Lawnmower injuries in children: a 10-year experience

Approximately 77,800 annual lawnmower-related injuries are treated in the USA, with 9,300 involving children. This work reviews the literature and reports our 10-year experience with lawnmower injuries. We retrospectively reviewed patients with lawnmower injuries admitted to the Women and Children’s Hospital of Buffalo from 1995 to 2005 and reviewed the literature. Sixteen patients with mower-related injuries were admitted to our institution, with three due to walk-behind mowers and 13 due to riding mowers. The mean age was 7.5 years. Riding mower injuries had a higher average injury severity score (14.3 vs. 9) and a longer average length of hospital stay (15 vs. 2 days). All of the walk-behind mower injuries were extremity injuries, with two requiring amputations. Eleven of the riding mower injuries had extremity injuries alone, one had isolated torso injuries, and one had both extremity and torso injuries. Three required amputations, and the two patients with torso injuries required extensive surgical reconstructions. Pediatric lawnmower injuries, particularly due to riding mowers, are a highly preventable cause of morbidity and mortality. Increased public safety awareness and further manufacturer safety modifications should be strongly encouraged in order to limit this cause of pediatric trauma.     

Anorectal injuries in children

 Anorectal injuries (ARI) are uncommon in children in civil practice. In developed countries the injuries are mainly due to sexual abuse and firearms. This report reviews the experience in tropical Africa. A retrospective study of children aged 12 years or less managed for ARI over 10 years was undertaken. There were seven children, four girls and three boys. Four injuries were due to blunt trauma and three to penetrating trauma. Six patients presented within 6 h of injury and one after 24 h. Five had rectal bleeding, which was associated with vaginal bleeding in one girl. One girl each had vaginal bleeding and vaginal discharge without rectal bleeding. Diagnosis was by rectal examination and proctoscopy. In three patients a laparotomy was necessary to exclude an intraperitoneal rectal injury (IRI); this was positive in one case. One patient with abdominal findings had a laparotomy as the primary procedure. Overall, five patients had rectal injuries (extraperitoneal 3, intraperitoneal 2), which were associated with an anal injury in three while one patient had only an anal injury. An IRI was missed at initial assessment in one girl. Associated injuries were to the vaginal wall (3), urethra (1) and head (1). IRIs were treated by repair and proximal colostomy. Extraperitoneal injuries were treated by colostomy and drainage; in two patients the injuries were accessible and were repaired. Anal and external-sphincter injuries were repaired in two cases. Vaginal lacerations were repaired and other associated injuries treated accordingly. Three patients had wound infections. Faecal continence was maintained in all patients who had anal and external-sphincter injuries. One girl died of peritonitis from a missed IRI. It is concluded that ARI remains uncommon in children. Morbidity and mortality can, however, be high. Meticulous rectal palpation and visualisation is necessary to avoid missing injuries. Accepted: 9 September 1999     

Conservative treatment of caustic esophageal injuries in children: 20 years of experience

The authors present their experience in the medical treatment of 1,296 caustic esophageal injuries in children over the last 20 years in two study groups, one comprising the period up to 1989 and the other 1990 to 1996, comparing the different treatments used in each group. The treatment was based fundamentally on dilatations with anterograde mercury bougies, Savary bougies, or retrograde thread-guided bougies with gastrostomy. Pneumatic balloons or stenting procedures have also been employed in the last 3 years. Early fiberendoscopy was used systematically in the second group, which provides a more accurate evaluation of the esophageal lesions. Antibiotic coverage was done systematically during the first 10 days in all serious cases, while steroids were employed routinely only in the last 3 years. The results were similar in both groups, with a dilatation average of 32 in the first and 30 in the second group and an initial dilatation interval of 3 to 4 weeks in both. Using updated exploration and dilatation techniques, we drastically reduced the number of gastrostomies needed for retrograde thread-guided dilatations from 51 in the first group to 5 in the second, consequently improving the patients' life quality. There was no mortality and only five esophageal perforations, which did not require surgical treatment. Accepted: 5 January 1999     

Accidental injuries in children in day-care centers

A telephone survey of all licensed group day-care centers serving 2- to 6-year-old children in Maryland was conducted to determine the rate of injuries, their nature, and the circumstances of occurrence. Eighty-two percent of the 523 operating centers were contacted. Two centers declined to participate. Twenty-nine injuries were reported. A total of 18,728 children were surveyed (children who attended half a day were given half credit per day) or 92,640 child-days. Yearly injury rates of 7.02% for medically attended injuries, 4.29% for injuries limiting activity, and a total yearly injury rate of 11.30% were calculated. This general injury rate was similar to incidence figures from a non-day-care center injury study. This lack of improvement in injury rates in licensed day care is of concern and deserves increased attention from pediatricians.     

Management of children with disorders of sex development: 20-year experience in southern Thailand

Background

Disorders of sex development (DSD) is a group of sexual differentiation disorders resulting in genital anomalies with defects in gonadal hormone synthesis and/or incomplete genital development. These conditions result in problems concerning the sex assignment of the child. This study aims to describe the clinical features, diagnosis and management of children with DSD in southern Thailand.

Methods

The medical records of 117 pediatric patients diagnosed with DSD during the period of 1991–2011 were retrospectively reviewed.

Results

Disorders of sex development were categorized into 3 groups: sex chromosome abnormalities (53.0%), 46,XX DSD (29.9%) and 46,XY DSD (17.1%). The two most common etiologies of DSD were Turner syndrome (36.8%) and congenital adrenal hyperplasia (29.9%). Ambiguous genitalia/intersex was the main problem in 46,XX DSD (94%) and 46,XY DSD (100%). Sex reassignment was done in 5 children (4.3%) at age of 3–5 years: from male to female in 4 children (1 patient with congenital adrenal hyperplasia, 1 patient with 45,X/46,XY DSD, and 2 patients with 46,XX ovotesticular DSD) and from female to male in 1 patient with 46,XX ovotesticular DSD. Of the total 20 children with 46,XY DSD, 16 (80%) were raised as females.

Conclusion

Management of DSD children has many aspects of concern. Sex assignment/reassignment depends on the phenotype (phallus size) of the external genitalia rather than the sex chromosome.     

Epidemiology of school injuries: a 2-year experience in a municipal health department

School injuries occurring in a municipal school system during a 2-year period were reviewed to identify epidemiologic features of school injuries, to determine data requirements for ongoing injury surveillance, and to identify potential preventive strategies. Overall, 3,009 injuries were reported (2.82/100 students per year). Elementary school students had only a slightly higher rate (2.85) than secondary school students (2.78). However, the cause, nature, school location of injury, and body area injured formed distinct patterns in these two groups. Playgrounds were responsible for the highest overall and elementary school rates, whereas sports areas and classrooms had the highest rates among secondary school students. Falls were the most frequent cause of injury in elementary schools whereas, as expected, sports injuries were the most frequent cause among secondary school students. Contusions and abrasions of the head were the most frequent type of injury for both groups, although more common among elementary school students, whereas fractures, sprains, strains, and dislocations were more frequent among secondary school students. Although the proportion of severe injuries to secondary school students was slightly higher (39 v 35%), the rate of referral of students to a hospital or physicians among secondary school students (1.21 per 100 student-hours) was almost twice the rate of elementary school students (0.65 per 100 student-hours). Problems with definition of injury severity and the need to explore the social aspects of schools as a factor in injuries emerged as important considerations for future research.     

Infant acute lymphoblastic leukemia: a 20-year children's hospital experience

We reviewed our 20-year experience with infant acute lymphoblastic leukemia (ALL). Nine infants (4.2% of all ALL) were identified; all were < 6 months of age. White blood cell counts ranged from 42,000-1.6 million/microL, 6 of 8 had hepatosplenomegaly, and 6 of 9 (66.6%) had central nervous system disease. Of 7 with cytogenetic information, 6 (85.7%) had diploidy; the remaining child was 47, XY,+8,del(21)(q22). Four had the MLL-11q23 abnormality. All received chemotherapy. Four underwent stem cell transplantation. Survival was 67%, (15 months-21 years). Deaths occurred at 9 months, 15 months (graft vs. host), and 7 years (complications of small bowel transplantation). Only 1 undergoing stem cell transplantation died. There were no late recurrences or second malignancies. Despite extensive disease and age < 6 months at diagnosis (a poor prognostic feature), for ALL patients our 67% survival is at least as good as reported, although it is less favorable than childhood ALL.     

Intussusception in children: 11-year experience in Vladivostok

Idiopathic intussusception is an important abdominal emergency in infancy and childhood. The nonoperative management by air enema has always been the standard of care in Russia. Our purpose is to assess our reduction rate and the rate of complications. We performed a retrospective analysis of all intussusception cases seen at the Department of Paediatric Surgery from 1994 to 2005. The data obtained included age, sex, clinical presentation, diagnostic procedures, mode of treatment, and results. Patients included 280 children from 1 month to 14 years of age. Eighty-one percent of children were under age 1 year old, 61% were boys. The duration of symptoms before treatment was less than 18 h in 65%, 18–24 h in 21%, and more than 24 h in 14% of patients. The successful reduction rate was 86.1%. One patient with a duration of symptoms more than 24 h experienced colon perforation. Thirty-nine patients underwent surgery and, among these, abnormalities in the intestinal wall required resection in 12 cases. An association between the duration of symptoms and the outcome of the non-surgical treatment was present; non-surgical reduction was successful in 97.3% in the group with the duration of symptoms less than 18 h, 86.4% in 12–24 h, and 33.3% in more than 24 h. Air enema is a safe and effective approach for uncomplicated intussusception reduction with a high success rate, but the duration of symptoms directly increases the complication rate.     

The calcifying epithelioma of Malherbe in children: a 15-year experience

The calcifying epithelioma of Malherbe is a benign tumour of hair-cell matrix, from which it derives its name of pilomatrixoma. Although a relatively benign lesion, diagnostic difficulty may arise and the definitive diagnosis of these firm subcutaneous tumours is often made only after histological analysis. Over 15 years, 46 patients have had 51 lesions excised. A brief historical overview is presented.     

Indiana pouch in children: A 15-year experience

ObjectiveWe report our experience with the Indiana pouch (continent urinary reservoir) in 12 consecutive children over the last 15 years and report their follow-up.Material and methodsTwelve consecutive children, who underwent the continent urinary reservoir procedure in the form of an Indiana pouch, were prospectively enrolled in the study. All consecutive children who were referred to our service with multiple failed surgeries for exstrophy–epispadias repair, cloacal exstrophy, genitourinary rhabdomyosarcoma with residual disease in the trigonal area not amenable to partial cystectomy, and neuropathic bladder with nephrogenic metaplasia were included over the period 1997–2012. All these children were offered the same form of bladder substitution (Indiana pouch) as described by the Indiana group many years ago. Postoperative care was on a fixed protocol, and follow-up details recorded over the years. They were followed up for dry interval with clean intermittent catheterisation, social acceptance, and early and late complications.ResultsOut of these 12 patients (7 males and 5 females), eight patients had exstrophy–epispadias with multiple failed operations carried out elsewhere, cloacal exstrophy (2), residual rhabdomyosarcoma in the trigonal area with incontinence following chemotherapy (1), and neuropathic bladder with recurrent diffuse neoplastic polyposis (1). In the follow-up period of 1–15 years (median 24 months) all the patients had a dry interval of 4 h or more with clean intermittent catheterisation. One patient had wound dehiscence during the postoperative period and another required stomal revision 1 year after initial surgery.ConclusionsThe Indiana pouch is a reliable, safe, and effective form of bladder substitution. It can be reconstructed in a wide range of lower urinary tract disorders. In the vast majority of children with multiple failed surgical procedures for exstrophy–epispadias, the Indiana pouch is a safe, reliable, and reproducible procedure to provide a socially acceptable quality of life with a dry interval of 4 h.     

Acquired central diabetes insipidus in children: a 12-year Brisbane experience

OBJECTIVE: To study the clinical, endocrine and radiological features and progress of children presenting with acquired diabetes insipidus (CDI). METHODOLOGY: Chart review of children presenting because of CDI to Brisbane paediatric endocrine clinics between 1987 and 1999. RESULTS: Thirty-nine children (female/male ratio 21/18) aged 0.1-15.4 years (mean age 6.7 years) were identified. Aetiologies were head trauma or familial in eight cases (20.5%) each, central nervous system (CNS) tumours in five cases (12.8%), CNS malformations in four cases (10.2%), histiocytosis in three cases (7%) and hypoxia and infection in two cases (5.1%) each. Seven cases (17.9%) remain undiagnosed. Of the 32 (82%) cases with isolated anti-diuretic hormone deficiency at presentation, 24 cases (61.5%) experienced no further endocrine deficit. Additional endocrine deficits occurred mainly in the tumour or undiagnosed groups. On follow-up brain magnetic resonance imaging (MRI) scans in the seven undiagnosed cases, six patients had mild or no change and one patient had marked improvement of MRI findings. These changes occurred 10-48 months (mean 18 months) after presentation. CONCLUSIONS: Children without an aetiological diagnosis for the uncommon condition of acquired CDI require careful follow-up. More intensive investigation at presentation (e.g. estimation of cerebrospinal fluid human chorionic gonadotrophin) promises to lessen the number of such cases. Pituitary stalk biopsies should be reserved for those patients with progressive MRI changes. If these changes do not occur early, our experience suggests that follow-up MRI scans may need to be performed only yearly.     

Survival after recurrence of osteosarcoma: a 20-year experience at a single institution

BACKGROUND: Approximately one-third of patients with osteosarcoma who have a complete response to their initial treatment can be expected to relapse. It is important to define what host, tumor, or treatment characteristics determine outcome after relapse. We present findings in 59 patients treated at our institution from 1974 to 1996 who have relapsed one or more times after their initial response. METHODS: Host and tumor characteristics at diagnosis and relapse, therapeutic interventions and survival outcomes were determined from examination of medical records and a follow-up questionnaire. RESULTS: Of the 59 patients, 37 initially presented with localized disease of the extremity, 11 with localized non-extremity disease, and 11 with metastatic disease. This report focuses on those with localized disease of the extremity. For these patients, median time from original diagnosis to first recurrence was 14 months. Median survival after first recurrence was 31 months. The median post initial relapse survival was the same for patients whose first relapse occurred before or after 14 months from original diagnosis. Seventeen of 29 patients with systemic metastasis at first recurrence had complete removal of their disease and had a median post-op survival of 2.5 years, while the remaining 12 patients with no surgery, had a median survival of 2 years. Of the 37 patients who presented with primary disease only in the extremities and relapsed: 31 died (2 more than 6 years from first recurrence) and 6 are alive from 6 to 24 years from first recurrence (5 without disease and 1 with disease). Three of the five disease-free survivors had three or more relapses. CONCLUSION: With a long follow-up time, we found 15% of patients with relapsed osteosarcoma who originally presented with localized disease in the extremity are alive with no evidence of disease at 10 years from first recurrence (Kaplan-Meier estimate). Even patients with multiple relapses may have long-term disease-free survival after salvage therapy. Chemotherapy and time to first recurrence were unrelated to survival after relapse in this study. Complete surgical removal of metastatic disease may be important for long-term survival.     

Ketoacidosis at presentation of type 1 diabetes mellitus in children: a retrospective 20-year experience from a tertiary care hospital in Serbia

Diabetic ketoacidosis (DKA) has significant morbidity and mortality and is common at diagnosis in children. The aim of this study was to determine the frequency and clinical characteristics of DKA over a 20-year period among children diagnosed with type 1 diabetes mellitus (T1DM) at University children's hospital in Belgrade, Serbia. The study population comprised of 720 patients (366 boys) diagnosed with type 1 diabetes aged <18 years between January 1992 and December 2011. Of all patients diagnosed with T1DM, 237 (32.9 %) presented with DKA. The majority had either mild (69.6 %) or moderate (22.8 %) DKA. Sixty (55.0 %) of all children under 5 years had DKA compared to sixty-two (20.9 %) in the 5- to 10-year-old group and one hundred fifteen (36.6 %) in the 11- to 18-year-old patients (p?<?0.01), while 2.5 % of the entire DKA cohort were in real coma. During the later 10-year period, children less often had DKA at diagnosis compared with the earlier 10-year period (28.0 vs. 37.4 %) (p?<?0.01), but the frequency of severe DKA was higher in the age group <5 year and in the age group >11 year during 2002–2011, compared with the earlier 10-year period (12.9 vs. 3.4 %, p?<?0.01 and 17.1 vs. 3.8 %, p?<?0.01). Conclusion: The overall frequency of DKA in children with newly diagnosed type 1 diabetes decreased over a 20-year period at our hospital. However, children aged <5 years and adolescents are still at high risk for DKA at diagnosis.     

Indications and results of renal biopsy in children: a 36-year experience

Background

This study was conducted to investigate retrospectively the indications for renal biopsy (RB) in native kidneys and to analyze pathological findings in a single tertiary pediatric hospital in Southern Italy for the last 36 years.

Methods

All patients who underwent RB at our hospital from 1979 to 2014 were included. All renal tissue specimens were studied under light and immunofluorescent microscopy, while electron microscopy was performed only for specific clinical indications.

Results

The study group included 213 patients (female 43.2%) who underwent 225 percutaneous native kidney biopsies. Median age was 10.4 years (range 0.6–24 years). The most frequent indication for RB was nephrotic syndrome (44.4%), followed by proteinuria (27.6%), asymptomatic hematuria (17.3%) and acute kidney injury (9.8%). Gross hematuria appeared after biopsy in less than 5% of the patients, but none of them needed blood transfusion. Adequate renal tissue sample was obtained in 95.5% of the renal biopsies. Primary glomerulonephritis (GN) was the most common finding (61.4%), followed by secondary GN (21.4%), tubulointerstitial diseases (3.7%) and hereditary nephropathy (2.8%), while in 10.7% of the cases, normal renal tissues were found. According to histopathological diagnosis, the most common causes of primary GN were IgA nephropathy (20.9%), followed by minimal change disease (18.1%) and focal segmental glomerulosclerosis (11.6%).

Conclusions

The epidemiology of glomerular disease in our single-center cohort is similar to that shown in other national and international reports. Moreover, our study shows that percutaneous ultrasound-guided RB is a safe, reliable and effective technique in children.