Relative rates and features of musculoskeletal complications in adult sicklers

The purpose of this study was to prospectively look for the relative rates and features of musculoskeletal complications in a sample of adult homozygous SS sicklers in Yaoundé. During a 3-year period, known homozygous SS sicklers aged sixteen years or more, with suspicion or evidence of locomotor system disease, including leg ulcer, were consecutively investigated through complete medical history, clinical examination, full blood count, C-reactive protein, standard radiographs of the area of complaint, and, when necessary, CT scan and pus analysis. Those patients with no definite diagnosis were excluded. The study group comprised 84 patients aged 16 to 51 years (mean age: 22 years), with a male/female ratio of 0.75. Four of them (4.5%) were older than 40 years. Thirty five (41.6%) presented a total of 50 lesions of aseptic osteonecrosis, which were located in the hips in 25 cases (50%), in the lumbar spine in 20 cases (40%), in the humeral head in four cases (10%) and in the talar body in one case. The hip necrosis was grade I in 6 cases, grade II in four, grade III in 11 and terminal in four. Multiple sites of necrosis were observed in six patients. Nineteen (22.6%) of the sicklers came on with 36 malleolar ulcers, more frequently in males (sex ratio: 5/1) and 28 (78%) located on the medial side. Fifteen sites of osteomyelitis were noted in 14 patients (17.8%) and septic arthritis in six (7%). Less frequent complications were impingement syndrome, gout osteoarthropathy, stress fracture, subtalar fusion, knee osteoarthritis, tendonitis of the anterior tibialis, and recurrent dislocation of the patella. All patients were managed conventionally, except for advanced aseptic necrosis in which the indication for arthroplasty was delayed till the terminal stage. As suggested by another recent report from Senegal, efforts should be made to improve the life expectancy of sicklers in Sub-Saharan African countries, by acting on education, social and medical care. Orthopaedic surgery should focus on reducing the failure rate of joint replacement in terminal stages of osteonecrosis and designing core decompression trials in early stages.     

Nuclear imaging for musculoskeletal infections in children

We retrospectively reviewed all patients who underwent bone scanning for possible osteomyelitis at the Naval Regional Medical Center (Portsmouth, VA, U.S.A.) between 1980 and 1983. Among 63 children, there were 20 sites of osteomyelitis. We were able to conclude that a high proportion of neonates with septic arthritis will have osteomyelitis and that bone scan is not helpful in this age group. Nuclear imaging of the foot was less reliable than imaging of the remainder of the extremities. The bone scan can be a useful adjunct in the diagnosis of osteomyelitis in certain children, but is not a substitute for an accurate clinical examination and appropriate workup.     

Anesthesia-related complications in children

BACKGROUND: Careful preoperative assessment and adequate planning of an appropriate anesthetic are the cornerstones safe pediatric anesthetic practice. A prospective study was carried out in pediatric surgical patients to identify and quantitate both intra-operative and post anesthesia recovery room complications, management and outcome. METHODS: Two hundred and seventy children, aged day 1-16 years who had surgery over twelve months period were recruited in the study. There were 151 males (56%) and 119 females (44%). There were 15 neonates (5.5%), 69 infants below 1 year (25%), 99 (36.7%) toddlers and younger children (1-5 years); older children >5 years were 87 (32.2%). Anesthetists managing the patients were free to use drugs and technique they considered appropriate for each patient. A standardized form was used to collect patient's details, type of surgery, technique of anesthesia, duration of anesthesia and surgery. The incidence of intra-operative and post-anesthesia recovery room complications was determined. RESULTS: Twenty five intraoperative complications were recorded in 14 (5.1%) patients while forty postoperative complications were recorded in 25 (9.25%) patients. The incidence of intraoperative complications was 9.3% while that of postoperative complications was 14.8%. There were no statistically significant differences. P = 0.0635, Odds ratio = 0.5867, 95% CI: 0.3449 - 0.9981. Intraoperative adverse events were mainly cardiovascular and respiratory. After cardiovascular complication, pain was the second commonest postoperative complication observed in the recovery room. Occurrence of complication was not related to ASA physical status but the outcome of management of complications was directly related to ASA status. Three preterm infants weighing 1.6 kg, 1.9 kg and 2 kg respectively were transferred to Intensive Care Unit for ventilatory support. Neonates and infants < below 12 months old had the highest rate of adverse events both intraoperatively and in the postanesthesia recovery room. There were two cases of cardiac arrest. Mortality rate was 0.34%. CONCLUSION: Preterm infants are more prone to developing respiratory complications. Anesthesia-related morbidity and mortality can either be minimized or avoided with early identification and prompt management of any complication.     

Screening for musculoskeletal problems in children using a questionnaire

Background

On April 1, 2016, the Ministerial ordinance was enforced, and musculoskeletal examination of the extremities was made mandatory. From 2008, the University of us started musculoskeletal direct examination. To expand the examination, from 2016, we started to use the marksheet-type questionnaire. This study aimed to report the results of a musculoskeletal examination and investigate the association between musculoskeletal examination and age/gender and reports the reliability of the collected questionnaire data.

Magnetic resonance imaging of the musculoskeletal system in children

Pediatric applications of magnetic resonance imaging (MRI) differ from those in adults primarily with respect to the focus on congenital and developmental abnormalities and those pathologic conditions that are unique to children. Sedation is often required for younger children to avoid motion. Quality diagnostic images also require the use of appropriate sizes of surface and planar coils. MRI is an excellent method to evaluate bone marrow involvement and soft-tissue extension of osteosarcoma and Ewing's sarcoma. In children, it is important to be aware of the changes in normal bone marrow signal that occur with maturation and with the normal progression of the replacement of red marrow by yellow marrow. Aplastic and hypercellular anemias have differing MRI features. The high-contrast resolution of the soft tissues, including the spinal cord, and the capability for direct imaging in any plane make MRI an excellent modality for the evaluation of the spine, including congenital malformations.     

Infectious complications in critically injured children

PURPOSE: Infection will complicate the care of a significant number of injured adults. Trauma is the leading cause of mortality in the pediatric population, yet little information is available regarding the incidence of infection in this group. This study evaluates infectious complications in the critically injured child. METHODS: All children admitted to the pediatric intensive care unit from an urban level-1 trauma center during an 80-consecutive-month period were studied. Infection was defined by Centers for Disease Control criteria and was identified by a retrospective review of the medical records. Demographic and clinical information, including microbiologic data, were compiled for all study patients. Data were analyzed using Student's (t)test or chi2 analysis where appropriate. RESULTS: Five hundred twenty-three children were at risk for infection during the study period. Seventy-eight infections were documented in 53 children (incidence, 10.1%). Nosocomial infections accounted for 78% of these with a majority (85%) being device associated. Common infections in this group included lower respiratory (n = 35), primary bloodstream (n = 10), and urinary tract (n = 7). Trauma-related infections were primarily wound (n = 9), intraabdominal (n = 3), or central nervous system (n = 3). Bacterial pathogens predominated, and the most frequent microorganisms recovered were Staphylococcus aureus, Pseudomonas sp, and Haemophilus sp. Children with infectious complications were more severely injured (injury severity score [ISS] 24 versus 17, P < .001) and had a longer hospital stay (21 days v 6 days, P < .001) compared with children without infection during the same period. Overall mortality rate for the study group was 5.7% and was not significantly different from children without infection. CONCLUSIONS: Infection is a significant source of morbidity in the critically injured child. Nosocomial infections predominate, and a majority of these are device related, emphasizing the need for continued vigilance toward prevention in this high-risk group.     

Intestinal stoma complications in immunocompromised children

BACKGROUND/PURPOSE: When performing an urgent gastrointestinal operation on an immunocompromised child, the pediatric surgeon may have to decide between performing an intestinal anastomosis (and risk leakage or sepsis) or creating an intestinal stoma. This study evaluates the postoperative course of those patients treated with intestinal stomas and the long-term survival rate of such patients. METHODS: A 13-year retrospective review of immunocompromised children with intestinal stomas was performed. Patients were assessed as to their diagnosis, indication for surgery, stoma type, postoperative complications (within 30 days of surgery), ostomy-related complications, and survival. RESULTS: 19 stomas (8 ileostomies and 11 colostomies) were created in 18 patients. Six children had immunodeficiency disorders; 12 were immunosuppressed from chemotherapy treatment for cancer. Indications for surgery included infectious complications (n = 8); neoplasm-induced bowel obstruction, perforation, or invasion (n = 10); and Hirschsprung's disease (n = 1). Postoperative complications occurred in 13 cases (68%); two warranted reoperation. Four of six patients with neutropenia had serious postoperative infectious complications. Stoma complications occurred in 6 cases (32%); 1 required revision. All 3 patients in whom bleeding developed from their stoma site were thrombocytopenic. Nine of 18 patients (50%) died, yet no patient died of complications attributable to their stomas. Of the surviving 9 children, 6 underwent stoma takedown at a mean of 19 months after creation; 1 has a permanent colostomy, and 2 currently are undergoing chemotherapy. CONCLUSION: Although immunocompromised children who require intestinal stomas frequently die of their underlying illnesses and their stomas often produce considerable morbidity, stoma creation does not jeopardize their chance of survival.     

Pain associated with the musculoskeletal system in children from Warsaw schools

Objective

To assess the prevalence of pain in the musculoskeletal system and possible reasons for these complaints among early age children from Warsaw schools.

Material and methods

The study was conducted in 34 randomly selected primary schools in Warsaw in 2011. 2748 survey-questionnaires were given to parents or legal guardians by children. Of these, 1509 surveys were subject to a final analysis. The survey included 66 questions regarding, among other things, pain in the musculoskeletal system in children. Additionally, there were questions about possibly occurring diseases, any postural defects, significant obesity, as well as effects of these complaints on the child''s physical activity. Survey data regarded 6–7-year-old children.

Results

In the group of 1509 respondents, 242 children (16%) complained about pain in the musculoskeletal system. Pain was located most frequently in the knee joints, and more rarely in the spine and joints in the upper extremities. In the group of children who complained about pain, moderate physical activity was statistically significantly limited. According to parents, physicians did not diagnose any medical conditions in 106 children. Joint disease was diagnosed in 33 children. Postural defects were diagnosed in 589 children. In 123 children complaining about pain at least one postural defect was diagnosed. Such defects were diagnosed statistically significantly more rarely (p = 0.011) in 1234 children who did not complain about pain (460 children). Platypodia or other foot deformation was observed in 25% of these children, spinal curvature in 12%, abnormal knee joint position in 11% and uneven hip position in 2% children. Of note, 17% of all children were significantly overweight. In overweight children the prevalence of pain, especially in the knee joints and feet, was significantly higher.

Conclusions

This study aims to underline the problem of musculoskeletal pain in early-age children which limits their physical activity. Also the authors draw attention to the issue of postural defects in a large group of school children. This issue undoubtedly requires more attention and a plan how to create more effective methods of prevention.     

Major complications of jejunal feeding in children

Aim of the study

The aim of the study was to identify major gastrointestinal complications associated with direct jejunal feeding. We hypothesized that jejunal feeding may cause life-threatening surgical complications in a minority of patients.

Hand complications in children from digital sucking

Digital sucking is common in children. Although orthodontic complications have been reported, hand complications of digital sucking are seldom described. Five patients are reported; two had digital deformities and three had infections. Deformities of the digits were improved with splinting. Infections required surgical drainage followed by postoperative splint protection to prevent digital sucking. Splinting prohibited sucking in four of five patients.     

Colostomy complications in infants and children.

This study analyses the morbidity and mortality of colostomy formation and closure over a 17-year period during which 138 consecutive infants and children had a colostomy formed as the initial management of Hirschsprung's disease or anorectal malformation. Complications after colostomy formation were encountered in 38 (27.5%) patients and included colostomy prolapse, stenosis, retraction, dysfunction, skin excoriation and parastomal hernia. The complication rate with transverse colostomies was higher than with other types. Colostomy closure was associated with complications in nine patients (6.5%), the most serious of which was adhesive small bowel obstruction (5). The mortality was less than 1%, but significant morbidity still exists. Refinements in surgical technique may help reduce the incidence of complications, but stoma prolapse, particularly with transverse colostomies, remains a major challenge.     

Neurological complications of spinal tuberculosis in children

Neurological complications of thoracic and lumbar spinal tuberculosis were studied in 32 patients under the age of 16 years. The majority had lesions involving three or more vertebral bodies. Paraplegia occurred in 8 patients and was always associated with bladder and bowel dysfunction. Lesions located at T4/5 were most commonly accompanied by paraplegia. Deterioration of the neurological status was related to the degree of spinal stenosis, whereas the degree of kyphosis was of less importance. Radiculopathy is rare in children with Pott’s disease.

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Résumé  Sont étudiees les complications neurologiques de la tuberculose vertébrale observées chez 32 enfants agés de 16 ans au maximum avec une 1ésion de la région thoracique et la région lombaire. Dans la plupart des cas l’atteinte a été de trois vertebres et plus. 8 cas de paraplégie complète ont été notés toujours accompagnés par la dysfonction des organes du bassin. Les problémes moteurs sont observés le plus souvent dans les cas de la lésion des vertebres T4-T5. La gravité des troubles neurologiques dépend de la sténose du canal rachiden. On ne trouve pas de relation directe entre la caractère de la myelopathie et l’importance de la cyphose. La radiculopathie est observée très rarement chez les enfants souffrant du mal de Pott.

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Accepted: 7 February 1999     

Renal complications of Fabry disease in children

Fabry disease is an X-linked α-galactosidase A deficiency, resulting in accumulation of glycosphingolipids, especially globotriaosylceramide, in cells in different organs in the body. Renal failure is a serious complication of this disease. Fabry nephropathy lesions are present and progress in childhood while the disease commonly remains silent by routine clinical measures. Early and timely diagnosis of Fabry nephropathy is crucial since late initiation of enzyme replacement therapy may not halt progressive renal dysfunction. This may be challenging due to difficulties in diagnosis of Fabry disease in children and absence of a sensitive non-invasive biomarker of early Fabry nephropathy. Accurate measurement of glomerular filtration rate and regular assessment for proteinuria and microalbuminuria are useful, though not sensitive enough to detect early lesions in the kidney. Recent studies support the value of renal biopsy in providing histological information relevant to kidney function and prognosis, and renal biopsy could potentially be used to guide treatment decisions in young Fabry patients. This review aims to provide an update of the current understanding, challenges, and needs to better approach renal complications of Fabry disease in children.     

Colostomy complications in infants and children.

Seventy-seven colostomies were performed in 74 patients: 35 for high anorectal agenesis, 34 for Hirschsprung's disease, 2 for necrotizing enterocolitis, 2 for small left colon syndrome, and 1 for volvulus neonatorum with perforation. There were 55 boys and 19 girls with a mean age of 0.8 years. The different types of colostomies performed were: transverse loop in 48, sigmoid loop in 21, transverse end in 4, descending end in 2, sigmoid end in 1, and transverse double barrel in 1. Forty-seven patients developed stomal complications (74.6%). Eleven patients died, but only in 2 (2.7%) were the deaths directly related to colostomy formation. Five patients required stomal revision (6.8%). The incidence of complications was neither related to the age nor to the primary indication for the colostomy, but sigmoid colostomy was associated with a lower complication rate compared to transverse colostomy (52% versus 81% 0.02 greater than p greater than 0.01). A sigmoid loop colostomy should be used whenever possible.