caregivers of children with esophageal atresia.

STUDY DESIGN

We used a prospective cohort study design, inviting primary caregivers of children with esophageal atresia to complete the following questionnaires: Parent Experience of Child Illness (PECI), Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety, PROMIS Depression, 12-Item Short Form Survey (SF-12), and Pediatric Quality of Life Inventory (PedsQL). The PECI, PROMIS Anxiety and Depression, and SF-12 assessed caregiver QoL, and the PedsQL assessed patient QoL. Patients with Gross type E esophageal atresia served as controls.

RESULTS

The primary caregivers of 100 patients (64 males, 36 females; median age, 4.6 years; range, 3.5 months to 19.0 years) completed questionnaires. The majority (76 of 100) of patients had Gross type C esophageal atresia. A VACTERL (vertebral anomalies, anorectal malformation, cardiac anomalies, tracheoesophageal fistula, renal anomalies, limb anomalies) association was found in 30, ≥1 esophageal dilatation was performed in 57, and fundoplication was performed in 11/100. When stratified by esophageal atresia types, significant differences were found in 2 PECI subscales (unresolved sorrow/anger, P = .02; uncertainty, P = .02), in PROMIS Anxiety (P = .02), and in SF-12 mental health (P = .02) and mental component summary scores (P = .02). No significant differences were found for VACTERL association, nor esophageal dilatation. Requirement for fundoplication resulted in lower SF-12 general health score, and lower PedsQL social and physical functioning scores.

CONCLUSIONS

We have demonstrated that caring for a child with esophageal atresia and a previous requirement for fundoplication impacts caregiver QoL.

Cognitive, academic, and behavioral functioning in school-aged children born with esophageal atresia

PURPOSE

To characterize cognitive, academic, and behavioral functioning in children who underwent neonatal surgical repair of esophageal atresia (OA) and compare outcomes according to clinical characteristics (presence of additional congenital anomalies, longer hospitalization, and prematurity).

METHODS

Intellectual, language, attention, and executive functioning were assessed in 71 5-year-olds and 72 8-year-olds born with OA. At 8 years, memory and academic skills were also assessed. Parents rated children's executive functioning and behavior via questionnaires. Outcomes were compared to normative data and within subgroups of the sample.

RESULTS

Intellectual functioning varied depending on the assessment tool, with some evidence of lower than expected intellectual development in children with OA. At 5 years, children with OA showed age-appropriate language and self-regulation, but reduced verbal attention. At 8 years, the OA group had lower than expected sustained attention, divided attention, and mathematics but typical memory and literacy. Parents consistently reported increased working memory difficulties. Other executive functioning and behavioral symptoms were transiently observed. Findings did not consistently differ according to clinical characteristics.

CONCLUSIONS

Children with OA may be at risk of transient and persisting cognitive difficulties, particularly in attention and working memory. Difficulties were not strongly associated with additional congenital anomalies, longer hospitalization, or prematurity.

LEVEL OF EVIDENCE

Level IV.

Esophageal morbidity in patients following repair of esophageal atresia: A systematic review

BACKGROUND

Esophageal atresia (EA) is a life-threatening congenital condition, affecting one in 2600 newborns. Morbidity remains high, with many patients experiencing complications, including anastomotic leak/stricture, and gastro-esophageal reflux disease (GERD). Increased understanding of esophageal motility patterns may help explain the etiology of these complications.

AIMS

We aimed to review knowledge regarding esophageal motility and related complications in children with EA, evaluate patients' symptomatology and relate this to esophageal motility.

METHODS

We performed a systematic review (PROSPERO: CRD42018092277), according to the PRISMA protocol. Two investigators independently conducted search strategies (OvidMEDLINE, PubMed, Cochrane Review, BMJ BestPractice), identifying complications in patients following EA repair. Rates of esophageal dysmotility, GERD, dysphagia, anastomotic leak, anastomotic stricture, recurrent fistula formation, and esophagitis were sought.

RESULTS

A total of 65 publications met selection criteria (n = 4882). Rates of morbidity were high: esophageal dysmotility (78%), GERD (43%), dysphagia (44%), anastomotic leak (19%), anastomotic stricture (26%), recurrent fistula formation (7%), and esophagitis (47%). No correlation appeared to exist with severity of symptoms.

CONCLUSIONS

This systematic review identified high rates of complications in children with EA, with esophageal dysmotility present in the majority of patients. Increasing survival, with resultant longer timeframes to develop morbidities, makes standardized follow-up regimens crucial.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

Level 3.

An evaluation of the presentation and severity of Australian football injury in children

Introduction

Child participation in sport is important for physical, cognitive and psychosocial wellbeing. Australian rules football has high participation, but also carries a high risk of injury due to the contact nature of the sport. This study aimed to evaluate changes in the presentation and hospital admission of paediatric Australian rules football-related injuries, and to compare the severity of these injuries with those from other team ball sports.

Materials and methods

At an Australian paediatric major trauma service, ED and hospital trauma registry data relating to Australian rules football injury between 2009 and 2015 were obtained. Data from other common team ball sports with a shared field of play were also identified.

Results

During the study period, there were 10,003 ED presentations, and 1110 admissions resulting from team ball sports. With 4751 ED presentations and 616 admissions, Australian rules football accounted for almost one-third of all sports-related presentations and admissions, and around half of the team ball sports cohort. Compared to other team ball sports patients, Australian rules football-related patients were 40% more likely to be admitted, and nearly twice as likely to be classified as severe injury. Australian rules football players presented with different injury patterns were compared to other team ball sports players; admitted players were significantly more likely to have sustained head or neck injuries, and were more than twice as likely to sustain truncal injury.

Conclusions

Australian rules football is a common cause of ED presentations and results in substantial morbidity, both overall and when compared with other team ball sports. Australian rules football should remain a focus for ongoing and active research into strategies which reduce injury risk.

Considering difference: clinician insights into providing equal and equitable burns care for Aboriginal and Torres Strait Islander children

OBJECTIVE

To better understand issues driving quality in burn care related to equity of outcomes and equality of provision for Aboriginal and Torres Strait Islander children.

METHODS

Seventy-six interviews with team members who provide care for Aboriginal and Torres Strait Islander children in six paediatric burn units across five Australian jurisdictions were completed. Interface research methodology within a qualitative design guided data collection and analysis.

RESULTS

Three themes were identified: i) Burn team members who identify the requirement to meet the specific needs of Aboriginal and Torres Strait Islander children and deliver differential care; ii) Burn team members who believe in equal care, but deliver differential care based on the specific needs of Aboriginal and Torres Strait Islander children; and iii) Burn team members who see little need for provision of differential care for Aboriginal and Torres Strait Islander children and rather, value the provision of equal care for all.

CONCLUSION

Burn team members conflate equitable and equal care, which has implications for the delivery of care for Aboriginal and Torres Strait Islander children. Equitable care is needed to address disparities in post-burn outcomes, and this requires clinicians, healthcare services and relevant system structures to work coherently and intentionally to reflect these needs. Implications for public health: Changes in health policy, the embedding of Aboriginal and Torres Strait Islander liaison officers in burn care teams and systems that prioritise critical reflexive practice are fundamental to improving care.

Survival Trends and Syndromic Esophageal Atresia

BACKGROUND AND OBJECTIVES

Presence of a syndrome (or association) is predictive of poor survival in esophageal atresia (EA). However, most reports rely on historical patient outcomes, limiting their usefulness when estimating risk for neonates born today. We hypothesized improved syndromic EA survival due to advances in neonatal care.

METHODS

A retrospective single-center review of survival in 626 consecutive patients with EA from 1980 to 2017 was performed. Data were collected for recognized risk factors: preterm delivery; birth weight <1500 g; major cardiac disease; vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb abnormalities (VACTERL); and non-VACTERL syndromes. Cox proportional hazards regression models were used to evaluate temporal trends in survival with respect to year of birth and syndromic EA.

RESULTS

Overall, 87% of 626 patients with EA survived, ranging from 82% in the 1980s to 91% in the 2010s. After adjusting for confounders, syndromic EA survival did not improve during the study, with no association found between year of birth and survival (hazard ratio [HR] 0.98, 95% confidence interval [CI]: 0.95-1.01). Aside from lethal non-VACTERL syndromes, patients with nonlethal non-VACTERL syndromes (HR 6.85, 95% CI: 3.50-13.41) and VACTERL syndrome (HR 3.02, 95% CI: 1.66-5.49) had a higher risk of death than those with nonsyndromic EA.

CONCLUSIONS

Survival of patients with syndromic EA has not improved, and patients with non-VACTERL syndromes have the highest risk of death. Importantly, this is independent of syndrome lethality, birth weight, and cardiac disease. This contemporary survival assessment will enable more accurate perinatal counseling of parents of patients with syndromic EA.

Changes in emergency department blood product use for major paediatric trauma following the implementation of a major haemorrhage protocol

OBJECTIVE

Fixed ratio blood product administration may improve outcomes in trauma patients with massive blood loss. The present study aimed to describe the impact of a major haemorrhage protocol (MHP) on the ratio of blood products administered for paediatric major trauma.

METHODS

Retrospective observational study in a state-designated paediatric major trauma centre in Melbourne, Australia. Children with major trauma who received blood products in the ED were identified from a hospital trauma registry. Blood product ratios before, during and after implementation of a hospital MHP were compared in consecutive 2 year blocks.

RESULTS

Over a 6 year period, 767 major trauma patients were identified, of whom 47 received blood products in the ED and were included in the analysis; 14 pre-MHP implementation, 24 during-MHP implementation and nine post-MHP implementation. No patients received blood products at a ratio of 1:1:1 for red blood cells:fresh frozen plasma:platelets, respectively, during any time period. In this cohort of predominantly blunt trauma, blood products were infrequently administered in the ED because of the low prevalence of massive blood loss. Coagulopathy and hypofibrinogenaemia were commonly observed, nearly half of included patients were managed operatively and one quarter did not survive their injuries.

CONCLUSION

The implementation of a MHP did not change the ratio of blood product administration in this cohort of patients because of the infrequency of massive blood loss. Future studies may focus on the impact of treating coagulopathy and hypofibrinogenaemia on patient-centred outcomes.

Selective approach to preoperative echocardiography in esophageal atresia

PURPOSE

Preoperative echocardiography is used routinely in neonates with esophageal atresia to identify patients in whom congenital cardiac disease will impact upon anesthetic and surgical decision-making. We aimed to determine the suitability of selective preoperative echocardiography.

METHODS

We performed a single-center retrospective review of neonates with esophageal atresia over 6 years (2010-2015) at our tertiary pediatric institution. Data included preoperative clinical examination, chest x-ray, and echocardiography. Endpoints were cardiovascular, respiratory, radiological, and echocardiography findings. Selective strategies were assessed using sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

We identified 115 neonates with esophageal atresia. All underwent preoperative echocardiography. Cardiac defects were identified in 49/115 (43%) (major 9/115, moderate 4/115). Sensitivity, specificity, positive predictive value, and negative predictive value of abnormal clinical and radiologic assessment for major and moderate cardiac defects were 92%, 25%, 13%, 96%; for clinical examination alone were 92%, 25%, 14%, 96%; for absence of murmur, cyanosis, and abnormal respiratory examination were 92%, 28%, 13%, 97%. Selective strategies reduce echocardiograms performed by 22%.

CONCLUSION

Selective strategies allow for identification of neonates with esophageal atresia who may have deferral of echocardiogram unill after surgery. Selection may improve timeliness of care and resource utilization, without compromising patient safety.

Periprocedural analgesia and sedation in air enema reduction for intussusception: A retrospective Australian cohort study

AIM

Periprocedural analgesia or sedation for air enema reduction (AER) of intussusception is a matter of debate. We set out to review Australian periprocedural pain management in AER.

METHODS

Retrospective electronic medical record review of emergency department presentations of intussusception at an Australian children's hospital over 2 years for periprocedural analgesia and sedation and short-term outcomes.

RESULTS

A total of 73 patients (mean age 23 months) had ultrasound-confirmed intussusception. Prior to AER, analgesia was administered to 61 of 73 (83.5%) patients. Opioids were administered in 48 of 73 (65.8%) and 8 of 73 (11.0%) received sedation. Thirteen of 73 (17.8%, 95% confidence interval 9.0-26.6) had spontaneously reduced; 60/73 that underwent primary AER had successful reduction in 54 (90.0%, 95% confidence interval 82.4-97.6). A total of seven patients required surgery. No AER attempts were complicated by bowel perforation.

CONCLUSION

The use of periprocedural analgesia for AER in this Australian series was common, whilst sedation use was infrequent. No perforations occurred.

The burden of esophageal dilatations following repair of esophageal atresia

AIM

To describe the burden of esophageal dilatations in patients following esophageal atresia (EA) repair.

METHOD

A retrospective review was performed at The Royal Children's Hospital, Melbourne, of all neonates undergoing operative repair for EA over a 17-year period (1999-2015). Stricture was defined by radiological and/or intra-operative findings of narrowing at the esophageal anastomosis. Data recorded included EA type, perinatal details, operative approach, esophageal anastomosis outcome, dilatation requirement, and survival. Key endpoints were anastomotic leakage and tension, esophageal dilatation technique, dilatation frequency, fundoplication, and complications.

RESULTS

During the study period, 287 newborn EA patients were admitted, of which 258 underwent operative repair and survived to primary discharge. Excluding 11 patients with isolated tracheoesophageal fistula, 247 patients were included in the final analysis. Intra-operative anastomotic tension was documented in 41/247 (16.6%), anastomotic leak occurred in 48/247 (19.4%), and fundoplication was performed in 37/247 (15.0%). Dilatations were performed in 149/247 (60.3%). Techniques included bougie-alone (92/149, 61.7%), combination of bougie and balloon (51/149, 34.2%), and balloon-alone (6/149, 4.0%). These patients underwent 1128 dilatations; median number of dilatations per patient was 4 (interquartile range 2-8). Long-gap EA and anastomotic tension were risk factors (p < 0.01) for multiple dilatations. Complications occurred in 13/1128 (1.2%) dilatation episodes: 11/13 esophageal perforation, 2/13 clinically significant aspiration. Perforations were rare events in both balloon (6/287, 2.1%) and bougie dilatations (4/841, 0.5%); one patient had a perforation from guidewire insertion.

CONCLUSIONS

Esophageal dilatation occurred in a majority of EA patients. Long-gap EA was associated with an increased burden of esophageal dilatation. Perforations were rare events in balloon and bougie dilatations.

TYPE OF STUDY

Original article - retrospective review.

LEVEL OF EVIDENCE

II.

Predictors of Mortality after Primary Discharge from Hospital in Patients with Esophageal Atresia

OBJECTIVE

To describe esophageal atresia mortality rates and their associations in our cohort.

STUDY DESIGN

Patients with esophageal atresia, managed at The Royal Children's Hospital, Melbourne (1980-2018), who subsequently died, were retrospectively identified from the prospective Nate Myers Oesophageal Atresia database. Data collected included patient and maternal demographics, vertebral anomalies, anorectal malformations, cardiovascular anomalies, tracheoesophageal fistula, renal anomalies, and limb defects (VACTERL) associations, mortality risk factors, and preoperative, operative, and postoperative findings. Mortality before discharge was defined as death during the initial admission.

RESULTS

A total of 88 of the 650 patients (13.5%) died during the study period; mortality before discharge occurred in 66 of the 88 (75.0%); mortality after discharge occurred in 22 of the 88 (25.0%). Common causes of mortality before discharge were palliation for respiratory anomalies (15/66 [22.7%]), associated syndromes (11/66 [16.7%]), and neurologic anomalies (10/66 [15.2%]). The most common syndrome leading to palliation was trisomy 18 (7/66 [10.6%]). Causes of mortality after discharge had available documentation for 17 of 22 patients (77.3%). Common causes were respiratory compromise (6/17 [35.3%]), sudden unexplained deaths (6/17 [35.3%]), and Fanconi anemia (2/17 [11.8%]). Of the patients discharged from hospital, 22 of 584 (3.8%) subsequently died. There was no statistical difference in VACTERL association between mortality before discharge (31/61 [50.8%]) and mortality after discharge (11/20 [55.0%]), nor in incidence of twins between mortality before discharge (8/56 [14.3%]) and mortality after discharge (2/18 [11.1%]).

CONCLUSIONS

We identified predictors of mortality in patients with esophageal atresia in a large prospective cohort. Parents of children with esophageal atresia must be counselled appropriately as to the likelihood of death after discharge from hospital.

Survey of major trauma centre preparedness for mass casualty incidents in Australia, Canada, England and New Zealand

BACKGROUND

Mass casualty incidents (MCIs) are increasing. Trauma centres play a key role in MCIs due to their readiness and expansive multidisciplinary expertise for injury management. Previous studies have shown deficiencies in trauma centre disaster preparedness. The aim of this study was to describe the current disaster preparedness of Major Trauma Centres (MTCs) in Australia, Canada, England and New Zealand.

METHODS

A cross-sectional survey of all (n = 82) MTCs was undertaken. The anonymous survey collected data about disaster preparedness in nine key areas. Respondents were encouraged to consult appropriately at their centre to provide an accurate representation of their centre's preparedness.

FINDINGS

Responses were received from 69 (84%) centres; 61 completed all questions. 91% had a disaster preparedness committee and 80% had an all-hazards emergency plan. 79% had held an MCI drill in the past 2 years. 54% reported a system in place to calculate maximum capacity, but testing of surge capacity was uncommon. 55% reported the presence of stored resources for an MCI and 58% had a database of staff trained in Emergency Management. 74% had a training and education plan available for staff involved in an MCI and a plan for professional debriefing of staff post-MCI, while 62% had a post-disaster employee assistance programme. Most centres had appropriate back-up communication, safety and security plans.

INTERPRETATION

The disaster preparedness of MTCs was high for communication, safety and security but there was clear need for improvement in other areas including surge capacity, human resources and post-disaster recovery.

Clinical data and Pediatric Quality of Life Inventory (PedsQL™) scores for children with duodenal atresia

This article presents raw data obtained from a prospectively collected database of children with duodenal atresia at tertiary pediatric surgery hospital. For all potential participants, pertinent demographic, clinical and operative data was obtained from the database. Potential participants were then contacted and invited to complete a Pediatric Quality of Life Inventory (PedsQL™) 4.0 core score and gastrointestinal module questionnaires. Participant's response to each item in the questionnaires is provided, as well as their calculated health related quality of life scores. Data has the potential to be reused in future studies examining quality of life in duodenal atresia, paediatric gastrointestinal conditions, surgical neonatal conditions and children with trisomy 21. Further analysis and discussion is contained in related research article titled "Quality of life outcomes in children born with duodenal atresia" [1].

The Role of Fibroblast Growth Factor 10 Signaling in Duodenal Atresia

Introduction

Duodenal atresia (DA) is a congenital bowel obstruction requiring major surgery in the first week of life. Three morphological phenotypes are described, reflecting increasing degrees of obstruction and discontinuity of the duodenum. The cause of DA is not known. Tandler’s original “solid cord” hypothesis conflicts with recent biological evidence, and is unable to account for differing DA types. In humans, a genetic etiology is supported by the association between Trisomy 21 and DA, and reports of familial inheritance patterns. Interruption of FGF10/FGFR2b signaling is the best demonstrated genetic link to DA in mice, with 35–75% of homozygous knockout embryos developing DA.

Purpose

This review examines the current evidence surrounding the etiology of DA. We focus on research regarding FGF10/FGFR2b signaling and its role in duodenal and other intestinal atresia. Further, we outline planned future research in this area, that we consider necessary to validate and better understand this murine model in order to successfully translate this research into clinical practice.

Conclusion

Determining the etiology of DA in humans is a clinical and scientific imperative. Fgf10/Fgfr2b murine models represent current science’s best key to unlocking this mystery. However, further research is required to understand the complex role of FGF10/FGFR2b signaling in DA development. Such complexity is expected, given the lethality of their associated defects makes ubiquitous interruption of either Fgf10 or Fgfr2b genes an unlikely cause of DA in humans. Rather, local or tissue-specific mutation in Fgf10, Fgfr2b, or their downstream targets, is the hypothesized basis of DA etiology.

Traumatic spinal cord injury in Victoria, 2007-2016

OBJECTIVE

To investigate trends in the incidence and causes of traumatic spinal cord injury (TSCI) in Victoria over a 10-year period.

DESIGN, SETTING, PARTICIPANTS

Retrospective cohort study: analysis of Victorian State Trauma Registry (VSTR) data for people who sustained TSCIs during 2007-2016.

MAIN OUTCOMES AND MEASURES

Temporal trends in population-based incidence rates of TSCI (injury to the spinal cord with an Abbreviated Injury Scale [AIS] score of 4 or more).

RESULTS

There were 706 cases of TSCI, most the result of transport events (269 cases, 38%) or low falls (197 cases, 28%). The overall crude incidence of TSCI was 1.26 cases per 100 000 population (95% CI, 1.17-1.36 per 100 000 population), and did not change over the study period (incidence rate ratio [IRR], 1.01; 95% CI, 0.99-1.04). However, the incidence of TSCI resulting from low falls increased by 9% per year (95% CI, 4-15%). The proportion of TSCI cases classified as incomplete tetraplegia increased from 41% in 2007 to 55% in 2016 (P < 0.001). Overall in-hospital mortality was 15% (104 deaths), and was highest among people aged 65 years or more (31%, 70 deaths).

CONCLUSIONS

Given the devastating consequences of TSCI, improved primary prevention strategies are needed, particularly as the incidence of TSCI did not decline over the study period. The epidemiologic profile of TSCI has shifted, with an increasing number of TSCI events in older adults. This change has implications for prevention, acute and post-discharge care, and support.

Quality of life assessment in esophageal atresia patients: a systematic review focusing on long-gap esophageal atresia

BACKGROUND

Children born with esophageal atresia (EA) have inherent abnormalities in esophageal motility which may impact upon patient and family Quality of Life (QoL). Currently, paucity of data exists for long-term outcomes of long-gap EA. We aimed to: (1) summarize QoL tools reported in the literature, focusing upon studies involving long-gap EA patients, and (2) compare QoL for long-gap versus non-long-gap EA patients.

METHOD

We performed a systematic review of Cochrane Register of Controlled Trials, PubMed, EMBASE, and Ovid databases (January 1980-May 2018) in accordance with the PRISMA protocol.

RESULT

Six studies were identified (536 patients total), and 419/536 (78%) patients completed QoL assessment. Response rates ranged from 29% to 100%. Median study size was 86 (range 8-159). Esophageal atresia type was described in 477 patients, and 74/477 (16%) were long-gap. Common assessment tools were Gastrointestinal Quality of Life Index and 36-Item Short-Form Health Survey. Compared with healthy individuals, long-gap EA patients suffered more gastrointestinal symptoms. There were no significant differences in QoL outcomes between long-gap and non-long-gap EA patients.

CONCLUSION

Current literature suggests no significant difference in QoL outcomes between long-gap and non-long-gap EA patients. However, due to questionnaire variability and range of response rates, the data should be interpreted with care.

LEVEL OF EVIDENCE

Level II.

Thoracostomy in children with severe trauma: An overview of the paediatric experience in Victoria, Australia

OBJECTIVE

Thoracic trauma is a leading cause of paediatric trauma deaths. Traumatic cardiac arrest, tension pneumothorax and massive haemothorax are life-threatening conditions requiring emergency and definitive pleural decompression. In adults, thoracostomy is increasingly preferred over needle thoracocentesis for emergency pleural decompression. The present study reports on the early experience of thoracostomy in children, to inform debate regarding the best approach for emergency pleural compression in paediatric trauma.

METHODS

Retrospective review of Ambulance Victoria and The Royal Children's Hospital Melbourne, Trauma Registry between August 2016 and February 2019 to identify children undergoing thoracostomy for trauma, either pre-hospital or in the ED.

RESULTS

Fourteen children aged 1.2-15 years underwent 23 thoracostomy procedures over the 31 month period. The majority of patients sustained transport-related injuries, and underwent thoracostomies for the primary indications of hypoxia and hypotension. Two children were in traumatic cardiac arrest. Ten children underwent needle thoracocentesis prior to thoracostomy, but all required thoracostomy to achieve the necessary definitive decompression. All patients were severely injured with multiple-associated serious injuries and median Injury Severity Score 35.5 (17-75), three of whom died from their injuries. Thoracostomy in our cohort had a low complication rate.

CONCLUSION

In severely injured children, thoracostomy is an effective and reliable method to achieve emergency pleural decompression, including in the young child. The technical challenges presented by children are real, but can be addressed by training to support a low complication rate. We recommend thoracostomy over needle thoracocentesis as the first-line intervention in children with traumatic cardiac arrest, tension pneumothorax and massive haemothorax. [Correction added on 23 September 2019 after first online publication: in the second sentence of the conclusion, the words "under review process" were mistakenly added and have been removed.].

Delayed diagnosis of anorectal malformations in neonates

BACKGROUND

Anorectal malformations (ARM) are common congenital abnormalities of the terminal hindgut. Ideally, ARM should be diagnosed at, or shortly following, birth by careful physical examination of the perineum. Delayed diagnosis has been implicated as a risk factor for complications, including intestinal perforation. This study aimed to determine the rate of delayed diagnosis and associated intestinal perforation in ARM.

METHODS

A retrospective review was performed for all ARM patients managed at The Royal Children's Hospital over a 16-year period (2000-2015). Data collected included ARM type, timing of diagnosis and complications. Delayed diagnosis was defined as being at more than 24 h of age.

RESULTS

A total of 243 ARM patients (male 146/243, 60%) were included. The most frequent ARM types were perineal fistula (83/243, 34%) and rectovestibular fistula (40/243, 16%). Diagnosis was delayed beyond 24 h of age in 92 of 243 (38%) patients. The ARM type most commonly delayed in diagnosis was perineal fistula (37/83, 45%). Two patients in whom diagnosis was delayed suffered an intestinal perforation.

CONCLUSION

Delayed diagnosis in ARM patients remains a common, and potentially fatal, occurrence. Improved assessment of newborns is required to ensure timely diagnosis of ARM, and avoidance of complications associated with delayed diagnosis.

Rule of 4's: Safe and effective pleural decompression and chest drain insertion in severely injured children

The intersecting scenarios of multi-trauma, thoracic injury and traumatic cardiac arrest present some of the most demanding moments in paediatric trauma. For these reasons, decision support through teamwork, checklists, technology and guidelines are central to ensuring quality paediatric trauma care. The 'Rule of 4's' is a simple aide-memoire, which guides clinicians of all grades, expertise and distractedness in a reliable approach to injured children who require safe and effective emergency pleural decompression and timely insertion of a chest drain. The Rule of 4's enables these important therapeutic goals to be met through: (i) four steps in a 'good plan'; (ii) fourth (or fifth) intercostal space as the basis for siting a 'good hole'; (iii) 4× uncuffed endotracheal tube size (4× [age/4 + 4]) to guide selection of a 'good tube'; and (iv) 4 cm mark for a 'good stop' to ensure the drain is in far enough but not too far.

The long-term quality of life outcomes in adolescents with Hirschsprung disease

BACKGROUND

Postoperative outcomes for Hirschsprung disease (HD) remain variable, with many patients affected by constipation and/or fecal incontinence. The long-term impact upon quality of life (QoL) for HD patients is unclear. We measured long-term QoL outcomes in adolescents with HD using validated questionnaires.

METHODS

Patients with HD, managed at a large tertiary pediatric institution between 1997 and 2004, were identified. Patients and/or their proxy completed validated questionnaires. Results were compared with published healthy population controls. Two questionnaires assessed QoL: Pediatric Quality of Life Inventory (PedsQL) and Fecal Incontinence and Constipation Quality of Life (FICQOL). Three measures assessed functional outcomes: Baylor Continence Scale, Cleveland Clinic Constipation Scoring System, and Vancouver Dysfunctional Elimination Symptom Survey.

RESULTS

Interviews were completed for 58 (70% response rate) patients [M:F, 49:9; median age, 14.5 years (11.1-18.7)]. No significant differences were found in general QoL scores between patients and healthy controls (84.84 versus 81.49, p = 0.28). Disease-specific questionnaires revealed reduced QoL in patients and families, with 17% of parents reporting the bowel dysfunction stopped their child from socializing and 47% of parents experiencing some degree of anxiety/depression regarding their child's bowel condition. Fecal incontinence (r = -0.59, p < 0.01), constipation (r = -0.36, p = 0.01), and dysfunctional elimination (r = -0.59, p < 0.01) all negatively correlated with QoL scores.

CONCLUSIONS

In this study, generic QoL in the adolescent HD population was comparable to healthy populations. However, children with HD have ongoing bowel dysfunction which negatively impacts upon their QoL.

LEVEL OF EVIDENCE

Prognosis study:- level II (prospective cohort study).

The burden of surgery and postoperative complications in children with inflammatory bowel disease

BACKGROUND

Pediatric inflammatory bowel disease (IBD) may be associated with a higher burden of surgery and postoperative complications. This study aimed to measure the burden in pediatric IBD over a 20-year period in a large tertiary referral center.

METHODS

A retrospective review was conducted of children diagnosed with IBD between 1996 and 2015, with a focus upon operative intervention (excluding endoscopy) and postoperative outcomes.

RESULTS

Of 786 IBD patients, 121/581 (20.8%) with Crohn's disease (CD) and 22/205 (10.7%) with ulcerative colitis (UC) underwent surgery during the study period. When comparing 10-year epochs for CD, median time from diagnosis to intervention decreased from 34 months to 3 months (P < 0.0001). Postoperative complications occurred in 16/121 (13%) CD patients (bowel obstruction: 10, anastomotic stricture: 4, stomal issues: 4, anastomotic leak: 1). Within the UC cohort, the median time from diagnosis to intervention decreased from 62 months to 6 months (P = 0.0019). Postoperative complications occurred in 9/22 (41%) UC patients (bowel obstruction: 7, stomal issues: 3, anastomotic stricture: 1). Compared with CD, complications were more frequent in UC patients (P = 0.004).

CONCLUSION

Surgery and postoperative complications are common in pediatric IBD. The timing of intervention has trended towards earlier operations in both CD and UC.

LEVEL OF EVIDENCE

Treatment study-level III (retrospective comparative study).

FGF10 and the Mystery of Duodenal Atresia in Humans

Background: Duodenal atresia (DA) is a congenital obstruction of the duodenum, which affects 1 in 7000 pregnancies and requires major surgery in the 1st days of life. Three morphological DA types are described. In humans, the association between DA and Down syndrome suggests an underlying, albeit elusive, genetic etiology. In mice, interruption of fibroblast growth factor 10 (Fgf10) gene signaling results in DA in 30–50% of embryos, supporting a genetic etiology. This study aims to validate the spectrum of DA in two novel strains of Fgf10 knock-out mice, in preparation for future and translational research.

Methods: Two novel CRISPR Fgf10 knock-out mouse strains were derived and embryos generated by heterozygous plug-mating. E15.5–E19.5 embryos were genotyped with respect to Fgf10 and micro-dissected to determine the presence and type of DA.

Results: One twenty seven embryos (32 wild-type, 34 heterozygous, 61 null) were analyzed. No wild-type or heterozygous embryos had DA. However, 74% of Fgf10 null embryos had DA (49% type 1, 18% type 2, and 33% type 3).

Conclusion: Our CRISPR-derived strains showed higher penetrance of DA due to single-gene deletion of Fgf10 in mice than previously reported. Further, the DA type distribution in these mice more closely reiterated that observed in humans. Future experiments will document RNA and protein expression of FGF10 and its key downstream signaling targets in normal and atretic duodenum. This includes exploitation of modern, high-fidelity developmental tools, e.g., Fgf10^flox/+–tomato^flox/flox mice.

Horse-related injuries in children - unmounted injuries are more severe: A retrospective review

INTRODUCTION

Horse-related injuries account for one quarter of all paediatric sports fatalities. It is not known whether the pattern of injury spectrum and severity differ between children injured whilst mounted, compared with those injured unmounted around horses. We aimed to identify any distinctions between the demographic features, spectrum and severity of injuries for mounted versus unmounted patients.

PATIENTS AND METHODS

Trauma registry data were reviewed for 505 consecutive paediatric patients (aged<16years) admitted to a large paediatric trauma centre with horse-related injuries over a 16-year period. Patients were classified into mounted and unmounted groups, and demographics, injury spectrum, injury severity, and helmet usage compared using odds ratios and Wilcoxon rank-sum tests.

RESULTS

More patients (56%) were injured in a private setting than in a sporting or supervised context (23%). Overall, head injuries were the most common horse-related injury. Mounted patients comprised 77% of the cohort. Mounted patients were more likely to sustain upper limb fractures or spinal injuries, and more likely to wear helmets. Unmounted were more likely to be younger males, and more likely to sustain facial or abdominal injuries. Strikingly, unmounted children had significantly more severe and critical Injury Severity Scores (OR 2.6; 95% CI 1.5, 4.6) and longer hospital stay (2.0days vs 1.1days; p<0.001). Unmounted patients were twice as likely to require intensive care or surgery, and eight times more likely to sustain a severe head injury.

CONCLUSIONS

Horse-related injuries in children are serious. Unmounted patients are distinct from mounted patients in terms of gender, age, likelihood of personal protective equipment use, severity of injuries, and requirement for intensive or invasive care. This study highlights the importance of vigilance and other safety behaviours when unmounted and around horses, and proposes specific targets for future injury prevention campaigns, both in setting of organised and private equestrian activity.

Oesophageal atresia: Are "long gap" patients at greater anesthetic risk?

BACKGROUND

Long gap oesophageal atresia occurs in approximately 10% of all oesophageal atresia infants and surgical repair is often difficult with significant postoperative complications. Our aim was to describe the perioperative course, morbidity, and early results following repair of long gap oesophageal atresia and to identify factors which may be associated with complications.

METHODS

This is a single center retrospective cohort study of consecutive patients with oesophageal atresia undergoing surgical repair at The Royal Children's Hospital Melbourne from January 2006 to June 2017.

RESULTS

Two hundred and thirty-nine consecutive oesophageal atresia infants included 44 long gap oesophageal atresia infants and 195 non-long gap infants. A high rate of prematurity (24.7%), major cardiac (17%), and other surgically relevant malformations (12.6%) was found in both groups. The median age at oesophageal anastomosis surgery was 65.5 days for the long gap group vs 1 day for the oesophageal atresia group (mean difference 56.8 days, 95% CI 48.1-65.5 days, P < .01). Surgery for long gap oesophageal atresia included immediate primary anastomosis (n = 10), delayed primary anastomosis (n = 11), oesophageal lengthening techniques (n = 12) and primary oesophageal replacement (n = 6). Long gap oesophageal atresia was not associated with an increased incidence of difficult intubation (OR 2.8, 95% CI 0.6-22.1, P = .17), intraoperative hypoxemia (OR 1.6, 95% CI 0.6-4.5, P = .32), or hypotension (OR 0.9, 95% CI 0.5-1.8, P = .81). The surgical duration (177.7 vs 202.1 minute, mean difference [95% CI], 28 [5.5-50.4 minutes], P = .04) and mean duration of postoperative mechanical ventilation (107 vs 199.8 hours, mean difference [95% CI], 91.8 [34.5-149.1 hours], P < .01) were shorter for the non-long gap group. Overall in-hospital mortality was 7.5% (15.9% long gap vs 5.6% non-long gap oesophageal atresia OR 1.1, 95% CI 0.4-3.4, P = .85).

CONCLUSION

Long gap oesophageal atresia infants have a similar incidence of perioperative complications to other infants with oesophageal atresia. Current surgical approaches to long gap repair, however, are associated with longer anesthetic exposures and require multiple procedures in infancy to achieve oesophageal continuity.

The spectrum of pediatric injuries sustained in snow sports

BACKGROUND

Snow sports are popular among children but carry the potential for significant injury. Head injuries are less common than fractures and sprains but may be fatal. Helmets are recommended for all snow sports, and yet their effectiveness remains unknown. We aimed to evaluate the spectrum of injuries sustained at three large alpine resorts and to assess the effect of helmet usage on injury severity.

METHODS

We performed a retrospective analysis of prospectively collected pediatric trauma data (2005-2015) from the three largest alpine resorts in our state. Data were analyzed using Spearman's correlation, chi-square, and odds ratio.

RESULTS

A total of 6299 incidents were reviewed. Skiers accounted for 3821 (60.7%) patients, while snowboarders accounted for 2422 (38.5%) patients. More than half (53.5%) of the injuries were related to falls, predominantly affecting knees in skiers and wrists in snowboarders. Overall, helmet usage decreased with age (p<0.001), though helmet uptake was positively associated with higher level of ability in both skiers and snowboarders (p<0.001). Concussions in both skiers and snowboarders were inversely correlated with the rates of helmet usage (p<0.05).

CONCLUSION

Helmet usage was associated with reduced rates of concussion. However, helmet usage decreased with age. We advocate for promotion of helmet usage, using mandatory guidelines, across all pediatric age groups.

LEVEL OF EVIDENCE

Level II - Retrospective study.

Is selective echocardiography in duodenal atresia the future standard of care?

BACKGROUND

Duodenal atresia (DA) is associated with cardiac defects that may have perioperative care implications. Standard preoperative care includes echocardiography to identify such cardiac defects, but this dogma has been challenged. We aimed to assess selective and selective strategies for preoperative echocardiography in DA patients.

METHODS

Single-center retrospective review of neonates with DA over a 16-year period was performed. Data included preoperative cardiovascular and respiratory examination, chest x-ray, and echocardiography. We compared the current nonselective versus selective strategies, limiting preoperative echocardiogram to those in whom: (1) cardiac or respiratory or chest x-ray examination was abnormal, or (2) cardiac or respiratory examination was abnormal. Sensitivity, specificity, positive and negative predictive values were compared with chi-square tests.

RESULTS

Seventy-one of 109 (65%) consecutive neonates with DA underwent preoperative echocardiography according to a nonselective, physician-determined strategy. Forty of 71 (56%) patients had cardiac defects, including 16/40 (27%) major defects. Sixteen additional postoperative echocardiograms revealed 2 missed major defects. In the same cohort, selective strategies would have performed 17-24% fewer echocardiograms without significant detriment in performance.

CONCLUSIONS

All strategies considered missed some major cardiac defects. A selective strategy, determining DA patients not requiring preoperative echocardiogram, could reduce the number of echocardiograms performed without compromising patient safety.

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

Level II.

Can common serum biomarkers predict complicated appendicitis in children?

PURPOSE

As appendicitis in children can be managed differently according to the severity of the disease, we investigated whether commonly used serum biomarkers on admission could distinguish between simple and complicated appendicitis.

METHODS

Admission white blood cell (WBC), neutrophil (NEU), and C-reactive protein (CRP) levels were analysed by ROC curve, and Kruskal-Wallis and contingency tests. Patients were divided according to age and histology [normal appendix (NA), simple appendicitis (SA), complicated appendicitis (CA)].

RESULTS

Of 1197 children (NA = 186, SA = 685, CA = 326), 7% were <5 years, 55% 5-12, 38% 13-17. CA patients had higher CRP and WBC levels than NA and SA (p < 0.0001). NEU levels were lower in NA compared to SA or CA (p < 0.0001), but were similar between SA and CA (p = 0.6). CA patients had higher CRP and WBC levels than SA patients in 5-12- (p < 0.0001) and 13-17-year groups (p = 0.0075, p = 0.005), but not in <5-year group (p = 0.72, p = 0.81). We found CRP >40 mg/L in 58% CA and 37% SA (p < 0.0001), and WBC >15 × 10⁹/L in 58% CA and 43% SA (p < 0.0001).

CONCLUSIONS

Admission CRP and WBC levels may help the clinician predict complicated appendicitis in children older than 5 years of age. Early distinction of appendicitis severity using these tests may guide caregivers in the preoperative decision-making process.

Long-term health status and trajectories of seriously injured patients: A population-based longitudinal study

BACKGROUND

Improved understanding of the quality of survival of patients is crucial in evaluating trauma care, understanding recovery patterns and timeframes, and informing healthcare, social, and disability service provision. We aimed to describe the longer-term health status of seriously injured patients, identify predictors of outcome, and establish recovery trajectories by population characteristics.

METHODS AND FINDINGS

A population-based, prospective cohort study using the Victorian State Trauma Registry (VSTR) was undertaken. We followed up 2,757 adult patients, injured between July 2011 and June 2012, through deaths registry linkage and telephone interview at 6-, 12-, 24-, and 36-months postinjury. The 3-level EuroQol 5 dimensions questionnaire (EQ-5D-3L) was collected, and mixed-effects regression modelling was used to identify predictors of outcome, and recovery trajectories, for the EQ-5D-3L items and summary score. Mean (SD) age of participants was 50.8 (21.6) years, and 72% were male. Twelve percent (n = 333) died during their hospital stay, 8.1% (n = 222) of patients died postdischarge, and 155 (7.0%) were known to have survived to 36-months postinjury but were lost to follow-up at all time points. The prevalence of reporting problems at 36-months postinjury was 37% for mobility, 21% for self-care, 47% for usual activities, 50% for pain/discomfort, and 41% for anxiety/depression. Continued improvement to 36-months postinjury was only present for the usual activities item; the adjusted relative risk (ARR) of reporting problems decreased from 6 to 12 (ARR 0.87, 95% CI: 0.83-0.90), 12 to 24 (ARR 0.94, 95% CI: 0.90-0.98), and 24 to 36 months (ARR 0.95, 95% CI: 0.95-0.99). The risk of reporting problems with pain or discomfort increased from 24- to 36-months postinjury (ARR 1.06, 95% CI: 1.01, 1.12). While loss to follow-up was low, there was responder bias with patients injured in intentional events, younger, and less seriously injured patients less likely to participate; therefore, these patient subgroups were underrepresented in the study findings.

CONCLUSIONS

The prevalence of ongoing problems at 3-years postinjury is high, confirming that serious injury is frequently a chronic disorder. These findings have implications for trauma system design. Investment in interventions to reduce the longer-term impact of injuries is needed, and greater investment in primary prevention is needed.

An audit of patient-controlled analgesia after appendicectomy in children

BACKGROUND

Patient-controlled analgesia (PCA) is commonly used after appendicectomy in children.

AIM

The aim of this study was to characterize the analgesic use of children prescribed PCA after appendicetomy, in order to rationalize future use of this modality.

METHODS

We retrospectively audited all cases of acute appendicitis over a 4-year period in a single pediatric hospital, recording demographics, surgical approach, pathology, analgesia use, pain scores, and duration of PCA. We preplanned subgroup analyses for surgical approach, pathology, and intraoperative nonsteroidal anti-inflammatory drug (NSAID) administration. We subsequently identified a patient subgroup who were unlikely to require PCA and conducted a (2 months) prospective audit of such patients (uncomplicated appendicitis with intraoperative NSAID) having non-PCA (oral) analgesia.

RESULTS

Of the 649 patients undergoing appendicectomy for acute appendicitis, 85% were prescribed an opioid PCA, 8% received an opioid infusion (younger patients), and 7% received neither PCA nor infusion. Of the 541 bolus only PCA patients, 49% had laparoscopic surgery, 36% had complicated appendicitis, and 49% received intraoperative NSAID (diclofenac). Mean (SD) duration of PCA was shorter with uncomplicated vs complicated appendicitis (21.9 ± 10.7 vs 32.8 ± 21.1 h, P < 0.001, difference in means [95% CI]: 10.9 [7.7-14.1]), and with intraoperative NSAID (23.2 ± 14.4 vs 28.4 ± 17.4 h, P < 0.001, difference in means [95% CI]: 5.2 [2.5-7.9]). There was no difference in the time to PCA cessation between laparoscopic and open approach. Morphine consumption and pain scores were lower in the early postoperative period for those patients receiving intraoperative NSAID. In the prospective audit, 44 of 69 patients had uncomplicated appendicitis. Thirty-eight of these were prescribed oral analgesia and none required any parenteral opioid or acute pain service intervention postoperatively. Parental satisfaction level was high (>90%) with oral analgesia.

CONCLUSIONS

It is feasible that children with uncomplicated appendicitis given intraoperative NSAID can be successfully managed without PCA.

Heterogeneity in cervical spine assessment in paediatric trauma: A survey of physicians' knowledge and application at a paediatric major trauma centre

OBJECTIVE

Evidence-based decision-making tools are widely used to guide cervical spine assessment in adult trauma patients. Similar tools validated for use in injured children are lacking. A paediatric-specific approach is appropriate given important differences in cervical spine anatomy, mechanism of spinal injury and concerns over ionising radiation in children. The present study aims to survey physicians' knowledge and application of cervical spine assessment in injured children.

METHODS

A cross-sectional survey of physicians actively engaged in trauma care within a paediatric trauma centre was undertaken. Participation was voluntary and responses de-idenitified. The survey comprised 20 questions regarding initial assessment, imaging, immobilisation and perioperative management. Physicians' responses were compared with available current evidence.

RESULTS

Sixty-seven physicians (28% registrars, 17% fellows and 55.2% consultants) participated. Physicians rated altered mental state, intoxication and distracting injury as the most important contraindications to cervical spine clearance in children. Fifty-four per cent considered adequate plain imaging to be 3-view cervical spine radiographs (anterior-posterior, lateral and odontoid), whereas 30% considered CT the most sensitive modality for detecting unstable cervical spine injuries. Physicians' responses reflected marked heterogeneity regarding semi-rigid cervical collars and what constitutes cervical spine 'clearance'. Greater consensus existed for perioperative precautions in this setting.

CONCLUSIONS

Physicians actively engaged in paediatric trauma care demonstrate marked heterogeneity in their knowledge and application of cervical spine assessment. This is compounded by a lack of paediatric-specific evidence and definitions, involvement of multiple specialties and staff turnover within busy departments. A validated decision-making tool for cervical spine assessment will represent an important advance in paediatric trauma.

Paediatric surgery for the busy GP - Getting the referral right

BACKGROUND

Is a child who presents with a possible non-acute surgical complaint a welcome prospect? Unavoidable deliberations follow: normal versus abnormal, common versus exotic, routine versus urgent, investigate or not, and reassurance versus referral. Delayed or inadequately investigated referrals are uncommon in general paediatric surgery; rather, those that may be unnecessary, inappropriately ascribed as 'urgent' or over-investigated are more commonplace.

OBJECTIVE

This article seeks to optimise a general practitioner's assessment of children with surgical presentations to ensure any resulting paediatric surgery referrals are necessary, timely and appropriately investigated.

DISCUSSION

Common, non-acute complaints presenting in childhood, including testicular maldescent, inguinal hernia and hydrocoele, non-retractile foreskin, and abdominal wall herniae, are discussed in this article. Each summary outlines the basis of the complaint, recommended pre-referral work-up and typical management of these paediatric surgery referrals. Online guidelines may be useful (eg www.rch.org.au/kidsconnect/prereferral_guidelines).