Xiaohan Hu

Ultrasonographic and clinical predictors of intussusception

OBJECTIVE The objective of this study was to determine the positive and negative clinical predictors of intussusception and the correlation of ultrasonography and air enema in establishing this diagnosis. STUDY DESIGN This was a prospective descriptive cohort study. SETTING This study was performed in a tertiary care pediatric emergency department. PARTICIPANTS Eighty-eight of 245 candidates were assessed for clinical predictors of intussusception. All 245 cases were examined for correlation between ultrasonography and air enema. INTERVENTIONS A questionnaire, ultrasonography, and air enema were used. RESULTS Thirty-five of the 88 patients assessed for clinical predictors were positive for intussusception. Significant positive predictors were right upper quadrant abdominal mass (positive predictive value [PPV] 94%), gross blood in stool (PPV 80%), blood on rectal examination (PPV 78%), the triad of intermittent abdominal pain, vomiting, and right upper quadrant abdominal mass (PPV 93%, p = 0.0001), and the triad with occult or gross blood per rectum (PPV 100%, p = not significant). Significant negative predictors were a combination of > or = 3 of 10 clinically significant negative features (negative predictive value 77%, p = 0.035). Of the total 245 cases, intussusception (as confirmed by doughnut, target, or pseudokidney sign) was ruled out by ultrasonography in 97.4%. Alternate ultrasound findings comprised 27% of negative cases. CONCLUSIONS Excellent positive predictors of intussusception were identified prospectively. Although no reliable negative predictors were found, patients at low risk may be screened by ultrasonography.

Risk factors for severe injuries associated with falls from playground equipment

A case control study design was used to determine the risk factors for severe injuries associated with falls from playground equipment. Children presenting to the Hospital for Sick Children in Toronto because of falls from playground equipment (1995-1996) were identified through daily review of admissions and emergency department visits. Cases were defined as children with a severe injury (AIS > or = 2), whereas, controls were children with a minor injury (AIS < 2). Data on age, sex, socioeconomic status, prior experience on the equipment, previous playground injury, type of equipment, height of fall, undersurface, nature of injury, body part involved, and disposition were collected via telephone interview, field trip measurement, and mailed questionnaire. A total of 126 children were studied--67 cases and 59 controls. There were no differences between the two groups on age, sex, socioeconomic status, prior exposure to the equipment, or previous playground injury. Extremity fractures predominated in the case group, while, facial lacerations predominated in the control group. The median height of fall for cases was 199 cm, compared with 160 cm for controls (P = 0.021). Cases were also more likely to have fallen from a height of > 150 cm (73%), compared with controls (54%), P = 0.027. The majority of cases (82%) and controls (86%) fell onto an impact absorbing undersurface (P = 0.540). The median depth of impact absorbing undersurface, however, for both case and control injuries was 3 cm--well below the recommended safety standards. Height of fall was an important risk factor for severe injury associated with falls from playground equipment. Above 150 cm, the risk of severe injury was increased 2-fold.

Thrombosis of the portal venous system after splenectomy for pediatric hematologic disease

Splenic, portal, or mesenteric venous thrombosis after splenectomy for hematologic disease has not been reported in the pediatric literature. It is a rare complication associated with significant morbidity and mortality in adult reports. Between 1981 and 1991, 3 patients (13-year-old boy with hereditary elliptocytosis [HE], 13-year-old boy with thalassemia intermedia [TI], and 18-year-old girl with idiopathic thrombocytopenic purpura [ITP]) presented with abdominal pain, nausea, with or without fever, at 4, 11, and 13 days postsplenectomy, respectively. Abdominal Doppler ultrasound (US) and/or computed tomography (CT) showed: (1) an intraluminal filling defect with partial obstruction to flow in the right branch of the portal vein with the remaining vessels patent (HE); (2) splenic vein thrombosis with complete occlusion of the main portal vein and proximal superior mesenteric vein (TI); and (3) complete thrombosis of the splenic vein, proximal superior mesenteric vein and portal vein (including central radicles), with retrogastric collateralization (ITP). Subsequent imaging showed either complete resolution of vascular obstruction on no treatment (patient 1), or portal venous cavernomatous transformation with hepatofugal flow after 6 months of systemic anticoagulation (patients 2 and 3), and all 3 patients are currently asymptomatic. Postoperative sonographic evaluation of a consecutive series of pediatric splenectomies for hematologic disease (n = 16), was performed at a median of 51 days (range, 3 to 124). This demonstrated one case of asymptomatic left portal venous thrombosis with subsequent recanalization in the absence of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Blunt cardiac injuries in children : A postmortem study

We reviewed the records of the Chief Coroner for all pediatric (< 16 years of age) trauma fatalities in Ontario (pediatric population of 2 million) for the period January 1, 1988 through December 31, 1990. Forty-one (14.5%) of 282 patients for which complete autopsy data were available had sustained cardiac injuries. Nineteen patients (46%) died at the scene of the accident, 15 patients (37%) died in an emergency department, and seven patients (17%) died during hospitalization. Rupture of a cardiac chamber occurred in 16 cases; it was the main cause of death in eight cases and a contributing factor in the remainder. Cardiac contusion without chamber rupture was present in 25 cases, but in none of the cases was it the cause of death. Brain injury was the cause of death in 16 (64%) of the cases of cardiac contusion. Cardiac injuries are more common among children who die from blunt trauma than previous reports have suggested. However, because these injuries are often rapidly fatal, many patients die before they reach a hospital. With improvements in emergency medical services and the resulting reduction in transit time, more patients may reach trauma centers alive. A high index of suspicion and rapid diagnosis and treatment of these injuries can save the lives of some of these patients.

The physical, psychological, and socioeconomic costs of pediatric trauma.

This prospective study examined the physical, psychological, and socioeconomic effects of injuries on children and their immediate families. Ninety-two injured children admitted with minor (ISS less than 16) or major (ISS greater than or equal to 16) injuries were compared with a control group of 59 children admitted during the same period with acute appendicitis. The two populations were similar in mean age, sex ratio, parental age and work status, and number of siblings. The parents of the injured children had a lower level of education than those of the controls. Fifty-four percent of the minor injury patients and 71% of the major injury patients had persistent physical limitations at 12 months in contrast to none of the controls. Thirty-eight percent of minor injury patients had pre-existing behavioral disturbances compared with 14% of major injury patients and 10% of controls. Behavioral disturbances among major trauma patients showed a sharp rise to 41% at 12 months and tended to persist in cases with continuing physical limitations. The major injury patients and those with significant head injuries exhibited a decrease in academic performance; minor injury patients and those without head injury showed no change. Maternal malaise rose sharply to about 40% in both injury groups in contrast to 7% in the controls and was more common in the presence of persistent physical limitations. Only 73% of families in the major injury group had returned to normal family life compared with 87% of the minor injury group and 100% of controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional limitations and recovery in children with severe trauma : a one-year follow-up

To examine functional limitations, recovery rates, and association with Injury Severity Scores (ISSs), we followed 92 children with severe trauma and 59 control subjects with appendicitis at 6 months and 1 year after discharge. Physical health status was assessed by the Rand Health Insurance Study instrument. Overall, 73% and 55% of trauma patients had one or more functional limitations at 6 months and 1 year, respectively, in contrast to 14% and 9% of the controls. Overall functional status of the trauma patients improved by 22% in the first 6 months and 24% in the second. Much higher recovery rates (73% and 46%) were noted for self care. Although ISS did not correlate with overall functional status, higher ISSs were related to impairment in patients whose principal injury was to the head or the face-chest-abdomen but not in those whose principal injury was to an extremity. This study shows that many children with severe trauma are left with disabilities. Recovery rates are not uniform but depend on type of limitation. Functional impairment and recovery are related more to the body parts involved than to ISS.