Intra-abdominal mass and iron deficiency anemia in a 15-year-old boy: Case report and literature review

Castleman\u27s disease is rare lymphoproliferative disorder that typically presents as a mediastinal mass, although 10% of cases may be intra-abdominal. Given its rarity, diagnosis is often delayed until other pathology has been ruled out. We present the case of a 15-year-old boy with a one-year history of progressive fatigue, failure to thrive, and severe iron resistant, iron deficiency anemia. Extensive work-up revealed an intra-abdominal mass. At laparotomy, a discrete lymphoid-appearing mass was found at the base of the mesentery. Excision led to rapid and complete resolution of his symptoms, including resolution of anemia. Pathology demonstrated Castleman\u27s disease of the hyaline vascular subtype. Increased awareness of this entity and its association with severe iron deficiency anemia though the overproduction of IL-6 may allow earlier detection and treatment. © 2014 The Authors. Published by Elsevier Inc. All rights reserved

Reported provision of analgesia to patients with acute abdominal pain in Canadian paediatric emergency departments

Objectives: Evidence exists that analgesics are underutilized, delayed, and insufficiently dosed for emergency department (ED) patients with acute abdominal pain. For physicians practicing in a Canadian paediatric ED setting, we (1) explored theoretical practice variation in the provision of analgesia to children with acute abdominal pain; (2) identified reasons for withholding analgesia; and (3) evaluated the relationship between providing analgesia and surgical consultation. Methods: Physician members of Paediatric Emergency Research Canada (PERC) were prospectively surveyed and presented with three scenarios of undifferentiated acute abdominal pain to assess management. A modified Dillman’s Tailored Design method was used to distribute the survey from June to July 2014. Results: Overall response rate was 74.5% (149/200); 51.7% of respondents were female and mean age was 44 (SD 8.4) years. The reported rates of providing analgesia for case scenarios representative of renal colic, appendicitis, and intussusception, were 100%, 92.1%, and 83.4%, respectively, while rates of providing intravenous opioids were 85.2%, 58.6%, and 12.4%, respectively. In all 60 responses where the respondent indicated they would obtain a surgical consultation, analgesia would be provided. In the 35 responses where analgesia would be withheld, 21 (60%) believed pain was not severe enough, while 5 (14.3%) indicated it would obscure a surgical condition. Conclusions: Pediatric emergency physicians self-reported rates of providing analgesia for acute abdominal pain scenarios were higher than previously reported, and appeared unrelated to request for surgical consultation. However, an unwillingness to provide opioid analgesia, belief that analgesia can obscure a surgical condition, and failure to take self-reported pain at face value remain, suggesting that the need exists for further knowledge translation efforts

Lung growth and lung function after a) fetal lamb tracheal occlusion and exogenous surfactant at birth in congenital diaphragmatic hernia and b) selective perfluorocarbon distention in healthy newborn piglets

This study sought to maximize prenatal and postnatal interventions in order to accelerate lung growth and improve lung function in two animal models. Prenatal interventions consisted of fetal tracheal occlusion (TO), antenatal glucocorticoids and exogenous surfactant at birth (SURF) in an ovine model of congenital diaphragmatic hernia (CDH). CDH, CDH+TO, CDH+SURF, CDH+TO+SURF and unoperated twin control lambs were compared. Prenatal growth of both lungs was accelerated after fetal TO. Prophylactic surfactant did not improve gas exchange or ventilation but did increase lung compliance over 8 hours. The incidence of tension pneumothoraces was slightly decreased after exogenous surfactant. Fetal TO yields the best results in terms of overall postnatal lung function, likely acting via surfactant independent mechanisms.Postnatal intervention involved perfluorocarbon (PFC) liquid distention of the right upper lobe in healthy newborn piglets. Postnatal lung growth, as measured indirectly by rates of DNA synthesis, was not accelerated after PFC distention

Reported provision of analgesia to patients with acute abdominal pain in Canadian paediatric emergency departments

Objectives: Evidence exists that analgesics are underutilized, delayed, and insufficiently dosed for emergency department (ED) patients with acute abdominal pain. For physicians practicing in a Canadian paediatric ED setting, we (1) explored theoretical practice variation in the provision of analgesia to children with acute abdominal pain; (2) identified reasons for withholding analgesia; and (3) evaluated the relationship between providing analgesia and surgical consultation. Methods: Physician members of Paediatric Emergency Research Canada (PERC) were prospectively surveyed and presented with three scenarios of undifferentiated acute abdominal pain to assess management. A modified Dillman’s Tailored Design method was used to distribute the survey from June to July 2014. Results: Overall response rate was 74.5% (149/200); 51.7% of respondents were female and mean age was 44 (SD 8.4) years. The reported rates of providing analgesia for case scenarios representative of renal colic, appendicitis, and intussusception, were 100%, 92.1%, and 83.4%, respectively, while rates of providing intravenous opioids were 85.2%, 58.6%, and 12.4%, respectively. In all 60 responses where the respondent indicated they would obtain a surgical consultation, analgesia would be provided. In the 35 responses where analgesia would be withheld, 21 (60%) believed pain was not severe enough, while 5 (14.3%) indicated it would obscure a surgical condition. Conclusions: Pediatric emergency physicians self-reported rates of providing analgesia for acute abdominal pain scenarios were higher than previously reported, and appeared unrelated to request for surgical consultation. However, an unwillingness to provide opioid analgesia, belief that analgesia can obscure a surgical condition, and failure to take self-reported pain at face value remain, suggesting that the need exists for further knowledge translation efforts

Appendectomy versus non-operative treatment for acute uncomplicated appendicitis in children: study protocol for a multicentre, open-label, non-inferiority, randomized controlled trial

Background: Appendectomy is considered the gold-standard treatment for acute appendicitis. Recently the need for surgery has been challenged in both adults and children. In children there is growing clinician, patient and parental interest in non-operative treatment of acute appendicitis with antibiotics as opposed to surgery. To date no multicentre randomised controlled trials that are appropriately powered to determine efficacy of non-operative treatment (antibiotics) for acute appendicitis in children compared to surgery (appendectomy) have been performed.Methods: Multicentre, international, randomised controlled trial with a non-inferiority design. Children (age 5-16 years) with a clinical and/or radiological diagnosis of acute uncomplicated appendicitis will be randomised (1:1 ratio) to receive either laparoscopic appendectomy or treatment with intravenous (minimum 12 hours) followed by oral antibiotics (total course 10 days). Allocation to groups will be stratified by gender, duration of symptoms (&gt; or&lt; 48 hours) and centre. Children in both treatment groups will follow a standardised treatment pathway. Primary outcome is treatment failure defined as additional intervention related to appendicitis requiring general anesthesia within 1 year of randomization (including recurrent appendicitis) or negative appendectomy. Important secondary outcomes will be reported and a cost effectiveness analysis will be performed. The primary outcome will be analysed on a non-inferiority basis using a 20% non-inferiority margin. Planned sample size is 978 children.Discussion: The APPY trial will be the first multicentre randomised trial comparing non-operative treatment with appendectomy for acute uncomplicated appendicitis in children. The results of this trial have the potential to revolutionise the treatment of this common gastrointestinal emergency. The randomised design will limit the effect of bias on outcomes seen in other studies.</p

Appendectomy versus observation for appendicitis in neutropenic children with cancer

BACKGROUND: Optimal management of neutropenic appendicitis (NA) in children undergoing cancer therapy remains undefined. Management strategies include upfront appendectomy or initial nonoperative management. We aimed to characterize the effect of management strategy on complications and length of stay (LOS) and describe implications for chemotherapy delay or alteration. METHODS: Sites from the Pediatric Surgery Oncology Research Collaborative performed a retrospective review of children with NA over a 6-year period. RESULTS: Sixty-six children, with a median age of 11 years (range 1-17), were identified with NA while undergoing cancer treatment. The most common cancer diagnoses were leukemia (62%) and brain tumor (12%). Upfront appendectomy was performed in 41% of patients; the remainder had initial nonoperative management. Rates of abscess or perforation at diagnosis were equivalent in the groups (30% vs 24%; P =.23). Of patients who had initial nonoperative management, 46% (17 of 37) underwent delayed appendectomy during the same hospitalization. Delayed appendectomy was due to failure of initial nonoperative management in 65% (n = 11) and count recovery in 35% (n = 6). Cancer therapy was delayed in 35% (n = 23). Initial nonoperative management was associated with a delay in cancer treatment (46% vs. 22%, P =.05) and longer LOS (29 vs 12 days; P =.01). Patients who had initial nonoperative management and delayed appendectomy had a higher rate of postoperative complications (P,.01). CONCLUSIONS: In pediatric patients with NA from oncologic treatment, upfront appendectomy resulted in lower complication rates, reduced LOS, and fewer alterations in chemotherapy regimens compared to initial nonoperative management