David Manson

Evaluation of the Utility of Radiography in Acute Bronchiolitis

n n Objectivesn To determine the proportion of radiographs inconsistent with bronchiolitis in children with typical presentation of bronchiolitis and to compare rates of intended antibiotic therapy before radiography versus those given antibiotics after radiography.n n n Study designn We conducted a prospective cohort study in a pediatric emergency department of 265 infants aged 2 to 23 months with radiographs showing either airway disease only (simple bronchiolitis), airway and airspace disease (complex bronchiolitis), and inconsistent diagnoses (eg, lobar consolidation).n n n Resultsn The rate of inconsistent radiographs was 2 of 265 cases (0.75%; 95% CI 0-1.8). A total of 246 children (92.8%) had simple radiographs, and 17 radiographs (6.9%) were complex. To identify 1 inconsistent and 1 complex radiograph requires imaging 133 and 15 children, respectively. Of 148 infants with oxygen saturation >92% and a respiratory disease assessment score <10 of 17 points, 143 (96.6%) had a simple radiograph, compared with 102 of 117 infants (87.2%) with higher scores or lower saturation (odds ratio, 3.9; 95% CI, 1.3-14.3). Seven infants (2.6%) were identified for antibiotics pre-radiography; 39 infants (14.7%) received antibiotics post-radiography (95% CI, 8-16).n n n Conclusionsn Infants with typical bronchiolitis do not need imaging because it is almost always consistent with bronchiolitis. Risk of airspace disease appears particularly low in children with saturation higher than 92% and mild to moderate distress.n n

Spontaneous reduction of intussusception: clinical spectrum, management and outcome

Background. To analyze the spectrum of clinical features, management and outcome of children with documented spontaneous reduction of intussusception (SROI).¶Materials and methods. Review of records of 50 children (33 boys, ¶17 girls; age range 11 days–15 years; mean age 4 years) with documented SROI, in whom intussusception was initially diagnosed by sonography (US) in 44, air enema in 2, and computed tomography in 4, in the 6-year period 1992–1998.¶Results. Symptoms suggestive of intussusception were present in 21 (3 of whom had Henoch-Schönlein purpura and 4 had previous ileocolic intussusception reduced by air enema). Intussusception was an incidental finding in the other 29, in 28 of whom the finding was in the small bowel. Intussusception was limited to the small bowel in 43 and was ileocolic in 7. SROI was usually documented on US. Laparotomy performed in only 4 showed no evidence of intussusception or pathologic lead point. Outcome in all patients was favorable.¶Conclusions. SROI may present in symptomatic or asymptomatic children and occurs more commonly than previously reported. These intussusceptions are usually short-segment, small-bowel intussusceptions with no recognizable lead point. In asymptomatic patients, conservative observation is warranted. Intervention should be dictated by the clinical findings in symptomatic patients.

Imatinib mesylate: An attractive alternative in young children with large, surgically challenging dermatofibrosarcoma protuberans

To document the clinical activity of imatinib mesyalte in a child with a dermatofibrosarcoma protuberans (DFSP). An 18‐month‐old girl presented with a large extremity DFSP. As surgical resection would have caused unacceptable functional defects, imatinib mesylate was administered to induce tumor reduction and or stabilization. After 23 weeks of therapy, magnetic resonance imaging (MRI) of the tumor showed a reduction in the subcutaneous thickness in the transverse plane. The drug was tolerated well without any adverse reactions. Imatinib mesylate offers a non‐surgical alternative for the treatment of large DFSP in children.

Analgesia in Children with Sickle Cell Crisis: Comparison of Intermittent Opioids Vs. Continuous Intravenous Infusion of Morphine and Placebo-Controlled Study of Oxygen Inhalation

The objectives of the study were to compare the efficacy and safety of a continuous infusion (CIV) of morphine and intermittent parenteral opioids (IPO) in children with sickle cell vaso-occlusive crises (VOCs); to determine whether 50% oxygen administration through a face mask can reduce the duration of severe pain in patients receiving CIV morphine; and to measure morphine concentration at steady state for pharmacokinetic and pharmacodynamic analysis in patients receiving CIV morphine. The study was designed as a prospective, controlled, before-and-after evaluation of two different analgesic regimens. For patients receiving CIV morphine, there was a randomized, double-blind, placebo-controlled study of O2 vs. air. The patients were 66 children with sickle cell disease, 3-18 years old, requiring opioid therapy for severe VOC (32 patients in phase A, 34 in phase B). The analgesic regimens were as follows: phase A: meperidine, morphine, or codeine IM or IV bolus every 3 or 4 hours; phase B: morphine sulfate, loading dose 0.15 mg followed by CIV 0.04 mg/kg/hr. The infusion rate was adjusted every 8 hours according to pain and/or symptoms of opioid toxicity. Pain assessment was by behavioral observation (BPS). In terms of results, the mean opioid dose (morphine equivalent) was similar in both groups (0.032 +/- 0.020 mg/kg/hr in phase A and 0.035 +/- 0.011 in phase B). However, the duration of severe pain was significantly shorter in phase B (0.9 +/- 1.0 days) than in phase A (2.0 +/- 1.8 days). No severe opioid toxicity was observed in either group. Oxygen did not shorten the duration of severe pain compared to the placebo group (0.94 +/- 1.08 and 0.95 +/- 1.19 days, respectively) nor did it prevent the appearance of new pain sites. Pharmacokinetic analysis was performed in 24 patients of phase B. Total body clearance (TBC) of morphine was greater in children before puberty than after (40.4 +/- 10 vs. 28 +/- 11 mL/kg/min; p < 0.05). In conclusion, in children with severe VOCs, continuous infusion of morphine provides better analgesia than intermittent opioid therapy. Fifty percent oxygen inhalation had no effect on the duration of pain.

Clinical utility of high-resolution pulmonary computed tomography in children with antibody deficiency disorders.

Objective. To assess the value of high-resolution computed tomography (HRCT) in determining the extent and significance of lung disease in children with antibody deficiency states. Materials and methods. Seventy HRCT scans performed on 37 children with various antibody deficiency disorders over a 5-year period were retrospectively scored using a previously described demerit scoring system (0–25 with 0 = worst, 25 = best). Points are subtracted from 25 with increasing severity of disease. The potential correlations between CT scores and clinical factors, including age at diagnosis, age at CT, type of immunoglobulin deficiency, length of respiratory symptoms before diagnosis, number of pneumonias before diagnosis, type, length and success of therapy, patient compliance and pulmonary function tests (PFTs), were assessed. Results. Of the 37 children, a demonstrated 22 abnormal scans (CT score ≤ 22). All nine demonstrated bronchiectasis with a lower lobe and right middle lobe predominance. Statistically significant correlations were seen between severity of lung disease (CT score) and length of respiratory symptoms before diagnosis (p = 0.01), success of therapy (P = 0.001) and PFTs (P = 0.0008). Of seven children who were followed with repeated scans, 4 of the 7 demonstrated CT scores which improved on high-dose intravenous immunoglobulin replacement therapy. Conclusion. HRCT is a useful adjunct to demonstrate the extent and severity of lung disease at diagnosis and during therapy. Correlation with clinical factors suggests a higher risk group needing more aggressive management.

Survival and Late Effects in Children With Hodgkin's Lymphoma Treated With MOPP/ABV and Low-Dose, Extended-Field Irradiation

PURPOSEnReduced-intensity protocols for pediatric Hodgkins lymphoma are aimed at preserving excellent relapse-free survival while decreasing the incidence of late effects.nnnPATIENTS AND METHODSnWe retrospectively reviewed the outcome of 123 children treated consecutively for Hodgkins lymphoma at a single institution. Patients with stages I-IIIB disease received three cycles of mechlorethamine, vincristine, procarbazine, and prednisone (MOPP)/ doxorubicin, bleomycin, and vinblastine (ABV) followed by 15 Gy of extended-field irradiation, while those with stage IV disease were treated with six to eight cycles of MOPP/ABV chemotherapy with or without radiotherapy.nnnRESULTSnAt a median follow-up of 8.5 years (range, 1.4 to 15.5 years), the estimated 10-year overall survival and event-free survival are 94% (SE, 2.2%) and 88% (SE, 3.1%) respectively. There have been 12 treatment failures and six disease-related deaths. A very large mediastinal mass ( 50% of the maximal thoracic diameter) was associated with a 10-year event-free survival of 50% (SE, 14%) compared with 91% (SE, 4.0%) for smaller masses (P < .001). Late cardiopulmonary toxicity is largely absent, and the incidence of hypothyroidism is 14%. There have been no cases of secondary leukemia and four secondary solid malignancies observed to date.nnnCONCLUSIONnMOPP/ABV and low-dose, extended-field radiotherapy is an effective treatment for pediatric Hodgkins lymphoma. With median follow-up of 8.5 years, late cardiopulmonary effects and secondary malignancies from this treatment regimen are infrequent. Continued longitudinal observations, particularly for breast cancer in female patients and gonadotoxicity, will determine whether the goal of decreasing treatment-related complications while maintaining excellent survival has been achieved.

Traumatic diaphragmatic injuries in infants and children: imaging findings

Objectives. Traumatic diaphragmatic injuries (DI) in infants and children are uncommon and are often associated with multiple severe injuries. Delayed presentation can be life threatening due to organ herniation and strangulation. We present the imaging findings in a relatively large population of children who experienced this rare injury.¶Methods. Medical records of all patients admitted to our Trauma Service from 1977 to 1998 with DI were retrospectively reviewed recording imaging, clinical and surgical or autopsy findings.¶Results. Of sixteen patients with DI (7 females, 9 males; age 3 weeks to 15 years), 14 suffered from blunt trauma secondary to high-energy impact, and 2 from penetrating injuries. Unilateral DI occurred equally on each side, with one bilateral injury. Associated injuries, present in 81 %, included severe head injuries, visceral, mesenteric and vascular injuries and multiple fractures. Six patients died from multiple organ failure (3), head injury (2), and shock (1). Findings in the initial chest X-ray suggested the diagnosis in 13 (81 %) of 16 injuries, and CT demonstrated irregularity and thickening of the diaphragm in 4 out of 7.¶Conclusions. Plain film findings suggested the diagnosis in most; CT and MR were useful adjuncts. High index of suspicion and awareness of the mechanism of injury can lead to prompt diagnosis, early repair, and decreased morbidity and mortality.

Tracheoesophageal fistula without esophageal atresia: are pull-back tube esophagograms needed for diagnosis?

BackgroundA pull-back tube esophagogram (PBTE) is widely accepted in the literature as the radiological investigation of choice for the diagnosis of tracheoesophageal fistula without esophageal atresia. However, PBTE is rarely performed in our institution, as we have been successful in confirming the presence of such fistulae with a contrast material swallow (CS). We hypothesized that PBTE is not the radiological investigation of choice for the diagnosis of the fistula in this condition.ObjectiveWe sought to determine what proportion of patients with tracheoesophageal fistula without esophageal atresia can be diagnosed promptly by a CS and what the indications are for a PBTE.Materials and methodsWe retrospectively analyzed the clinical and radiological findings in patients with tracheoesophageal fistula without esophageal atresia to determine whether the fistula was diagnosed with a CS or PBTE.ResultsWe identified 20 children (13 female and 7 male) with tracheoesophageal fistula without esophageal atresia. Their age at diagnosis ranged from 3 days to 168 months with a median of 9 days. The diagnosis was documented by CS in 12, PBTE in 7 and CT in 1. In three of the seven who had the fistula documented by PBTE, a previous CS had shown contrast material in the trachea, but no fistulous tract or aspiration was identified.ConclusionWe believe that CS should be the examination of choice in most patients suspected of having a tracheoesophageal fistula without esophageal atresia. A PBTE is indicated in patients who are intubated or are at significant risk of aspiration. Furthermore, a PBTE is also indicated where contrast material is seen in the airway on CS and there is uncertainty whether this is due to aspiration or a fistula.

Posttraumatic torsion of accessory lobe of the liver and the gallbladder

Abstract Torsion of an accessory lobe of the liver and of the gallbladder is a rare etiology for acute abdominal pain in children and infants. We report a case of an 8-year-old girl who was admitted with acute epigastric pain and vomiting, after her brother had jumped on her back. Physical examination revealed an afebrile child with a nontender right upper quadrant (RUQ) mass. Color Doppler ultrasound and contrast-enhanced CT demonstrated a heterogeneous, avascular mass with displacement of a thickened-wall gallbladder. A torted, congested accessory lobe of the liver and the gallbladder were resected at laparotomy. Imaging and operative findings are presented and a differential diagnosis is discussed in order to increase awareness of this rare condition.

Pediatric Abdominal Radiograph Use, Constipation, and Significant Misdiagnoses

OBJECTIVEnTo determine the proportion of children diagnosed with constipation assigned a significant alternative diagnosis within 7 days (misdiagnosis), if there is an association between abdominal radiograph (AXR) performance and misdiagnosis, and features that might identify children with misdiagnoses.nnnSTUDY DESIGNnWe conducted a retrospective cohort study of consecutive children <18 years who presented to a pediatric emergency department in Toronto, between 2008 and 2010. Children assigned an International Statistical Classification of Diseases and Related Health Problems 10th Revision code consistent with constipation were eligible. Misdiagnosis was defined as an alternative diagnosis during the subsequent 7 days that resulted in hospitalization or an outpatient procedure that included a surgical or radiologic intervention. Constipation severity was classified employing text word categorization and the Leech score.nnnRESULTSn3685 eligible visits were identified. Mean age was 6.6 ± 4.4 years. AXR was performed in 46% (1693/3685). Twenty misdiagnoses (0.5%; 95% CI 0.4, 0.8) were identified (appendicitis [7%], intussusception [2%, bowel obstruction [2%], other [9%]). AXR was performed more frequently in misdiagnosed children (75% vs 46%; P = .01). These children more often had abdominal pain (70% vs 49%; P = .04) and tenderness (60% vs 32%; P =.01). Children in both groups had similar amounts of stool on AXR (P = .38) and mean Leech scores (misdiagnosed = 7.9 ± 3.4; not misdiagnosed = 7.7 ± 2.9; P = .85).nnnCONCLUSIONSnMisdiagnoses in children with constipation are more frequent in those in whom an AXR was performed and those with abdominal pain and tenderness. The performance of an AXR may indicate diagnostic uncertainty; in such cases, the presence of stool on AXR does not rule out an alternative diagnosis.