Sarah Bouchard

Falls from heights among children: a retrospective review.

BACKGROUND Falls are a major cause of emergency room visits and admissions in pediatric hospitals. METHODS To better understand the epidemiology of falls from height and develop prevention strategies, the authors reviewed all admissions after a fall at a single institution from 1994 to 1997. Inclusion criteria are falls from a minimum height of 10 feet. RESULTS Of 1,410 patients admitted after a fall, 64 patients including 45 boys and 19 girls with a mean age of 7.4 years (range, 1 to 18) are included in this study. Fifty (78%) children fell from 20 feet or less (two stories) and 14 (22%) from height greater than 20 feet. Patients mainly fell from balconies (n = 15), windows (n = 13), trees (n = 9), roofs (n = 6), stairs (n = 6), diving board (n = 3) and miscellaneous (n = 12). Over 60% of falls occurred in private houses and during the summer months. Fifty-five patients (86%) sustained only one system injury, two patients had no significant injury, and seven patients had multisystem injury. Major injuries included head trauma (39%), musculoskeletal (34%), abdominal (12%), maxillofacial (8%), and spine (6%). A surgical intervention was required for 43% of intracranial trauma, 39% of musculoskeletal injuries, 60% of facial trauma, and 50% of spine fractures. Mean length of stay in hospital varied according to the injured system. The overall survival rate is 98% with only one death after a fall greater than 50 feet. CONCLUSIONS Although rarely mortal, falls from height carry a significant morbidity and are costly to the health care system. To decrease the occurrence of injuries caused by falls, strategies should include awareness campaigns, parents education about the mechanisms of falls, increase parenteral supervision during playing activities, and legislative measures to ensure the safety of windows and balconies before the onset of summer.

Canadian Pediatric Surgical Network: a population-based pediatric surgery network and database for analyzing surgical birth defects. The first 100 cases of gastroschisis

PURPOSE Outcomes studies for gastroschisis are constrained by small numbers, prolonged accrual, and nonstandardized data collection. The aim of this study is to create a national pediatric surgical network and database for gastroschisis (GS) that tracks cases from diagnosis to hospital discharge. METHODS The 16-center network serves a population of 32 million. Gastroschisis cases are ascertained at prenatal diagnosis. Perinatal data include maternal risk and fetal ultrasound variables, delivery plan and outcome, a postnatal bowel injury score, intended and actual surgical treatment, and neonatal outcomes. Institutional review board-approved data collection conforms to regional privacy legislation. Deidentified data are centralized and accessible for research through the network steering committee. RESULTS To date, 114 cases of pre- and/or postnatal gastroschisis have been uploaded. Of 106 live-born infants (40 [38%] by cesarean delivery), 100 had complete records, and overall survival to discharge was 96%, with a mean survivor length of stay (LOS) of 46 days. Infants treated with attempted urgent closure (61%) had significantly shorter LOS (42 vs 57 days; P = .048) but comparable LOS compared with those treated with silos and delayed closure. Fetal bowel dilation 18 mm or greater did not predict a difference in outcome. CONCLUSION Population-based databases allow rapid case accrual and enable studies that should aid in the identification of optimal perinatal treatment.

Catastrophic cardiac injuries encountered during the minimally invasive repair of pectus excavatum

This paper presents four severe cardiac injuries that occurred in patients who underwent the minimally invasive repair of pectus excavatum (MIRPE). These complications occurred in different clinical settings, namely in a patient with an extremely severe form of pectus, in a patient who had previously undergone an open repair, after a previous open heart surgery, and at the time of bar removal. The purpose of this article is to review the circumstances leading to these cardiac injuries, share what we have learned from these patients, and hopefully help avoid these complications in the future.

THE OTOLARYNGOLOGIC MANIFESTATIONS OF GASTROESOPHAGEAL REFLUX: WHEN IS A PH STUDY INDICATED?

PURPOSE The aim of this study was to evaluate the pertinence of pH studies for persistent ear, nose, and throat (ENT) symptoms and their eventual relationship to gastroesophageal reflux (GER). METHODS Retrospective analysis was performed of age, reason for referral, pH study, treatment, and follow-up of patients with ENT symptoms suspected to have GER. RESULTS Of 3,000 esophageal pH studies performed over 16 years, 105 children were referred for ENT symptoms by an otorhinolaryngologist to rule out GER. Mean age was 33 months; 65% were boys. Reasons for referral included (number and mean age): stridor (n = 31, 8 months), laryngomalacia (n = 18, 13 months), recurrent otitis (n = 12, 42 months), laryngitis (n = 16, 50 months), dysphonia (n = 14, 59 months), laryngeal papillomatosis (n = 8, 62 months), sinusitis (n = 5, 56 months), and dysphagia (n = 1). Overall, 41% of study results were positive: stridor (58%), laryngomalacia (61%), laryngitis (56%) and sinusitis (40%). Patients with otitis, dysphonia and laryngeal papillomatosis had GER in 1%, 14%, and 25%, respectively. Follow-up in the three larger groups of patients showed resolution of the ENT symptoms after medical treatment of the reflux in 83% of patients with stridor and reflux, 86% with laryngitis and reflux, and 80% with laryngomalacia and reflux. Four fundoplications were performed: one neurologically impaired patient, and four nonresponders. CONCLUSIONS The authors recommend that a pH study be performed in children with stridor, laryngomalacia, laryngitis, and sinusitis when faced with failure of the usual treatment. However, a pH study does not seem as beneficial for recurrent otitis, dysphonia, or laryngeal papillomatosis.

Chest x-ray as a primary modality for preoperative imaging of pectus excavatum

BACKGROUND Adolescents with a pectus excavatum mostly present with cosmetic complaints and rarely have significant physical limitations. The preoperative evaluation includes pulmonary functions tests, echocardiography, and chest computed tomography (CT) scan to measure the Haller index. In most patients, the chest CT is performed only to measure the Haller index. The purpose of this study was to evaluate whether indices measured on chest radiograph (CXR) and CT scan are comparable. METHODS Cases of pectus excavatum treated with the minimally invasive approach in the last year were prospectively collected. In patients for whom a preoperative CXR and CT scan were available, an index was measured using both imaging modalities and compared. RESULTS Both preoperative imaging studies were available in 12 patients. The mean Haller indices on CT scan and CXR were 3.97 and 4.08, respectively. The Pearson correlation score between the 2 groups was 0.984. CONCLUSIONS We propose that the Haller index measured on CT scan be replaced by CXR measurement in asymptomatic patients in whom a chest CT scan is otherwise not necessary. This will limit radiation exposure to children. When in doubt, a CT scan of the chest can be used for the preoperative evaluation.

Gastroschisis closure--does method really matter?

BACKGROUND/PURPOSE Management of gastroschisis varies. This study aims to determine which aspects of practice influence outcomes. METHODS All cases of simple gastroschisis (N = 99) in the Canadian Pediatric Surgery Network database were analyzed looking at methods of preoperative bowel protection, timing of closure, and closure techniques; and outcome measures included time to onset of enteral feeds, duration of parenteral nutrition (PN), and length of stay (LOS). RESULTS One third of infants had initial bowel protection using a spring-loaded silo, which was significantly associated with a delay (beyond 24 hours) in establishing primary closure. Neither preoperative bowel protection methods nor defect closure techniques conferred any significant effects on success at establishing primary closure or functional outcomes. After adjusting for all covariates, only failure to establish primary closure was associated with impaired outcomes with significantly delayed initiation of enteral feeds and prolonged LOS. Low birth weight (<2000 g) and younger gestational age (<36 weeks) were associated with a 3-fold increased risk of longer PN dependence and 5-fold risk of extended LOS, respectively. Babies undergoing the sutureless spontaneous closure technique had significant delays in initiating enteral feeds but no increased requirements for PN or LOS. CONCLUSIONS Modes of preoperative bowel protection and techniques of abdominal wall closure ultimately have no association with functional outcomes in infants with gastroschisis. Failure to establish primary closure, however, is significantly associated with delays in establishing intestinal function and subsequent time to discharge.

A contemporary evaluation of surgical outcome in neonates and infants undergoing lung resection

BACKGROUND/PURPOSE The timing and need of resection of asymptomatic congenital lung lesions are controversial. The morbidity of such surgery needs to be considered in the decision analysis. We analyzed the contemporary outcome of infants and neonates undergoing lung resection. METHODS With institutional review board approval, all patients 12 months or younger undergoing lung resection between 1995 and 2004 in 2 hospitals were reviewed. Demographic data, indications for surgery, operative procedure, complications, use of regional anesthesia, length of stay (LOS), and follow-up were assessed. RESULTS Forty-five patients (28 male, 17 female) with a median age of 4 months (2 days-12 months) were evaluated. Congenital lesions (42) were the most frequent indication for surgery. Twenty-two (48.9%) patients had cardiorespiratory symptoms or infection preoperatively. Lobectomy was the most common operation (40/45). Three patients had intraoperative difficulty (bleeding, hypotension, desaturation). Significant postoperative complications occurred in 7 patients: prolonged air leak or chest tube drainage (4), anemia or bleeding (2), respiratory distress requiring reintubation (1). Fewer complications occurred in asymptomatic vs symptomatic patients (1/23 vs 6/22). Of 12 patients, 7 (58%) requiring 24 hours of ventilation or longer were 3 months or younger. Increasing age did significantly influence the chance of successful extubation (P = .01; odds ratio, 1.5; 95% confidence interval, 1.0-2.0), as did the use of epidural anesthesia (P < .001). Median LOS was 6 days (2-89 days). Asymptomatic patients had shorter LOS (median, 4 days; range, 2-20 days; P = .024) vs symptomatic patients (median, 8 days; range, 4-89 days). The only death occurred from underlying heart disease. Mean follow-up at 35 months (12-132 months) revealed no subjective reduction in cardiopulmonary function. CONCLUSIONS Lung resection is safe and well tolerated in infancy. Surgery should be scheduled before the development of symptoms but likely after 3 months of age to improve the chances of postoperative extubation. The use of regional anesthesia may facilitate this.

Long-term transgene expression in cardiac and skeletal muscle following fetal administration of adenoviral or adeno-associated viral vectors in mice

In utero gene transfer may provide advantages for the correction of congenital genetic disorders. In the present study we compare the ability of adenovirus (AdCMVLacZ), and two serotypes of adeno‐associated virus (AAVCMVLacZ serotypes 2 and 2/5), to target cardiac and skeletal muscle after prenatal systemic or intramuscular injection in mice and assess the immune response to the vectors.

Perineal hemangioma, anorectal malformation, and genital anomaly: A new association?

Two patients presented as full-term baby girls with anorectal and genital malformations with extensive perineal hemangiomas. The first patient had a vestibular anus with a perineal hemangioma involving the bladder, rectal, and vaginal walls. Skin ulcerations required a transverse loop colostomy for wound care. The vulva, urethral opening, and clitoris were deviated to the left, labia minora were absent, and the labia majora were abnormal. The second patient had an anus displaced anteriorly and deviated to the right. The external anal sphincter was hypertrophic on the left and atrophic on the right. Rectal examination showed agenesis of the right levator ani and a dentate line located at the skin level. She had a large perineal, sacral, vaginal, pararectal and retroperitoneal hemangioma and developed extensive skin ulcerations. She had only a hemiclitoris located to the left of the midline, near absence of labia minora, and hypertrophied labia majora. The urethra was displaced to the left and opened in the vestibule. Both patients had a spinal malformation (one with tethered cord and one with spina bifida) and a normal karyotype. Steroids and interferon allowed near-complete resolution of hemangiomas in both patients. The authors were impressed by the similarity of these two cases and could not find any previous description of this association.

Risk of incomplete pyloromyotomy and mucosal perforation in open and laparoscopic pyloromyotomy.

BACKGROUND Despite randomized controlled trials and meta-analyses, it remains unclear whether laparoscopic pyloromyotomy (LP) carries a higher risk of incomplete pyloromyotomy and mucosal perforation compared with open pyloromyotomy (OP). METHODS Multicenter study of all pyloromyotomies (May 2007-December 2010) at nine high-volume institutions. The effect of laparoscopy on the procedure-related complications of incomplete pyloromyotomy and mucosal perforation was determined using binomial logistic regression adjusting for differences among centers. RESULTS Data relating to 2830 pyloromyotomies (1802 [64%] LP) were analyzed. There were 24 cases of incomplete pyloromyotomy; 3 in the open group (0.29%) and 21 in the laparoscopic group (1.16%). There were 18 cases of mucosal perforation; 3 in the open group (0.29%) and 15 in the laparoscopic group (0.83%). The regression model demonstrated that LP was a marginally significant predictor of incomplete pyloromyotomy (adjusted difference 0.87% [95% CI 0.006-4.083]; P=0.046) but not of mucosal perforation (adjusted difference 0.56% [95% CI -0.096 to 3.365]; P=0.153). Trainees performed a similar proportion of each procedure (laparoscopic 82.6% vs. open 80.3%; P=0.2) and grade of primary operator did not affect the rate of either complication. CONCLUSIONS This is one of the largest series of pyloromyotomy ever reported. Although laparoscopy is associated with a statistically significant increase in the risk of incomplete pyloromyotomy, the effect size is small and of questionable clinical relevance. Both OP and LP are associated with low rates of mucosal perforation and incomplete pyloromyotomy in specialist centers, whether trainee or consultant surgeons perform the procedure.