Pediatric postmortem computed tomography: initial experience at a children’s hospital in the United States

Pediatric Radiology - Postmortem CT might provide valuable information in determining the cause of death and understanding disease processes, particularly when combined with traditional autopsy....     

Trend and causes of neonatal mortality in a level III children’s hospital in Shanghai: a 15-year retrospective study

Background

To determine the trend and causes of neonatal mortality in a large level III neonatal intensive care unit in Shanghai during a 15-year period.

Methods

This is a retrospective, single-centered study. All neonates who died during the period from January 1, 1999 to December 31, 2013 at Children’s Hospital of Fudan University were included. We extracted relevant clinical information from their medical records, analyzed neonatal mortality rate and the characteristics of these patients, and compared neonatal deaths between different periods and populations.

Results

Among a total of 50,957 admissions during the study period, there were 929 neonatal deaths. The neonatal mortality rate was 1.82%. Trends in neonatal mortality rate showed an increase in the period from 1.0% in 2003 to 2.2% in 2013. The main causes of neonatal mortality were complications of preterm birth (33.6%), congenital anomalies (21.3%), infections (12.6%), and birth asphyxia (9.1%). The proportions of complications of preterm birth (P < 0.001) and congenital anomalies (P = 0.018) increased yearly, while the proportions of birth asphyxia (P < 0.001) and infections (P < 0.001) decreased. Proportions of deaths caused by birth asphyxia (P = 0.005) and infections (P < 0.001) were both higher in the migrating population than in the permanent residents.

Conclusions

Neonatal mortality rate increased from 2003 to 2013 in our study. The proportion of preterm infants in neonatal deaths also increased within the same period. Complications of preterm birth were the main cause of neonatal mortality and the percentage increased year by year. Neonates in the migrating population appeared to be at a higher risk of death during the neonatal period compared to those in the permanent residents, and efforts should be made towards improving perinatal care to prevent infections and birth asphyxia in this vulnerable population.

     

How can we improve perinatal care in isolated multiple intestinal atresia? A retrospective study with a 30-year literature review

IntroductionMultiple intestinal atresia (MIA) is a rare cause of neonatal intestinal obstruction. To provide an overview of the current prenatal, surgical, and nutritional management of MIA, we report our experience and a literature review of papers published after 1990.MethodsAll cases of isolated MIA (non-hereditary, not associated with apple-peel syndrome or gastroschisis) treated at our institution between 2005 and 2016 were reviewed and compared with cases found in the literature.ResultsSeven patients were prenatally suspected of having intestinal obstruction and were postnatally diagnosed with MIA, with a mean 1.7 (1–2) resections–anastomoses (RA) and 6 (1–10) strictureplasties performed, resulting in a mean resected bowel length of 15.1 cm (15–25 cm). Median time to full oral feed was 46 days (14–626 days). All patients were alive and none had orality disorder after a mean follow-up of 3.1 years (0.2–8.1 years). Three surgical strategies were found in the literature review: multiple RA (68%, 34/50) including Santulli's technique in four of 34 (12%) and anastomoses over a transanastomotic tube (32%, 16/50), with a 98% survival rate, and short-bowel syndrome for only two patients.ConclusionBowel-sparing surgery and appropriate medical management are key to ensuring a favorable nutritional and gastrointestinal outcome and a good prognosis. Prenatal assessment and standardization of the surgical course of treatment remain challenging.     

Pediatric TBI in Finland: An examination of hospital discharges (1998–2012)

Background

Traumatic brain injury constitutes a persistent health problem among pediatric populations worldwide and is often referred to as a silent epidemic. There remains a paucity of scientific exploration with regard to understanding the ecological risk profiles of well-defined populations. In Finland, the healthcare system covers all hospitals, provides uniform access to care and has a universal surveillance system that allows for epidemiological examination of a wide variety of health issues. The present study aims to clarify the incidence, type and geographical presentation of pediatric TBI in Finland.

Posterior reversible encephalopathy syndrome in children: Radiological and clinical findings – A retrospective analysis of a German tertiary care center

PurposeTo report the radiological and clinical spectrum of posterior reversible encephalopathy syndrome (PRES) in children in a German tertiary referral center.MethodsThe radiological report data bases of the authors' university hospitals were searched for paediatric patients with PRES. Clinical and paraclinical data as well as various imaging features at symptom onset and during follow-up were tabulated in patients fulfilling the criteria for PRES.ResultsA total of 18 paediatric patients with PRES were included into the study. Mean age was 9 years (IQR 7–12), 38.9% were females. Most frequent predisposing causes were renal and haemato-oncologic diseases frequently associated with endotheliotoxic cytostatic medication. Frontal lesions occurred as frequently as parietal lesions followed by occipital lesions. The superior frontal sulcus topographic lesion pattern occurred as frequent as the parieto-occipital one. In 38% of cases residual lesions were encountered with focal laminar necroses being most frequent. Initial clinical syndromes associated with PRES included seizures in 18, altered mental state in 5, and hemiparesis and visual disturbances in 2 children. Mean arterial blood pressure at onset of PRES was 140/85 mmHg (IQR systolic: 124–169, diastolic: 78–93 mmHg).ConclusionPaediatric PRES in this cohort comprises a broad radiological and clinical spectrum. The occurrence of frontal lesions, a superior frontal sulcus associated lesion pattern, and the development of focal laminar necrosis appear to be frequent in children.     

Rooming‐in for preterm infants: How far should we go? Five‐year experience at a tertiary hospital

Aim: To determine the rate of rooming-in among preterm infants born in a tertiary hospital. Methods: We reviewed the records of all preterm infants born at our hospital during a 5-y period, 2000 to 2004. Results: Of the 18953 neonates born at our institution during this time, 1356 (7.2%) were <37 wk gestational age. Considering only preterm infants with birthweight 1500 g, 806 (74.1%) stayed with their mothers and 282 (25.9%) were admitted to the NICU. Of all the preterm infants that initially stayed with their mothers, 42 (5.2%) needed to be transferred to the NICU. When we stratified these preterm infants according to birthweight, we found that 29% of those <1750 g were transferred to the NICU, compared to only 5% of those 1750 g.
Conclusion: Our study supports the idea that the majority of preterm infants, especially those with birthweight <1750 g, can safely remain near their mothers at all times during hospital stay, with both clinical and financial benefits. Neonates with birthweight <1750 g should be evaluated carefully to decide whether rooming-in is the best option. Rooming-in should be encouraged in preterm infants.     

Amyand’s hernias in childhood (a report on 21 patients): a single-centre experience

Purpose

Amyand’s hernia is a very rare type of hernia and is characterised by the presence of a vermiform appendix in the inguinal hernia sac. It may present as a tender inguinal or inguinoscrotal swelling, and is usually misdiagnosed as an irreducible or strangulated inguinal hernia. This is a presentation of our experiences with these unusual hernias.

Methods

This study conducted a retrospective analysis of 21 patients with Amyand’s hernias operated on at our institution between April 2007 and February 2011. The age and sex distributions of the patients, the types of hernias, and preoperative diagnostic tests were evaluated.

Results

Twenty patients were male (95.3 %) and one was female (4.7 %). The median age was 20.3 months (ranging from 2 months to 10 years). In nine patients, the conditions were diagnosed using ultrasonographic (USG) imaging preoperatively. Nine of the 21 patients underwent emergency operations. The 12 remaining patients were operated on after preparations were completed. The operative findings included 12 normal appendixes, five inflamed appendixes, one perforated appendix, and three hernias whose inner hernia sac surface was adhered to the appendix. Nine patients underwent inguinal hernia repair with appendectomy, and 12 patients had hernia repair without an appendectomy. Recurring hernias and appendicitis were not detected in any patients within the follow-up time.

Conclusions

Although a routine appendectomy is not required for a normal-looking appendix, in a case where the inflammatory status of the appendix adheres to the surface of the hernia sac, an appendectomy is required. We believe that USG examination in the diagnosis of Amyand’s hernias can provide additional contribution.     

High success rates of sedation-free brain MRI scanning in young children using simple subject preparation protocols with and without a commercial mock scanner–the Diabetes Research in Children Network (DirecNet) experience

Background

The ability to lie still in an MRI scanner is essential for obtaining usable image data. To reduce motion, young children are often sedated, adding significant cost and risk.

Objective

We assessed the feasibility of using a simple and affordable behavioral desensitization program to yield high-quality brain MRI scans in sedation-free children.

Materials and methods

222 children (4–9.9 years), 147 with type 1 diabetes and 75 age-matched non-diabetic controls, participated in a multi-site study focused on effects of type 1 diabetes on the developing brain. T1-weighted and diffusion-weighted imaging (DWI) MRI scans were performed. All children underwent behavioral training and practice MRI sessions using either a commercial MRI simulator or an inexpensive mock scanner consisting of a toy tunnel, vibrating mat, and video player to simulate the sounds and feel of the MRI scanner.

Results

205 children (92.3%), mean age 7?±?1.7 years had high-quality T1-W scans and 174 (78.4%) had high-quality diffusion-weighted scans after the first scan session. With a second scan session, success rates were 100% and 92.5% for T1-and diffusion-weighted scans, respectively. Success rates did not differ between children with type 1 diabetes and children without diabetes, or between centers using a commercial MRI scan simulator and those using the inexpensive mock scanner.

Conclusion

Behavioral training can lead to a high success rate for obtaining high-quality T1-and diffusion-weighted brain images from a young population without sedation.     

Trends in cause and place of death for children in Portugal (a European country with no Paediatric palliative care) during 1987–2011: a population-based study

Background

Children and adolescents dying from complex chronic conditions require paediatric palliative care. One aim of palliative care is to enable a home death if desired and well supported. However, there is little data to inform care, particularly from countries without paediatric palliative care, which constitute the majority worldwide.

Methods

This is an epidemiological study analysing death certificate data of decedents aged between 0 and 17 years in Portugal, a developed Western European country without recognised provision of paediatric palliative care, from 1987 to 2011. We analysed death certificate data on cause and place of death; the main outcome measure was home death. Complex chronic conditions included cancer, cardiovascular, neuromuscular, congenital/genetic, respiratory, metabolic, gastro-intestinal, renal, and haematology/immunodeficiency conditions. Multivariate analysis determined factors associated with home death in these conditions.

Results

Annual deaths decreased from 3268 to 572. Of 38,870 deaths, 10,571 were caused by complex chronic conditions, their overall proportion increasing from 23.7% to 33.4% (22.4% to 45.4% above age 1-year). For these children, median age of death increased from 0.5 to 4.32-years; 19.4% of deaths occurred at home, declining from 35.6% to 11.5%; factors associated with home death were year of death (adjusted odds ratio 0.89, 95% confidence interval 0.89–0.90), age of death (6–10 year-olds 21.46, 16.42–28.04, reference neonates), semester of death (October–March 1.18, 1.05–1.32, reference April–September), and cause of death (neuromuscular diseases 1.59, 1.37–1.84, reference cancer), with wide regional variation.

Conclusions

This first trend analysis of paediatric deaths in Portugal (an European country without paediatric palliative care) shows that palliative care needs are increasing. Children are surviving longer and, in contrast with countries where paediatric palliative care is thriving, there is a long-term trend of dying in hospital instead of at home. Age, diagnosis, season and region are associated with home death, and should be considered when planning services to support families choosing this option. Priorities should address needs of the youngest children, those with cancer, neuromuscular and cardiovascular conditions, as well as inequities related to place of residence.

     

Long-term outcome of laparoscopic Nissen-Rossetti fundoplication versus Thal fundoplication in children with esophageal hiatal hernia: a retrospective report from two children’s medical centers in Shanghai

Background

This study was undertaken to investigate the intraoperative and postoperative complications, efficacy and outcome of two laparoscopic fundoplications for the treatment of esophageal hiatal hernia in children.

Methods

To find a rational procedure, we performed a retrospective analysis of 136 children with esophageal hiatal hernia who underwent laparoscopic Nissen-Rossetti or Thal fundoplication at two children’s hospitals in Shanghai over 13 years. The median follow-up time of the children was 42 months (range: 1-138 months). Their age varied from 1 month to 11 years (median: 18.6 months).

Results

All the children underwent laparoscopic fundoplications (72 cases of Nissen-Rossetti and 60 cases of Thal fundoplication) and 4 children converted to open surgery. The mean age of the children at the time of operation was 1.6±1.9 years, and the mean weight was 9.1±5.6 kg. Gastroesophageal reflux was significantly more severe after a Thal fundoplication (P=0.003) and slight esophageal stenosis was significant after a Nissen-Rossetti fundoplication (P=0.02). The recurrent rate of hiatal hernia was 2.8% (2/72) after Nissen-Rossetti fundoplication in contrast to 5% (3/60) after Thal fundoplication. No death occurred after surgery.

Conclusion

There was no statistical difference of recurrence between laparoscopic Nissen-Rossetti and Thal fundoplication in the long-term outcomes. The rate of slight dysphagia was higher in the Nissen-Rossetti group. The Thal group had a significantly higher recurrence rate of gastroesophageal reflux. There still exited learning curve for this procedure. The incidence rate of complications is significantly related to the proficiency of pediatric surgeon.

     

Relationship of serum insulin-like growth factor I (IGF-I) with nutritional status in pediatric patients with malignant diseases—a single Romanian center experience

The aim of this study was to analyze insulin-like growth factor I (IGF-I) serum level in pediatric patients with cancer compared with pediatric patients with nononcological diseases and to assess the relationship between IGF-I and nutritional status of oncological patients. From January 2009 to July 2012, we assessed 151consecutively hospitalized patients in a tertiary emergency pediatric hospital. The patients were divided into two groups: group I, consisting of patients with malignant diseases (64 patients), and group II, the control group, consisting of 87 age- and gender-matched patients with different pediatric diseases. The anthropometric parameters (weight, height, body mass index, middle upper arm circumference (MUAC), and tricipital skinfold thickness (TST) and biochemical parameters (proteins, albumin, and total IGF-I) were comparatively evaluated at the diagnosis and after intensive chemotherapy in the malignant group. Anthropometric and biochemical parameters in group I were significantly different from those in group II for height, MUAC, TST, total proteins, and albumin (p?<?0.05). Twenty-five out of 64 patients with malignant diseases and 5 out of 87 patients in the control group had malnutrition. IGF-I in patients with cancer was much lower than in the control group (median 48.3 ng/ml, range 25.00–662.00 ng/ml vs 129.00 ng/ml, range 25.00–745.00 ng/ml) (p?=?0.014). We found a positive correlation between IGF-I, MUAC, and TST at the diagnosis of the malignant disease. Also, we identified positive correlations between IGF-I, protein, and albumin. Serum IGF-I levels in cancer patients were significantly lower at diagnosis than after chemotherapy (48.3 ng/ml, range 25.00–662.00 ng/ml vs 110.0 ng/ml, range 25.00–573.00 ng/ml; p?=?0.04). Conclusion: IGF-I seems to be an accurate biochemical parameter used in malnutrition assessment of children with cancer. IGF-I correlated with the anthropometric parameters of the arm, serum protein, and albumin. These parameters most accurately characterize the nutritional status.     

Prevention of vitamin K deficiency bleeding with three oral mixed micellar phylloquinone doses: results of a 6-year (2005–2011) surveillance in Switzerland

In 2003, the Swiss guidelines to prevent vitamin K deficiency bleeding (VKDB) were adapted. As two oral doses (2 mg, hour/day 4) of mixed micellar VK preparation had failed to abolish late VKDB, a third dose (week 4) was introduced. This report summarizes the new guidelines acceptance by Swiss pediatricians and the results of a prospective 6-year surveillance to study their influence on the incidence of VKDB. The new guidelines acceptance by Swiss pediatricians was evaluated by a questionnaire sent to all pediatricians of the Swiss Society of Paediatrics. With the help of the Swiss Paediatric Surveillance Unit, the incidence of VKDB was monitored prospectively from July 1, 2005 until June 30, 2011. Over a 6-year period (458,184 live births), there was one case of early and four cases of late VKDB. Overall incidence was 1.09/10⁵ (95 % confidence intervals (CI) 0.4–2.6). Late VKDB incidence was 0.87/10⁵ (95 % CI 0.24–2.24). All four infants with late VKDB had an undiagnosed cholestasis at the time of bleeding; parents of 3/4 had refused VK prophylaxis, and in 1/4, the third VK dose had been forgotten. Compared with historical control who had received only two oral doses of mixed micellar VK (18 cases for 475,372 live births), the incidence of late VKDB was significantly lower with three oral doses (Chi²,Yates correction, P?=?0.007). Conclusion VKDB prophylaxis with 3?×?2 mg oral doses of mixed micellar VK seems to prevent adequately infants from VKDB. The main risk factors for VKDB in breast-fed infants are parental VK prophylaxis refusal or an unknown cholestasis.     

Familial small supernumerary marker chromosome (sSMC) (14)(:P11–q11:)In a child with translocation down syndrome

We report a case of familial small supernumerary marker chromosome (sSMC)in a child with translocation Down syndrome (DS)and mother. The GTG-banded chromosomal analysis of DS child revealed 47,XY,+21,+mar and mother karyotype was 47,XX,+mar. The GTG-banded sSMC had a similar morphology of small acrocentric chromosomes. Fluorescence in situ hybridization (FISH)evaluation of sSMC using centromere probes(13/21,14/22,22)confirmed sSMC as derivative chromosome 14. The sSMC was not specifically stained with whole chromosome paint and arm-specific probes for chromosome 14;thus it has been described as der(14)(:p11–q11:).The phenotypic changes were not evident, may be due to trisomy condition in the child or the sSMC contain repetitive sequences.     

Assessment of distance from skin surface to muscle for evaluation of the risk of inadvertent intramuscular insulin injection at potential injection sites among patients attending a tertiary care children's hospital in Sri Lanka–an observational study

BackgroundInsulin therapy is essential for type 1 diabetes. While a reasonable glycemic control prevents complications, inadvertent intramuscular (IM) insulin injection results in hypoglycemia and fluctuations of blood glucose levels.ObjectiveTo assess the subcutaneous thickness (SCt) at the potential insulin injection sites, in order to determine the suitable needle length.MethodsDiabetic and non-diabetic children (n = 125; aged 2–14 years) attending a tertiary care hospital were examined, after excluding those who had skin abnormality at the injection site, were hospitalized for > 3 days, or had any other chronic illnesses. Dermal thickness (Dt) and SCt at the potential insulin injection sites were measured with ultrasonography.ResultsThe mean age of the patients was 8 years and 57% were boys; mean Dt was 2.1 ± 0.4 mm, SCt was 7.45.6 ± 3.7 mm, and maximum SCt was 29.8 mm in the anterior abdominal wall. SCt increased with age and by raising a skin fold (sf). There was no difference (P > 0.05) in Dt between genders, and limbs showed thinner Dt values than the abdomen. SCt changed with the injection site: it was the lowest in the thigh and the highest in the abdomen. SCt was thicker in females, with or without sf (P < 0.001). For all sites, IM risk was high for 15-mm needles: it was highest in the thighs (98%) and reduced to 86% with sf. IM risk was low for 5-mm needles: it was highest in the thigh (38%), and reduced to 12% with sf. Compared with girls (up to 42%), IM risk was higher for boys (up to 54%), even for 5-mm needles with a sf.ConclusionUsing a short needle is recommended for children, particularly for boys. Regardless of the needle length, the raised sf technique is associated with reduced IM risk.