Esophageal Surveillance Practices in Esophageal Atresia Patients: A Survey by the Eastern Pediatric Surgery Network

IntroductionEndoscopic surveillance guidelines for patients with repaired esophageal atresia (EA) rely primarily on expert opinion. Prior to embarking on a prospective EA surveillance registry, we sought to understand EA surveillance practices within the Eastern Pediatric Surgery Network (EPSN).MethodsAn anonymous, 23-question Qualtrics survey was emailed to 181 physicians (surgeons and gastroenterologists) at 19 member institutions. Likert scale questions gauged agreement with international EA surveillance guideline-derived statements. Multiple-choice questions assessed individual and institutional practices.ResultsThe response rate was 77%. Most respondents (80%) strongly agree or agree that EA surveillance endoscopy should follow a set schedule, while only 36% claimed to perform routine upper GI endoscopy regardless of symptoms. Many institutions (77%) have an aerodigestive clinic, even if some lack a multi-disciplinary EA team. Most physicians (72%) expressed strong interest in helping develop evidence-based guidelines.ConclusionsOur survey reveals physician agreement with current guidelines but weak adherence. Surveillance methods vary greatly, underscoring the lack of evidence-based data to guide EA care. Aerodigestive clinics may help implement surveillance schedules. Respondents support evidence-based protocols, which bodes well for care standardization. Results will inform the first multi-institutional EA databases in the United States (US), which will be essential for evidence-based care.Level of EvidenceThis is a prognosis study with level 4 evidence.     

Midazolam exposure in the paediatric intensive care unit predicts acute post-traumatic stress symptoms in children

BackgroundClinically significant post-traumatic stress symptoms (PTSS) have been reported in up to a quarter of paediatric intensive care unit (PICU) survivors. Ongoing PTSS negatively impacts children's psychological development and physical recovery. However, few data regarding associations between potentially modifiable PICU treatment factors, such as analgosedatives and invasive procedures, and children's PTSS have been reported.ObjectivesWe sought to investigate the medical treatment factors associated with children's PTSS after PICU discharge.MethodsA prospective longitudinal cohort study was conducted in two Australian tertiary referral PICUs. Children aged 2-16 y admitted to the PICU between June 2008 and January 2011 for >8 h and <28 d were eligible for participation. Biometric and clinical data were obtained from medical records. Parents reported their child's PTSS using the Trauma Symptom Checklist for Young Children at 1, 3, 6, and 12 months after discharge. Logistic regression was used to assess potential associations between medical treatment and PTSS.ResultsA total of 265 children and their parents participated in the study. In the 12-month period following PICU discharge, 24% of children exhibited clinically elevated PTSS. Median risk of death (Paediatric Index of Mortality 2 [PIM2]) score was significantly higher in the PTSS group (0.31 [IQR 0.14–1.09] v 0.67 [IQR 0.20–1.18]; p = 0.014). Intubation and PICU and hospital length of stay were also significantly associated with PTSS at 1 month, as were midazolam, propofol, and morphine. After controlling for gender, reason for admission, and PIM2 score, only midazolam was significantly and independently associated with PTSS and only at 1 month (adjusted odds ration (aOR) 3.63, 95% CI 1.18, 11.12, p = 0.024). No significant relationship was observed between the use of medications and PTSS after 1 month.ConclusionsElevated PTSS were evident in one quarter (24%) of children during the 12 months after PICU discharge. One month after discharge, elevated PTSS were most likely to occur in children who had received midazolam therapy.     

Assessment of referral patterns for boys with suspected undescended testes and identification of risk factors to aid diagnosis

IntroductionUndescended testis (UDT) is a clinical diagnosis and a common reason for referral to paediatric urology outpatients. Our aim was to assess current referral patterns at our unit and to identify predictive factors that may better aid primary care physicians (PCP) in diagnosing UDT based on history and physical exam.MethodsA retrospective analysis of referrals to outpatients from 2014 to 2016 was performed to assess current referral patterns including referral source, age, reason for referral and outcome following assessment by a single consultant paediatric urologist.A prospective analysis of new referrals was performed to identify predictive factors which may aid in the diagnosis of UDT including gestational age, presence of scrotal asymmetry and previously obtained imaging.ResultsFrom 2014 to 2016, 259 boys were referred with suspected UDT. The majority of referrals were received from PCPs (62%) followed by Neonatology (29%), Paediatrics (8%) and general surgery (1%). Median age at time of assessment was 29 (5–180) months. One hundred and eight (41.7%) boys were diagnosed with UDT.There were 74 boys assessed prospectively. Median age at assessment was 24.5 (6–171) months. We identified 3 predictors of a diagnosis of UDT; history of prematurity (p = 0.001), UDT mentioned to the parents at birth (p = 0.027) and scrotal asymmetry on examination (p < 0.001). Greatest diagnostic inaccuracy was found in boys referred beyond one year of age (27.7%). In this cohort, the absence of all three risk factors was associated with a negative predictive value of 94.1%.ConclusionThe majority of boys with suspected UDT are referred beyond the age recommended for orchidopexy (6–12 months). The majority of boys referred for assessment did not have UDT. We have identified three predictive factors that may aid referring physicians when assessing boys, particularly those older than 1 year.     

危重患儿下肢深静脉血栓10例

目的：探讨危重患儿下肢深静脉血栓（DVT）的危险因素、诊断及治疗。方法：回顾性分析10例DVT的临床资料。结果：9例患儿应用股静脉插管。诊断DVT后均接受抗凝，祛聚综合治疗。4例行溶栓治疗；10例全部治愈，随访9例无复发，1例固原发病行截肢。结论：DVT在儿科发病率低，中心静脉插管是儿科DVT的主要危险因素，综合应用溶栓、抗凝及祛聚治疗，效果良好，后遗症少。     

Comparative study of two customary cerebrospinal fluid shunting systems in early childhood hydrocephalus

Summary The validity of clinical studies on shunt-treated hydrocephalic patients is often hindered by inhomogeneity of the patient population examined, technical devices used, or by other specific factors. In an effort to introduce a homogeneous clinical study on hydrocephalic patients 66 hydrocephalic newborns and infants have been treated exclusively with CORDIS Orbis-Sigma Valve (OSV) System (CORDIS Corporation, Miami, USA) in 1990–1995. The results are compared with an equivalent group of 53 children treated with CODMAN Holter Valve (HV) System (CODMAN Inc., Randolph, USA) during a similar 5-year-period (e.g., 1986–1991). Searching for different reasons of shunt insufficiency in both groups demonstrates a more than double risk of shunt complication for ventriculo-atrial HV treated patients (VA-HV) in comparison with those treated ventriculo-peritoneally with OSV System (VP-OSV): 4.22 versus 1.98 mean surgical procedures per person. The different revision and survival rates are discussed and specific problems are mentioned.     

Strategic planning in academic paediatric hospitals: The need for child health input

Over the past two decades, a number of Canadian paediatric academic programs, previously operated as separate hospitals, have been integrated into larger teaching hospitals or regional health authorities. The present article describes the recent experience of the Children’s Hospital of Western Ontario within the London Health Sciences Centre (London, Ontario) to illustrate the potential deleterious effects of planning, system and program changes in a large academic hospital without child health input at the executive decision-making level. The vision of the London Health Sciences Centre Executive Leadership Team and Board of Directors was divergent from that of the paediatric health care providers, which resulted in the resignation of a number of paediatric subspecialists and compromised the ability of the Department of Paediatrics to deliver paediatric care and educate future professionals. The present article highlights the need for the involvement of paediatric stakeholders in strategic planning in the hope that other academic centres can learn from this experience.     

C-spine clearance in poly-trauma patients: A narrative review

The incidence of cervical spine injury in patients with polytrauma is 3.7%. Early identification and management of cervical spine injuries in these patients play a crucial role in preventing secondary cervical spine and cord injuries. C-spine clearance assumes a pivotal role in reducing the morbidity and mortality associated with cervical spine injury. Despite the availability of various validated management algorithms and protocols for C-spine clearance, there are several controversies regarding C-spine clearance, such as the ideal protocol and imaging modality, clearance of obtunded patients and management of patients that lie out of the described protocols and rules. The current article aims to provide a comprehensive review of the relevant literature and address the prevalent controversies.