Complex Pediatric Cases Research Articles

Selective iliofemoral stent placement for complex pediatric cases: a decade of institutional experience.

Pediatric iliofemoral venous thromboembolism that is resistant to conventional treatments poses significant management challenges. Stent placement represents a potentially underutilized strategy in children when stenosis or thrombosis persists intraprocedurally or recurs postoperatively, despite treatments such as venoplasty, lysis, and thrombectomy. This study aims to report our institutional experience with iliofemoral stenting in 17 pediatric patients with recurrent iliofemoral venous thromboembolism or stenosis. We performed an IRB-approved retrospective review of pediatric patients (<18 years of age) who underwent iliofemoral venous stenting for recurrent stenosis or thrombosis between January 2012 and December 2022 at a single tertiary care institution. Patient demographics, risk factors for venous thromboembolism, presenting symptoms, and procedural characteristics were recorded. The primary outcome was stent patency rates at interval imaging follow-up. Seventeen patients with mean age of 14.6 years (range 7-17) and mean BMI of 27.7 were stented during the study period. Sixteen of 17 patients presented with evidence of May-Thurner anatomy. 14/17 patients presented with acute iliofemoral venous thromboembolism, 2/17 with chronic venous thromboembolism, and 1/17 with left lower extremity swelling without thrombosis. Seventy-three total angiographic procedures were performed, which included angioplasty, lysis, and thrombectomy, and 23 stent placements. Patients underwent an average of 3 procedures (range 1-9) over a mean of 2.8 months (range 0-17 months) prior to undergoing stent placement. Stents were deployed successfully in all patients. The median follow-up was 18 months (range, 1-77 months). Primary and secondary patency rates were 13/17 (76%) and 14/14 (100%) at 12 months and 12/17 (71%) and 14/14 (100%) at 24 months, respectively. In our experience of 17 patients, stent placement appears to be a durable option for children with iliofemoral venous thromboembolism following failure to establish vessel patency or development of recurrent thrombosis/stenosis postoperatively.

Innovative Techniques Associated with Traditional Abdominal Surgery in Complex Pediatric Cases: A Tertiary Center Experience.

Pediatric abdominal surgery is constantly evolving, alongside the advent of new surgical technologies. A combined use of new tools and traditional surgical approaches can be useful in the management of complex cases, allowing less invasive procedures and sometimes even avoiding multiple interventions. This combination of techniques has implications even from the anesthetic point of view, especially in post-operative pain control. Thereby, tertiary level centres, including highly-specialized professionals and advanced equipment, can maximize the effectiveness of treatments to improve the final outcomes. Our paper aims to present some possible combinations of techniques recently used at our institution to provide a one-session, minimally invasive treatment within different areas of abdominal surgery.

Vascularized fibula flap in the management of segmental bone loss following osteomyelitis in children at a Ugandan hospital.

Background: Hematogenous osteomyelitis is commonly observed in the pediatric population across sub-Saharan Africa. This retrospective case series was designed to evaluate the complications and outcomes of treatment using a vascularized fibula flap (VFF) to fill segmental bone defects secondary to osteomyelitis in children in a low-resource setting in CoRSU Rehabilitation Hospital, Uganda. Methods: Clinical notes and radiographs of children with a diagnosis of osteomyelitis that subsequently underwent a VFF procedure between October 2013 and December 2017 were reviewed. All patients were clinically and radiographically evaluated in 2019. Results: Forty-four children, with an average bone defect of 10.5 cm, were included. Eighty-four percent of children had successful VFF limb reconstruction. Integration of the graft was radiologically sound in 20.8 weeks on average. The postoperative phase was uneventful in 29 % of patients. Complications were observed in the remaining patients, including flap failure (6), donor leg neurapraxia (3), cutaneous paddle necrosis (11), graft fracture (2), skin graft loss (6), fixator failure (1) and non-union (2). Functional outcomes were rated as excellent in 13 patients, good in 14, fair in 9 and poor in 8. There was no recurrence of the bone infection in any of the enrolled children. Conclusion: Despite being a complex and demanding procedure, VFF is a good option for reconstructing post-osteomyelitis bone defects, particularly when associated with loss of soft tissue envelope. Considering the more than satisfactory functional and clinical outcomes, this procedure should be kept in mind for these complex pediatric cases of bone and soft tissue loss, even in a low-resource setting.

Clinical Care Coordination in Medically Complex Pediatric Cases: Results From the National Survey of Children With Special Health Care Needs.

This study uses a secondary analysis of the 2009-2010 National Survey of Children with Special Health Care Needs (NS-CSHCN) to describe care coordination (CC) for children with medical complexity (CMC). Chi-square test, t test, and multivariate logistic regression statistical tests are used to determine the relationships and differences between sources of CC and factors associated with receiving clinic-based CC for CMC and their family. Among CMC, 66.47% received no CC support and 25.73% received clinic-based CC. In multivariate models, families reporting dissatisfaction with communication between health care providers or reporting family-centered care were less likely to receive clinic-based CC. Families were more likely to receive clinic-based CC if they had younger children, lower household income, and greater school absenteeism. Clinic-based CC is associated with improved communication between health providers but must become more family-centered and minimize student absenteeism for the CMC population.

Renal Impairment Related to Different Antifungal Medications in Cases of Invasive Candida Infections in Tawam Hospital Pediatric Population between 2008-2015

Background: As a tertiary hospital, Tawam Hospital has been dealing with more and more complex pediatric cases. Such cases are often at higher risk of developing Invasive Candida Infections (ICI). Amphotericin B preparations continued to provide the widest coverage for all Candida strains and have been the drug of choice for definitive and empirical therapy in our institute. However, renal complications have always been a concern with this group of antifungals. Numerous studies have reported contradicting results in terms of which Amphotericin B preparation has less renal side effects. Therefore, we are here to report our own experience.Methods:We performed a retrospective cohort study of all children (15 years and younger) with ICI who were treated at Tawam Hospital from 2008 to 2015. Results:Out of the 40 patients included in this study, 7 patients were treated with Amphotericin B Liposomal (ABL). Two of them had elevated Urea/Creatinine after initiating the therapy. 11 patients were treated with Amphotericin B Lipid Complex (ABLC). Two of them had elevated Urea/Creatinine after initiating the therapy. Fluconazole was used in 14 patients. 2 of them had high Urea/Creatinine before therapy which did not show any further deterioration while on therapy. Two patients were treated with a combination of Fluconazoleand LAB. They both had high Urea/Creatinine before and after therapy. However, one of them was known to have renal failure. While 4 cases were treated with the combination of Fluconazole and ABLCamong whom one patient had high Urea/Creatinine before therapy that went down while on therapy. Conclusions:Although Amphotericin B is known to be associated with renal side effects, the newer preparations seem to offer a much safer alternative. Among the two available preparations, ABLCseemed to be safer in our experience. Fluconazole continued to have minimal renal side effects. However, just like most of the published studies on this topic, our study was limited by the small number of patients included and the retrospective nature of the study.Keywords: Invasive candida infections, Renal impairment, Amphotericin B Lipid Complex, Amphotericin B Liposomal Fluconazole.Abbreviations:ICI: Invasive Candida Infections, Amphotericin B Lipid Complex (ABLC), Amphotericin B Liposomal (ABL), CSF: cerebrospinal fluid, CLEAR: Collaborative Exchange of Antifungal Research,

Use of three-dimensional, CAD/CAM-assisted, virtual surgical simulation and planning in the pediatric craniofacial population

ObjectiveVirtual Surgical Planning (VSP) and computer-aided design/computer-aided manufacturing (CAD/CAM) have recently helped improve efficiency and accuracy in many different craniofacial surgeries. Research has mainly focused on the use in the adult population with the exception of the use for mandibular distractions and cranial vault remodeling in the pediatric population. This study aims to elucidate the role of VSP and CAD/CAM in complex pediatric craniofacial cases by exploring its use in the correction of midface hypoplasia, orbital dystopia, mandibular reconstruction, and posterior cranial vault expansion. Method/DescriptionA retrospective analysis of thirteen patients who underwent 3d, CAD/CAM- assisted preoperative surgical planning between 2012 and 2016 was performed. All CAD/CAM assisted surgical planning was done in conjunction with a third party vendor (either 3D Systems or Materialise). Cutting and positioning guides as well as models were produced based on the virtual plan. Surgeries included free fibula mandible reconstruction (n = 4), lefort I osteotomy and distraction (n = 2), lefort II osteotomy with monobloc distraction (n = 1), expansion of the posterior vault for correction of chiari malformation (n = 3), and secondary orbital and midface reconstruction for facial trauma (n = 3). The patient's age, diagnosis, previous surgeries, length of operating time, complications, and post-surgery satisfaction were determined. ResultsIn all cases we found presurgical planning was helpful to improve accuracy and significantly decrease intra-operative time. In cases where distraction was used, the planned and actual vectors were found to be accurate with excellent clinical outcomes. There were no complications except for one patient who experienced a wound infection post-operatively which did not alter the ultimate reconstruction. All patients experienced high satisfaction with their outcomes and excellent subjective aesthetic results were achieved. ConclusionsPreoperative planning using CAD/CAM and VSP allows for safe and precise craniofacial reconstruction in complex pediatric cases with a reduction of operative time.

Fever and Seizure in a Young Infant: A Simulation Case.

Fever in early infancy is a common problem for which management can be challenging. All residents need to be able to recognize critical illness such as meningitis in febrile infants and manage complications such as seizures. Many new residents are not competent performing bedside procedures as there is little opportunity to perform them while in medical school. This simulation case revolves around fever and subsequent seizures in an infant. Designed to last 2 hours, the case is specific for subinterns but is relevant for clerkship students and interns in pediatrics, family medicine, and emergency medicine. In this case, a 5-week-old infant presents with fever and lethargy. He develops seizures with respiratory depression requiring antiseizure medication and respiratory support. His final diagnosis is bacterial meningitis. Major equipment required includes an infant mannequin and an infant lumbar puncture task trainer. A pilot study was conducted in 2015 with all subinterns on the pediatric service. Students' perceived competence in diagnosis/management, procedural skills, and managing complex pediatric cases rose sharply after completing the session. Critical actions include obtaining IV access, performing blood and urine cultures, considering lumbar puncture, recognizing respiratory depression, performing bag and mask ventilation, administering antiseizure medication, counseling parents, and starting appropriate anti-infective therapy. This clinical simulation case allows students to demonstrate clinical reasoning skills, procedural skills such as performing a lumbar puncture and bag-mask ventilation, and management skills. Materials are provided for students to perform self-assessments of perceived competency in procedural, diagnosis, and management skills related to the case.

3 mm Spot Size IMPT vs. IMRT for 3 Complex Pediatric Cases

3 mm Spot Size IMPT vs. IMRT for 3 Complex Pediatric Cases

The Provision of Anaesthesia for Children by Non-Subspecialist Anaesthetists: Expectations of Newly Qualified Consultant Anaesthetists and their Prospective Employers in Victoria

We surveyed newly qualified consultant anaesthetists and their prospective employers in Victoria, regarding their expectations for the provision of paediatric anaesthesia by anaesthetists who have not completed subspecialty training in paediatric anaesthesia (generally-trained anaesthetists). Responses were received from 15 of 19 (79%) eligible Directors and 26 of 37 (70%) newly qualified Australian and New Zealand College of Anaesthetists (ANZCA) Fellows. Of those responding, 80% of Directors and 82% of Fellows would expect a generally-trained anaesthetist to anaesthetise children two years of age or older Regional Directors expected generally-trained anaesthetists to anaesthetise younger children than metropolitan Directors, and Directors' expectations were not influenced by their own practice. Testing these age limits with a series of simple case descriptions showed there is recognition from both Directors and Fellows that the stated age limits would be modified in both directions by case complexity and comorbidities. The new consultants who responded were significantly less confident than Directors in their ability to resuscitate and stabilise a critically ill child prior to transfer if required. Only 50% agreed they still met all the requirements of the ANZCA paediatric module and only 37.5% had the level of confidence they achieved during their paediatric rotations. We suggest that current training provides capacity to routinely anaesthetise well children two years of age or older However it appears more training would be required for most anaesthetists undertaking anaesthesia for younger patients or more complex paediatric cases. This raises the question of subspecialty endorsements within ANZCA Fellowship.

Extension of Retracted Glaucoma Drainage Tube Using a 22-gauge Intravenous Catheter in Complex Pediatric Glaucoma

To describe the use of the readily available, sterile, and economical 22-gauge intravenous catheter (Venflon) as a preferable option for extending the tube of glaucoma drainage devices in cases of tube retraction in complex pediatric cases. A report of noncomparative retrospective evaluation of 2 pediatric cases with tube retraction treated with the extension of the tube. The tube of the drainage devices (1 Baerveldt and 1 Molteno) was extended using a segment of a 22-gauge intravenous catheter (Venflon). The available follow-up for both the cases is 8.5 months. In both cases an adequate length of the tube was obtained in the anterior chamber. In the first case an excellent drainage bleb formed over the plate and the intraocular pressure (IOP) reduced from 28 to 11 mm Hg. In the second case only a 25% reduction of IOP (from 40 to 30 mm Hg) and a shallow bleb was seen for a few weeks only as extensive fibrosis over the plate limited the drainage. There has been no displacement of the tube in the follow-up period. The readily available, sterile, and economical 22-gauge intravenous catheter (venflon) segment is a structurally and functionally appropriate, and cost effective option for extension of both Baerveldt and Molteno drainage implants in complex pediatric cases. However other factors limiting drainage from tube, such as extensive scarring over the plate may limit the reduction of IOP.

On the performances of Intensity Modulated Protons, RapidArc and Helical Tomotherapy for selected paediatric cases

BackgroundTo evaluate the performance of three different advanced treatment techniques on a group of complex paediatric cancer cases.MethodsCT images and volumes of interest of five patients were used to design plans for Helical Tomotherapy (HT), RapidArc (RA) and Intensity Modulated Proton therapy (IMP). The tumour types were: extraosseous, intrathoracic Ewing Sarcoma; mediastinal Rhabdomyosarcoma; metastastis of base of skull with bone, para-nasal and left eye infiltration from Nephroblastoma of right kidney; metastatic Rhabdomyosarcoma of the anus; Wilm's tumour of the left kidney with multiple liver metastases. Cases were selected for their complexity regardless the treatment intent and stage. Prescribed doses ranged from 18 to 53.2 Gy, with four cases planned using a Simultaneous Integrated Boost strategy. Results were analysed in terms of dose distributions and dose volume histograms.ResultsFor all patients, IMP plans lead to superior sparing of organs at risk and normal healthy tissue, where in particular the integral dose is halved with respect to photon techniques. In terms of conformity and of spillage of high doses outside targets (external index (EI)), all three techniques were comparable; CI90% ranged from 1.0 to 2.3 and EI from 0 to 5%. Concerning target homogeneity, IMP showed a variance (D5%–D95%) measured on the inner target volume (highest dose prescription) ranging from 5.9 to 13.3%, RA from 5.3 to 11.8%, and HT from 4.0 to 12.2%. The range of minimum significant dose to the same target was: (72.2%, 89.9%) for IMP, (86.7%, 94.1%) for RA, and (79.4%, 94.8%) for HT. Similarly, for maximum significant doses: (103.8%, 109.4%) for IMP, (103.2%, 107.4%) for RA, and (102.4%, 117.2%) for HT. Treatment times (beam-on time) ranged from 123 to 129 s for RA and from 146 to 387 s for HT.ConclusionFive complex pediatric cases were selected as representative examples to compare three advanced radiation delivery techniques. While differences were noted in the metrics examined, all three techniques provided satisfactory conformal avoidance and conformation.

On the performances of different IMRT treatment planning systems for selected paediatric cases

BackgroundTo evaluate the performance of seven different TPS (Treatment Planning Systems: Corvus, Eclipse, Hyperion, KonRad, Oncentra Masterplan, Pinnacle and PrecisePLAN) when intensity modulated (IMRT) plans are designed for paediatric tumours.MethodsDatasets (CT images and volumes of interest) of four patients were used to design IMRT plans. The tumour types were: one extraosseous, intrathoracic Ewing Sarcoma; one mediastinal Rhabdomyosarcoma; one metastatic Rhabdomyosarcoma of the anus; one Wilm's tumour of the left kidney with multiple liver metastases. Prescribed doses ranged from 18 to 54.4 Gy. To minimise variability, the same beam geometry and clinical goals were imposed on all systems for every patient. Results were analysed in terms of dose distributions and dose volume histograms.ResultsFor all patients, IMRT plans lead to acceptable treatments in terms of conformal avoidance since most of the dose objectives for Organs At Risk (OARs) were met, and the Conformity Index (averaged over all TPS and patients) ranged from 1.14 to 1.58 on primary target volumes and from 1.07 to 1.37 on boost volumes. The healthy tissue involvement was measured in terms of several parameters, and the average mean dose ranged from 4.6 to 13.7 Gy. A global scoring method was developed to evaluate plans according to their degree of success in meeting dose objectives (lower scores are better than higher ones). For OARs the range of scores was between 0.75 ± 0.15 (Eclipse) to 0.92 ± 0.18 (Pinnacle3 with physical optimisation). For target volumes, the score ranged from 0.05 ± 0.05 (Pinnacle3 with physical optimisation) to 0.16 ± 0.07 (Corvus).ConclusionA set of complex paediatric cases presented a variety of individual treatment planning challenges. Despite the large spread of results, inverse planning systems offer promising results for IMRT delivery, hence widening the treatment strategies for this very sensitive class of patients.

Pediatrics for anesthesiologists

Complex pediatric cases will more and more often be undertaken by general anesthesiologists. However, keeping up with the pediatric literature can be difficult. In this brief review, we examine the most recent information on the perioperative management of pediatric patients with sickle cell disease, and look at the recent utilization of aprotinin to control blood loss in children of Jehovah's Witnesses. We review the encouraging results of intestinal transplantations recently performed at the University of Nebraska, and we look at the tremendous potential for umbilical cord blood transplantation to treat malignant and nonmalignant diseases in children successfully.