Ibrahim Abu-Kishk

Risk factors affecting the immediate postoperative course in pediatric scoliosis surgery.

Study Design. A retrospective analysis of pediatric records of idiopathic scoliosis (IS) and neuromuscular scoliosis (NMS) etiology, in a search for complications and their risk factors immediately following surgical repair. Objective. To evaluate the influence of pre- and intraoperative parameters on the postoperative course and lay the cornerstone for a course-prediction model. Summary of Background Data. Only a few studies have addressed the immediate postoperative complications of pediatric scoliosis surgery. Methods. Our study included all children who underwent spinal fusion for scoliosis in our hospital between 1998 and 2006. The following data were collected: curve etiology, Cobb angle, number of fused vertebrae, fusion approach, and the addition of thoracoplasty. We evaluated the influence of this data on the rate of delayed extubations, length of intensive care unit (ICU) hospitalization, and the presence of major and minor immediate postoperative complications. Results. The study included 126 children (95 IS and 31 NMS). Delayed extubations were recorded in 17 children (3% of IS vs. 45% of NMS). The most common major and minor complications were pulmonary and hematological-biochemical, respectively. Overall pulmonary complications (major and minor) were recorded in 38 children. Major complications (of any category) were recorded in 19 children. Average length of ICU hospitalization was 3.8 days. The rate of complications in the NMS group was significantly higher than in the idiopathic group. Posterior fusions were associated with a significantly lower rate of pulmonary complications and shorter ICU hospitalizations, in comparison to anterior and combined fusions. Cobb angle, number of fused vertebrae, and the addition of thoracoplasty did not correlate with any postoperative parameters. Conclusion. While NMS etiology, anterior and combined fusions correlated with a worse course, the Cobb angle, number of fused vertebrae, and the addition of thoracoplasty did not. Optimization of postoperative care should be carried out accordingly. Scoliosis surgery is safe even in extreme curves and long fusions. Thoracoplasty can be added whenever indicated, in order to improve the overall outcome.

Blunt pancreatic trauma in children

PurposeTo report our experience with blunt pancreatic trauma in pediatric patients and evaluate several various management strategies.MethodsTen children admitted over the last 10 years with pancreatic blunt trauma were included in the present series.ResultsThe average time from injury to hospital admission was 2.4 days. All injuries resulted from accidents: bicycle handlebar injuries (5), being kicked by a horse (2), falls from a height (2), and injury sustained during closure of an electric gate (1). Additional systemic and abdominal injuries were recorded in 7 patients. The amylase levels at the time of patient admission were normal in 3 patients, mildly raised in 4 patients, and elevated in 3 patients. Abdominal computed tomography was performed in 10 patients, ultrasonography in 5, and endoscopic retrograde cholangiopancreatography (ERCP) in 4. Pancreatic injuries comprised 4 grade I, 3 grade II, and 3 grade III injuries. Grade I and II injuries were successfully managed by conservative treatment. The 3 children with grade III trauma and pancreatic ductal injury in the neck (1), body (1), and tail (1) of the gland were surgically treated, having an uneventful postoperative stay of 8–14 days and no complications during the 1-year follow-up period.ConclusionThe present study supports early ERCP as an essential part of the initial patient evaluation when pancreatic transection is highly suspected.

Bicycle-related injuries in children: Disturbing profile of a growing problem

CONTEXT We observed a changing pattern of bicycle-related injuries in children, with the focus changing from head trauma to thoracic and abdominal injuries, and a trend to increasingly severe injuries. OBJECTIVE To assess the changing injury pattern, and investigate the development of preventive measures to improve safety. DESIGN, SETTING, AND PARTICIPANTS Retrospective record review of 142 paediatric patients admitted to our Department of Paediatric Surgery between 1996 and 2005 following bicycle-related injuries. Clinical, laboratory, diagnostic, and therapeutic aspects were analysed. Additional information concerning childrens bicycle-related injuries in Israel was obtained from the Gertner Institute (Israel National Center for Trauma and Emergency Medicine Research) and from Beterem (The National Center for Childrens Safety & Health, the Safe Kids Israeli Chapter) National Report on Child Injuries in Israel 2006. MAIN OUTCOME MEASURES The nature and severity of injuries were reviewed, and two 5-year periods compared-from 1996 to 2000 (53 children-Group 1), and from 2001 to 2005 (89 children-Group 2). RESULTS Head trauma was more common in the Group 1 patients (52.6% vs. 45.2%), but skull fractures and intracranial haemorrhage occurred more frequently in Group 2 (28.5% vs. 16.7%; 21.3% vs. 8.3%, respectively). Injury to the stomach or duodenum, kidneys and liver were all more common in Group 2. Splenic injury occurred with equal frequency in both groups, but more severe injuries were seen in Group 2. More children in Group 2 required intensive care (31% vs. 19.3%). CONCLUSIONS There is a changing pattern of bicycle-related injuries in children, with chest and abdominal injuries dominating, and an increasing incidence of more severe injury. These findings are important in decision-making regarding preventive measures.

Superior mesenteric artery syndrome after scoliosis repair surgery: a case study and reassessment of the syndromeʼs pathogenesis

We carried out a retrospective analysis to investigate the prevalence of superior mesentery artery syndrome (SMAS) in children who underwent scoliosis surgical repair at our hospital between 1998 and 2006 and to reassess the syndromes pathogenesis. Among 133 consecutive pediatric patients, two cases were identified, both 13-year-old girls with idiopathic scoliosis, undergoing surgery using third-generation instrumentation systems. Conservative management achieved resolution of the symptoms without recurrence. SMAS prevalence in our series was 1.6%. SMAS might occur after derotation and translation forces application, and even with nonextreme corrections. Low BMI and significant weight loss at presentation are not mandatory.

Neuroleptic Malignant Syndrome in a Child Treated with an Atypical Antipsychotic

Neuroleptic malignant syndrome (NMS) is an uncommon potentially fatal side effect of neuroleptic drugs, characterized by movement disorder, altered mental status and autonomic instability. A single dose of clotiapine was administered to an 11‐year old male with acute psychosis. The previously healthy child had signs consistent with NMS including hyperthermia, hypertension, motor and mental changes. Repeat examination performed two weeks later, demonstrated that while his hyperthermia subsided, his mental status deteriorated. Olanzapine was administered, after which the child had hyperthermia, dystonia and more pronounced restlessness, once again consistent with NMS. He developed respiratory failure and was intubated and mechanically ventilated. Lorazepam, dantrolene and bromocriptine were administered as treatment of possible NMS. His mental condition, movement disorder and autonomic dysfunction improved significantly. Two weeks later, the patient was discharged in good general condition without the need for any ongoing medical treatment. There are only few case reports of NMS in children treated with olanzapine, an atypical antipsychotic. In children, caution must be exercised when prescribing antipsychotics, particularly atypical antipsychotics as these drugs may cause NMS. Because of the low incidence of NMS, a high index of suspicion is needed to identify cases so prompt treatment can be undertaken.

Changes in serum hepcidin levels in acute iron intoxication in a rat model

Hepcidin is an important and recently discovered regulator of iron homeostasis. Acute iron intoxication is one of the leading causes of overdose mortality in children. It is difficult to estimate the degree of iron intoxication since iron serum levels do not correlate with the actual clinical severity. In the current study we aimed to investigate whether serum hepcidin levels are elevated in acute iron intoxication. Rats were divided into two iron dose groups and one control group. Each group was further subdivided into four time groups following the administration of iron. Levels of hepcidin, iron and liver enzymes were measured, and animals were followed for signs of toxicity. Serum hepcidin levels were significantly higher in the group treated with toxic doses of iron (p=0.005). No significant difference in serum iron levels was found between the groups. In acute iron intoxication serum hepcidin levels increase significantly and remain elevated for at least 6h. We postulate that beyond the first hour after iron administration, serum hepcidin levels provide a better estimate of the amount of iron intake than do serum iron levels.

The contribution of intraoperative transinguinal laparoscopic examination of the contralateral side to the repair of inguinal hernias in children

BackgroundBilateral inguinal hernias are relatively common in children. This fact has led to a controversy of more than 50 years concerning the necessity of bilateral surgical exploration during the repair of unilateral inguinal hernias in children. The advent of transinguinal laparoscopic visualization of the contralateral side is a turning point and a major contribution to the subject, offering the opportunity to reassess the systematic bilateral exploration and the “wait and see” policies currently in use at most services of pediatric surgery.Data sourcesThe current information concerning intraoperative transinguinal laparoscopic evaluation of inguinal hernias in children was summarized in a didactic way. A MEDLINE search (PubMed) from 1995 to the present days was conducted.ResultsA patent processus vaginalis (PPV) is not equal to a future symptomatic hernia. There is still no definitive evidence on which PPVs will become a hernia (5.8% to 11.6%) and which remain clinically insignificant. Diagnostic intraoperative transinguinal laparoscopic evaluation of the contralateral side is today the most simple and accurate way to reduce the incidence of negative explorations.ConclusionDiagnostic intraoperative transinguinal laparoscopic evaluation of the contralateral side during pediatric inguinal hernia repair is a simple, accurate, fast, and effective method to assess the contralateral processus vaginalis, improving decision-making, reducing the number of negative explorations, and sparing the surgeon the embarrassment associated with the appearance of a metachronous hernia at a later date. It is easily learned and should be part of every pediatric surgeon’s practice.

Transient renal insufficiency following dipyrone overdose

Aim To describe the incidence of acute renal insufficiency after dipyrone overdose in children. Methods The medical records of all patients ≤18 years of age during a 3-year period presenting at Assaf Harofeh Medical Center due to toxic exposure were retrospectively reviewed. Patients suffering from dipyrone overdose were compared with all the other patients. Results 235 cases were included in the final analysis. Of these, 26 (11%) patients were exposed to dipyrone (median age 15 years). Three of the 26 patients (12%) had transient non-oliguric renal insufficiency. One other patient who did not receive dipyrone also developed transient renal insufficiency. Conclusions Dipyrone overdose is frequent and may cause acute non-oliguric renal insufficiency. Renal function should be monitored in such patients.

Use of Adult Criteria for Slice Imaging May Limit Unnecessary Radiation Exposure in Children Presenting With Hematuria and Blunt Abdominal Trauma

OBJECTIVE To examine whether it would be safe to use adult criteria for imaging in pediatric blunt renal trauma and hematuria. MATERIAL AND METHODS From 1999 to 2007, 46 consecutive children were admitted for renal trauma and hematuria. All had abdominal computed tomography (CT) scan. Patients were divided into 2 groups: microhematuria and macrohematuria. Outcomes analyzed were presence of renal injury per CT, grade of renal injury, and indication for and details of surgical intervention. RESULTS Twenty-seven patients (59%) had microhematuria. Nineteen (41%) had macrohematuria. On abdominal CT scan, no injury was found in 18 patients with microhematuria (67%) and 3 (16%) with macrohematuria. Two microhematuria patients required surgical intervention. In both cases, no actual renal intervention was performed during surgery. Three macrohematuria patients required surgical intervention; all had renal relevant procedures. The performance of the macro-microhematuria distinction in the prediction of renal injury on CT scan is relatively poor: sensitivity 59%, specificity 14%, positive predictive value (PPV) 84%, and negative predictive value (NPV) 62%, whereas the performance of macrohematuria criteria in the prediction of renal-relevant injury is sensitivity 100%, specificity 61%, PPV 18%, and NPV 93%. CONCLUSIONS The yield of abdominal CT in pediatric renal trauma is low in patients presenting with microhematuria. Our data suggest that it may be possible that adult criteria for renal imaging are sufficient for children with abdominal blunt trauma and microhematuria. Adopting such strategy will result in substantial reduction in exposure to radiation, supposedly without increasing the patients risk.

Oral N-acetylcysteine has a deleterious effect in acute iron intoxication in rats.

Acute iron intoxication is associated with depletion of reduced glutathione in hepatocytes and changes in the glutathione system enzymes. We hypothesized that treatment with N-acetylcysteine (NAC), a glutathione reducing agent and an antioxidant, would reduce mortality in acute iron intoxication. We used a rat model to test this hypothesis. Male rats were assigned to 4 groups. Group 1 received 400 mg/kg elemental iron by oral gavage, group 2 received the same dose of iron followed by NAC, group 3 received NAC only, whereas group 4 received distilled water. Iron and liver transaminases in the blood, and glutathione system enzymes in the liver and erythrocytes were measured. Mortality in group 2 was significantly higher after 2, 6, and 24 hours compared with group 1 (P < .001). No deaths were observed in groups 3 and 4. Serum iron levels were significantly higher in group 2 rats compared to group 1 rats (P < .001). Hepatic and erythrocyte glutathione system enzymes were significantly lower among rats in group 2 compared to rats in group 1. The administration of NAC probably increased the absorption of iron through the gastrointestinal tract, causing higher serum iron levels with significant hepatic damage. These results indicate that in a rat model of acute iron intoxication, orally administered NAC may increase mortality.