Chance Of Spontaneous Resolution Research Articles

Inguinal Hernia in Premature Infants: To Operate Before or After Discharge from Hospital?

IntroductionThis study aims to find out the optimal timing for herniotomy for premature infants with inguinal hernia (IH): early during hospitalisation or delayed after hospital discharge. MethodA retrospective cohort study was conducted on premature infants diagnosed with IH during their initial hospitalization between 2015 and 2020. Demographic data and clinical outcomes were compared between infants undergoing herniotomy before discharge (“early”) and those who were discharged without herniotomy (“delayed”). Student's t-test or Mann–Whitney U test and Fisher's exact test were used for statistical analysis. ResultsOf 219 premature infants, 189 (86.3%) underwent early herniotomy, while 30 were discharged with unoperated IH. In the delayed group, 15 (50%) underwent planned delayed herniotomy, and the remaining 15 experienced spontaneous resolution (absence of inguinal bulge over at least 1-year follow-up). The gestational age and birth weight of both groups were similar. At surgery, the delayed group median (interquartile range) was significantly older (42.1[38–49] vs 37.7 [36–40] weeks, p < 0.001) and heavier (3.27 [2.21–4.60] vs 2.22 [2.00–2.70] kg, p < 0.001). Two infants (1%) in the early group presented with incarcerated IH requiring urgent operation. In the delayed group, no infant developed incarcerated IH while awaiting elective operation (time from diagnosis to operation 44 [21–85] days). There was no statistically significant difference in respiratory and surgical complications between the two groups, although the delayed group had lesser surgical complications (0% vs 9.5%). ConclusionDeferring herniotomy after discharge for premature infants is safe with close monitoring and associated with a chance of spontaneous resolution. Level of EvidenceLevel III, treatment study.

Acquired Cold–Induced Urticaria in Pediatric Patients: A 22-Year Experience in a Tertiary Care Center (1996–2017)

To describe 2 decades of experience evaluating and managing pediatric acquired cold-induced urticaria (ACU).The study included 415 children and adolescents (aged 4 months to 18.3 years at diagnosis) with ACU evaluated at Boston Children’s Hospital from 1996 to 2017.Three authors used a retrospective electronic medical record review of visits coded for urticaria or temperature-induced urticaria to identify patients <19 years of age diagnosed with ACU on the basis of history of urticaria, angioedema, and/or anaphylaxis with cold exposure.Most patients were atopic (78%), but only a minority (26%) had urticaria associated with other triggers. Anaphylaxis was described in 19% of the cohort, with the majority of anaphylaxis triggered by swimming (78%). Repeat episodes of anaphylaxis were described in 7% of patients. Cold stimulation testing (positive in 70% of those tested) was associated with anaphylaxis risk; however, 12% of those with negative cold testing results still experienced anaphylaxis. Disease resolution, seen in 9% (at a median age of 10 years), was more likely in those without anaphylaxis.Children and adolescents with cold urticaria are likely to have other allergic disease (such as allergic rhinitis, asthma, food allergy, atopic dermatitis, and oral allergy syndrome). The risk for anaphylaxis is significant, as is the chance of spontaneous resolution. Negative results of cold stimulation testing do not exclude anaphylaxis risk. Patients and families should be counseled regarding the risks of swimming, and epinephrine prescription is appropriate.This article follows a previous report from the same group, which described similar findings in 2004, with practical findings for patient management. ACU is uncommon, with an estimated incidence of 0.05%. The authors of this report deliver several important take-home messages: (1) ACU carries real risk for anaphylaxis; (2) counseling should address risks of swimming and other cold exposures; (3) prescribing epinephrine autoinjectors is appropriate for patients with ACU; (4) the ice cube test cannot be used to exclude anaphylaxis risk; (5) disease resolution is less likely in patients with anaphylaxis; (6) patients with ACU have greater risks of asthma, rhinitis, eczema, and food allergy; and (7) nearly 10% of children and adolescents may outgrow this diagnosis in time.

New congenital anomalies of the kidney and urinary tract and outcomes in Robo2 mutant mice with the inserted piggyBac transposon.

BackgroundDisruption of ROBO2 in humans causes vesicoureteral reflux (VUR)/congenital anomalies of the kidney and urinary tract (CAKUT). PiggyBac (PB) is a DNA transposon, and its insertion often reduces—but does not eliminate—gene expression. The Robo2 insertion mutant exhibited non-dilating VUR, ureteropelvic junction obstruction (UPJO) not found in reported models. We studied the incidence and outcomes of VUR/CAKUT in this mutant and explored the relationship between Robo2 gene expression and the occurrence and severity of VUR/CAKUT.MethodsThe urinary systems of newborn mutants were evaluated via Vevo 770 micro-ultrasound. Some of the normal animals—and all of the abnormal animals—were followed to adulthood and tested for VUR. Urinary obstruction experiments were performed on mice with hydronephrosis. The histology of the kidney and ureter was examined by light microscopy and transmission electron microscopy. Robo2PB/PB mice were crossed with Hoxb7/myr-Venus mice to visualize the location of the ureters relative to the bladder.ResultsIn Robo2PB/PB mice, PB insertion led to an approximately 50 % decrease in Robo2 gene expression. The most common (27.07 %, 62/229) abnormality was non-dilating VUR, and no statistically significant differences were found between age groups. Approximately 6.97 % displayed ultrasound-detectable CAKUT, and these mice survived to adulthood without improvement. No severe CAKUT were found in Robo2PB/+ mice. The refluxing ureters showed disorganized smooth muscle fibers, reduced muscle cell populations, intercellular edema and intracytoplasmic vacuoles in smooth muscle cells. Both UPJ and UVJ muscle defects were noted in Robo2PB/PB mice.ConclusionsRobo2PB/PB mice is the first Robo2-deficient mouse model to survive to adulthood while displaying non-dilating VUR, UPJO, and multiple ureters with blind endings. The genetic background of these mutants may influence the penetrance and severity of the CAKUT phenotypes. VUR and other CAKUT found in this mutant had little chance of spontaneous resolution, and this requires careful follow-up. We reported for the first time that the non-dilated refluxing ureters showed disorganized smooth muscle fibers and altered smooth muscle cell structure, more accurately mimicking the characteristics of human cases. Future studies are required to test the role of Robo2 in the ureteric smooth muscle.

Postvoidal residual urine is the most significant non-invasive diagnostic test to predict the treatment outcome in children with non-neurogenic lower urinary tract dysfunction

Uroflowmetry (UF) alone is often inadequate or unreliable to diagnose lower urinary tract dysfunction (LUTD). Therefore, other non-invasive tests, such as ultrasound (US), post-voiding residual volume (PVR) assessment and symptom scales, are used as well for objective definition of the problem. The aim of this study was to investigate the possible predictive function of the non-invasive diagnostic tests for the response to treatment. The prospective registry data of 240 patients with LUTD, from November 2006 to September 2013, were retrospectively analyzed. All patients were aged 5-14 years old. Patients with a previous diagnosis of vesicoureteral reflux (VUR), neurogenic bladder, monosymptomatic nocturnal enuresis (NE) were excluded from the study. Uroflowmetry, US, PVR and the Dysfunctional Voiding and Incontinence Symptom Scale (DVISS) were performed on every patient at their first visit and follow-ups. A DVISS <9 was considered as the DVISS response; parental opinion was based on International Continence Society criteria of clinical response. Time passed until clinical response was the last outcome parameter. Mean age was 8.2 years. Median follow-up was 60.5 months. A total of 62% of patients had complete response, 28.1% had partial response, and 9.7% had no response. Demographic variables were not associated with clinical outcome. Co-existing enuresis nocturna, multiple pharmacotherapy, and increased DVISS were associated with longer time until clinical response. Post-voiding residual volume assessment was the only test to have a prognostic value. Resolution rates of LUTD ranged from 40 to 90%. High resolution rate could be attributed to the long follow-up period, and the chance of spontaneous resolution. Treatment modalities and co-existing NE were associated with longer time until clinical response. Only PVR was associated with prognosis. This was the first study in literature to report such findings. It was seen that the normalization of pathologic patterns was a good sign for treatment success. The DVISS results showed significantly higher rates of incontinence compared to initial symptoms defined by the patients and/or their parents. This showed the importance of using scoring systems to better define the severity of symptoms. It was hard to establish a standardized cut-off value for bladder wall thickness on US. However, US was a good test for diagnosing additional pathologies. Increased PVR was the single tool that was associated with prognosis and, therefore, should always be performed after UF. In addition, DVISS can help parents be counseled about their treatment expectations.

Individualizing Management of Vesicoureteral Reflux

BackgroundApproaches to the management of vesicoureteral reflux (VUR) in children have changed rapidly in recent years. Multiple studies published over the last decade have contributed to these changes by challenging the dogma that all children with reflux require and benefit from continuous antibiotic prophylaxis. The advent and wide acceptance of endoscopic treatment for VUR has also contributed to these changes. Although new guidelines for VUR management have recently been proposed, they are broad and relatively non-specific. Many physicians and parents remain unsure which children are at risk from their VUR, and which would benefit from antibiotic prophylaxis or surgical intervention.Materials and MethodsA literature search, followed by an additional search based on bibliographies, was performed for articles reporting on VUR and the utility of antibiotic prophylaxis for its treatment, as well as the chance of spontaneous resolution.ResultsArticles selected for review included those that provided information to assist physicians in determining if a child with VUR is at increased risk of pyelonephritis or persistent VUR, and would benefit from intervention. Particular emphasis was placed on recent prospective, randomized trials in children with VUR.ConclusionsBecause of the multiple factors affecting risk in a child with VUR, specific guidelines for intervention cannot be provided. However, an accurate understanding of these risk factors will help the physician and parents to develop a more individualized management plan for a child with VUR.

Perianal abscess and fistula-in-ano in children: clinical characteristic, management and outcome

The aims of this study are to evaluate the clinical characteristics of perianal abscess and fistula-in-ano in children, and to assess our experience in treatment, and to identify factors that affected the clinical outcomes. A retrospective review of children with perianal abscess and fistula-in-ano was carried out in a tertiary care children's hospital from January 2005 to December 2010. Demographic information of the patients, localization of the lesions, treatment procedures, microbial organisms in pus, usage of antibiotics, abscess recurrence, development of fistula-in-ano, and duration of symptoms were recorded. Patients with systemic diseases and inflammatory bowel diseases were excluded from the study. A total of 158 children (146 males, 12 females) treated for perianal abscess and fistula-in-ano with a median age of 7.2months (ranging 16days to 18years) were eligible for the study. Initial examination of the 136 patients revealed perianal abscess and 22 patients with fistula-in-ano. Primary treatment was incision and drainage (I/D) for the fluctuating perianal abscess (73.5%), and local care for the spontaneously (S/D) drained abscess (26.5%) with or without antibiotic therapy. Patients were divided into two groups according to age distribution, 98 of the patients were younger than 12months, and 60 were older than 12months of age. There was no significant difference in sex distribution, localization of the lesions, treatment procedures, recurrence of abscess and fistula-in-ano formation between the two age groups (p>0.05). Recurrence rates (27% in I/D and 30.6% in S/D, p>0.05) and development of fistula-in-ano (20% in I/D and 27.8 in S/D, p>0.05) were not significant I/D and S/D groups. Kind of the microorganisms in pus swaps did not effect the fistula-in-ano formation. Usage of antibiotics significantly reduced the development of fistula-in-ano (p=0.001), but did not effect the recurrence of perianal abscess (p>0.05). The mean follow-up period was 10.6±8.6months. While the 9 of the overall 52 fistula-in-ano (22 initial, 30 after abscess treatment) were resolved spontaneously, 43 of the remaining needed surgical intervention (fistulotomy/fistulectomy). Although management of perianal abscess is still controversial, simple drainage of the perianal abscess with additional antibiotic therapy reduces the development of fistula-in-ano. Fistula-in-ano within children has a chance of spontaneous resolution thus the immediate surgical intervention should be avoided.

Parálisis del VI par bilateral y III par izquierdo postraumático

To describe a case of combined bilateral cranial nerve palsy of traumatic origin. To determine the lesions that produce the symptoms is useful to define the final prognosis and the best treatment. We report the case of a patient who developed a bilateral sixth nerve and left third nerve palsy after head trauma. The underlying lesion was a diffuse axonal injury. After an observation period during which no spontaneous improvement occurred, we administered botulinum toxin with a successful clinical result. Bilateral combined traumatic cranial nerve palsies are rare. When a diffuse axonal injury is present, the chance of spontaneous resolution is poor.

Splenic sequestration in patients with sickle cell disease.

Splenic sequestration is a potentially life threatening event that is characteristic for sickle cell disease. For reasons unknown a fraction of or even the entire blood volume is trapped in the splenic sinuses within a few hours and thus is no longer available for circulation. The result is splenomegaly, hypovolemia, anemia and extreme reticulocytosis. If the sequestered blood volume is very large the patient goes into fatal hypovolemic shock unless transfused instantly. If the sequestered volume is small there is a chance of spontaneous resolution. The etiology of splenic sequestration is not known. Children with homozygous sickle cell disease (HbSS) are at risk until age 6 years while individuals with compound heterozygous disease (HbSbetaThal, HbSC, HbSD) may develop splenic sequestration even in adulthood. Parents of infants and toddlers with sickle cell disease need to learn how to palpate the spleen in order to detect splenomegaly as early as possible and take the child to the hospital. Splenic sequestration with a drop in hemoglobin of more than 3 g/dl below the patient's usual hemoglobin level is a clear indication for splenectomy regardless of the patient's age as splenic sequestration tends to recur.

Grommet insertion: some basic questions answered.

A very large number of grommets are inserted to improve middle ear ventilation in children. A retrospective survey of 1011 admissions for myringotomy and/or grommet insertion has been used to answer some basic questions about such admissions and the fate of grommets inserted. No attempt has been made to assess the benefits of this mode of treatment. The average number of admissions per child was 1.6, with 64% being admitted only once. A child aged 3-4 years when first listed had the greatest chance of repeated admissions. Nearly 50% of the grommets had been extruded within 6 months and 80% within 1 year. Children put on the waiting list because of middle ear effusions present in summer months had a greater chance of spontaneous resolution in the subsequent few months than those listed in winter months. Significant complications occurred in 2.2% of grommet insertions.