The frequency of mediastinal injury in acute posterior sternoclavicular dislocations: a multicenter study.
Fournier MN, Sinclair MR, Zheng ET et al.
J Pediatr Orthop (2020) 40 :e927-e931.
Acute posterior sternoclavicular dislocations are rare injuries that can be associated with injury to the great vessels and other mediastinal structures, from either initial trauma or subsequent treatment. This has resulted in recommendation that a thoracic or vascular surgeon be present during operative treatment. The authors retrospectively reviewed records of 125 skeletally immature patients, younger than 25 years (110 boys and 15 girls), from six participating centers over a period of 19 years (1999–2018). Acute injuries occurring within 10 days of presentation were included. Injury/compression of the mediastinal structures was characterized on preoperative CT scans. Sporting injury (74%) was the most common cause of acute posterior sternoclavicular dislocations, followed by falls from standing height (10%) and high-energy motor vehicle accident (10%). Compression of ipsilateral brachiocephalic vein was the most common finding on cross-sectional imaging (50%). Treatment consisted of closed reduction in 11 patients, and open reduction and internal fixation in 114 (90%). The authors found that although more than 50% of injured patients had evidence of external vascular compression, no mediastinal injuries requiring intervention were identified. The authors concluded that open reduction of acute posterior sternoclavicular dislocations can be safely performed in acute settings.
Resolution of hydronephrosis after pyeloplasty in children.
Värelä S, Omling E, Börjesson A et al.
J Pediatr Urol. doi.org/10.1016/j.jpurol.2020.10.031
Ureteropelvic junction obstruction is the third most common cause of antenatal hydronephrosis and is usually treated with Anderson-Hynes pyeloplasty. In this retrospective study the authors sought to determine the time of resolution of hydronephrosis following pyeloplasty, by type of obstruction and surgical approach. Obstruction was defined as extrinsic, caused by a crossing vessel at the ureteropelvic junction, or intrinsic, without a crossing vessel or other apparent cause of obstruction. They included 125 children ages 15 years and younger, treated with either open or robotic-assisted laparoscopic pyeloplasty. Indications for pyeloplasty were ureteropelvic junction obstruction with progressive impairment of renal function on Tc99m mercaptoacetyltriglycine (MAG3) scintigraphy, or presence of symptoms, such as pain or recurrent upper urinary tract infections. The children were followed for 2 years with US (performed at 1, 3, 6, 12 and 24 months) and MAG3 scan (performed at 3 and 12 months). Resolution of hydronephrosis was defined as anteroposterior (AP) diameter of renal pelvis of less than10 mm or a decrease in AP diameter to less than 50% of preoperative AP diameter. The degree of hydronephrosis had resolved by 90% and 93% at 12 and 24 months, respectively. All children with persistent urinary tract dilatation had improved drainage and stable or improved function on MAG3. There was no difference in time of resolution of hydronephrosis between types of obstruction (intrinsic or extrinsic) and between types of surgery (open versus robotic-assisted laparoscopy). Rate of resolution of hydronephrosis was not related to severity of urinary tract dilatation. The authors concluded that hydronephrosis resolves within 24 months after pyeloplasty in most children, and type of obstruction and surgical approach do not affect the time to resolution. They recommended continued follow-up with US in children with persistent dilatation, and the use of MAG3 scintigraphy if the dilatation increases. The authors further suggested that children with complete resolution at 12 months post-surgery do not need further follow-up.
A simple screening tool for an unfavorable bladder in children with myelomeningocele: is the height to width ratio of the cystogram useful to predict high-pressure bladder?
Kumano Y, Hayashi C, Gohbara A et al.
J Pediatr Urol (2020) 16 :839e1-839e5.
Urological follow-up in children with myelomeningocele is performed for early identification of unfavorable bladder, which is characterized by high storage pressure, poor bladder compliance and irregular shape. Intravesical pressure of 40 cm H2O at the time of urethral leakage is a critical value in upper urinary tract deterioration. Videourodynamic study (VUDS) is the key exam in this subset of children. However, because of the difficulty of the procedure and its interpretation, VUDS is performed in few children’s hospitals, whereas cystography is widely performed. The aim of this study was to determine the usefulness of the height-to-width ratio of the urinary bladder on cystogram, as a screening tool for identifying high-pressure bladder in children with myelomeningocele. The authors retrospectively reviewed records of 81 children (41 boys and 40 girls younger than 13 years) with myelomeningocele who underwent VUDS. Children with history of bladder surgery, vesicoureteral reflux grades III–V, children not needing clean intermittent catheterization, and uncooperative children resulting in inaccurate VUDS were excluded from the study. Maximum detrusor pressure (MDP) was defined as pressure at end-filling or at leak. Height-to-width ratio was calculated as ratio of maximum height to maximum width at maximum bladder capacity. Children were categorized into two groups: children with high-pressure bladder (MDP 40 cm H2O or greater) and those with low-pressure bladder (MDP less than 40 cm H2O) on VUDS. Height-to-width ratio was significantly higher for high-pressure bladders than low-pressure bladders. The cut-off score between groups was 1.4. The sensitivity and specificity of height-to-width ratio in discriminating children with high-pressure bladder from all children with myelomeningocele were 87% and 57%, respectively, with receiver-operator characteristics area under the curve (AUC) of 0.71. The authors indicated that a limitation of the study was that this method did not take into consideration the presence or absence of trabeculations, which are related to intravesical pressure. The authors concluded that height-to-width ratio is a useful tool for objectively evaluating bladder shape and that the cut-off point of 1.4 could be used as a screening tool for identifying high-pressure bladder in this population.
Additional value of advanced neurosonography and magnetic resonance imaging in fetuses at risk for brain damage.
Van Der Knoop BJ, Zonnenberg IA, Verbeke JI et al.
Ultrasound Obstet Gynecol (2020) 56: 348–358.
There is debate among obstetricians regarding use of fetal MRI in addition to fetal neurosonography for diagnosing brain abnormalities. This prospective observational study from two Dutch tertiary medical centers evaluated pregnant women whose fetuses were at risk for brain anomalies based on earlier US brain anatomy, concern for congenital infection (cytomegalovirus or toxoplasmosis), alloimmune thrombocytopenia, early onset fetal growth disturbance, trauma, hydrops or monochorionic twinning. Fetal US included three routine images in the axial plane followed by advanced multiplanar fetal neurosonography exam consisting of three axial, six coronal and five sagittal images, which was performed biweekly. The MR exam included a diffusion-weighted imaging sequence. After birth, the infants had neonatal neurosonography at 24 h and at term-equivalent age, and an MR at term-equivalent age. Postnatal imaging searched for periventricular, basal ganglia and thalamic abnormalities in echogenicity as well as intraventricular hemorrhage, and MR searched for signal intensity abnormalities. The children were followed up with psychomotor evaluation at 1 year of age and with infant development analysis as well as behavioral, sensory and linguistic analyses and the Bailey Scale of Infant Development III at 2 years. There were 39 infants who completed the entire study. Of those 39, 6 showed brain abnormality on routine axial US images of the fetal brain, 21 showed periventricular abnormality on multiplanar neurosonography as increased periventricular abnormality, while 2 showed signal intensity changes on MRI. Intraventricular hemorrhage was seen in 3 infants on axial US, 11 on multiplanar advanced US and 1 on the MR exam. Basal ganglia or thalamic abnormality was seen in 0 routine US exams, 12 advanced multiplanar US exams and 0 MR exams. At 2 years of age, 20 children had scores of at least 1 standard deviation below the mean, suggesting behavioral (n=5), sensory (n=17) or linguistic (n=6) developmental delay. The authors concluded that in this group at risk for neurodevelopmental abnormalities, advanced multiplanar US was superior to routine US as well as MR in noting imaging findings that are harbingers of those abnormalities affecting the developmental parameters studied. The authors’ findings disagreed with two much larger studies cited by the authors, which suggested additional value from prenatal MR imaging. The authors acknowledged that their limited numbers of participants and limited MR sequences were limitations of their work. However, they noted that their fetal US examinations were enhanced by transvaginal examinations, in which transvaginal placement of the transducer close to the fetal skull and the anterior fontanel provides images that can appear similar to neonatal neurosonograms.
Abstracted by: Preet Sandhu, MD.
Harris L. Cohen, MD.
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