Päivi Salminen

Capsule endoscopy in pediatric patients: Technique and results in our first 100 consecutive children

Abstract Objective. Capsule endoscopy (CE) offers noninvasive methods to assess small bowel pathology but only limited data are available on the feasibility, safety, and findings in children. In this study, we report our results of 100 consecutive CE in children. Material and methods. Single center retrospective study. All pediatric patients (mean age 119 months, range from 8 to 188 months) undergoing CE were included until 100 investigations were completed. The indications for CE were: suspicion or evaluation of Crohns disease (n = 35) or ulcerative colitis (n = 24), gastrointestinal bleeding (n = 18), and miscellaneous (n = 23). Results. The youngest patients able to swallow the capsule were 84 months old. When the patient was unable to swallow the capsule (n = 51), it was guided into the duodenum with endoscope. In two patients, the capsule remained in the stomach during the 8 h of recording and in 23 cases the capsule failed to reach the cecum. The capsule was expelled naturally in all except one patient. In 39% of the patients, CE revealed a significant finding (multiple ulcers, bleeding, tumors, strictures). In patients examined for bleeding or for a suspicion of Crohns disease, the respective proportions were 50% and 60%. Conclusions. This study shows that CE is a feasible diagnostic method to study the small intestine in pediatric patients and that CE can be done in children as young as 8 months old. The diagnostic yield is highest in cases with bleeding or a high suspicion of Crohns disease.

Head and Neck Arteriovenous Malformations: Results of Ethanol Sclerotherapy

BACKGROUND AND PURPOSE: Peripheral AVM is a locally aggressive disease with a high tendency to recur; its treatment is complex, especially in the anatomically delicate head and neck area. Here, we report results of ethanol sclerotherapy for head and neck AVM and discuss its potential use for peripheral AVM. MATERIALS AND METHODS: We retrospectively assessed degree of AVM eradication, complications, and clinical or imaging signs of recurrence for 19 patients treated with ethanol sclerotherapy for head and neck AVM (1 intraosseous, 18 soft-tissue AVMs). RESULTS: Of the 19 patients, 11 had complete eradication of arteriovenous shunting at DSA, with 1 recurrence (mean follow-up 15 months), and for 7 patients, treatment is ongoing. During 59 treatment sessions, 12 patients experienced 14 complications, 1 leading to permanent functional damage. CONCLUSIONS: Ethanol sclerotherapy has potential for complete eradication of head and neck AVM with low recurrence within the first year after completion of treatment. Complete eradication may require several treatment sessions during which complications should be minimized with careful techniques.

An interdisciplinary specialist team leads to improved diagnostics and treatment for paediatric patients with vascular anomalies.

Patients with vascular anomalies are often misdiagnosed, leading to delayed or improper treatment. The aim of this study was to evaluate the impact of an interdisciplinary team on the diagnosis and treatment of paediatric patients with vascular anomalies.

Heading for a fall - moped and scooter accidents from 2002 to 2007

Background and Aims: Mopeds and scooters have become increasingly popular among Finnish teenagers. The aim of this retrospective study was to assess incidence of and injury patterns associated with moped and scooter accidents in adolescents. Materials and Methods: All 222 patients treated for moped and scooter-related injuries at Helsinki Childrens Hospital and Töölö Trauma Centre from January 2002 to December 2007 were included. Information was drawn from patient records and compared with nation-wide Finnish data gathered from public data-bases. Results: The annual number of patients at our centres increased from 14 to 76 and the proportion of girls increased from 7% to 25%. A similar trend was found on a national level. In our material, collisions between mopeds and other motorized vehicles accounted for 52% of accidents, and 33% of patients were injured from falling. Seventy-five percent of patients were hospitalized, and 50% needed at least one procedure requiring general anaesthesia. Five percent of the patients were under the influence of alcohol. Trauma of the head occurred in 22%; helmets did not protect against severe trauma. On a national level the proportion of 15- to 17-year-old road traffic victims has doubled in five years. Among this age group, more than half of all road-traffic accidents involve mopeds and scooters. Conclusions: Over a time span of six years, moped accidents among adolescents have become very common. Our results suggest that measures should be taken to diminish the number of moped and scooter accidents and to improve driver safety.

Neuropilin-2 and vascular endothelial growth factor receptor-3 are up-regulated in human vascular malformations

Despite multiple previous studies in the field of vascular anomalies, the mechanism(s) leading to their development, progression and maintenance has remained unclear. In this study, we have characterized the expression levels of vascular endothelial growth factors and their receptors in 33 human vascular anomalies. Analysis with quantitative real-time PCR and gene-specific assays showed higher expression of neuropilin-2 (NRP2) and VEGF-receptor-3 (VEGFR-3) mRNAs in vascular malformations (VascM) as compared to infantile hemangiomas (Hem). In addition, the expression levels of PlGF and VEGF-C mRNA were significantly higher in venous VascM when compared to the other VascM and Hem. Higher expression of NRP2 and VEGFR-3 were confirmed by immunohistochemistry. To further study the importance of NRP2 and VEGFR-3, endothelial cell (EC) cultures were established from vascular anomalies. It was found that NRP2 and VEGFR-3 mRNA levels were significantly higher in some of the VascM ECs as compared to human umbilical vein ECs which were used as control cells in the study. Furthermore, adenoviral delivery of soluble decoy NRP2 prevented the proliferation of ECs isolated from most of the vascular anomalies. Our findings suggest that NRP2 functions as a factor maintaining the pathological vascular network in these anomalies. Thus, NRP2 could become a potential therapeutic target for the diagnosis and treatment of vascular anomalies.

Sclerotherapy complications of peripheral venous malformations

Background Sclerotherapy is often the primary treatment for peripheral venous malformations. It is mostly sufficient alone, but can be combined with other endovascular techniques. Despite its mini-invasiveness, it is not without potentially severe complications. Here, we systematically report sclerotherapy complications in trunk and extremity venous malformations. Methods We retrospectively assessed the complications of 127 consecutive patients who had received sclerotherapy for peripheral venous malformation in our tertiary care unit (January 2007–August 2013). We applied the Clavien–Dindo classification to grade the severity of complications. We mostly used detergent sclerosants (85.7%), and less often ethanol (5.7%) or bleomycin (4.2%). In 4.2% of the procedures, we combined glue, coils, endovascular laser or particles to sclerotherapy. Results The overall complication rate per procedure was 12.5%. Most complications (83.3%) were local and managed conservatively. We encountered four severe complications, all related to blood coagulopathy. Subcutaneous lesion location and use of ethanol significantly increased the risk of local complications. Conclusion Sclerotherapy alone or combined with other endovascular techniques is a safe method for local venous malformations with moderate risk for conservatively manageable complications. Blood coagulopathy constitutes a risk for, otherwise rare, severe complications.

Second branchial cleft fistulae: Patient characteristics and surgical outcome

BACKGROUNDS Second branchial cleft anomalies predispose to recurrent infections, and surgical resection is recommended as the treatment of choice. There is no clear consensus regarding the timing or surgical technique in the operative treatment of these anomalies. Our aim was to compare the effect of age and operative techniques to patient characteristics and treatment outcome. METHODS A retrospective study of pediatric patients treated for second branchial sinuses or fistulae during 1998-2012 at two departments in our academic tertiary care referral center. Comparison of patient characteristics, preoperative investigations, surgical techniques and postoperative sequelae. RESULTS Our data is based on 68 patients, the largest series in the literature. One-fourth (24%) of patients had any infectious symptoms prior to operative treatment. Patient demographics, preoperative investigations, use of methylene blue, or tonsillectomy had no effect on the surgical outcome. There were no re-operations due to residual disease. Three complications were observed postoperatively. CONCLUSIONS Our patient series of second branchial cleft sinuses/fistulae is the largest so far and enables analyses of patient characteristics and surgical outcomes more reliably than previously. Preoperative symptoms are infrequent and mild. There was no difference in clinical outcome between the observed departments. Performing ipsilateral tonsillectomy gave no outcome benefits. The operation may be delayed to an age of approximately three years when anesthesiological risks are and possible harms are best avoided. Considering postoperative pain and risk of postoperative hemorrhage a routine tonsillectomy should not be included to the operative treatment of second branchial cleft fistulae.

Risk factors and morbidity of infantile haemangioma: preterm birth promotes ulceration.

We identified the characteristics of an infantile haemangioma (IH) that predispose children to complications, interventions and long‐term morbidity and examined perinatal risk factors for IH.

Effects of surgical correction of neuromuscular scoliosis on gastric myoelectrical activity, emptying, and upper gastrointestinal symptoms.

Objectives: Gastrointestinal complications are frequent after surgical correction of neuromuscular scoliosis, but the effects of scoliosis surgery on gastric function and upper gastrointestinal symptoms over the long term are unknown. Methods: Thirty-one children (16 spastic, 15 flaccid patients) who underwent surgical correction of neuromuscular scoliosis were included in a prospective follow-up study. Median (range) age at surgery was 14.9 (5–20) years and follow-up time 4.3 (2–8) years. Electrogastrography (n = 28), gastric emptying scintigraphy (n = 17), and structured upper gastrointestinal symptoms questionnaire (n = 26) were evaluated before and after surgery. The results were related to patients’ clinical state, type and extent of corrective spinal surgery, and gastrointestinal complications. Results: The median main scoliosis curve of 81 degrees (51–129 degrees) was corrected to 25 degrees (1.0–85 degrees) after surgery. In electrogastrogram, power ratio increased from preoperative 1.4 (0.30–11) to postoperative 6.2 (1.2–26) in the spastic group (P = 0.008), whereas in the flaccid group, power ratio remained unchanged at 2.2 (0.1–17). Patients with prolonged postoperative paralytic ileus had the most substantial increase in gastric power ratio (P = 0.038). Correction of sagittal spinal balance correlated with increased postprandial normogastric activity after surgery (R2 = 0.459; P = 0.004). The gastric emptying results, upper gastrointestinal symptoms, and body mass index were not significantly altered after scoliosis surgery. Conclusions: Gastric myoelectrical power increased after surgical correction of spastic neuromuscular scoliosis and was associated with prolonged postoperative paralytic ileus. Correction of poor, stooped spinal balance improved gastric myoelectrical activity. The net effect of scoliosis surgery on gastric emptying, upper gastrointestinal symptoms, and clinical nutritional state was minimal.

Inheritance Patterns of Infantile Hemangioma

BACKGROUND AND OBJECTIVE: Infantile hemangioma (IH) includes, among its other risk factors, familial clustering, but a definitive understanding of IH’s inheritance model and genetic basis is lacking. Our objective was to collect IH pedigrees in Finland, to study the inheritance patterns of IH within these families, and to analyze the characteristics of familial IHs. METHODS: We identified 185 patients with IH who visited our vascular anomaly clinic between 2004 and 2007. Based on hospital records and a questionnaire sent to these patients and their families, IH characteristics and family history of IH were studied. We compared characteristics between patients with positive (familial) and negative (sporadic) IH family history. Families with positive IH family history were further interviewed for extended pedigree data. RESULTS: One-third of our IH cohort’s families reported a family history positive for IH, with IH characteristics and perinatal data between the familial and sporadic cases being similar. IH patients with affected first-degree relatives reported higher long-term discomfort rates than the sporadic cases. Of the 40 families interviewed, 11 included ≥4 IH-affected family members; these were most commonly first-degree relatives (63%). Segregation patterns match with autosomal dominant inheritance with an incomplete penetrance or maternal transmission. We also present a case of monozygotic twins that manifest identical IHs. CONCLUSIONS: Based on this large number of IH pedigrees, we suggest at least 2 possible mechanisms of inheritance: autosomal dominant and maternal transmission. This study highlights the need for additional genetic studies to define inheritance of this common disease.