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Non-accidental trauma (NAT) is a major cause of morbidity and mortality for children around the world and most significantly impacts children under one year of age. Prompt and comprehensive treatment of these children relies on a high index of suspicion from any medical provider that treats pediatric patients. This review discusses those most at risk for experiencing NAT, and common initial presentations, to assist providers in the identification of potential victims. In addition, this review provides guidance on the recommended workup for these patients so that the full extent of associated injuries may be identified and the appropriate healthcare team may be assembled.

Abstract Background Older aged adults and those with pre-existing conditions are at highest risk for severe COVID-19 associated outcomes. Methods Using a large dataset of genome-wide RNA-seq profiles derived from human dermal fibroblasts (GSE113957) we investigated whether age affects the expression of pattern recognition receptor (PRR) genes and ACE2, the receptor for SARS-CoV-2. Results Extremes of age are associated with increased expression of selected PRR genes, ACE2 and four genes that encode proteins that have been shown to interact with SAR2-CoV-2 proteins. Conclusions Assessment of PRR expression might provide a strategy for stratifying the risk of severe COVID-19 disease at both the individual and population levels.

Superior mesenteric artery (SMA) syndrome is a rare condition in which the third portion of the duodenum is compressed between the SMA anteriorly and the aorta posteriorly. The resulting duodenal obstruction is often due to rapid weight loss and commonly resolves with distal tube feeds. Occasionally, patients fail this medical management, and require a surgical bypass. We present the case of a male adolescent who presented with SMA syndrome and underwent laparoscopic duodenojejunostomy using a retroperitoneal technique that avoids crossing of the transverse colon and does not create a duodenal diverticulum proximal to the mesenteric root.

New aspects concerning the photodegradation (PD) of ampicillin are reported by photoluminescence (PL), Raman scattering and FTIR spectroscopy. The exposure of ampicillin in the absence (AM) and in the presence of the excipient (AMP) to UV light leads to an intensity diminution of the photoluminescence excitation (PLE) and photoluminescence (PL) spectra and the emergence of a new IR band at 3450 cm−1. The photoluminescence studies demonstrate that the AM PD is amplified in the presence of excipients and an alkaline medium. In this last case, the PD process of AM involves the emergence of new compounds, whose presence is highlighted by: (i) the emergence of the isosbestic point at 300 nm in the UV-VIS spectra; (ii) a change in the ratio between the absorbance of IR bands situated in the spectral ranges 1200–1660 and 3250–3450 cm−1; and (iii) a change in the ratio between the intensities of the Raman lines localized in the spectral ranges 1050–1800 and 2750–3100 cm−1. A chemical mechanism of the PD processes of AM in an alkaline medium is proposed.

Since the first reported case in 1959, ventricular cholecystic (VC) shunts have been used as an alternative treatment for hydrocephalus, most often used in the event of ventriculoperitoneal shunt failure. To date, all surgical placements of VC shunts have been performed using an open operative technique. This case report describes the laparoscopic placement of a VC shunt in a 20-month-old male child. A three-year follow-up appointment after surgery demonstrated no reported complications. We describe the first documented laparoscopic technique for this procedure and discuss a decision algorithm for VC shunts as well as some of the benefits of this minimally invasive approach. Keywords: Ventricular cholecystic shunt, Ventricular gallbladder shunt, Ventriculobiliary shunt

Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory disorder which has been first reported in 2001 by Hamano and colleagues in a patient with autoimmune sclerosing pancreatitis. Almost every organ in the human body can be affected by IgG4-RD from infiltration with IgG4-positive plasma cells. Involvement of lungs with IgG4 is reported previously, but still, there is no clear picture of the pathophysiology behind lung involvement. Here, we are presenting a patient who has IgG4-RD presenting as pseudotumor of the lungs.

Ulcerative colitis (UC) is a chronic systemic inflammatory condition primarily involving the large bowel mucosa with relapsing and remitting episodes. It is also associated with multiple extra-intestinal manifestations [EIM], including skeletal muscle involvement which is rare. Review of the literature reported only a few cases of inflammatory myositis in association with UC. We report an unusual presentation of recurrent inflammatory myositis of lower extremities in a 28-year-old male with quiescent UC and on long-term mesalamine therapy.

Fetus in Fetu (FIF) is a rare congenital anomaly in which a malformed parasitic twin is found within the body of a living child or adult. In this case report, an 18 month-old male child presented with a large abdominal mass and failure to thrive. Imaging studies confirmed the presence of a large retroperitoneal fetus in fetu with significant mass effect of the adjacent structures. A surgical resection was performed and pathology confirmed the diagnosis. These rare cases have become more frequently reported and a review of the literature for the past 15 years will describe the demographics, updated genetic findings, pathology and outcomes of this unusual tumor. Recent findings will also discuss an infrequent association with teratomas that may warrant a longer follow-up for surveillance of malignancy.

Objective: To compare the recurrence rate after conjunctival autograft alone versus conjunctival autograft with mitomycin-C in the treatment of primary and recurrent pterygium. Methods: This was a prospective, randomized, interventional comparative study of patients with primary and recurrent pterygium who were randomized to receive either simple excision with conjunctival autograft (CA) or simple excision with CA and mitomycin-C applied. They were followed up for 6 months and observed for recurrence of the pterygium. Statistical analyses were used to compare the 2 groups. Results: Fifty-eight patients (62 eyes) diagnosed with primary and recurrent pterygium were evaluated. The mean age was 44.81 ± 12.35 years (range 25 to 70 years). Thirty eyes were treated with conjunctival autograft (15 primary, 15 recurrent) and 32 eyes (17 primary, 15 recurrent) with conjunctival autograft combined with intraoperative application of low-dose mitomycin-C (0.02% for 3 minutes). The mean follow-up period was 25 ± 1.40 months (range 24 to 28 months). There was a 3.22% recurrence rate (2 eyes) from the recurrent pterygium group. There was no significant difference in the rate of recurrence (p = 0.53) between the 2 treatments for both primary and recurrent pterygium. No mitomycin C-related complication was observed during the length of the study. Conclusion: Conjunctival autograft surgery alone for primary and recurrent pterygium is effective and safe in reducing the recurrence rate of pterygium within 6 months.

A 12 year-old boy presented with right lower abdominal and groin pain. Intraoperatively, he was found to have acute appendicitis associated with a strangulated Meckel's diverticulum, or Littre's hernia. Both the appendix and Meckel's diverticulum were resected laparoscopically while the inguinal hernia was repaired four months later. We present an uncommon finding of a strangulated Littre's hernia discovered concurrently with acute appendicitis. The presentation, management and review of the literature of this condition are discussed.

IntroductionData examining rates of postoperative complications among SARS-CoV-2 positive children are limited. The purpose of this study was to evaluate the impact of symptomatic and asymptomatic SARS-CoV-2 positive status on postoperative respiratory outcomes for children.MethodsThis retrospective cohort study included SARS-CoV-2 positive pediatric patients across 20 hospitals who underwent general anesthesia from March to October 2020. The primary outcome was frequency of postoperative respiratory complications, including: high-flow nasal cannula/non invasive ventilation, reintubation, pneumonia, Extracorporeal Membrane Oxygenation (ECMO), and 30-day respiratory-related readmissions or emergency department (ED) visits. Univariate analyses were used to evaluate associations between patient and procedure characteristics and stratified analyses by symptoms were performed examining incidence of complications.ResultsOf 266 SARS-CoV-2 positive patients, 163 (61.7%) were male, and the median age was 10 years (interquartile range 4-14). The majority of procedures were emergent or urgent (n = 214, 80.5%). The most common procedures were appendectomies (n = 78, 29.3%) and fracture repairs (n = 40,15.0%). 13 patients (4.9%) had preoperative symptoms including cough or dyspnea. 26 patients (9.8%) had postoperative respiratory complications, including 15 requiring high-flow oxygen, 8 with pneumonia, 4 requiring non invasive ventilation, 3 respiratory ED visits, and 2 respiratory readmissions. Respiratory complications were more common among symptomatic patients than asymptomatic patients (30.8% vs. 8.7%, p = 0.01). Higher ASA class and comorbidities were also associated with postoperative respiratory complications.ConclusionsPostoperative respiratory complications are less common in asymptomatic versus symptomatic SARS-COV-2 positive children. Relaxation of COVID-19-related restrictions for time-sensitive, non urgent procedures in selected asymptomatic patients may be reasonably considered. Additionally, further research is needed to evaluate the costs and benefits of routine testing for asymptomatic patients.Level of evidenceIii, Respiratory complications.

BackgroundSurgical care is an important, yet often neglected component of child health in low- and middle-income countries (LMICs). This study examines the potential impact of scaling up surgical care at first-level hospitals in LMICs within the first 20 years of life.MethodsEpidemiological data from the global burden of disease 2019 Study and a counterfactual method developed for the disease control priorities; 3rd Edition were used to estimate the number of treatable deaths in the under 20 year age group if surgical care could be scaled up at first-level hospitals. Our model included three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries.ResultsAn estimated 314,609 (95% UI, 239,619-402,005) deaths per year in the under 20 year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs. Most of the treatable deaths are in the under-5 year age group (80.9%) and relates to improved obstetrical care and its effect on reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries are the leading cause of treatable deaths after age 5 years. Sixty-one percent of the treatable deaths occur in lower middle-income countries. Overall, scaling up surgical care at first-level hospitals could avert 5·1% of the total deaths in children and adolescents under 20 years of age in LMICs per year.ConclusionsImproving the capacity of surgical services at first-level hospitals in LMICs has the potential to avert many deaths within the first 20 years of life.

Objectives: To determine the efficacy of a 7-day treatment of methylprednisolone 16mg in reducing the size of nasal polyps and on improvement of nasal symptoms. Methods: Design: Randomized double-blind placebo-controlled trial Setting: Out-patient department of the East Avenue Medical Center Patients: Patients 18 years old and above with nasal polyposis determined by history and endoscopic examination Results: There was a significant decrease in polyp size by an average of 16% (P < .05) among 12 out of the 23 patients (52.17 %) in the steroid group versus placebo. The treatment group also exhibited an improvement in nasal symptoms of rhinorrhea, congestion and anosmia compared to the placebo. Conclusion: Medical treatment with oral methylprednisolone given at a low dose of 16 mg for one week resulted in reduction of the size of nasal polyps and improved the symptoms of rhinorrhea, nasal congestion and anosmia. Other associated symptoms like headache, epistaxis, sneezing, itchiness, epiphora, cough, postnasal drip, throat discomfort, facial pain, eye complaints and fever did not differ between the steroid and placebo groups. Recommendation: One week of oral steroids can be used to treat nasal polyps initially. If there is response, this mode of management can be combined with a long-term course of intranasal steroid sprays9,10. Patients who do not respond may be referred for surgery. Keywords: Nasal polyposis, methylprednisolone, rhinorrhea, nasal congestion, anosmia

We report the case of a 17-year-old male who presented with intractable nausea and vomiting. Cross-sectional imaging revealed a large retrogastric abdominal mass. Fine needle aspiration done via endoscopic ultrasound (EUS) was nondiagnostic. Exploratory laparotomy revealed a large inflammatory mass densely adherent to the stomach and retroperitoneum. Incisional biopsy frozen section revealed spindle cells, and subsequent resection of the mass with en-bloc subtotal gastrectomy with Roux-en-y gastrojejunostomy reconstruction was performed. Final pathology demonstrated a lymphatic malformation with reactive myofibroblastic proliferation. Inflammatory abdominal lymphatic malformations are especially rare and not well described in the literature. These masses may present diagnostic challenges until the specimen is sent for pathologic analysis.

BackgroundEconomic, social, and psychologic stressors are associated with an increased risk for abusive injuries in children. Prolonged physical proximity between adults and children under conditions of severe external stress, such as witnessed during the COVID-19 pandemic with "shelter-in-place orders", may be associated with additional increased risk for child physical abuse. We hypothesized that child physical abuse rates and associated severity of injury would increase during the early months of the pandemic as compared to the prior benchmark period.MethodsWe conducted a nine-center retrospective review of suspected child physical abuse admissions across the Western Pediatric Surgery Research Consortium. Cases were identified for the period of April 1-June 30, 2020 (COVID-19) and compared to the identical period in 2019. We collected patient demographics, injury characteristics, and outcome data.ResultsThere were no significant differences in child physical abuse cases between the time periods in the consortium as a whole or at individual hospitals. There were no differences between the study periods with regard to patient characteristics, injury types or severity, resource utilization, disposition, or mortality.ConclusionsApparent rates of new injuries related to child physical abuse did not increase early in the COVID-19 pandemic. While this may suggest that pediatric physical abuse was not impacted by pandemic restrictions and stresses, it is possible that under-reporting, under-detection, or delays in presentation of abusive injuries increased during the pandemic. Long-term follow-up of subsequent rates and severity of child abuse is needed to assess for unrecognized injuries that may have occurred.

BackgroundOlder aged adults and those with pre-existing conditions are at highest risk for severe COVID-19 associated outcomes.MethodsUsing a large dataset of genome-wide RNA-seq profiles derived from human dermal fibroblasts (GSE113957) we investigated whether age affects the expression of pattern recognition receptor (PRR) genes and ACE2, the receptor for SARS-CoV-2.ResultsExtremes of age are associated with increased expression of selected PRR genes, ACE2 and four genes that encode proteins that have been shown to interact with SAR2-CoV-2 proteins.ConclusionsAssessment of PRR expression might provide a strategy for stratifying the risk of severe COVID-19 disease at both the individual and population levels.