Meckel′s diverticulum and ectopic epithelium: Evaluation of a complex relationship

Introduction: Meckel′s diverticulum is the most common congenital anomaly of the gastrointestinal tract. Currently, for any incidentally discovered Meckel′s diverticulum, the management approach is based on weighing the statistical odds of future complications against the risks of a diverticulectomy. Materials and Methods: The temporal relationship between age at Meckel′s diverticulectomy and the presence of ectopic epithelium was evaluated in our series. A meta-analysis of all reported recent literature on this condition was subsequently performed to evaluate the strength of the relationship between ectopic epithelium and symptomatic Meckel′s diverticulum. Results: There was a paucity of ectopic epithelium in Meckel′s diverticulectomy specimens in infants operated on at less than 1 year of age. Having two or more ectopic epithelia in a diverticulum does not appear to carry an additive risk for complications. The meta-analysis confirmed that ectopic epithelium was the most significant factor that influenced surgical intervention in all series of Meckel′s diverticulum. Conclusion: The relationship between ectopic epithelium and the development of symptomatic Meckel′s diverticulum is complex. Further understanding of the development of ectopic rests in the diverticulum will facilitate elucidating the pathophysiology in symptomatic cases

Pediatric firearm injury trends in the United States: A national trauma data bank (NTDB) analysis.

AIM OF STUDY: Firearm injuries are the second leading cause of injury-related death in the USA in children less than 18. We compared overall and intent-specific firearm hospitalizations across age group and race to understand recent trends. METHODS: A retrospective cohort of 20,083 children from the national trauma data bank involved in incidences of firearm discharges from 2013 to 2017 was divided by race, discharge intent, gun type, and four age groups: infants (ages 0-2), toddlers (3-6), children (7-12), and adolescents (13-18). Discharge intent and gun type were determined by ICD-9-CM and ICD-10-CM External Causes of Injury codes. Injury severity score (ISS), hospital discharge disposition, and length of stay (LOS) were used as predictors for morbidity and mortality. RESULTS: From 2013 to 2017, there were on an average 4016 firearm injuries reported to the NTDB (n = 20,083). 71% (n = 14,313) of the incidents were assaults. Victims who identified as African American and Caucasian made up 60% (n = 11,890) and 26% (n = 5162) of the total victims, respectively, and were predominantly male (86%, n = 17,202). Victims who identified as Caucasian made up 70% of suicides (n = 819), while African Americans made up 70% of assaults (n = 9733). 87% (n = 17,525) of the patient population were adolescents. The number of accidental firearm discharges compared to firearm assaults was greater for toddlers, while the opposite was true for infants, children, and adolescents. Average LOS by age group varied each year, though children had the highest total average LOS. Average ISS was highest for infants and adolescents (11.5 and 10.4) and American Indians and Caucasians (10.1 and 11.1). Overall mortality rate was 6% (n = 1220) and had no significant differences between years. Mortality rate was highest for infants (7%, n = 25). CONCLUSIONS: Adolescent males and African Americans were disproportionately affected by overall and assault-specific firearm discharges. Firearm injury prevention legislation is critical to prevent these injures

Congenital mesenteric defect: Description of a rare cause of distal intestinal obstruction in a neonate

AbstractINTRODUCTIONInternal hernias are a rare cause of bowel obstruction in the neonate and present with bilious vomiting. Newborns may be at risk of loss of significant length of bowel if this rare condition is not considered in the differential diagnosis of bilious emesis.PRESENTATION OF CASEWe report a case of a twin with an internal hernia through a defect in the ileal mesentery who presented with neonatal bowel obstruction. The patient had a microcolon on the contrast enema suggesting that the likely etiology was an intra-uterine event most likely a vascular accident that prevented satisfactory meconium passage into the colon.discussionAn internal hernia is rarely considered in the differential diagnosis of distal bowel obstruction in a neonate with a microcolon. Congenital trans-mesenteric hernias constitute only 5–10% of internal hernias. True diagnosis of trans-mesenteric hernias is difficult due to lack of specific radiology or laboratory findings to confirm the suspicion.conclusionWhen clinical and radiological findings are not classical, rare possibilities such as an internal hernia must be considered in the differential diagnosis, to avoid catastrophic bowel loss

Pediatric Nonaccidental Trauma: Experience at a Level 1 Trauma Center

Introduction. Pediatric nonaccidental trauma (NAT) is difficult to diagnose. Several isolated injuries in NAT could happen in the setting of accidental trauma (AT), and having a high index of suspicion is important to correctly identify abuse. NAT has a significant mortality rate if the sentinel event is not adequately diagnosed, and the infant is not separated from the perpetrator. Level 1 pediatric trauma centers (PTC) see a significant number of NAT. We evaluated the injury patterns of NAT admissions at our level 1 PTC. Methods. Retrospective analysis of all cases of NAT for children under the age of two admitted at an ACS level 1 pediatric trauma center between the years of 2016 and 2018. Charts were queried for demographic data, injury patterns, mortality, and disposition. Correlation between disposition status and injury patterns was performed. The Fisher Exact test and student t-test were used to study the significance of differences in categorical and continuous data, respectively. Results. 32/91 (35%) trauma patients under the age of two years were diagnosed as NAT in the three-year study period. 21/32 (39%) male and 11/26 (42%) female admissions were confirmed NAT (p=NS). 20 were under 1 year of age, and 12 were aged between 1 and 2 years (p=NS). 13 (41%) were Caucasian, 6 (19%) were Hispanic/Latino, 11 (34%) were Black, and 2(6%) were of unknown ethnicity (p=NS). Facial, torso, lower extremity, retinal, and internal organ injury were significantly more common with NAT. Medicaid coverage was noted in 31/32 (97%) NAT patients. 20/32 (62.5%) patients were legally displaced as a result of the NAT. Conclusion. 1/3rd of all admissions at a pediatric level 1 trauma center were identified as NAT. A high index of suspicion is necessary to not miss NAT, as injury patterns are variable. Nearly 1/3rd of all victims go back to the same environment where they sustained NAT increasing their susceptibility to future NAT

Wernicke's encephalopathy in an adolescent following bariatric surgery

Bariatric surgery is a common and effective treatment modality for morbid obesity worldwide. In the pediatric population, the most commonly performed procedure is the sleeve gastrectomy (SG), and it is considered a restrictive operation, limiting the amount of food a person can tolerate. Its popularity in children lies in its efficacy and low-risk profile. However, side-effects and risks still exist and must be monitored for carefully. Here, we present a case of a 16-year-old female who presented with a chief complaint of paraparesis and confused mental state following a gastric sleeve procedure for obesity a few months prior. MRI of the head demonstrated hyperintensities in dorsomedial parts of her bilateral thalami, mamillary bodies, periaqeductal grey matter, and inferior aspect of the tectal plate, thereby confirming the diagnosis of Wernicke's encephalopathy (WE). There have been only two previous reports of WE following SG in a pediatric patient that have been reported in the literature. We suggest that the mechanism for her thiamine deficiency was secondary to a preexisting subclinical deficiency that became clinically significant secondary to the food restriction imposed by her SG procedure. Pediatric patients who receive a SG procedure should be evaluated for preexisting Thiamine deficiency, started on supplementation at adequate doses and observed for the development of overt deficiency that can potentially result in WE. We recommend using MRI to support the clinical diagnosis due to difficulty in obtaining immediate results from laboratory tests for Vitamin B1 levels. Our review suggests that Hispanic ethnicity and female sex increase the risk of Wernicke's encephalopathy after bariatric surgery

A nationwide database analysis of demographics and outcomes related to Extracorporeal Membrane Oxygenation (ECMO) in congenital diaphragmatic hernia.

PURPOSE: The aim of the study was to understand the use of Extracorporeal Membrane Oxygenation (ECMO) in congenital diaphragmatic hernia (CDH) and its outcomes. METHODS: The 2016 Kid\u27s Inpatient Database (KID) obtained from the national Healthcare Cost and Utilization Project (HCUP) was used to obtain CDH birth, demographic, and outcome data associated with ECMO use. Categorical variables were analyzed and odds ratios (OR) with 95% confidence intervals (CI) are reported for variables found to have significance (p \u3c 0.05). Appropriate regressions were used for comparing categorical and continuous data using SPSS 25 for Macintosh. RESULTS: The database contained 1189 cases of CDH, of which 133 (11.2%) received ECMO. The overall mortality of neonates with CDH was 18.9% (225/1189). Newborns with CDH on ECMO had a survival of 46% (61/133) compared to 85.5% without ECMO (903/1056) (OR 6.966, p \u3c 0.001, 95% CI 4.756-10.204). ECMO increased length of stay from 24.6 to 69.8 days (OR 2.834, p \u3c 0.001, 95% CI 2.768-2.903) and average cost from $375,002.20 to$1641,586.83 (OR 4.378, p \u3c 0.001, 95% CI 3.341-5.735). CONCLUSIONS: Increased length of stay, costs, and outcomes with ECMO use in CDH should prompt an examination of criteria necessitating ECMO

Diaphragmatic Eventration Misdiagnosed as Diaphragmatic Hernia in a Preterm Infant with Respiratory Distress: A Case Report and Review of Diagnosis and Management

Introduction: Eventration of diaphragm is a congenital anomaly that results from a failure of muscular development of part or all of the hemidiaphragm. Clinically, eventration of diaphragm refers to an abnormal elevation of an intact diaphragm. In some cases, it may be difficult to distinguish it from congenital diaphragmatic hernia (CDH).Case Presentation: A three-week-old male, born prematurely at 30 weeks GA, who was weaned off respiratory support on the first DOL, developed respiratory distress. A chest X-ray obtained at that time when compared with the one from DOL#1 showed a new right lower lobe (RLL) opacity, suggestive of lobar atelectasis. Chest MRI revealed the “atelectatic” RLL to be the liver, raising the suspicion for CDH. Thoracoscopic evaluation revealed instead a diaphragmatic eventration, for which a plication procedure was performed.Discussion: Respiratory distress is the most common clinical manifestation of CDH and diaphragmatic eventration. As in the case of CDH, diaphragmatic eventration can be associated with various degrees of pulmonary hypoplasia due to the compression of the developing lung by the abdominal viscera. The degree of pulmonary hypoplasia and respiratory distress vary depending upon the size of the defect. Patients may be asymptomatic with small localized defects, whereas large defects in neonates can cause respiratory distress.Conclusion: Symptoms of diaphragmatic eventration can be misleading, becoming a diagnostic dilemma despite a proper evaluation. Eventration must be considered in the differential diagnosis of a newborn with respiratory symptoms and a new CXR image suggestive of lower lobe infiltrate.&nbsp;<br

The Hunger Games: A Systematic Review of Pediatric Bariatric Surgery

Introduction: As childhood obesity in the US reaches alarming levels, bariatric surgery is becoming a more commonly implemented treatment option due to its high success rate compared with behavioral modification and medical therapy alone. The mechanisms by which it affects body weight and metabolic homeostasis are not well understood. The goal of the present study was to perform a systematic review of pediatric bariatric surgery to evaluate its effectiveness in the context of the physiologic changes that are produced.Materials and Methods: The PubMed database, MEDLINE, Springer Link, Cochrane, and article bibliographies were used to identify original English-language articles published between 2009 and 2014 evaluating pediatric patients. Included studies evaluated patients undergoing Roux en Y gastric bypass, laparoscopic sleeve gastrectomy or laparoscopic adjustable gastric banding and analyzed weight loss, BMI reduction, postoperative complications and co-morbidity resolution post-procedure; all articles had at least a one year follow up.Results: Five studies were included in our evaluation of the three most common bariatric procedures currently performed on the pediatric population for a total of 1,395 patients. The average patient age was 18.2 and 72% of patients were females. Most patients underwent roux en Y gastric bypass (RYGB) (n=659), followed by laparoscopic adjustable gastric banding (LAGB) (n=554) and finally laparoscopic sleeve gastrectomy (LSG) (n=149). The greatest decrease in BMI was seen in the RYGB group who lost an average BMI of 16.7kg/m2, followed by the LSG group with a loss of 14.0kg/m2. The LAGB patients lost 8.2kg/m2. Postoperative complications varied in severity, however the only death occurred in a patient following RYGB.Conclusion:Bariatric surgery has proven to reduce BMI and weight in the adolescent population resulting in an enhanced quality of life and resolution of significant co-morbidities. The mechanism of weight loss is different among the three most common procedures, as is their affect on gut hormone profiles. Ghrelin may have an effect on weight loss, however it is not solely responsible for the procedures’ weight loss effect as levels vary postoperatively. RYGB has been shown to produce the greatest weight loss but postoperative ghrelin levels are not consistently decreased compared to LSG, which demonstrates low ghrelin levels routinely. Additional studies are needed to measure weight loss as it relates to postoperative gut hormone levels, as determining the physiologic changes after these procedures will guide future therapies