Child restraint systems: Understanding confidence in proper use and addressing the need for education.

Objective: To quantify the extent of proper local child restraint system (CRS) use and to better understand changes to the level of self-reported confidence with increased CRS installations. With the goal being to improve safety for children travelling in personal vehicles across London, ON and the region. Methods: Public CRS clinics were initiated by Injury Prevention staff after they obtained the Child Passenger Safety Technician certification. Additionally, an online survey was commissioned targeting Ontario parents who had installed at least one CRS in the last five years. Results: From September 2018 to September 2019, 96 comprehensive CRS checks were performed, with 29% of systems found to be installed correctly. Survey results showed a high level of reported confidence with CRS installation (N = 514, 70% female, 43% one child). Parents who had installed only one CRS reported higher confidence in their first install, compared to parents who had installed two or more systems. Conclusions: The error rate with CRS installation and use seen in London, Ontario and the region, is similar to that reported in previous research. Survey results showed high levels of self-reported confidence in CRS use, especially for parents who have installed only one CRS. There presents a need to better understand the root cause of the discrepancy between level of confidence and proper CRS use and to expand our understanding of CRS knowledge retention and transferability to subsequent systems.

Impact of antegrade enema initiation on healthcare utilization in pediatric patients: A population-based cohort study.

BACKGROUND: When constipation is refractory to first-line interventions, antegrade enema use may be considered. We aimed to assess the impact of this intervention on healthcare utilization. METHODS: We conducted a population-based, quasi-experimental study with pre-post comparison of the intervention group and a non-equivalent control group using linked clinical and health administrative data from Ontario, Canada. Subjects included children (0-18 years) who underwent antegrade enema initiation from 2007 to 2020 and matched controls (4:1) from the general population. To assess the change in healthcare utilization following antegrade enema initiation, we used negative binomial generalized estimating equations with covariates selected a priori. KEY RESULTS: One hundred thirty-eight subjects met eligibility criteria (appendicostomy = 55 (39.9%); cecostomy tube = 83 (60.1%)) and were matched to 550 controls. There was no significant difference in the change in the rate of hospitalizations (rate ratio (RR) 1.05, 95% confidence interval (CI) 0.35-1.75), outpatient visits (RR 1.05, 95% CI 0.91-1.18), or same-day surgical procedures (RR 1.51, 95% CI 0.60-2.43) across cases in 2 years following antegrade enema initiation compared with controls. Cases had an increased rate of emergency department (ED) visits, which was not observed in controls (RR 1.52, 95% CI 1.11-1.79), driven in part by device-related complications. CONCLUSIONS AND INFERENCES: Understanding healthcare utilization patterns following antegrade enema initiation allows for effective health system planning and aids medical decision-making. The observed increase in ED visits for device-related complications speaks to the need to improve preventive management to help mitigate emergency care after initiation of antegrade enemas.

Histopathological Changes of Long-Term Peritoneal Dialysis Using Physiological Solutions: A Case Report and Review of the Literature.

BACKGROUND: Long-term peritoneal dialysis (PD), especially with nonphysiological solutions, is afflicted with the severe complication of encapsulating peritoneal sclerosis (EPS). Physiologic PD solutions have been introduced to reduce pH trauma. Data on peritoneal biopsies in pediatrics with long-term PD using physiological solutions are scant. CASE REPORT: We report an adolescent who had been on 10-h continuous hourly cycles using mostly 2.27% Physioneal™ for 5 years. There were two episodes of peritonitis in October 2017 (Klebsiella oxytoca) and May 2018 (Klebsiella pneumoniae), which were treated promptly. This adolescent, who lost two kidney transplants from recurrent focal and segmental glomerulosclerosis, underwent a peritoneal membrane biopsy at the time of a third PD catheter placement, 16 months after the second renal transplant. Laparoscopically, the peritoneum appeared grossly normal, but fibrosis and abundant hemosiderin deposition were noted on histology. The thickness of the peritoneum was 200-900 (mean 680) µm; normal for age of 14 years is 297 [IQR 229, 384] µm. The peritoneum biopsy did not show specific EPS findings, as the mesothelial cells were intact, and there was a lack of fibrin exudation, neo-membrane, fibroblast proliferation, infiltration, or calcification. CONCLUSIONS: While the biopsy was reassuring with respect to the absence of EPS, significant histopathological changes suggest that avoiding pH trauma may not ameliorate the effects of glucose exposure in long-term PD.

Pediatric cervical spine fracture case report: Best practice to delay transition to rear-facing restraint.

Pediatric physicians and motor vehicle safety experts have been advocating for change in child passenger restraint practices for decades. As professional recommendations evolve to support extended rear-facing restraint, actual practices remain disparate. We report a case of pediatric cervical spine fracture due to motor vehicle collision, an uncommon, yet predictable, pattern of injury for which prevention education is undoubtedly preferable to managing the consequences of premature forward-facing in vulnerable pediatric patients. Currently, 9 kg is a minimum legal standard for forward-facing child restraint system use in Ontario, rather than a recommended transition time. We advise that parents should be counselled on the benefits of rear-facing as long as possible and discuss realistic transition times using their child restraint system manual as a reference, with the goal of approaching, but not exceeding, the maximum weight, height and fit requirements for optimal safety.

Evaluation of a population health strategy to reduce distracted driving: Examining all "Es" of injury prevention.

BACKGROUND: Cell phone use while driving (CPWD) increases the risk of crashing and is a major contributor to injuries and deaths. The objective of this study was to describe the evaluation of a multifaceted, evidence-based population health strategy for the reduction of distracted driving. METHODS: A multipronged campaign was undertaken from 2014 to 2016 for 16- to 44-year-olds, based on epidemiology, focused on personal stories and consequences, using the "Es" of injury prevention (epidemiology, education, environment, enforcement, and evaluation). Education consisted of distracted driving videos, informational cards, a social media AdTube campaign, and a movie theater trailer, which were evaluated with a questionnaire regarding CPWD attitudes, opinions, and behaviors. Spatial analysis of data within a geographic information system was used to target advertisements. A random sample telephone survey evaluated public awareness of the campaign. Increased CPWD enforcement was undertaken by police services and evaluated by ARIMA time series modeling. RESULTS: The AdTube campaign had a view rate of >10% (41,101 views), slightly higher for females. The top performing age group was 18- to 24-year-olds (49%). Our survey found 61% of respondents used handheld CPWD (14% all of the time) with 80% reporting our movie trailer made them think twice about future CPWD. A stakeholder survey and spatial analysis targeted our advertisements in areas of close proximity to high schools, universities, near intersections with previous motor vehicle collisions, high traffic volumes, and population density. A telephone survey revealed that 41% of the respondents were aware of our campaign, 17% from our print and movie theater ads and 3% from social media. Police enforcement campaign blitzes resulted in 160 tickets for CPWD. Following campaign implementation, there was a statistically significant mean decrease of 462 distracted driving citations annually (p = 0.001). CONCLUSION: A multifaceted, evidence-based population health strategy using the Es of injury prevention with interdisciplinary collaboration is a comprehensive method to be used for the reduction of distracted driving. LEVEL OF EVIDENCE: Therapeutic, level IV.

Comparison of drugs used for intubation of pediatric trauma patients.

PURPOSE: Rapid sequence intubation (RSI) drugs, such as propofol, affect clinical outcomes, but this has not been examined in the pediatric population. This descriptive study compares the outcomes associated with intubation drugs used in pediatric traumatic brain injury (TBI) patients. METHODS: A retrospective chart review and descriptive analysis of intubated TBI patients, ages 0-17, admitted to Children's Hospital London Health Sciences Centre (LHSC) from January 2006-December 2016 was performed. RESULTS: Out of 259 patients intubated, complete data was available for 107 cases. Average injury severity score was 28; 46 were intubated at LHSC, 55 at primary care site, and 6 on scene. Intubation attempts were recorded in 87 of 107 paper charts. First-pass intubation success rate was 88.5%. Propofol (n = 21), midazolam (n = 31), etomidate (n = 13), and ketamine (n = 7) were the most commonly used intubation drugs. Paralytics were used in 50% of patients. Following use of propofol, Pediatric Adjusted Shock Index was increased as a result of worsening hypotension. Mean total hospital length of stay was 21 days with 7.5 days in ICU. Survival was 87%. CONCLUSION: Great variability exists in the use of induction agents and paralytics for RSI. Propofol was commonly used and is potentially associated with poorer clinical outcomes. TYPE OF STUDY: Retrospective. LEVEL OF EVIDENCE: IV.

A Rare Case of Cecal Bascule in a Child With Normal Neurodevelopment.

Cecal volvulus is a rare cause of bowel obstruction in adults and an extremely rare presentation in children. One form known as a cecal bascule has only previously been reported in children with neurodevelopmental issues or with severe chronic constipation. We present the case of a 10-year-old boy who presented with an acute history of left lower quadrant abdominal pain, who upon investigation was found to have a cecal bascule.

Outcomes of extracorporeal, transumbilical versus intracorporeal laparoscopic appendectomy for acute uncomplicated appendicitis in children and adolescents: A retrospective observational cohort study.

BACKGROUND: An extracorporeal (ECA), transumbilical appendectomy has been proposed as a treatment for appendicitis. This study assessed the 30-day perioperative outcomes and cost between ECA and traditional intracorporeal (ICA) techniques for acute uncomplicated appendicitis. METHODS: IRB approval was obtained for this retrospective cohort study of acute uncomplicated appendicitis in children aged 4 to 17 between April 2014 and April 2017. Patients were grouped based on ICA versus ECA. Operative time, length of stay, and complication rates were recorded. RESULTS: A total of 289 patients were included, and of these 217 underwent ICA, and 72 underwent ECA. Median weight-for-age percentile was the only demographic characteristic different between groups (ECA 50 [0.1-100] vs. ICA 71 [0-100]; p < 0.01). Median operative time was significantly shorter in the ECA group (21.0 min [8.0-61.0] vs. 38.0 min [19.0-87.0]; p < 0.0001). Length of stay and complication rates were similar between groups. The median per case cost was significantly lower in the ECA group (CAD$ 593.05 range: 499.70-900.81 vs. CAD$ 858.78 range: 490.36-1106.29; p < 0.001). CONCLUSIONS: Extracorporeal transumbilical laparoscopic appendectomy is associated with shorter operative times and no increased risk of 30-day postoperative complications in children and adolescents. This offers a new operative approach that may reduce hospital cost and resources. LEVEL OF EVIDENCE: III.

Robotic-assisted, spleen-preserving distal pancreatectomy for a solid pseudopapillary tumour in a pediatric patient: a case report and review of the literature.

Solid pseudopapillary tumour is a rare carcinoma of the pancreas with low-grade malignant potential that typically presents in females in their third decade. The tumour most commonly occurs in the tail of the pancreas, although any site can be affected. Surgical resection is the standard treatment and offers an excellent prognosis. Robotic-assisted laparoscopic surgery is an emerging technique for the treatment of pancreatic neoplasms. We report a case of a 17-year-old female with acute onset abdominal pain who was found to have a mass in the distal pancreas. A robotic-assisted laparoscopic distal pancreatectomy with spleen preservation was successfully performed, its first reported use in a pediatric patient. The patient had an uncomplicated recovery. The robotic approach can be considered for younger patients presenting with a solid pseudopapillary tumour in the distal pancreas.

A 15 year cohort review of in-hospital pediatric trauma center mortality: A catalyst for injury prevention programming.

BACKGROUND: The objective of our study was to identify the most common mechanisms of injury leading to death in our pediatric population. METHODS: A retrospective cohort of fatally injured children 0-17 years old treated at our trauma center during 2000-2015. RESULTS: The mortality rate in our population was 8% (n = 103). Fifty-five percent were male. The majority (76%) of fatal injuries were blunt. Overall, motor vehicle collisions (MVCs) were the most common mechanism of injury (61%), followed by assault/abuse (9%). Of the deaths caused by MVCs, 37 (59%) were occupants, 11 (17%) were pedestrians, and 6 (10%) were cyclists. In the infant sub-population, assault/abuse was the most common mechanism of injury. CONCLUSION: MVCs were the leading cause of death in this population. In the infant subpopulation (<1 year), abusive head trauma emerged as the leading mechanism. Injury prevention programming should target abusive head trauma in infants and teen road safety.

Surgical intervention in pediatric trauma at a level 1 trauma hospital: a retrospective cohort study and report of cost data.

BACKGROUND: Given that the management of severely injured children requires coordinated care provided by multiple pediatric surgical subspecialties, we sought to describe the frequency and associated costs of surgical intervention among pediatric trauma patients admitted to a level 1 trauma centre in southwestern Ontario. METHODS: All pediatric (age < 18 yr) trauma patients treated at the Children's Hospital - London Health Sciences Centre (CH-LHSC) between 2002 and 2013 were included in this study. We compared patients undergoing surgical intervention with a nonsurgical group with respect to demographic characteristics and outcomes. Hospital-associated costs were calculated only for the surgical group. RESULTS: Of 784 injured children, 258 (33%) required surgery, 40% of whom underwent orthopedic interventions. These patients were older and more severely injured, and they had longer lengths of stay than their nonsurgical counterparts. There was no difference in mortality between the groups. Seventy-four surgical patients required intervention within 4 hours of admission; 45% of them required neurosurgical intervention. The median cost of hospitalization was $27 571 for the surgical group. CONCLUSION: One-third of pediatric trauma patients required surgical intervention, of whom one-third required intervention within 4 hours of arrival. Despite the associated costs, the surgical treatment of children was associated with comparable mortality to nonsurgical treatment of less severely injured patients. This study represents the most recent update to the per patient cost for surgically treated pediatric trauma patients in Ontario, Canada, and helps to highlight the multispecialty care needed for the management of injured children.

CONTEXTE: La prise en charge des enfants grièvement blessés nécessite la coordination des soins fournis dans le contexte de plusieurs surspécialités chirurgicales pédiatriques. Dans ce contexte, nous avons cherché à décrire la fréquence et les coûts des interventions chirurgicales chez les patients pédiatriques victimes de trauma admis dans un centre de traumatologie de niveau 1 dans le sud-ouest de l'Ontario. MÉTHODES: Tous les patients pédiatriques (moins de 18 ans) ayant subi un trauma traités à l'Hôpital pour enfants du Centre des sciences de la santé de London entre 2002 et 2013 ont été retenus pour l'étude. Nous avons comparé les caractéristiques démographiques et les résultats cliniques des patients ayant subi une intervention chirurgicale et de ceux n'en ayant pas subi. Les coûts d'hospitalisation n'ont été calculés que pour le premier groupe. RÉSULTATS: Parmi les 784 enfants à l'étude, 258 (33 %) avaient eu besoin d'une intervention chirurgicale; 40 % de ceux-ci avaient subi des interventions orthopédiques. Ces patients étaient plus âgés et plus grièvement blessés que les enfants n'ayant pas subi d'intervention chirurgicale, et leur séjour à l'hôpital était généralement plus long. Nous n'avons relevé aucune différence entre les 2 groupes quant à la mortalité. En outre, 74 des patients ayant subi une intervention chirurgicale ont dû être opérés dans les 4 heures suivant l'admission; 45 % d'entre eux ont eu besoin d'une intervention neurochirurgicale. Le coût médian d'une hospitalisation était de 27 571 $. CONCLUSION: Le tiers des patients pédiatriques victimes de trauma ont eu besoin d'une intervention chirurgicale, et le tiers de ceux-ci ont dû être opérés dans les 4 heures suivant leur arrivée. Malgré les coûts, le traitement chirurgical des enfants était associé à un taux de mortalité comparable à celui du traitement non chirurgical des patients blessés moins grièvement. Cette étude est la source d'information la plus récente sur le coût par patient associé au traitement chirurgical des enfants victimes de trauma en Ontario, et elle met en évidence le besoin de soins de multiples spécialités.

Emergency case of spontaneous common bile duct (CBD) perforation.

Spontaneous or non-traumatic common bile duct (CBD) perforation in children is a rare condition leading to difficulty and delay in diagnosis and resulting in high mortality. Presentation can vary significantly. Patients usually present with sudden obstructive jaundice, acholic stools, and abdominal pain and distension. Treatment tends to be surgical, consisting of CBD exploration, and possibly, repair. We report the case of a 22-month-old female with spontaneous CBD perforation. She presented with a 1-month history of increasing abdominal distension, abdominal pain, and jaundice. On exploratory laparotomy, a large amount of bile-stained ascitic fluid was drained. She was managed conservatively with 3 weeks of external intra-abdominal drains. Follow-up at 6 months showed complete recovery. Due to the rarity of spontaneous bile duct perforation, delayed diagnosis and intervention is common. Physicians must consider this diagnosis in a child with abdominal pain in order to prompt timely surgical management for a successful outcome.

Establishing a pediatric robotic surgery program in Canada.

Despite the introduction of robotic surgery in 2000, few pediatric surgeons outside the United States have embraced this technology. We discuss our experience with establishing the first Canadian pediatric robotic surgery program. After simulator training, live animal surgery and observation of robotically assisted cases at an outside institution, we performed our first pediatric da Vinci® surgery in July 2013. A prospective database was established to assess outcomes. Forty one children have undergone robotically assisted surgery for the following 42 procedures: (a) pyeloplasty (17), (b) ureteral reimplantations (12), (c) uretero-uretostomy (1), (d) cholecystectomies (10), (e) interval appendectomy (1) and (f) distal pancreatectomy (1). The average age was 9.7 years (range 1.6-17.9) and 66% of patients were female. Average operative time was 174 min (range 47-301). Length of stay was 3 days (range 0-20). All procedures were completed without conversion to open or laparoscopy. There were no technical failures. Two post re-implantation patients had urine leaks which required conservative treatment. Despite the lack of haptic feedback, we have noted that the markedly enhanced three-dimensional visualization and instrument dexterity offer significant advantages for complex reconstructive pediatric surgery. This platform may also enable trainees to perform more advanced minimally invasive pediatric surgery. We have successfully established the first pediatric robotic surgery program in Canada. Our da Vinci® system is shared with our adult colleagues, which enables more frequent use as well as some cost sharing. A dedicated group of operative nurses and surgeons are required to allow adoption of this new technology.

Home safe home: Evaluation of a childhood home safety program.

BACKGROUND: The London Health Sciences Centre Home Safety Program (HSP) provides safety devices, education, a safety video, and home safety checklist to all first-time parents for the reduction of childhood home injuries. The objective of this study was to evaluate the HSP for the prevention of home injuries in children up to 2 years of age. METHODS: A program evaluation was performed with follow-up survey, along with an interrupted time series analysis of emergency department (ED) visits for home injuries 5 years before (2007-2013) and 2 years after (2013-2015) implementation. Spatial analysis of ED visits was undertaken to assess differences in home injury rates by dissemination areas controlling differences in socioeconomic status (i.e., income, education, and lone-parent status) at the neighborhood level. RESULTS: A total of 3,458 first-time parents participated in the HSP (a 74% compliance rate). Of these, 20% (n = 696) of parents responded to our questionnaire, with 94% reporting the program to be useful (median, 6; interquartile range, 2 on a 7-point Likert scale) and 81% learning new strategies for preventing home injuries. The median age of the respondent's babies were 12 months (interquartile range, 1). The home safety check list was used by 87% of respondents to identify hazards in their home, with 95% taking action to minimize the risk. The time series analysis demonstrated a significant decline in ED visits for home injuries in toddlers younger than2 years of age after HSP implementation. The declines in ED visits for home injuries remained significant over and above each socioeconomic status covariate. CONCLUSION: Removing hazards, supervision, and installing safety devices are key facilitators in the reduction of home injuries. Parents found the HSP useful to identify hazards, learn new strategies, build confidence, and provide safety products. Initial finding suggests that the program is effective in reducing home injuries in children up to 2 years of age. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.

Early coagulopathy and metabolic acidosis predict transfusion of packed red blood cells in pediatric trauma patients.

BACKGROUND: Severely injured pediatric trauma patients often present to hospital with early coagulopathy and metabolic acidosis. These derangements are associated with poor outcomes, but it is unclear to what degree they predict transfusion of packed red blood cells (pRBC). METHODS: We retrospectively identified pediatric trauma patients from a level 1 trauma center from 2006 to 2013. Inclusion criteria were age less than 18years, Injury Severity Score greater than 12, and pRBC transfusion within 24h of admission. RESULTS: We identified 96 pediatric trauma patients who underwent pRBC transfusion within 24h of presentation to hospital. On admission, 43% of these patients had one or more signs of coagulopathy, and 81% had metabolic acidosis. Size of pRBC transfusion in the first 24h ranged from 3 to 177mL/kg (mean 29mL/kg), and nineteen patients (20%) underwent massive transfusion (>40ml/kg in 24h). Univariate analysis indicated that size of pRBC transfusion was associated with initial base excess (r=0.46), international normalized ratio (r=0.35), partial thromboplastin time (r=0.41), fibrinogen (r=0.46), and BIG score (Base deficit, INR, Glasgow Coma Scale (GCS), r=0.36). Platelet count, age, GCS, and direct versus referred presentation were not predictive. Multivariable linear regression confirmed that coagulopathy and metabolic acidosis remained predictive after adjusting for direct versus referred presentation (R(2)=0.30). CONCLUSIONS: Early coagulopathy and metabolic acidosis predict size of pRBC transfusion among pediatric trauma patients. Further research is needed to develop massive transfusion protocols and guidelines for activation.

Making the transition from video-assisted thoracoscopic surgery to chest tube with fibrinolytics for empyema in children: Any change in outcomes?

BACKGROUND: There is ongoing variation in the use of video-assisted thoracoscopic surgery (VATS) and chest tube with fibrinolytics (CTWF) for empyema in children. Our objective was to report outcomes from a centre that recently made the transition from VATS to CTWF as the primary treatment modality. METHODS: We conducted a historical cohort study of children with empyema treated with either primary VATS (between 2005 and 2009) or CTWF (between 2009 and 2013). RESULTS: Sixty-seven children underwent pleural drainage for empyema during the study period: 28 (42%) were treated with primary VATS, and 39 (58%) underwent CTWF. There were no significant differences between the VATS and CTWF groups for length of stay (8 v. 9 d, p = 0.61) or need for additional procedures (4% v. 13%, p = 0.19). Length of stay varied widely for both VATS (4-53 d) and CTWF (5-46 d). Primary VATS failed in 1 (4%) patient, who required an additional chest tube, and CTWF failed in 5 (13%) patients. Additional procedures included 3 rescue VATS, 2 additional chest tubes and 1 thoracotomy. All patients recovered and were discharged home. CONCLUSION: Primary VATS and CTWF were associated with similar outcomes in children with empyema. There appears to be a subset of children at risk for treatment failure with CTWF. Further research is needed to determine if these patients would benefit from primary VATS.

CONTEXTE: Il existe une certaine variation dans le choix de l'intervention chirurgicale thoracoscopique assistée par vidéo (CTAV) ou de l'installation d'un drain thoracique accompagné de fibrinolytiques (DTIF) pour traiter la pleurésie purulente chez les enfants. L'objectif de cette étude était de décrire les résultats observés dans un centre ayant récemment remplacé la CTAV par le DTIF comme traitement de première intention. MÉTHODES: Nous avons mené une étude de cohorte rétrospective auprès d'enfants atteints de pleurésie purulente, qui ont été traités soit par CTAV (entre 2005 et 2009), soit par l'installation d'un DTIF (entre 2009 et 2013). RÉSULTATS: Pendant la période à l'étude, 67 enfants ont subi un drainage pleural. De ce nombre, 28 (42 %) ont été traités par CTAV, et 39 (58 %) par DTIF. Aucune différence significative n'a été observée entre ces 2 groupes sur le plan de la durée du séjour (8 j. [CTAV] contre 9 j. [DTIF], p = 0,61) et du recours à des interventions supplémentaires (4 % [CTAV] contre 13 % [DTIF], p = 0,19). La durée du séjour était toutefois très variable dans les 2 cas : entre 4 et 53 jours dans le groupe de la CTAV, et entre 5 et 46 jours dans celui du DTIF. La CTAV a échoué dans un cas (4 %), et un drain thoracique supplémentaire a dû être installé. La pose d'un DTIF s'est soldée par un échec dans 5 cas (13 %), qui ont nécessité 3 CTAV d'urgence, l'installation de 2 drains thoraciques additionnels et une thoracotomie. Tous les patients se sont rétablis et ont obtenu leur congé. CONCLUSION: La CTAV et le DTIF employés comme traitements de première intention sont associés à des résultats semblables chez les enfants atteints de pleurésie purulente, mais l'installation d'un DTIF semble être plus susceptible d'échouer chez un sous-ensemble d'enfants. D'autres recherches seront nécessaires pour déterminer s'il serait préférable d'avoir recours à la CTAV comme traitement de première intention.

Febrile Illness in an Infant With an Intracardiac Inflammatory Myofibroblastic Tumor.

We report a case of a child with a right ventricular inflammatory myofibroblastic tumor (IMT) who presented with fever, viral symptoms, and abdominal discomfort. Including this case, 49 intracardiac tumors have been previously reported in all age groups. The majority of intracardiac IMTs occur in pediatric patients, with approximately half presenting in children aged <12 months. Intracardiac IMTs are generally described as benign tumors; however, depending on their location, the initial presentation may involve heart failure or sudden death.(1) In addition to cardiac signs and symptoms, the clinical presentation of IMTs may also include constitutional signs such as fever, anemia, and elevated inflammatory markers. This case report reviews the diagnosis and management of IMTs, as well as the histopathologic features of this rare tumor type. Clinicians should be aware of their clinical presentation because early diagnosis and treatment can significantly reduce morbidity and mortality.

From focus groups to production of a distracted driving video: Using teen input to drive injury prevention programming.

BACKGROUND: The Impact program is an adolescent, injury prevention program with both school- and hospital-based components aimed at decreasing high-risk behaviors and preventing injury. The objective of this study was to obtain student input on the school-based component of Impact, as part of the program evaluation and redesign process, to ensure that the program content and format were optimal and relevant, addressing injury-related issues important for youth in our region. METHODS: Secondary schools were selected in various geographic regions with students varying in language, religion, and socioeconomic status. A mixed-methods questionnaire was developed and pretested on program content, format, relevance, quality, and effectiveness. Attitude and opinion questions on issues facing teens today were ranked on a 7-point Likert scale. Open-ended, qualitative questions were included in the focus groups, with responses themed. RESULTS: There were 167 respondents in the nine geographically, socioeconomically, and culturally diverse focus groups with a mean age of 16 years, 52% were male, and 69% were in Grade 11. Ninety-three percent of respondents rated the content of Impact as comprehensive (median, 6 of 7, with 7 being very comprehensive), and 29% rated the format a 5 of 7. Impact was rated relevant (89%), addressing issues for teens (median, 6 of 7). Issues suggested to highlight included texting and driving, drugs, partying, self-harm, and abusive relationships. Texting while driving was perceived as a significantly more common (81%) injury issue for adolescents compared with other driving risk factors (p < 0.001), with one student commenting, "If you don't (text and drive), you either don't have a phone or don't have a driver's license." CONCLUSION: Injury prevention programs must be continually evaluated to ensure they are relevant, addressing issues important for youth, and presented in a format that resonates with the audience. Student focus groups identified motor vehicle collisions and texting as important issues as well as a desire for teens to hear personal stories with a visual element. This provided the information needed to develop the next logical direction for our program, the production of a distracted driving video ("Distracted Driving: Josh's Story," http://youtu.be/BFPke9gBybc) to be incorporated into school presentations. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Laparoscopic-assisted percutaneous endoscopic gastrostomy: insertion of a skin-level device using a tear-away sheath.

BACKGROUND: This study describes our experience with the placement of a skin-level gastrostomy device (MIC-KEY) in a single procedure. METHODS: We identified infants, children and young adults who underwent laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) tube insertion between October 2009 and June 2013. The steps of this procedure include upper endoscopy, single-port laparoscopy, gastropexy via percutaneous T-fasteners and placement of a skin-level gastrostomy device (MIC-KEY) using a "push" technique with a tear-away sheath. RESULTS: We included 92 patients in our study. Mean age was 3.7 years (range 3 wk-5 yr), and mean weight was 11.2 (range 2.8-54) kg. Median procedural time was 20 (range 12-76) minutes. Total median duration for the most recent 25 procedures was lower than that of the first 25 (62 v. 79 min, p = 0.004). There were no intraoperative complications or conversions to open surgery. Postoperative complications were observed in 6 (6.5%) patients. Three retained T-fasteners were assessed endoscopically (n = 1) or removed via local excision (n = 2). Two patients experienced early dislodged feeding tubes that were replaced via interventional radiology (n = 1) or repeat LAPEG (n = 1). There was also 1 intra-abdominal fluid collection that was drained percutaneously but ultimately required a laparotomy and washout. There were no major complications in the most recent 50 procedures. CONCLUSION: Our results suggest that LAPEG is a safe, minimally invasive procedure for infants, children and young adults. This approach allows for immediate use of a skin-level gastrostomy device without the need for postoperative tube exchanges.

CONTEXTE: Cette étude décrit notre expérience avec la pose d'un dispositif de gastrostomie au niveau de la peau (MIC-KEY) en une seule intervention. MÉTHODES: Nous avons recensé les nourrissons, enfants et jeunes adultes ayant subi l'insertion d'un tube de gastrostomie par voie endoscopique percutanée sous laparoscopie (GEPL) entre octobre 2009 et juin 2013. Les étapes de cette intervention incluent une endoscopie haute, une laparoscopie à trocart unique, une gastropexie avec ancres en T percutanées et la pose d'un dispositif de gastrostomie au niveau de la peau (MIC-KEY) à l'aide de la technique « push ¼ et d'une pellicule amovible. RÉSULTATS: Nous avons inclus 92 patients dans notre étude. L'âge moyen était de 3,7 ans (de 3 semaines à 5 ans) et le poids moyen était de 11,2 (de 2,8 à 54) kg. La durée médiane de l'intervention a été de 20 minutes (entre 12 et 76 minutes). La durée totale médiane des 25 plus récentes interventions a été plus brève que celle des 25 premières (62 c. 79 minutes, p = 0,004). On n'a observé aucune complication peropératoire ni conversion vers une chirurgie ouverte. Des complications postopératoires ont été observées chez 6 (6,5 %) patients. Trois ancres en T persistantes ont été évaluées par voie endoscopique (n = 1) ou extraites par excision locale (n = 2). Les tubes d'alimentation se sont déplacés tôt chez 2 patients et ont été replacés en radiologie interventionnelle (n = 1) ou avec une nouvelle GEPL (n = 1). On a également noté un cas d'épanchement de liquide intra-abdominal qui a pu être drainé par voie percutanée, mais qui a finalement nécessité une laparotomie et un lavage. Aucune complication majeure n'a été signalée lors des 50 plus récentes interventions. CONCLUSION: Selon nos résultats, la GEPL est une intervention sécuritaire et minimalement effractive pour les nourrissons, les enfants et les jeunes adultes. Cette approche permet l'utilisation immédiate d'un dispositif de gastrostomie au niveau de la peau sans nécessiter de changements de sondes après l'intervention.