The scope of paediatric laparoscopy

Minimal access techniques have revolutionised surgery in the past twenty years. The concept originated in the early twentieth century and has now become part of standard surgical practice.The potential benefits of laparoscopy include reduced pain, functional impairment and inpatient stay and improved cosmesis. Recent technological advances have assisted in the application of the techniques to a paediatric population. There are now few paediatric surgical procedures remaining that have not been performed using minimal access techniques. The scope of laparoscopy in paediatric surgery encompasses neonatal surgery, thoracic surgery, gastrointestinal surgery, oncology and urology.The evidence base for laparoscopic over open surgery in childhood remains small but is growing. Laparoscopic surgery has been demonstrated to be at least equivalent to its open counterpart in some procedures and superior in a few.Recent advances in paediatric laparoscopy have largely concentrated on reducing the size of incisions needed to operate. This trend seems likely to continue with the introduction of natural orifice transluminal endoscopic surgery and the blurring of distinctions between surgeons, endoscopists and interventional radiologists.     

The scope of emergency paediatric surgery in Tanzania

This article helps to outline the scope of emergency paediatric operations in Tanzania by quantifying the nature of cases seen over a 12 month period in a teaching hospital. Data collected at the Kilimanjaro Christian Medical Centre (KCMC) showed that operative paediatric surgical emergencies represented 4% of all paediatric admissions. Of emergency procedures, 47 (43%) were for congenital abnormalities, 32 (29%) for infections, 19 (17%) for trauma and 12 (11%) for other reasons. Emergency operative mortality was 34%. The challenges to meet patient needs in the African setting include: a scarcity of surgeons with training in paediatric surgery, the variety of conditions which all surgeons must manage, a lack of equipment (e.g., neonatal ventilators) and educational resources. Potential avenues for overcoming these challenges are discussed, including the promotion of paediatric surgery as a profession, by the expansion of existing facilities, promoting African associations of paediatric surgery and highlighting the need for resources and continued education and training. We argue that surgical training in developing countries should include the skills needed to treat those paediatric conditions most likely to require urgent surgical intervention.     

Malignant versus benign paravertebral widening in children

Dorso-medial pleural reflection line anomalies occur in malignant tumours, neuroblastoma being the commonest one, in benign tumours, spinal inflammatory disorders and in cases of pseudotumours of different origin. The latter group comprises normal structure variants, malformations and acquired disease but also a small number of transitory or permanent lesions of uncertain or obscure origin. The radiological manifestations encountered are displacement, obliteration or blurring of the paraspinal contour, sometimes a frank paravertebral mass. Based on a case material consisting of 65 patients the importance of recognizing this feature is stressed. An approach to clinical and radiological diagnosis is discussed.     

Paediatric sleep resources in Canada: The scope of the problem

BACKGROUND:

Sleep-disordered breathing (SDB) is prevalent in children and is associated with significant comorbidity.

OBJECTIVES:

To describe paediatric sleep physician and diagnostic testing resources for SDB in Canadian children.

METHODS:

A 38-item, Internet-based survey was sent to the 32 members of the Canadian Pediatric Sleep Network (CPSN). A shorter telephone survey was administered to all 182 non-CPSN sleep laboratories across Canada.

RESULTS:

Responses were obtained from 29 of 31 (91%) CPSN members and 121 of 182 (66%) non-CPSN sleep facilities. Sixty-seven of 121 (55%) of the responding non-CPSN facilities reported that they see children <18 years of age. Thirty-six of 121 (30%) and 23 of 121 (19%), respectively, see children ≤12 years of age or ≤8 years of age. Marked disparities across provinces/territories were observed, with no practitioners or polysomnography in the Yukon, Northwest Territories, Nunavut, Saskatchewan, New Brunswick, Prince Edward Island, and Newfoundland and Labrador. Alberta has the smallest ratio of children to practitioners (approximately 167,000 to 1) and Ontario has the smallest ratio of children to polysomnograms performed per year (approximately 487,000 to 1). Reported wait times for polysomnography ranged from <1 month, to 1.5 to 2 years. In paediatric tertiary care centres, the number of polysomnograms performed per year ranged from 55 to 700 (median 480) and in other laboratories the range was 400 to 4000 (median 1100).

CONCLUSIONS:

The present study demonstrates a significant lack of resources and services for paediatric SDB care across Canada, with pronounced geographical disparities. Even if only affected children were tested with polysomnography, the authors estimate there are 7.5 times more children with SDB than current testing capacity.     

Superior mediastinal widening from traumatic cerebrospinal fluid leak

A rare cause of superior mediastinal widening from traumatic extravasation of cerebrospinal fluid is reported in two children following automobile accidents. Radiographic findings include widened superior mediastinum evolving during the immediate posttrauma phase, pleural effusion, and CSF leak into the superior mediastinum on metrizamide CT myelogram. Both children had neurologic deficits of the lower extremities.     

Paravertebral widening in a case of recurrent Wilms' tumour

In infants and children the association of paravertebral widening and abdominal tumour has been regarded as typical of neuroblastoma. However, a paraspinal mass may develop in other malignant tumours too, but seems to be extremely rare in nephroblastoma. The fourth case so far on record is reported. Microscopically the tumour was of the sarcomatous clear cell variant.     

Beyond cat scratch disease: widening spectrum of Bartonella henselae infection

Bartonella henselae was discovered a quarter of a century ago as the causative agent of cat scratch disease, a clinical entity described in the literature for more than half a century. As diagnostic techniques improve, our knowledge of the spectrum of clinical disease resulting from infection with Bartonella is expanding. This review summarizes current knowledge regarding the microbiology, clinical manifestations, diagnostic techniques, and treatment of B. henselae infection.     

Exploring the scope for advocacy by paediatricians

AIMS—To ascertain the type and extent of problems requiring advocacy in paediatrics. To develop an approach for analysing problems according to their root causes and the level of society at which advocacy is needed.METHODS—Nine paediatricians kept detailed clinical diaries for two weeks to identify problems. Classifications were developed to categorise problems by cause and the level of society at which they needed to be addressed. The press was surveyed for one week for childhood issues attracting media attention.RESULTS—60 problems requiring advocacy were identified. Root causes included failures within agencies, between agencies, and inadequate provision. In addition to advocacy required individually, "political" action was needed at the community level (16 issues), city level (16 issues), and nationally (15 issues). 103 articles were found in the press, these did not relate closely to issues identified by clinicians.CONCLUSIONS—Many opportunities for advocacy arise in the course of daily work. A systematic way of analysing them has been developed for use in planning action. To optimise the health and health care of children, there is a need to train and support paediatricians in advocacy work for local as well as national issues. Ten issues were identified that might be prioritised by paediatricians working on an agenda for action.     

Brain abnormality within the scope of a VACTERL association

We report the unusual finding of brain malformations in a male newborn with anomalies of VACTERL association. Magnetic resonance imaging revealed hypoplasia of cerebellum, pons and corpus callosum as well as kinking of diencephalon and mesencephalon. These malformations of ectodermal tissue are suggestive of a defect of morphogenesis that occurred earlier than usually postulated for VACTERL cases. They resulted in severe neurologic complications and an early death. The fact that a cousin of this patient has VACTERL anomalies without cerebral involvement indicates that variable expressivity in genetically predisposed individuals may be possible for this subgroup of VACTERL cases.