Can time to healing in pediatric blunt splenic injury be predicted?

Background

Current consensus guidelines do not recommend routine follow-up imaging for blunt splenic injury (BSI) in children. However, repeat imaging is recommended based on persistent symptoms. Wide variation of practice continues to exist among surgeons. By defining the natural evolution of BSI, we sought to identify patients at higher risk for delayed healing who could benefit from outpatient imaging.

Methods

A retrospective review of all children with BSI at a Level 1 Pediatric Trauma Center was completed. Grade of injury, hospital course, laboratory values and follow-up imaging results were obtained. Injured spleens were classified as ‘healed’, ‘healing’ (with echogenic scar), or ‘non-healing’ with persistence of parenchymal abnormalities.

Results

Between 2000 and 2014, 222 patients with BSI were identified. Seven patients (3%) underwent immediate splenectomy. Packed red blood cell transfusion was required in 13 (6%) of the 222 patients, and 3 (2%) of 145 with isolated splenic injuries. Seventy-one percent of patients underwent additional imaging 2–74 weeks post-injury. A receiver operating characteristics (ROC) curve was used to establish the relationship between sensitivity and specificity of capturing non-healing spleens over time. Optimal timing for post-injury imaging for grades I–II was 7–8 weeks; healing of higher-grade injuries could not accurately be predicted.

Conclusions

If return to full physical activity, in particular contact sports, is contingent upon documented healing of the splenic parenchyma after blunt trauma in the pediatric population, follow-up imaging for low-grade injuries is best obtained around 7–8 weeks. No such recommendations can be made for high-grade splenic injuries, as the exact time to healing cannot be predicted based on initial data.

Level of evidence

IV. Diagnostic test.

     

Iatrogenic ureteral injury: Can adult repair techniques be used on children?

ObjectiveIatrogenic ureteral injury in children is a rare occurrence, with sparse literature available regarding optimal repair techniques. We reviewed our experience in the management of iatrogenic pediatric ureteral injuries, particularly with respect to initial versus delayed diagnoses.MethodsAll pediatric iatrogenic ureteral injuries repaired by a single surgeon during 1986–2007 were reviewed.ResultsTen injuries were repaired over 20 years. Median patient age was 12 years. Injuries occurred during five open tumor resections, three laparoscopic procedures and two ureteroscopies. Diagnosis was immediate in four patients. Median ureteral defect length was 4 cm (range 2–5). All underwent ureteral reimplantation and psoas hitch Boari flap. Median follow up was 1 year, with no obstruction noted. Diagnosis was delayed in six patients by a median of 21 days. Five children (83%) were managed by temporary percutaneous nephrostomy tube and one (17%) by ureteral stent. Delayed repair was performed 1–3 months later. In the patients with laparoscopic or ureteroscopic injuries the median ureteral defect length was 4 cm (range 3–6). All underwent ureteral reimplantation and psoas hitch Boari flap. Median follow up was 1 year, with no obstruction noted. One child had a proximal ureteral defect 8 cm long; delayed ileal ureter was performed with good results 4 years postoperatively.ConclusionsPediatric iatrogenic ureteral injuries are rare and may be repaired by both immediate and delayed techniques as circumstances demand. Standard techniques used in the adult population may be employed in children with the expectation of good long-term results.     

Midline defects in FG syndrome: does tethered spinal cord contribute to the phenotype?

OBJECTIVES: FG syndrome is an X-linked recessive mental retardation syndrome with ano-rectal anomalies, constipation, and occasional urinary incontinence. Because tethered spinal cord syndrome (TCS) has similar symptoms, we evaluated imaging for TCS in patients with FG syndrome. STUDY DESIGN: Patients were recruited from the International FG Syndrome Support Group, and an FG Syndrome Consensus Group reviewed clinical histories, medical records, and photographs of each responding patient. Results of cranial and spinal imaging studies were available for 12 patients. RESULTS: Of 12 boys with FG syndrome, 6 had hypoplasia of the corpus callosum, and 3 of these had TCS (all with constipation and urinary symptoms). The other 9 did not have urinary symptoms. After surgical untethering, bowel and bladder symptoms improved. CONCLUSIONS: Tethered spinal cord syndrome occurred in 25% of patients with FG syndrome associated with hypoplasia of the corpus callosum and causing bowel and bladder incontinence. A high index of suspicion is necessary for early diagnosis, and timely intervention results in significant improvement in symptomatology.     

Editorial: Can dysregulated myelination be linked to ADHD pathogenesis and persistence?

Converging evidence from new epidemiologic, genetic, epigenetic, neuroimaging, and experimental model findings are further refining a long-standing concept, regarding the underlying neurobiology of attention-deficit/hyperactivity disorder (ADHD): that ADHD onset and its persistence into adulthood are the result of dysregulated myelination and associated alterations in neuronal plasticity – linked to disrupted brain maturation and the persistence of cognitive and emotional impairments across the life span. If supported by further work, this concept represents a pathophysiologic mechanism amenable to therapeutic intervention.     

Can spot urine measurement be a substitute for 24-hour urine measurement to estimate sodium intake in adolescents?

Importance::Several methods have been established in recent decades that allow use of spot urine to estimate dietary sodium intake. However, their accuracies ha...     

Health-related quality of life compared to life situation and incontinence in adults with myelomeningocele: Is SF-36 a reliable tool?

AimTo evaluate health-related quality of life (HRQoL) in adults with myelomeningocele (MMC) measured by SF-36.Materials and methodsAll individuals (134) with MMC from western Sweden born before 1981, 69 with a median age of 34 years (range 27–50), participated in a telephone interview. Of these, 61 took part in SF-36 (short form 36 health questionnaire survey).ResultsThe group overall had significant impairment of physical functioning (PF)***, role physical (RP)***, general health GH*** as well as a lower physical component summary (PCS)*** compared to the reference group, while the mental component summary (MCS) was significantly higher***. The comparison between life situation and PCS was favorable for individuals 20–29 years of age or employed. In individuals exhibiting dysphoria during the interview, PCS was negatively affected, however MCS was unaffected. MCS was higher in non-ambulatory individuals* and in those not able to name a negative life experience* (* < 0.05, ** < 0.001, *** < 0.0001). HRQoL as evaluated by SF-36 was unaffected by fecal incontinence, partnership and offspring.ConclusionOur findings indicate that life situation and incontinence were not truly reflected by SF-36. A personal interview with a qualitative approach is likely to be a better tool.     

Early complications after liver transplantation in children and adults: Are split grafts equal to each other and equal to whole livers?

Split‐liver transplantation (LT) allows transplantation of two recipients from one deceased donor, thereby increasing pool of grafts. However, split LT may be hampered by technical problems, and split grafts are still considered suboptimal organs in some centres. We analysed the outcomes in split‐ and whole‐liver recipients in a combined adult‐to‐paediatric transplantation programme. Records of paediatric and adult patients having undergone LT from 1999 to 2013 were analysed retrospectively. All splits were performed in situ. Adult split‐graft recipients were matched 1:2 with whole‐graft recipients (matching criteria: BMI, MELD, year of transplantation, age), and matched to the paediatric recipient transplanted from the same donor. Post‐LT complications were classified according to the Clavien scale. Among children, 32 split‐ and 31 whole‐graft recipients were analysed. Among adults, 20 split‐ and 40 matched whole‐graft recipients were analysed. In both populations, the post‐operative complications did not differ between split‐ and whole‐graft recipients. There was no difference in 1‐year graft and patient survival between split‐ and whole‐graft recipients in paediatric (90% vs. 97%, 94% vs. 97%, respectively) and in adult recipients (89% in both, 89% vs. 92%, respectively). In the analysis of both recipients issued from the same donor, there was no association in the prevalence and severity of complications. A case‐by‐case analysis showed that split mortality was unrelated to LT in all but one patient (small‐for‐size left split graft). In the setting of careful donor selection, recipient matching and surgical skill, in situ split LT is an effective and safe technique to increase the number of available organs, and split livers should no longer considered marginal grafts.     

Journey towards a personalised medicine approach for OSA: Can a similar approach to adult OSA be applied to paediatric OSA?

The concept of personalised medicine is likely to revolutionise the treatment of adult obstructive sleep apnoea as a result of recent advances in the understanding of disease heterogeneity by identifying clinical phenotypes, pathophysiological endotypes, biomarkers and treatable traits. Children with the condition show a similar level of heterogeneity and paediatric obstructive sleep apnoea would also benefit from a more targeted approach to diagnosis and management. This review aims to summarise the adult literature on the phenotypes and endotypes of obstructive sleep apnoea and assess whether a similar approach may also be suitable to guide the development of new diagnostic and management approaches for paediatric obstructive sleep apnoea.