Current issues in the diagnosis and management of pediatric empyema

Empyema is a rare but recognized complication of bacterial pneumonia in children. The incidence of empyema may be rising as vaccination practices and antibiotic prescribing practices promote the emergence of more virulent and resistant organisms. Diagnostic methods vary widely, from thoracentesis to plain radiographs to detailed computed tomography scans. Treatment practices also vary, with some practitioners preferring medical treatment, others employing chest tube drainage or fibrinolytic therapy, and still others aggressively pursuing surgical options. Further study is needed to define the ideal management of empyema. The authors review the current literature and propose an updated management algorithm that incorporates accepted practices as well as emerging trends in diagnosis and management of empyema.     

Current issues in pediatric transplantation

Pediatric solid organ transplantation is so successful that >80% of children will survive to become teenagers and adults. Therefore, it is essential that these children maintain a good quality life, free of significant long-term side effects. While intensive immunosuppressive regimens (containing CsA, tacrolimus, MMF, and steroids) effectively reduce acute or chronic rejection, they can produce long-term side effects including viral infection, renal dysfunction, hypertension, and stunting. The development of effective methods of diagnosis, prevention, and treatment of CMV means that this is no longer a significant cause of mortality, but morbidity remains high. In contrast, infection rates of EBV remain high in EBV-negative pre-transplant patients. However, pre-emptive reduction of immunosuppression or treatment with rituximab or adoptive T-cell therapy is effective in preventing/treating post-transplant lymphoproliferative disease. Recent protocols have concentrated on reducing CsA immunosuppression, to prevent unacceptable cosmetic effects, and to reduce the hypertension, hyperlipidemia, and nephrotoxicity. Both CsA and tacrolimus cause a 30% reduction in renal function, with 4-5% of patients developing severe chronic renal failure. The use of IL-2 inhibitors for induction therapy with low-dose calcineurin inhibitors, in combination with renal-sparing drugs such as MMF or sirolimus for maintenance immunosuppression, should prevent significant renal dysfunction in the future. The concept of steroid-free immunosuppression with IL-2 inhibitors, tacrolimus, and MMF is an attractive option, which may reduce stunting and renal dysfunction. However, these regimens may be associated with the increased development of de-novo autoimmune hepatitis in 2-3% of children. The most important challenge to long-term survival in transplanted children is the management of non-adherence and other adolescent issues, particularly when transferring to adult units, as this is the time when many successful transplant survivors lose their grafts.     

Implementation of a pediatric trauma cervical spine clearance pathway

Pediatric Surgery International - Pediatric cervical spine injuries are rare events. Missed injuries must be weighed against radiation exposure and excess resource utilization in a young...     

Current issues and controversies in the classification of pediatric hepatocellular tumors

Systematic histopathologic examination of hepatoblastoma specimens from patients enrolled in therapeutic protocols has allowed the identification of clinically relevant histologic subtypes that are being incorporated into risk stratification systems. Genetic and molecular studies have documented recurrent chromosomal abnormalities and aberrant activation of developmental, and oncogenic signaling pathways in hepatoblastoma. Molecular profiling has also identified molecular subclasses and gene signatures that could be used to stratify hepatoblastoma patients. Future international collaboration is needed to develop consensus pathology classifications, and to progressively incorporate genetic and molecular biomarkers into therapeutic pediatric liver tumors protocols. Pediatr Blood Cancer 2012; 59: 780–784. © 2012 Wiley Periodicals, Inc.     

A practical guide to suspected cervical spine injury

Cervical spine injury is fortunately a rare entity in the paediatric population. Their assessment can be difficult and prove problematic for those unfamiliar with their assessment. We have provided a suggested approach in this article, with some discussion of the injuries that may be encountered.     

儿童颈椎外伤的诊断及治疗

目的 探讨儿童颈椎外伤的临床特点、诊断、治疗方法及难点和要点.方法 回顾性分析我院1995年1月至2005年12月期间治疗的儿童颈椎外伤病例的临床资料,同时检索分析国内外关于儿童颈椎外伤的文献.结果 11例患儿纳入本研究,其中男8例,女3例;平均年龄(12.1±4.0)岁;受伤机制包括坠落伤(3例),运动伤(3例),车祸伤(2例),直接暴力伤(2例),因娱乐致伤(1例).受伤部位分布为C1-34例,C4-77例.4例合并神经系统症状,其中1例为无骨折脱位型脊髓损伤.4例接受手术治疗,7例行保守治疗.结论 儿童颈椎外伤相对少见,其在临床表现、影像学检查及治疗方法上均存在与年龄相关的特点.熟悉这些特点对儿童颈椎外伤患儿的诊断及治疗至关重要.     

Accuracy of visual determination of neutral position of the immobilized pediatric cervical spine

BACKGROUND: The definition of neutral position for the immobilized pediatric cervical spine is not well standardized. In this study, we attempted to determine whether 1) physicians and/or paramedics could accurately assess visually if the cervical spine was in a neutral position, 2) the visual assessments of the observers were in agreement, and 3) a radiographic Cobb angle would correlate with the visual determination. METHODS: Children presenting to a pediatric emergency department (ED) in full spinal immobilization were randomly selected (convenience sample) for this prospective study. The emergency physician and transporting paramedic independently determined positioning of the cervical spine. A radiologist, blinded to clinical information, determined Cobb angles from radiographs of the immobilized cervical spines. RESULTS: Of the 59 children studied, the evaluation of cervical spine position by the physician and paramedic correlated in 88% of the cases. For the 22 children with non-neutral Cobb angles (definition of neutral: between 5 degrees flexion and 5 degrees extension), observers agreed in 100% of the cases. However, in 21 of these cases (95%) the position was observed as neutral. CONCLUSIONS: Although visual determinations of neutral position of the cervical spine by two observers may correlate, radiographic studies demonstrate that neutral position was not achieved in 37% of the cases.     

Eosinophilic granuloma in the pediatric spine

BACKGROUND/AIMS: Eosinophilic granuloma (EG) involving the vertebrae in the pediatric population presents a difficult management scenario. Issues of surgical versus nonsurgical intervention, spinal stability and continued skeletal growth must all be considered. METHODS: A retrospective review of medical records and radiographs from 1964 to the present yielded 12 patients with age less than 18 at the time of diagnosis of primary spinal EG. RESULTS: Eleven of these 12 patients presented with pain; 2 patients had neurological deficits. Nine patients were managed nonsurgically, including those undergoing tissue diagnosis by needle (2) or extraspinal (3) biopsy; 3 patients underwent gross total resections. Radiographic diagnosis alone was made in 4. With an average follow-up of 8.1 years, survival is 100%. CONCLUSIONS: EG in the spine infrequently produces neurological deficits in the pediatric age group, although it may result in spinal instability. As such, nonsurgical management is the preferred strategy to effect symptomatic relief.     

Current issues in pediatric lupus nephritis: role of revised histopathological classification

Childhood-onset systemic lupus erythematosus (SLE) has an unpredictable natural history with variable clinical manifestations. The prognosis of SLE is linked closely to renal involvement with lupus nephritis (LN), which is more severe in patients with childhood-onset compared with adult-onset disease. The histopathological classification of LN facilitates treatment decisions, protocols, and clinical research. After the World Health Organization and modified WHO classifications of LN from 1974 to 1995, the International Society of Nephrology and Renal Pathology Society Working Group revised the histopathological classification of LN. The reclassification was published in 2004 after their consensus conference held at Columbia University in New York in May 2002. The aims of the reclassification were to standardize definitions, emphasize clinically relevant lesions, and encourage uniform and reproducible reporting among centers. Although the revised classification is time-consuming, it is important for future international collaboration on multicenter trials of disease-modifying agents. The prognosis of SLE and LN is linked to the histopathology of the renal lesion, but the clinical manifestations of LN, including nephrotic syndrome and hypertension, cannot predict the degree of renal involvement. However, we are many years away from completely understanding the etiopathogenesis of LN and the predictive role of the revised histological classification for direction of patient management.     

Primary osteosarcoma of the cervical spine: A pediatric case report and review of the literature

A 4 1/2-year-old girl with a primary osteosarcoma of the seventh cervical vertebra, treated by surgery and chemotherapy, and who is off therapy for 24 months with no evidence of disease is presented and the literature reviewed. © 1994 Wiley-Liss, Inc.     

小儿急性肾损伤的病因与诊断

急性肾损伤是多病因临床危重综合征,诊断标准的演变体现了对其认识的深入和临床实践的反馈作用,每个诊断标准均有其长处和局限性,连续动态的全面评估更有价值.目前,临床还在寻找更适宜的诊断时间窗和临床观察指标,制订更科学合理的诊断和分期标准,以便更早诊断和干预,降低病死率.