Early interim FDG PET/CT prediction of treatment response and prognosis in pediatric Hodgkin disease—added value of low-dose CT

Background

Interim 18F-FDG PET helps predict outcome and tailor treatment in adults with Hodgkin disease (HD).

Objective

The purpose of this study was to assess predictive values of interim 18F-FDG PET/CT in children with HD and to define the potential added value to interim PET of low-dose CT.

Materials and methods

Children were prospectively enrolled August 2002–April 2007. PET/low-dose CT was performed at staging, after 2 cycles, at the end of treatment and during follow-up (mean 45 months). Treatment was unchanged regardless of interim results. PET and low-dose CT were read independently.

Results

Of 34 enrolled children (ages 3–17 years), 27 achieved complete response, 4 had progressive disease and 3 had relapse. Interim PET alone had positive and negative predictive values of 67% and 89%, respectively. Interim low-dose CT alone had positive and negative predictive values of 35% and 100%, respectively. Interim PET/CT had positive and negative predictive values of 75% and 96%, respectively.

Conclusions

Early interim PET/CT was a good predictor of outcome. Integrated PET and low-dose CT improved the predictive value in children with HD.     

Dialyse im Neugeborenenalter

Background

There are several indications for dialysis therapy in neonates. Until now only few studies have evaluated the long-term outcome of these children.

Study design

In all, 43 neonates were dialysed between 1992 and 2012 at the University Children’s Hospital, Heidelberg: 20 had kidney disease, 18 suffered from hyperammonemia, and 5 had an acute kidney failure or multiorgan failure due to other systemic diseases. The organic and psychomotor developments of these patients have been retrospectively examined in this study.

Results

Detoxification and dehydration therapy were effective in all cases. None of our patients died of dialysis-related complications. The survival rate was high (84?%) in all groups. The psychomotor development was normal or mildly retarded in patients with kidney disease, whereas patients with underlying metabolic illness showed severe deficits (50?%).

Conclusion

Neonates with acute renal insufficiency or hyperammonemia should be immediately treated in perinatal centers with a dialysis facility since prompt treatment is crucial for survival and long-term outcome.     

Relationship of Exclusive Breast Feeding for 6 mo to Linear Growth up to 18 mo of Age

Objective

To assess if linear growth in infant is optimal, with exclusive breast feeding for 6 mo as advised by the WHO.

Methods

This prospective follow up study included 71 full term babies of middle socio economic group healthy mothers. The mothers were instructed to breast feed the babies who were followed up to 18 mo of age for assessment of linear growth. The study was conducted in Metro General Hospital, Noida, U.P. Fifty six babies weighed ≥2.5 kg, and 15 babies weighed <2.5 kg at birth. The main outcome measure was linear growth in exclusively breast fed infants.

Results

At 18 mo, infants ≥2.5 kg on exclusive breast feeding for <6 mo and receiving semisolids early gained more length by 3.4 cm than those receiving breast feeding for ≥6 mo, and infant <2.5 kg gained more weight by 1.2 kg.

Conclusion

For infants ≥2.5 kg of middle socioeconomic group, exclusive breast feed for 6 mo seems sufficient for optimal growth as compared to standard and reference growth data.     

Pattern of Pediatric Dermatoses at a Referral Centre

Objective

To determine the pattern of skin disorders seen among children attending a Medical College Hospital, Bangalore

Methods

All children 18 y and below attending the Pediatric Dermatology OPD with skin diseases between the period of January 2011 and June 2011 were included in the study.

Results

A total of 1,090 new cases (boys 589; girls 501) with 1,118 dermatoses were recorded during this period. Twenty eight children had more than one dermatoses. Most of the disorders were seen between 5 and 11 y age group. The most common dermatoses was infections and infestations (32.47 %) followed by eczematous eruptions and dermatitis (20.66 %), papulosquamous and related disorders (6.08 %) and pigmentary disorders (5.81 %). Insect bite reactions and papular urticaria formed 5.1 %. Acne was seen in 5.28 % of children followed by urticaria (3.67 %), photodermatoses 2.5 % and genetic disorders (3.04 %).

Conclusions

In the present setting bacterial infections and scabies still remained the most common pediatric dermatoses followed by molluscum contagiosum and atopic dermatitis. Childhood psoriasis contributed to major part of the study among papulosquamous disorders.     

Abdominal injuries related to bicycle accidents in children

Purpose

Bicycling is a well-liked sporting activity in which many children participate, and bicycle accidents are one of the most common causes of abdominal injuries in children. We evaluated the characteristics and outcomes of abdominal injuries due to bicycle accidents in children.

Patients and methods

This study was carried out retrospectively on children at the Department of Pediatric Surgery who were hospitalized for abdominal injury due to a bicycle accident, from 2008 to 2012. Abdominal injury-related bicycle accidents were evaluated with respect to patient characteristics, clinical presentation, management strategy, and outcome.

Results

Fifty-nine patients were hospitalized for abdominal injuries related to a bicycle accident. The mean age of the patients was 11.48 ± 3.6 years. Most patients had an imprint of the handlebar edge on their abdomen. The most common abdominal organ injury due to a bicycle accident was laceration of the liver. Most patients were treated conservatively. Surgery was performed in 14 (24.1 %) patients. Hospital stay was 1–68 (mean 4.34 ± 11.6) days.

Conclusions

Abdominal injuries following a bicycle accident are frequent, serious, and preventable. Most patients were treated conservatively. Bicycle injuries can be prevented.     

Clinical characteristics and outcome of hepatocellular carcinoma in children and adolescents

Purpose

Hepatocellular carcinoma (HCC) rarely occurs in children and adolescents and has been reported to be highly hepatitis B related more than 10 years ago. However, after global vaccination for hepatitis B virus (HBV), the characteristics and outcome of pediatric HCC remain undefined.

Methods

Patients with HCC admitted from 2004 to 2010 were retrospectively reviewed in a large tertiary hospital.

Results

45 (1.97 %) pediatric HCC were diagnosed (age ≤18 years), with predominantly male patients (93.3 %). 32 (71.1 %) children were HBV positive, 30 of whom had vertical transmission from their mothers. HBV positivity was associated with liver cirrhosis and portal vein invasion, and thus compromised survival. Advanced disease prevented surgical resection due to large tumor size (>10 cm, 66.7 %), early metastasis (24.4 %), bilateral involvement (57.8 %) and portal vein invasion (46.7 %). The median survival for resectable, transarterial chemotherapy and embolization and untreated patients was 28.6, 4 and 5 months, respectively (p < 0.001). Patients with distal metastasis had significantly poorer survival rate than those without metastasis (p < 0.001).

Conclusion

Screening of children whose mothers are HBV carriers is important in early detection of pediatric HCC. HBV-associated HCC in pediatric patients, especially in endemic areas, should be detected earlier for more resectability and improvement of surgical prognosis.     

Eltern von chronisch kranken Kindern

Background

The aim of this study was to examine parents’ health-related quality of life, psychosocial burden, and needs with regard to different paediatric chronic illness groups.

Material and Methods

In a cross-sectional study, 285 parents (167 mothers, 118 fathers) having a child suffering from juvenile idiopathic arthritis (N=161), type 1 diabetes (N=69), or haemophilia (N=55) completed a questionnaire concerning health-related quality of life, psychosocial burden, and needs.

Results

On average, parents reported moderate impairment of their quality of life. Higher health-related quality of life correlated with longer illness duration and lower perceived impairment of the ill child. Parents’ quality of life, psychosocial burden, and needs differed significantly among the three illness groups (p≤0.001). Parents of children with haemophilia reported the highest quality of life. Parents of children with juvenile idiopathic arthritis experienced the highest psychosocial burden and reported the most pronounced needs. Mothers had lower quality of life (p≤0.01) and reported higher psychosocial burdens (p≤0.01) and more pronounced needs (p≤0.001) than fathers did.

Conclusion

The study confirms illness-specific and gender differences in health-related quality of life, psychosocial burden, and needs of parents of chronically ill children.     

Does mothers’ perception of social support mediate the relationship between fecal incontinence and quality of life of the child?

Purpose

Fecal incontinence is a common problem in children and adolescents with anorectal malformation (ARM) and may negatively impact psycho-social well-being. Mothers’ perception of social support has been proved to contribute to children’s quality of life (QOL). Considering ARM studies, the role of family and social resources have received little attention. The aim of the present study was to analyze whether mothers’ perception of social support mediates the impact of child fecal incontinence on his/her QOL.

Methods

One hundred and nine mothers with a child born with ARM (aged 6–15 years old; mean age = 11 years) completed questionnaires including the fecal incontinence subscale of the Hirschsprung’s Disease/Anorectal Malformation QOL Questionnaire, the Pediatric QOL Inventory, and a social relationship questionnaire. Structural equation models were used to explore the relations hypothesized.

Results

No differences were found in the QOL scores across gender. The hypothesized model fits the data well; mothers’ perception of social support partially mediated the relationship between fecal incontinence and QOL.

Conclusions

An important direction for pediatric surgeons and their interdisciplinary teams may be to develop strategies to strengthen mothers’ social relationships.     

Nierenersatztherapie im Kindesalter

Background

Improvements in conservative therapy slowed down the progression of chronic kidney disease (CKD) to end stage renal disease in children and adolescents over the past decades and led to improved quality of life.

Therapy

Specialized paediatric nephrology units are spread across Germany and children with CKD and a glomerular filtration rate under 60 ml/min/1.73 m² (CKD III) should be regularly seen by a paediatric nephrologist. Preemptive kidney transplantation by a living related donor is the therapy of choice but is often not available. In those cases dialysis is used to bridge the patient until transplantation becomes possible. Modality and intensity of dialysis are individual decisions that need to be discussed carefully with patients and parents. Peritoneal and hemodialysis are both possible in children and adolescents with peritoneal dialysis being the method of choice.

Conclusion

The primary goal –renal transplantation – deserves highest priority since the regained quality of life bears no relationship to the minor and acceptable risks of renal transplantation nowadays.     

Predictive value of nerve trunk size in the neonate

Purpose

The diagnosis of Hirschsprung’s disease (HD) remains challenging. The identification of ganglion cells is difficult and acetycholine esterase (AChE) staining can be subject to a great variability, particularly in the neonatal period (<8 weeks). Nerve trunks greater than 40 µm are considered to be predictive for HD. The aim of this study was to evaluate the usefulness of measuring nerve trunk size in the newborn with HD.

Methods

Out of 292 biopsies 69 could be reanalyzed by three independent researchers. 40 µm was used as cutoff point for nerve trunk size. They were subdivided into three groups: (a) diagnosis of HD certain at the first biopsy, (b) no HD and (c) diagnosis of HD remains doubtful and re-biopsy taken.

Results

In 87 % of group A nerve trunk size was ≥40 µm (SD 13.8). In 84 % of group B trunk size was <40 µm (SD 16.2). In group C only 60 % of the patients showed a positive correlation between final diagnosis and nerve trunk size.

Conclusion

Using 40 µm as the cutoff point gave 13 % false-negative and 16 % false-positive cases. Measurement of the nerve trunk in the neonatal period does not seem to be a reliable method for detecting HD.     

Oxygen Saturation Immediately after Birth in Infants Delivered in Tertiary Care Hospital in India

Objective

To study the sequential changes in SpO₂ values in newborns delivered in a teaching hospital in India.

Methods

Full-term infants born by normal vaginal delivery to registered mothers at KLE University Hospital, Belgaum with birth weight more than 2,500 g, no congenital anomalies and who had received only routine care at birth were included in the study. After delivery, newborn infants were placed on a resuscitation trolley under a radiant warmer; the oxygen saturation sensor was attached (Nellcor DURA-Y multisite oxygen sensor) and then connected to the monitor (Planet 55 multiparameter recorder).

Results

The mean (SD) gestational age of infants included in the study was 38.8 (1.1) wk and birth weight was 2,800 (300) g. The median (IQR) oxygen saturation level (SpO₂) at 2 min of age was 69 % (68 %–79 %). The median level of SpO₂ at 90 % and 95 % saturation was attained at 6.5 min and at 11 min of life, respectively.

Conclusions

Infants delivered in resource poor facilities of developing countries take 11 min to reach 95 % saturations after birth but they are within the reference range values of Neonatal Resuscitation Program 2010 guidelines.     

CT-guided radiofrequency tumor ablation in children

Background

Image-guided radiofrequency ablation is a well-accepted technique of interventional oncology in adults.

Objective

To evaluate the efficacy and safety of CT-guided radiofrequency ablation as a minimally invasive treatment for metastatic neoplasms in children.

Materials and methods

A total of 15 radiofrequency ablation sessions were performed in 12 children and young adults (median age 9.5; range 5–18 years) with metastatic malignancies. Seven children and young adults had secondary hepatic lesions, three had pulmonary and two had bone lesions. Radiofrequency ablation was performed under conscious sedation.

Results

The median lesion size was 1.7 cm (range 1.3–2.8 cm). The median time for ablation was 8 min (range 7–10 min). Radiofrequency procedures were technically successful in all tumors. Postablation imaging immediately after, and 1 month and 3 months after radiofrequency ablation showed total necrosis in all patients. At 6-month follow-up, three patients (all with lesion size >2 cm) had local recurrence and underwent a second radiofrequency ablation session. At 2-year follow-up no patient had recurrence of the treated tumor. Post-ablation syndrome occurred in four children. No major complication occurred.

Conclusion

CT-guided radiofrequency tumor ablation was safe and efficient for palliative treatment in our cohort of patients.     

Epidemiology of rotavirus-associated hospital admissions in the province of Ferrara, Italy

Overview

Hospital discharge forms with specific codes for rotavirus gastroenteritis in children 0 to 14 years of age were reviewed in the period 2003–2005 in the province of Ferrara.

Results

A total of 4,238 children were admitted to the pediatric departments; 151 patients were diagnosed with rotavirus gastroenteritis. The average annual rate of hospitalization for rotavirus gastroenteritis was 1.54/1,000 children <14 years of age and 2.9/1,000 children <5 years of age. Most hospitalizations (72%) involved children aged <60 months. The average length of hospital stay was about 5 days. Considering the Emilia Romagna regional reimbursement codes referable to rotavirus disease, the estimated costs of our 151 cases range from €214,033 to €341,832.

Conclusions

The results of this study contribute to the awareness of rotavirus epidemiology in Italy and underline the potential impact of rotavirus vaccination in our province.     

Isolated splenic abscess in children, role of splenic preservation

Purpose

Splenic abscess (SA) is rare life threatening clinical condition in children. Diagnosis is delayed because of its non-specific clinical presentation. It has a high mortality rate even in the era of antibiotics. This study aim to determine the role of splenic preservation in the management of isolated splenic abscess in children, and to compare different treatment modalities for it.

Methods

A retrospective cross-sectional study of 20 years was conducted including all children <14 years of age with the principal diagnosis of “Splenic abscess”. We have excluded all splenic abscesses occurring after penetrating or blunt abdominal trauma.

Results

Total of 17 children were managed during the study period. Most of our patients were older than 10 years of age. Majority of patients had a significant delay in presentation. Fever, abdominal pain, and vomiting were the main mode of presentation. Splenomegaly on abdominal examination was present in 12 patients. 15 (88 %) children were managed conservatively; however, 2 children required surgical intervention.

Conclusion

Splenic abscess in children is a rare disease and its diagnosis is often delayed. Delay in diagnosis of SA in children can lead to life threatening complications. A high index of suspicion is needed to reduce delay in diagnosis. Children presenting with non-specific high grade fever vomiting and abdominal pain should be evaluated for SA. Timely ultrasound and CT scan will lead to earlier diagnosis. A conservative approach with intravenous antibiotics and early percutaneous drainage especially in immunocompetent children can preserve spleen to continue immune function.     

Blood Lead Levels among School Children after Phasing-Out of Leaded Petrol in Delhi, India

Objectives

The use of leaded petrol was prohibited in the Delhi city by the end of 1998. To determine the impact of use of unleaded petrol, this cross-sectional study was conducted to determine blood lead levels in primary school children.

Methods

Blood lead levels were estimated in 300 school children aged 6 to 10 y. The data regarding clinical features and putative risk factors for high blood lead levels was also collected.

Results

Of the 300 children, 36 (12 %) had high blood lead levels. Of the 36 children, 32 had blood lead levels between 10 and 19 μg/dl, 4 had 20–44 μg/dl and none had levels >45 μg/dl. Factors such as exposure to peeling paint, recent renovation of housing and near-distance of house to main road were significantly associated with high blood lead levels.

Conclusions

There is significant prevalence of high blood lead levels in school children in Delhi, even after with prohibition of use of leaded petrol.     

Head injury pattern in children can help differentiate accidental from non-accidental trauma

Objectives

Our aim was to define the radiographic findings that help differentiate abusive head trauma (AHT) from accidental head injury.

Methods

Our trauma registry was queried for all children ≤5 years of age presenting with traumatic brain injury (TBI) from 1996–2011.

Results

Of 2,015 children with TBI, 71 % had accidental injury and 29 % had AHT. Children with AHT were more severely injured (ISS 22.1 vs 14.4; p < 0.0001) and had a higher mortality rate (15 vs 5 %; p < 0.0001). Patients with AHT had higher rates of diffuse axonal injury (14 vs 8 %; p < 0.0001) and subdural hemorrhage (76 vs 23 %; p < 0.0001). Children with accidental injury had higher rates of skull fractures (52 vs 21 %; p < 0.0001) and epidural hemorrhages (11 vs 3 %).

Conclusions

AHT occurred in 29 % of children and resulted in increased mortality rates. These children had higher rates of subdural hemorrhages and diffuse axonal injury. Physicians initially evaluating injured children must maintain a high index of suspicion for abuse in those who present with subdural hematoma or diffuse axonal injury.     

Risk Factors for Incomplete Immunization in Children with HIV Infection

Objective

To document the immunization rates, factors associated with incomplete immunization, and missed opportunities for immunizations in children affected by HIV presenting for routine outpatient follow-up.

Methods

A cross-sectional study of immunization status of children affected by HIV presenting for routine outpatient care was conducted.

Results

Two hundred and six HIV affected children were enrolled. The median age of children in this cohort was 6 y. One hundred ninety seven of 206 children were HIV infected, nine were HIV exposed, but indeterminate. Fifty (25 %) children had incomplete immunizations per the Universal Immunization Program (UIP) of India. Hundred percent of children had received OPV. Ninety three percent of children got their UIP vaccines from a government clinic. Children with incomplete immunization were older, median age of 8 compared to 5 (p?=?0.003). Each year of maternal education increased the odds of having a child with complete UIP immunizations by 1.18 (p?=?0.008)-children of mothers with 6 y of education compared to those with no education were seven times more likely to have complete UIP vaccine status. The average number of visits to the clinic by an individual child in a year was 4. This represents 200 missed opportunities for immunizations.

Conclusions

HIV infected children are at risk for incomplete immunization coverage though they regularly access medical care. Including routine immunizations, particularly catch-up immunizations in programs for HIV infected children maybe an effective way of protecting these children from vaccine preventable disease.     

The socioeconomic impact of a pediatric ostomy in Uganda: a pilot study

Introduction

Multiple pediatric surgical conditions require ostomies in low–middle-income countries. Delayed presentations increase the numbers of ostomies. Patients may live with an ostomy for a prolonged time due to the high backlog of cases with insufficient surgical capacity. In caring for these patients in Uganda, we frequently witnessed substantial socioeconomic impact of their surgical conditions.

Methods

The operative log at the only pediatric surgery referral center in Uganda was reviewed to assess the numbers of children receiving ostomies over a 3-year period. Charts for patients with anorectal malformations (ARM) and Hirschsprung’s disease (HD) were reviewed to assess delays in accessing care. Focus group discussions (FGD) were held with family members of children with ostomies based on themes from discussions with the surgical and nursing teams. A pilot survey was developed based on these themes and administered to a sample of patients in the outpatient clinic.

Results

During the period of January 2012–December 2014, there was one specialty-certified pediatric surgeon in the country. There were 493 ostomies placed for ARM (n?=?234), HD (N?=?114), gangrenous ileocolic intussusception (n?=?95) and typhoid-induced intestinal perforation (n?=?50). Primary themes covered in the FGD were: stoma care, impact on caregiver income, community integration of the child, impact on family unit, and resources to assist families. Many patients with HD and ARM did not present for colostomy until after 1 year of life. None had access to formal ostomy bags. 15 caregivers completed the survey. 13 (86%) were mothers and 2 (13%) were fathers. Almost half of the caregivers (n?=?7, 47%) stated that their spouse had left the family. 14 (93%) caregivers had to leave jobs to care for the stoma. 14 respondents (93%) reported that receiving advice from other caregivers was beneficial.

Conclusion

The burden of pediatric surgical disease in sub-Saharan Africa is substantial with significant disparities compared to high-income countries. Significant socioeconomic complexity surrounds these conditions. While some solutions are being implemented, we are seeking resources to implement others. This data will inform the design of a more expansive survey of this patient population to better measure the socioeconomic impact of pediatric ostomies and guide more comprehensive advocacy and program development.