Observational study of falls in children from windows and balconies: What has changed?

AIM: To describe patterns of injury from window and balcony falls in children presenting to a tertiary paediatric trauma centre in New South Wales. METHODS: A retrospective review of cases of children <15 years who had sustained injuries in a fall from a building, identified from the trauma database between 1998 and 2019. RESULTS: A total of 381 falls from windows and balconies were recorded over the 22-year study period. There were 218 falls from windows (57%) and 163 from balconies. The majority (64%) were children under 4 years of age. The male to female ratio was 2:1. While many children sustained simple abrasions, contusions and lacerations, 17% sustained injuries with an injury severity scores of ≥12. There were four deaths. CONCLUSIONS: This study identified that children falling from buildings remains a problem in Australia. Although many injuries were minor, severe injuries and fatalities continue to occur.

Surgeon Performed Ultrasound for Diagnosis of Intussusception - A Pilot Study.

Aim: To study the diagnostic accuracy of surgeon performed ultrasound (SPU) in the diagnosis of children presenting with clinical suspicion of intussusception to a tertiary paediatric facility in NSW, Australia. Methods: Children under the age of 16 presenting to the emergency department with clinical features suggestive of intussusception were recruited. After obtaining consent SPU was performed by a Paediatric surgeon. All patients subsequently had an ultrasound performed in radiology department (RPU) on which management was based. Diagnosis and images of SPU were reviewed by an independent radiologist blinded to results of the formal study. Results: Of 7 children enrolled 5 were male. Age ranged from 3 months to 7 years (mean 2.64, SD 2.282), weight from 5.2kgs to 25.2kgs (mean 13.69, SD 6.721). Five out of the 7 children presented during day hours i.e. 8a.m.-5 p.m. (mean 12.72, SD 4.049). Mean time to SPU was 6.3 hours (SD7.1) and RPU was 8.3 hours (SD 7.6). SPU was earlier by 2 hours and correlation between SPU and RPU was 100 percent. Conclusion: SPU for intussusception can be performed early and accurately. Surgeons should train and use ultrasound as a reliable tool in evaluating the child with suspected intussusception.

Diagnostic accuracy of surgeon performed ultrasound (SPU) for appendicitis in children.

AIM: Compare the diagnostic accuracy of surgeon performed ultrasound to radiology performed ultrasound in children presenting with suspected appendicitis to a tertiary care pediatric hospital in Australia. METHODS: Children under 16 presenting to the emergency department of The Children's Hospital at Westmead were considered for the study. Patients with obvious signs of appendicitis not requiring ultrasound and those with established ultrasound diagnosis of appendicitis were excluded. Ultrasound was performed by a Pediatric Surgeon (SPU) after obtaining consent. The treating team was blinded to the results. Patient underwent formal ultrasound in radiology (RPU) and treatment was based on the formal report. SPU result was reviewed by a radiologist blinded to results of RPU. The results were compared. RESULTS: 65 children underwent ultrasound. 35 were male. Median age was 10 (range3-15). Median weight was 36 kg (range 12.6-76.2 kg), z-score median 0.21 (-1.83 to 2.74). Symptom duration ranged from few hours to 2 weeks but majority (45) had symptoms for less than 48 h. Prevalence of appendicitis was 45%. Thirty two underwent surgery. Negative appendicectomy rate was 9.4%. Thirty three did not have surgery. 8 represented but only one proceeded to appendicectomy. SPU was done earlier than RPU (median 12 h vs 14.15 h) p = 0.088. Diagnostic accuracy using ROC did not reveal significant difference. CONCLUSION: SPU can be performed earlier than RPU with reliable accuracy. Training surgical trainees will enable early diagnosis and management of appendicitis.

Assessment of postoperative outcomes of hypospadias repair with validated questionnaires.

PURPOSE: A standardized assessment for the optimal repair of hypospadias remains elusive. This study utilized validated questionnaires to assess the postoperative functional, cosmetic, and psychosocial outcomes of hypospadias repair. MATERIALS AND METHODS: 172 patients who underwent hypospadias repair under the care of a single surgeon were identified. 25 agreed for follow-up using the validated questionnaires of Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Scale (PPPS), and Pediatric Quality of Life Inventory (PedsQL™4.0). RESULTS: Mean follow-up was 59months postoperatively (range 7-113months). Techniques used included tubularized incised plate urethroplasty, meatal advancement and glanuloplasty, and a 2-stage repair. 23 of 25 patients achieved a HOSE score of 14 or more (maximum of 16). The PPPS scores correlated with severity of the hypospadias. Those with glanular hypospadias (mean score=10) scored higher than those with coronal (mean score=9) and penile/penoscrotal hypospadias (mean score=7). There was no correlation between PedsQL™4.0 scores and the severity of hypospadias or procedure used. CONCLUSION: Validated questionnaires revealed generally good functional, cosmetic, and early psychosocial outcomes after hypospadias repair. The use of validated questionnaires in routine follow-up sessions may facilitate objective assessment of both functional outcomes and patient satisfaction.

Pediatric "off-road vehicle" trauma: determinants of injury severity and type.

OBJECTIVES: This study aimed to describe the determinants of the severity and type of injuries sustained by children hurt in off-road vehicle (ORV) accidents. METHODS: This was a retrospective clinical study for which data were obtained from the trauma database at the Children's Hospital at Westmead covering the 10-year period between January 1, 1998, and December 31, 2007. Data points collected included age, sex, Injury Severity Score (ISS), body region injured, type of vehicle, accident setting, mechanism of injury, estimated speed, position of the rider, use of a helmet and/or protective clothing, and hospital length of stay. The study end points were determinants of injury severity and type. Statistical analysis of the collected data was done with the standard statistical software package, SPSS. RESULTS: A total of 288 children (242 male [84%] and 46 female [16%] patients) presented for ORV-related trauma. Helmets significantly diminished the chance of sustaining a head injury occasioning a skull fracture. Jumping was associated with increased ISS and a higher chance of sustaining an abdominal and/or thoracic injury. Older children were more likely to sustain pelvic and spinal injures, be injured while traveling at high speed, and be injured while going over a jump. Mean ISS was significantly lower if trauma was sustained while riding a mini motorcyle in any setting and any ORV at home. CONCLUSIONS: Further research (prospective, federal, and multi-institutional) is needed with a view to optimizing training schedules, rules, regulations, and licensing requirements for pediatric ORV riders.

Pediatric high-flow priapism and super-selective angiography--an Australian perspective.

High-flow priapism is an uncommon entity in the pediatric and adolescent population. It is usually caused by perineal trauma. Here we describe the experience of our institution in this condition over the past 10 years, the various treatment options available, and the successful application of super-selective angiographic embolization as our treatment modality of choice. Included here is the case of a 4-year-old boy (case 3) who, to our knowledge, is the youngest patient described with this condition in the literature.

Appendicitis and low-flow priapism in children.

Priapism is a sustained erection that is maintained for over 4 hours in the absence of sexual stimulation [Postgrad Med J. 2006;82(964):89-94; J Urol. 2003;170:1318-1324]. Distinction is made between low- and high-flow variants [J Urol. 2003;170:1318-1324; Cardiovasc Intervent Radiol. 2002;25(4):326-329]. Low-flow priapism (LFP) and acute appendicitis are rarely associated. Including ours, there are 4 cases reported in the literature, all of which have occurred in children. The complications of LFP are potentially serious and include loss of the phallus altogether. Treatment of LFP is should be prompt and is the same irrespective of the etiology.

Long standing balanitis xerotica obliterans resulting in renal impairment in a child.

Balanitis xerotica obliterans (BXO) is the most common cause of pathological phimosis in boys. Presented here is the case of a previously well 13-year-old boy who developed obstructive renal impairment (serum creatinine = 190 micromol/l) at least in part from phimosis due to BXO. A circumcision and, 2.5 months later, meatal dilatation were done. Nine months after his initial presentation, his serum creatinine returned to a permanently elevated nadir of 119 mumol/l. Presentation with the complications of phimosis can be delayed in teenage boys because they may feel embarrassed to come forward. Circumcision remains the definitive treatment of BXO induced phimosis though if the penile meatus is involved, more complex surgery is sometimes required. Topical steroids are useful for residual disease. Follow-up is very important due to the frequent involvement of the skin of the glans. In the very long term there is an increased chance of penile malignancy, which can occur even after circumcision.

Acute management of hemodynamically unstable pelvic trauma patients: time for a change? Multicenter review of recent practice.

BACKGROUND: Hemorrhage-related mortality (HRM) associated with pelvic fractures continues to challenge trauma care. This study describes the management and outcome of hemodynamically unstable patients with a pelvic fracture, with emphasis on primary intervention for hemorrhage control and HRM. METHODS: Blunt trauma patients [Injury Severity Score (ISS) >or=16] with a major pelvic fracture (Abbreviated Injury Score, pelvis >or=3) and hemodynamic instability [admission systolic blood pressure (SBP) or=6 units of packed red blood cells (PRBCs)/24 hours) were included into a 48-month (ending in December 2003) multicenter retrospective study of 11 major trauma centers. Data are presented as the mean +/- SD. RESULTS: A total of 217 patients (mean age 41 +/- 19 years, 71% male, ISS 42 +/- 16) were studied. The admission SBP was 96 +/- 37 mmHg and the Glascow Coma Scale (GCS) 11 +/- 5. Patients received 4 +/- 2 liters of fluids including 4 +/- 4 units of PRBCs in the emergency room (ER). In total, 69 (32%) patients died, among whom the HRM was 19%; 29% of the deaths were due to pelvic bleeding. Altogether, 120 of the 217 (55%) patients underwent focused abdominal sonography for trauma (FAST) or diagnostic peritoneal aspiration (DPA) and diagnostic peritoneal lavage (DPL); 60 of the 217 (28%) patients were found to have pelvic binding in the ER. In all, 53 of 109 (49%) patients had no bleeding noted at laparotomy, 26 of 106 (25%) had no abdominal findings, and 15 of 53 (28%) had had no prior abdominal investigation (FAST/DPL/computed tomography). Angiography was positive in 48 of 58 (83%) patients. The HRM was highest in patients with laparotomy as the primary intervention (29%) followed by the angiography group (18%), the combined laparotomy/pelvic fixation group (16%), and the pelvic fixation-only group (10%). CONCLUSION: HRM associated with major pelvic trauma is unacceptably high especially in the laparotomy group. Hence, nontherapeutic laparotomy must be avoided, concentrating instead on arresting pelvic hemorrhage. Standards of care must be implemented and abided by.

Bystander basic life support: an important link in the chain of survival for children suffering a drowning or near-drowning episode.

Eight children suffered drowning or near-drowning in Sydney pools over an 11-day period in January 2007. Four received basic life support (BLS) within 5 minutes of immersion and survived with good functional neurological outcomes. The other four were not discovered for >or= 5 minutes and all died. This cluster serves as a reminder that timely effective bystander BLS is crucial to survival and good clinical outcomes in near-drowning episodes.

Neonatal surgery in New South Wales--what is performed where?

OBJECTIVES: The aim of this study was to describe what surgical procedures are performed in the neonatal period in New South Wales (NSW) and where they are performed. METHODS: Population-based descriptive study was conducted in NSW in a 2-year period from July 1, 1996 to June 30, 1998, inclusive, using information from the NSW Health Department's Inpatient Statistics Collection. All neonates undergoing major surgery (excluding circumcisions) in NSW. RESULTS: In the first 4 weeks of life, 990 (0.6%) neonates underwent surgery. The most common surgical procedures were gastrointestinal, cardiovascular, hernia, genitourinary, and neurosurgical. Frenotomy accounted for 5% of all surgical procedures. Whereas 75% of neonatal surgery (including 88% of gastrointestinal and 97% cardiovascular surgery) occurs in children's hospitals, only 13% of the babies requiring surgery are born in the co-located obstetric hospitals. Perinatal centers accounted for 5.3% of surgery; urban hospitals for 8.4%; rural hospitals, 5.5%, and private hospitals, 6.4%. The mortality rate in the neonatal period was 3.0% overall. CONCLUSIONS: This is the first review of major neonatal surgery in Australia and provides baseline data for future comparisons. Whereas most neonates had surgery in a children's hospital, few of them were born in the most appropriate place, the co-located obstetric hospital. Parents should be informed of the level of institutional surgical expertise and be involved in the decision-making regarding the place of surgery for their infant. Parents and children have a right to expect the best possible results.

Further delineation of the phenotype associated with heterozygous mutations in ZFHX1B.

Mutations or deletions involving ZFHX1B (previously SIP1) have recently been found to cause one form of syndromic Hirschsprung disease (HSCR), associated with microcephaly, mental retardation, and distinctive facial features. Patients with the characteristic facial phenotype and severe mental retardation, but without HSCR, have now also been shown to have mutations in this gene. Mutations of ZFHX1B are frequently associated with other congenital anomalies, including congenital heart disease, hypospadias, renal tract anomalies, and agenesis of the corpus callosum (ACC). We present the clinical data and mutation analysis results from a series of 23 patients with this clinical syndrome, of whom 21 have proven ZFHX1B mutations or deletions (15 previously unpublished). Two patients with the typical features (one with and one without HSCR) did not have detectable abnormalities of ZFHX1B. We emphasize that this syndrome can be recognized by the facial phenotype in the absence of either HSCR or other congenital anomalies, and needs to be considered in the differential diagnosis of dysmorphism with severe mental retardation +/- epilepsy.