The full spectrum of handlebar injuries in children: a decade of experience.

BACKGROUND: Traumatic paediatric handlebar injury (HBI) is known to occur with different vehicles, affect different body regions, and have substantial associated morbidity. However, previous handlebar injury research has focused on the specific combination of abdominal injury and bicycle riding. Our aim was to fully describe the epidemiology and resultant spectrum of injuries caused by a HBI. METHODS: Retrospective data analysis of all paediatric patients (<18 years) in a prospectively identified trauma registry over a 10-year period. Primary outcome was the HBI, its location and management. The effects of patient age, vehicle type, the impact region, and Injury Severity Score (ISS) were also evaluated. HBI patients were compared against a cohort injured while riding similar vehicles, but not having sustained a HBI. RESULTS: 1990 patients were admitted with a handlebar-equipped vehicle trauma; 236 (11.9%) having sustained a HBI. HBI patients were twice as likely to be aged between 6 and 14 years old compared with non-HBI patients (OR 2.2; 95% CI 1.5-3.2). 88.6% of the HBI patients sustained an isolated injury, and 45.3% had non-abdominal handlebar impact. There were no significant differences in median ISS (p=0.4) or need for operative intervention (OR 1.1; 95% CI 0.9-1.5) between HBI and non-HBI patients. HBI patients had a significantly longer LOS (1.8 days vs. 1.2 days; p=0.001), and more frequently required a major operation (OR 3.4; 95% CI 2.2-5.4). The majority of splenic, renal and hepatic injuries were managed conservatively. CONCLUSIONS: Although the majority of paediatric HBI is associated with both intra-abdominal injury and bicycle riding, it produces a spectrum of potentially serious injuries and patients are more likely to undergo major surgery. Therefore these patients should always be treated with a high degree of suspicion.

Blunt abdominal trauma in children: how predictive is ALT for liver injury?

BACKGROUND: The liver is the second most commonly injured intra-abdominal organ in children. CT scanning is currently regarded as the "gold standard" in screening for intra-abdominal injury following blunt trauma. However, the risks associated with performing CT in children are not insignificant and, in addition, CT is not always readily available. This study investigates the utility of alanine aminotransferase (ALT) in screening for liver injury in paediatric trauma. METHODS: Two groups of patients were compiled from a prospectively identified trauma registry-one with liver injuries and another with intra-abdominal injuries other than to the liver. Inclusion in the study required that an initial ALT level had been obtained after injury. Where CT had been performed, a paediatric radiologist blind to the ALT results graded the severity of the liver injuries. The study groups were compared and a receiver operating characteristic (ROC) curve generated to derive the optimum ALT threshold to identify liver injury. RESULTS: 51 patients with liver injury and 65 with other intra-abdominal injuries were identified. An ALT level of > or =104 IU/l gave a sensitivity of 96% and a specificity of 80%. When liver injuries were stratified to identify only clinically significant liver injuries (grades III, IV and V), this ALT threshold identified 100% of patients with 70% specificity. CONCLUSIONS: In this sample, ALT appears to be a useful predictor for the presence or absence of liver injury. In haemodynamically stable children with clinical suspicion of isolated liver injury, identification of a normal ALT level (<104 IU/l) may reduce the need for unnecessary transportation for CT scanning with subsequent radiation exposure.

Comparison of thoracoscopic drainage with open thoracotomy for treatment of paediatric parapneumonic empyema.

The purpose of this study was to compare the efficacy of thoracoscopic drainage with open drainage of empyema in children. A retrospective case history audit was done of children presenting to a single major paediatric centre who underwent thoracoscopy drainage and decortication or open decortication and drainage (thoracotomy) between January 2000 and September 2002. Time to resolution of infection, duration of intercostal catheter (ICC) drainage, postoperative morphine requirements, and length of hospital admission were compared as primary measures of outcome. Thirty-three patients, 17 male and 16 female, aged between 1 month and 21 years were included in the study. Median age at surgery was 2.6 years. The location of the empyema was right-sided in 17 patients and left-sided in 16 patients. The empyema was drained by thoracoscopy in 11 patients, and 22 patients underwent thoracotomy. Two patients had thoracoscopy converted to thoracotomy for late-stage disease requiring greater surgical access. There were no differences between treatment groups with respect to duration of ICC drainage (p=0.6), duration of fever (p=0.6), length of stay (p=0.9), or postoperative morphine use (p=0.2). However, overall pain scores were lower in the thoracoscopy group, particularly on days 2 and 3; this approached statistical significance (p=0.07). This study has demonstrated that thoracoscopic drainage is an effective procedure for treating empyema in children. It is less invasive than open thoracotomy and is associated with less patient discomfort and less severe pain as measured by objective pain scores. We advocate thoracoscopic drainage for the majority of patients with empyema, except for those with advanced disease.

The learning curve for laparoscopic pyloromyotomy.

Over a 34-month period, 51 open and 33 laparoscopic pyloromyotomies were performed for infantile hypertrophic pyloric stenosis. The patients' weight ranged from 1.2 to 5.3 kg. The mean operating time was 28 minutes for the open group and 41 minutes for the laparoscopic group. The average time to accept normal feeds was 41 hours in the open group and 32 hours in the laparoscopic group. There were three perforations, one inadequate pyloromyotomy, and one wound infection in the open group. In the laparoscopic group one patient underwent conversion to open surgery because of a duodenal perforation and three other patients required subsequent open procedures for duodenal perforation (n = 1), pyloric perforation (n = 1) and inadequate pyloromyotomy (n = 1). Additional complications in the laparoscopic group included two cases of omental extrusion through the umbilical port wound and one suture abscess. On the basis of these results we have modified our technique, and there have been no complications after laparoscopic pyloromyotomy in our last 10 patients. We believe laparoscopic pyloromyotomy requires further evaluation before it is accepted into common practice.

Response of parkinsonian swallowing dysfunction to dopaminergic stimulation.

OBJECTIVES: To determine the degree of dopaminergic response of swallowing dysfunction in Parkinson's disease. METHODS: Fifteen patients with idiopathic Parkinson's disease and symptomatic dysphagia were studied. All had motor fluctuations in response to long term levodopa therapy. On two separate days, after overnight withdrawal of all antiparkinsonian medication, a modified barium swallow using cinefluoroscopy and different food consistencies was performed before and after administration of oral levodopa and subcutaneous apomorphine. RESULTS: Despite all patients having an unequivocal motor response to both agents, there were few significant responses in any of the quantitative or qualitative criteria of swallowing dysfunction assessed. The oral preparatory phase, generally considered a more voluntary component of swallowing, showed a response, but not with all consistencies. In a subgroup of patients the pharyngeal phase time also improved. CONCLUSIONS: These findings suggest that parkinsonian swallowing dysfunction is not solely related to nigrostriatal dopamine deficiency and may be due to an additional non-dopamine related disturbance of the central pattern generator for swallowing in the pedunculopontine nucleus or related structures in the medulla.

Pulmonary sequestrations detected by antenatal ultrasound.

We present three cases of abdominal and abdomino-thoracic extra-lobar pulmonary sequestrations detected by antenatal ultrasound (US) over a 12-month period. In addition, we briefly refer to a case previously described. A cystic mass was demonstrated in the left upper abdomen of the fetus in all four cases, with two extending into the thorax. The diagnosis was confirmed postnatally by fine-needle biopsy and later excision of the mass. In all four cases the lesion did not interfere with the pregnancy, and only one child demonstrated transient effects of mild pulmonary hypoplasia. Review of the antenatal scans showed that in each case the sequestration did not appear to grow during the pregnancy, with a relative decrease in size. Extra-lobar sequestration should always be considered in the differential diagnosis of an abdominal mass diagnosed on antenatal US, especially if cystic and extending from the abdomen through the diaphragm into the mediastinum. Although abdominal sequestrations are rare in comparison to thoracic lesions at postnatal diagnosis, they represent 21 of the 40 published series of pulmonary sequestrations diagnosed on antenatal US.