Traumatic pediatric bile duct injury: nonoperative intervention as an alternative to surgical intervention

Background

Nonoperative management of blunt pediatric liver injuries has become the standard of care in the absence of hemodynamic instability. However, associated bile duct injuries remain as difficult challenges. Few case reports have demonstrated the benefits of conservative approaches, but others have found better outcomes with surgical intervention. In this study, we report on our experience with interventional endoscopic and radiologic management of 5 pediatric patients with bile duct injuries who underwent unsuccessful surgical interventions.

Methods

We conducted a retrospective review of medical records of all pediatric patients who were admitted with major blunt liver trauma and bile duct injuries over a period of 5 years.

Results

There were 5 patients (4 boys and 1 girl) whose ages range from 3 to 11 years in this study. All patients had major liver laceration and bilomas. Two had intrahepatic and 3 had extra hepatic bile duct injuries (2 right hepatic ducts and 1 junction of cystic duct with common bile duct). All of them underwent previous laparotomies, once in 2 patients, twice in 2 patients, and thrice in 1 patient. All 5 patients were eventually treated successfully with interventional endoscopic and radiologic techniques. Three underwent endoscopic retrograde cholangiopancreatography stenting with percutaneous drainage. Two patients were managed with percutaneous drainage alone. The follow-up is up to 2.5 years with normal liver function test and bile duct ultrasound.

Conclusion

With the current advancement in endoscopic retrograde cholangiopancreatography and intervention radiology techniques, we believe that interventional endoscopic and radiologic management of bile duct injuries caused by blunt trauma in children is successful and efficacious even after multiple laparotomies.     

Nephrotoxicity as a cause of acute kidney injury in children

Many different drugs and agents may cause nephrotoxic acute kidney injury (AKI) in children. Predisposing factors such as age, pharmacogenetics, underlying disease, the dosage of the toxin, and concomitant medication determine and influence the severity of nephrotoxic insult. In childhood AKI, incidence, prevalence, and etiology are not well defined. Pediatric retrospective studies have reported incidences of AKI in pediatric intensive care units (PICU) of between 8% and 30%. It is widely recognized that neonates have higher rates of AKI, especially following cardiac surgery, severe asphyxia, or premature birth. The only two prospective studies in children found incidence rates of 4.5% and 2.5% of AKI in children admitted to PICU, respectively. Nephrotoxic drugs account for about 16% of all AKIs most commonly associated with AKI in older children and adolescents. Nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, amphotericin B, antiviral agents, angiotensin-converting enzyme (ACE) inhibitors, calcineurin inhibitors, radiocontrast media, and cytostatics are the most important drugs to indicate AKI as significant risk factor in children. Direct pathophysiological mechanisms of nephrotoxicity include constriction of intrarenal vessels, acute tubular necrosis, acute interstitial nephritis, and-more infrequently-tubular obstruction. Furthermore, AKI may also be caused indirectly by rhabdomyolysis. Frequent therapeutic measures consist of avoiding dehydration and concomitant nephrotoxic medication, especially in children with preexisting impaired renal function.     

Nonpenetrating gunshot injury as a cause of testicular rupture

We report 2 cases of testicular rupture owing to a nonpenetrating gunshot injury. Immediate surgical exploration on the basis of a large painful scrotum of acute onset accorded a correct diagnosis and appropriate treatment.     

Factors associated with pediatric firearm injury and enrollment in a violence intervention program

PurposeTo identify factors associated with firearm injury (FI) and willingness to enroll in a violence intervention program amongst pediatric victims of violence.MethodsCross-sectional study of victims of violence age 6–19 years presenting to a children's hospital emergency department from 2014 to 2017. Participants were interviewed by social workers prior to being offered enrollment in a violence intervention program. We used multivariate logistic regression analyses to identify factors associated with FI and enrollment in the violence intervention program.ResultsFour hundred seven patients were analyzed, 156 (38%) of which were victims of FI and 251 (62%) were victims of non-firearm-related physical assaults (PA). Multiple factors were associated with FI including older adolescent age, male sex, separated/divorced parents, losses in family/social network due to violence, being on probation, illicit substance use, gang affiliation, and lack of school enrollment. One hundred four patients (26%) enrolled in the violence intervention program. There was no difference in enrollment between FI and PA. However, older adolescent age, illicit substance use and probation were associated with significantly decreased odds of enrolling in the program.ConclusionsMultiple identifiable and potentially actionable risk factors exist amongst pediatric victims of acute FI. More specific targeting of at-risk groups may improve enrollment in violence interventions programs.Level of EvidenceThis is a prognostic study, investigating the natural history of pediatric firearm injuries, factors associated with firearm injuries as well as those associated with patient propensity to enroll in a violence intervention program. This study is observational in nature and utilizes patients with non-firearm-related physical assaults as a control group, making this study Level III evidence.     

Graft outcomes in pediatric kidney transplantation: focus on the role of race

While significant racial disparities in graft outcome persist among adult and pediatric kidney transplant recipients in the US, some international studies do not show these differences. The aim of this study is to examine predictors of graft outcomes and the impact of race in our pediatric kidney transplant cohort. Records of 109 pediatric kidney transplant recipients performed at our institution between 7/99 and 4/07 were studied. Patients were grouped based on race: African-American (AA) vs. non-AA. Fifty-five AA (12 ± 5 years) and 54 non-AA patients (11 ± 6 years) were studied. There were more females, pre-emptive transplants and living donors in the non-AAs. Survival analysis showed significantly higher rejection rates in AAs, P = 0.02, and lower unadjusted graft survival (P = 0.09). Cox Proportional Hazards Survival Regression Analysis revealed biopsy-proven acute rejection and delayed graft function contributed to worse graft survival, while pre-emptive transplantation had a favorable effect. Race was not an independent risk factor for decreased graft survival in the final model. In conclusion, our cohort showed several modifiable risk factors that can partially account for poorer graft survival in pediatric AA kidney transplant recipients.     

The pediatric trauma score as a predictor of injury severity in the injured child

The ability of the Pediatric Trauma Score (PTS) to accurately predict the degree of injury severity of the injured child was assessed by comparing two separate groups of pediatric trauma victims. The first group consisted of 110 patients evaluated at a regional pediatric trauma center whose data was collected and assessed by a single investigator. The second group consisted of a similar matched cohort of 120 patients from the National Pediatric Trauma Registry whose data was collated from multiple participating institutions. In both cases, a linear relationship between PTS and Injury Severity Score (ISS) was documented that was statistically significant to P less than .001. The linear regression coefficients of each group were similar as was the distribution of PTS and ISS. This study documents the validity of the PTS as an initial assessment tool and confirms its reliability as a predictor of injury severity.     

Wilson disease as a cause of liver injury in cystic fibrosis

Cystic fibrosis-related liver disease affects approximately one third of all patients with cystic fibrosis. Initial signs of other liver diseases including the genetically determined disorders of the liver co-inherited with cystic fibrosis may be obscured by or ascribed to cystic fibrosis-related liver disease. We report a patient shown to suffer simultaneously from cystic fibrosis and hepatic Wilson disease. Our case documents that in patients with cystic fibrosis presenting with liver disease, when unusual clinical and/or laboratory abnormalities appear and fail to respond to standard therapy, a second disease, including rare inherited metabolic disorders such as the hepatic form of Wilson disease or α₁-antitrypsin deficiency, should be suspected.     

Shock as a cause of unfavorable outcome in polytrauma with brain injury

In associated injuries to the organs of the abdominal, thoracic cavities, locomotor system in 160 patients with brain trauma, 150 of them were admitted at the state of shock. The difference in shock manifestations, depending on the character of localization of the main injuries, was noted.     

Isolated brain injury as a cause of hypotension in the blunt trauma patient

BACKGROUND: Emerging evidence suggests that, contrary to standard teaching, isolated brain injury may be associated with hypotension. This study sought to determine the frequency of isolated brain injury-induced hypotension in blunt trauma victims. METHODS: Hypotensive adult trauma patients were categorized according to the cause of hypotension: hemorrhagic (hemoglobin < 11.0), neurogenic, isolated brain, or other. Their clinical data and outcomes were compared. RESULTS: The cause of hypotension was hemorrhagic in 113 (49%), isolated brain injury in 30 (13%), neurogenic in 14 (6%), and other causes in 24 (10%). Fifty (22%) were indeterminate. Hemorrhagic, isolated brain, and neurogenic groups were similar in age, Injury Severity Score, and systolic blood pressure. The Glasgow Coma Scale score of the isolated brain group was lower than in the hemorrhagic group (4.4 vs. 8.4, p < 0.05). Mortality was higher in the isolated brain group compared with the hemorrhagic group (80% vs. 50%, p < 0.05) and in the subgroup of hemorrhagic patients with versus without associated brain injury (57% vs. 39%, p < 0.05). CONCLUSION: Isolated brain injuries account for 13% of hypotensive events after blunt trauma and are associated with an increased mortality compared with hemorrhage-induced hypotension. In hypotensive brain-injured patients, hemorrhagic sources should be excluded rapidly, and the focus should be on resuscitation.     

The essential role of psychosocial risk and protective factors in pediatric traumatic brain injury research

This article builds upon Traumatic Brain Injury Common Data Elements (TBI CDE) version 1.0 and the pediatric CDE Initiative by emphasizing the essential role of psychosocial risk and protective factors in pediatric TBI research. The goals are to provide a compelling rationale for including psychosocial risk and protective factors in addition to socioeconomic status (SES), age, and sex in the study design and analyses of pediatric TBI research and to describe recommendations for core common data elements in this domain. Risk and protective factor research is based on the ecological theory of child development in which children develop through a series of interactions with their immediate and more distant environments. Home, school, religious, and social influences are conceptualized as risk and/or protective factors. Child development and TBI researchers have interpreted risk and protective variables as main effects or as interactions and have used cumulative risk indices and moderation models to describe the relationship among these variables and outcomes that have to do with development and with recovery from TBI. It is likely that the number, type, and interaction among risk and protective factors each contribute unique variance to study outcomes. Longitudinal designs in TBI research will be essential to understanding the reciprocal relationships between risk/protective factors and the recovery/outcome made by the child. The search for effective interventions to hasten TBI recovery mandates the need to target modifiable risks and to promote protective factors in the child's environment.     

The role of foot orthoses as an intervention for patellofemoral pain

Foot orthoses often are prescribed for patients with patellofemoral pain. The purpose of this clinical commentary is to review the theoretical and research basis that might support this intervention and to provide our own clinical experience in providing foot orthoses for these patients. Literature is reviewed regarding (1) the effects of foot orthoses on pain and function, (2) the relationship between foot and lower-extremity/patellofemoral joint mechanics, (3) the effects of foot orthoses on lower-extremity mechanics, and (4) the effects of foot orthoses on patellofemoral joint position. The literature and our own clinical experience suggest that patients with patellofemoral pain may benefit from foot orthoses if they also demonstrate signs of excessive foot pronation and/or a lower-extremity alignment profile that includes excessive lower-extremity internal rotation during weight bearing and increased Q angle. The mechanism for foot orthoses having a positive effect on pain and function for these patients may include (1) a reduction in internal rotation of the lower extremity; (2) a reduction in Q angle; (3) reduced laterally-directed soft tissue forces from the patellar tendon, the quadriceps tendon, and the iliotibial band; and (4) reduced patellofemoral contact pressures and altered patellofemoral contact pressure mapping. Foot orthoses may be a valuable adjunct to other intervention strategies for patients who present with the previously stated structural alignment profile.     

The role of ureteroscopy in pediatric urology

PURPOSE OF REVIEW: Endoscopic evaluation and management of the diverse conditions involving the upper urinary tract using rigid or flexible endoscopes is now readily feasible and has been shown to be safe and efficacious even in the smallest children. RECENT FINDINGS: Reduction in the size of the endoscopes, improvements in electronic imaging systems, proliferation of ancillary equipment, and improvement in endourologic skills among pediatric urologists make endoscopic treatment of pediatric urolithiasis the treatment of choice. The safety and efficacy of holmium:YAG laser lithotripsy make it the intracorporeal lithotriptor of choice. Successful outcomes can be obtained for ureteral and renal calculi that are similar to the adult population. Endoscopic treatment can be effective in highly selected children with intraluminal ureteral obstruction in the hands of a very experienced endoscopic pediatric urologist. These conditions include renal hemangiomas or arteriovenous malformations, ureteropelvic junction obstruction, ureteral strictures, or ureteral polyps. SUMMARY: Pediatric ureteroscopic procedures are similar to their adult counterparts, in that basic endoscopic principles should be observed. Nevertheless, children pose specific technical challenges that require planning before endoscopy and that affect the risks and outcomes of these procedures. Future improvements in ureteroscopy will rely on the continued application of the new technology.