Elisabeth Rousseau

Upper gastrointestinal tract bleeding acquired in a pediatric intensive care unit: Prophylaxis trial with cimetidine

Essai controle en double-insu des effets de la cimetidine (n=19) contre placebo (n=21), chez des enfants de 10 jours a 14 ans. La cimetidine accroit le pH du suc gastrique dans les 3 heures apres la 1ere injection intraveineuse mais ne previent pas les saignements macroscopiques gastro-intertinaux (SMGI) chez les sujets a risque. Le type de prophylaxie est conteste et les transfusions sanguines demeurent indiquees chez les sujets a risque

Surgical complications of the hemolytic-uremic syndrome☆

Hemolytic-uremic syndrome (HUS) of childhood is a triad of acute hemolytic anemia, thrombocytopenia, and acute renal failure associated with a gastrointestinal prodrome. From 1977 to 1988, 134 patients with HUS were admitted to this institution. All patients presented with abdominal pain and diarrhea, which was virtually always bloody. Seventy-eight patients (60%) required dialysis. Five patients died (4%). One patient died as a result of colon perforation, the other four patients died of other nonsurgical complications of HUS. Three patients underwent exploratory laparotomy. One patient had a hemoperitoneum from mesenteric and transmural bleeding of the entire intraabdominal colon. Another patient had undergone surgery elsewhere for presumed intussusception with pancolitis found at exploration. Fourteen days postoperatively, he had a spontaneous perforation of the transverse colon. The third patient presented with pancolitis and perforation of the transverse colon. Despite surgical intervention he died on the sixth postoperative day. One other patient was treated conservatively for pancreatitis, which developed 3 weeks after her presentation with HUS. Complications requiring surgical intervention in HUS are rare, potentially lethal, and usually involve the colon.

Group A streptococcal supraglottitis

We describe four children with severe supraglottic infections caused by group A beta-hemolytic streptococci. In each case the clinical presentation suggested Hemophilus influenzae epiglottitis. In only one patient was there significant involvement of the epiglottis, whereas all had striking inflammation of the aryepiglottic folds. Group A beta-hemolytic streptococcus was isolated in blood cultures in two patients and from the supraglottic area and trachea in two others. Fever persisted for 6 to 22 days, and tracheal intubation was necessary for 2 to 16 days, despite appropriate antibiotic therapy. The evolution of streptococcal supraglottitis may be protracted, and it must be managed accordingly.

Prophylactic thyroidectomies in MEN2 syndrome: Management and outcomes

AIM OF THE STUDY The aim of the study was to evaluate the outcomes of prophylactic thyroidectomies performed in an academic setting in the context of multiple endocrine neoplasia type 2 (MEN2) syndrome. METHODS A chart review of patients <18years old who underwent prophylactic thyroidectomy for a MEN2 syndrome at a childrens hospital between 2006 and 2015 was performed. MAIN RESULTS The study included 21 patients (57% female) with a mean age of 6.2±2.5years. All patients were asymptomatic at first evaluation. Nineteen had MEN2A syndrome with RET proto-oncogene mutations identified. The remaining two were RET-negative with familial medullary thyroid cancer (FMTC). One patient had a concomitant Hirschsprung disease. Of the 11 patients who had RET proto-oncogene mutations ranked as Moderate Risk for medullary thyroid cancer (MTC) (American Thyroid Association), one had a microcarcinoma on the resected specimen, and the others had C-Cell Hyperplasia. Among the 8 patients who had RET proto-oncogene mutations ranked as High Risk level for MTC, all had microcarcinoma. Of the nine patients with microcarcinoma, three underwent surgery after 5years of age. No microcarcinoma exceeded 6mm. There were no permanent complications. Six patients experienced transient hypocalcemia, of which only one was symptomatic. No patients had lymph node involvement, and no recurrence was noted during the follow-up period. CONCLUSIONS Of 21 children with familial thyroid cancer syndrome who underwent a prophylactic thyroidectomy, nine had microcarcinoma. This study highlights the need for a complete familial history, including FMTC history and mandatory preventive surgical approach. LEVEL OF EVIDENCE III.

Motifs d’admission et causes de mortalité dans une unité multi-disciplinaire de soins intensifs pédiatriques

Contrairement aux services de néonatologie, les unités de soins intensifs pédiatriques sont relativement jeunes; il n’est donc pas surprenant que leur clientèle soit mal décrite dans la littérature médicale. Afin de mieux la définir, on a procédé à l’analyse rétrospective des dossiers de 4646 enfants âgés d’une semaine de vie à 18 ans, admis consécutivement dans une unité multidisciplinaire de soins intensifs sur une période de cinq ans, soit de 1979 à 1983. Cette unité fait partie d’un hôpital pédiatrique de 700 lits, lequel assure des soins tertiaires de toute catégorie, autant médicaux que chirurgicaux. Sur 4646 admissions, 2527 (54.3 pour cent) relèvent de la chirurgie et 2119 (45.6pour cent) de la pédiatrie. Les motifs justifiant l’admission sont très variés. Parmi les principaux, on retient les traumatismes majeurs (9.6 pour cent du total des admissions), les intoxications (4.6 pour cent) et les cardiopathies congénitales en phase postopératoire d’une chirurgie correctrice ou palliative (tétralogie de F allot (2.8 pour cent), C.I.A. (2.7 pour cent), etc.). Le taux global de mortalité est de 5.8 pour cent (26814646). Les infections sévères et les cardiopathies, dont la plupart sont congénitales, causent ensemble à peu près la moitié des décès (24.2 pour cent des décès chacun).La clientèle rencontrée en soins intensifs pédiatriques étant ainsi mieux définie, il devient plus facile d’orienter la formation du personnel et d’apporter certains correctifs pour faire diminuer le taux de mortalité.AbstractIn contrast with neonatal intensive care services, paediatric intensive care units are relatively new; thus, it is not surprising that their clientele has not been well described in the medical literature. In order to better define it, we did a retrospective analysis of 4646 consecutive admissions of children aged between a week and 18 years to a multidisciplinary paediatric intensive care unit over a period of five years (1979–83). This unit belongs to a 700-bedpaediatric hospital delivering medical as well as surgical tertiary care.Of the 4646 admissions, 2527 (54.3 per cent) were surgical and 2119 (45.6 per cent) medical. There were multiple diagnoses on admission. Among the most frequent diagnoses were major trauma (9.6 per cent of total), intoxications (4.6per cent) and congenital cardiopathies in the postoperative phase of a corrective or palliative surgery (tetralogy of Fallot (2.8per cent), ASD (2.7per cent), etc.) The global mortality rate was 5.8per cent (268/4646). Severe infections and cardiopathies, mostly congenital, were responsible for almost half the deaths (24.2 per cent each).This description of patients and problems encountered in a paediatric intensive care unit should facilitate planning for personnel training and can be used to establish guidelines for reducing mortality.

Pediatric thyroidectomy: Favorable outcomes can be achieved by a multidisciplinary team of pediatric providers

AIM OF THE STUDY Recent publications suggest pediatric surgeons may not be well suited to perform thyroid surgeries unless considered high volume. We sought to assess the outcome of thyroidectomies performed by pediatric surgeons in an academic setting. METHODS We reviewed charts of patients younger than 18 years who underwent thyroid surgeries at a free standing childrens hospital between April 2006 and October 2015. MAIN RESULTS The analysis included 118 surgeries in 98 patients (mean age 11.8 years). Most surgeries were performed by a single pediatric surgeon (average 10 thyroidectomies per year). The commonest indication for resection was thyroid nodule (64%). 80% of patients had a single surgery; the remainder had two, including 13 completion hemithyroidectomies. Cancer was found in 37% of specimens, with papillary subtype being most common (72%). Seven patients had locoregional metastases and one had pulmonary metastases. Among the 17 malignant cases that had a second intervention, 6 had malignancy in the resected specimen. There were no deaths in the follow up period (mean 2.7 years). Two patients had permanent hypocalcemia, and three had persistent unilateral recurrent laryngeal nerve injuries causing dysphonia for a total permanent complication rate of 4.2%. CONCLUSIONS We conclude that pediatric thyroidectomy is a safe procedure when performed by pediatric surgeons. Our rate of complications is comparable to those reported in the literature. Our data highlight the need for a vigilant and multidisciplinary approach for children with thyroid pathology. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE IV.