Background: The COVID-19 pandemic had accelerated the adoption of virtual care as an extension ... more Background: The COVID-19 pandemic had accelerated the adoption of virtual care as an extension of routine clinical practice. In addition, pre-clinical undergraduate medical education was affected by the transition to both synchronous and asynchronous online learning. The objective of this study was to assess the current experience and knowledge of medical students with regards to virtual care. A secondary objective was to identify opportunities for improvement in the undergraduate medical curriculum. Methods: An electronic survey was distributed to undergraduate medical students in Canadian medical schools. Main sections of the survey addressed experience with virtual care encounters and perceived impact of virtual learning on medical education. Result: Out of our 53 respondents, the majority (80%) of medical students perceived high educational importance of virtual care encounters. 91% of the students recognized the developing role of virtual care in current and future medical pr...
Background: Literature suggests that teamwork and team performance greatly impact medical trauma ... more Background: Literature suggests that teamwork and team performance greatly impact medical trauma outcomes. While trauma simulations have been shown to improve teamwork and clinical outcomes, there is a need to establish reliable teamwork evaluation tools. This study aims to test the reliability of the Teamwork Emergency Assessment Measure (TEAM), the Trauma Teamwork Assessment Tool (TTAT) and, specifically, the teamwork domain of the TTAT (TTATtw). Methods: An expert and nonexpert panel evaluated 3 prerecorded pediatric trauma in situ simu lations using TEAM and TTAT. Inter-rater reliability was determined using intraclass coefficient (ICC; 95% CI) and Cohen's kappa for TEAM, TTAT and TTATtw. Results: Average measures ICC data for TEAM (expert 0.954, nonexpert 0.941), TTAT (expert 0.851, nonexpert 0.828) and TTATtw (expert 0.964, nonexpert 0.889) proved to be "extremely" reliable for both expert and nonexpert panels. Single measures ICC data for TEAM (expert 0.591, nonexpert 0.676), TTAT (expert 0.326, nonexpert 0.342) and TTATtw (expert 0.445, nonexpert 0.711) demonstrated "fair to good," "poor" and "fair to good" reliability for both panels, respectively. Kappa indicated "moderate" agreement between expert and nonexpert panels for TEAM (0.467) and TTATtw (0.497) and indicated "fair" agreement for TTAT (0.329). Conclusion: The TEAM, TTAT and TTATtw were found to be reliable instruments when used by both a panel of experts and nonexperts. Further validation studies would be beneficial to warrant the tools appropriate for teamwork evaluation in pediatric trauma simulations. The association of etomidate with mortality in trauma patients. C. Hinkewich, R. Green, J. Tallon. From Dalhousie University, Halifax, NS Background: Etomidate is a commonly used medication to facili tate emergent endotracheal intubations in trauma patients, despite concerns regarding its safety. This study examined the association of etomidate use with patient mortality in trauma patients. Methods: This study is a retrospective review of adult trauma patients who required intubation at the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, since 2000. Patients who received etomidate were compared with those who did not, with a primary outcome of 28-day mortality. Secondary outcomes included length of stay in the hospital and intensive care unit (ICU), and mechanical ventilation days. Multivariate logistic models were created adjusting for age, Injury Severity Score (ISS), sex, comorbidities and injury type. Results: We included 315 patients for analysis. Patients who received etomidate had a more recent median arrival date (November 2006 v. February 2005, p = 0.0003) and a higher ISS (23.4 v. 26.8, p = 0.03); 28-day mortality was higher in the etomidate group (20.0% v. 10.8%, p = 0.04). There was no difference in ICU length of stay, hospital length of stay or number of days requiring mechanical ventilation. Etomidate was associated with an increased mortality, with a crude odds ratio of 2.06 (95% CI 1.08-3.91, p = 0.03). After adjustment for age, female sex, ISS and comorbidity, the odds ratio was 2.00 (95% CI 0.91-4.40, p = 0.08). Conclusion: Etomidate administration for emergent endotracheal intubation in trauma patients may be associated with increased mortality. Further investigation is warranted. Definition of isolated hip fractures as an exclusion criterion in trauma centre performance evaluations: a systematic review.
Injury-international Journal of The Care of The Injured, 2014
The purpose of this study was to determine the effective dose of radiation due to computed tomogr... more The purpose of this study was to determine the effective dose of radiation due to computed tomography (CT) scans in paediatric trauma patients at a level 1 Canadian paediatric trauma centre. We also explored the indications and actions taken as a result of these scans. We performed a retrospective review of paediatric trauma patients presenting to our centre from January 1, 2007 to December 31, 2008. All CT scans performed during the initial trauma resuscitation, hospital stay, and 6 months afterwards were included. Effective dose was calculated using the reported dose length product for each scan and conversion factors specific for body region and age of the patient. 157 paediatric trauma patients were identified during the 2-year study period. Mean Injury Severity Score was 22.5 (range 12-75). 133 patients received at least one CT scan. The mean number of scans per patient was 2.6 (range 0-16). Most scans resulted in no further action (56%) or additional imaging (32%). A decision to perform a procedure (2%), surgery (8%), or withdrawal of life support (2%) was less common. The average dose per patient was 13.5mSv, which is 4.5 times the background radiation compared to the general population. CT head was the most commonly performed type of scan and was most likely to be repeated. CT body, defined as a scan of the chest, abdomen, and/or pelvis, was associated with the highest effective dose. CT is a significant source of radiation in paediatric trauma patients. Clinicians should carefully consider the indications for each scan, especially when performing non-resuscitation scans. There is a need for evidence-based treatment algorithms to assist clinicians in selecting appropriate imaging for patients with severe multisystem trauma.
Background: Long-term peritoneal dialysis (PD), especially with nonphysiological solutions, is af... more Background: Long-term peritoneal dialysis (PD), especially with nonphysiological solutions, is afflicted with the severe complication of encapsulating peritoneal sclerosis (EPS). Physiologic PD solutions have been introduced to reduce pH trauma. Data on peritoneal biopsies in pediatrics with long-term PD using physiological solutions are scant. Case Report: We report an adolescent who had been on 10-h continuous hourly cycles using mostly 2.27% Physioneal™ for 5 years. There were two episodes of peritonitis in October 2017 (Klebsiella oxytoca) and May 2018 (Klebsiella pneumoniae), which were treated promptly. This adolescent, who lost two kidney transplants from recurrent focal and segmental glomerulosclerosis, underwent a peritoneal membrane biopsy at the time of a third PD catheter placement, 16 months after the second renal transplant. Laparoscopically, the peritoneum appeared grossly normal, but fibrosis and abundant hemosiderin deposition were noted on histology. The thickness ...
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Purpose: Rapid sequence intubation (RSI) drugs, such as propofol, affect clinical outcomes, but t... more Purpose: Rapid sequence intubation (RSI) drugs, such as propofol, affect clinical outcomes, but this has not been examined in the pediatric population. This descriptive study compares the outcomes associated with intubation drugs used in pediatric traumatic brain injury (TBI) patients. Methods: A retrospective chart review and descriptive analysis of intubated TBI patients, ages 0-17, admitted to Children's Hospital London Health Sciences Centre (LHSC) from January 2006-December 2016 was performed. Results: Out of 259 patients intubated, complete data was available for 107 cases. Average injury severity score was 28; 46 were intubated at LHSC, 55 at primary care site, and 6 on scene. Intubation attempts were recorded in 87 of 107 paper charts. First-pass intubation success rate was 88.5%. Propofol (n = 21), midazolam (n = 31), etomidate (n = 13), and ketamine (n = 7) were the most commonly used intubation drugs. Paralytics were used in 50% of patients. Following use of propofol, Pediatric Adjusted Shock Index was increased as a result of worsening hypotension. Mean total hospital length of stay was 21 days with 7.5 days in ICU. Survival was 87%. Conclusion: Great variability exists in the use of induction agents and paralytics for RSI. Propofol was commonly used and is potentially associated with poorer clinical outcomes. Type of Study: Retrospective.
Background: The objective of our study was to identify the most common mechanisms of injury leadi... more Background: The objective of our study was to identify the most common mechanisms of injury leading to death in our pediatric population. Methods: A retrospective cohort of fatally injured children 0e17 years old treated at our trauma center during 2000e2015. Results: The mortality rate in our population was 8% (n ¼ 103). Fifty-five percent were male. The majority (76%) of fatal injuries were blunt. Overall, motor vehicle collisions (MVCs) were the most common mechanism of injury (61%), followed by assault/abuse (9%). Of the deaths caused by MVCs, 37 (59%) were occupants, 11 (17%) were pedestrians, and 6 (10%) were cyclists. In the infant sub-population, assault/ abuse was the most common mechanism of injury. Conclusion: MVCs were the leading cause of death in this population. In the infant subpopulation (<1 year), abusive head trauma emerged as the leading mechanism. Injury prevention programming should target abusive head trauma in infants and teen road safety. Summary: A 15 year cohort review of pediatric trauma center mortality. Common mechanisms of injury leading to death were identified.
Background: An extra-corporeal (ECA), transumbilical appendectomy has been proposed as a treatmen... more Background: An extra-corporeal (ECA), transumbilical appendectomy has been proposed as a treatment for appendicitis. This study assessed the 30-day peri-operative outcomes and cost between ECA and traditional intra-corporeal (ICA) techniques for acute uncomplicated appendicitis. Methods: IRB approval was obtained for this retrospective cohort study of acute uncomplicated appendicitis in children aged 4 to 17 between April 2014 and April 2017. Patients were grouped based on ICA versus ECA. Operative time, length of stay, and complication rates were recorded. Results: A total of 289 patients were included, and of these 217 underwent ICA, and 72 underwent ECA. Median weight-forage percentile was the only demographic characteristic different between groups (ECA 50 [0.1-100] vs. ICA 71 [0-100]; p <0.01). Median operative time was significantly shorter in the ECA group (21.0 min [8.0-61.0] vs. 38.0 min [19.0-87.0]; p<0.0001). Length of stay and complication rates were similar between groups. The median per case cost was significantly lower in the ECA group (
Spontaneous or non-traumatic common bile duct (CBD) perforation in children is a rare condition l... more Spontaneous or non-traumatic common bile duct (CBD) perforation in children is a rare condition leading to difficulty and delay in diagnosis and resulting in high mortality. Presentation can vary significantly. Patients usually present with sudden obstructive jaundice, acholic stools, and abdominal pain and distension. Treatment tends to be surgical, consisting of CBD exploration, and possibly, repair. We report the case of a 22-month-old female with spontaneous CBD perforation. She presented with a 1-month history of increasing abdominal distension, abdominal pain, and jaundice. On exploratory laparotomy, a large amount of bile-stained ascitic fluid was drained. She was managed conservatively with 3 weeks of external intra-abdominal drains. Follow-up at 6 months showed complete recovery. Due to the rarity of spontaneous bile duct perforation, delayed diagnosis and intervention is common. Physicians must consider this diagnosis in a child with abdominal pain in order to prompt timel...
(IPM). The liver parenchyma was divided by a combination of CUSAÒ;, Thunderbeat (OlympusÒ;) and L... more (IPM). The liver parenchyma was divided by a combination of CUSAÒ;, Thunderbeat (OlympusÒ;) and LigasureÒ; keeping the transaction line as close as possible to the cystic neoplasm. Locking clips and vascular stapler were used to divide the RPPP and branches of RHV in contact with the neoplasm. Results: Operative time was 300 min. Blood loss was 150 ml and IPM was used twice. The patient did not develop any complication. Total hospital stay was five days. The histologic reports confirmed the preoperative diagnosis of BCA with ovarian stroma. Conclusions: The laparoscopic approach is a feasible and safe option to treat patients with large BCA in need for a radical resection even when the lesion is localized in the right posterior segments as far as the surgeon is skilled with advanced minimally invasive liver procedures.
We report a case of a child with a right ventricular inflammatory myofibroblastic tumor (IMT) who... more We report a case of a child with a right ventricular inflammatory myofibroblastic tumor (IMT) who presented with fever, viral symptoms, and abdominal discomfort. Including this case, 49 intracardiac tumors have been previously reported in all age groups. The majority of intracardiac IMTs occur in pediatric patients, with approximately half presenting in children aged <12 months. Intracardiac IMTs are generally described as benign tumors; however, depending on their location, the initial presentation may involve heart failure or sudden death.(1) In addition to cardiac signs and symptoms, the clinical presentation of IMTs may also include constitutional signs such as fever, anemia, and elevated inflammatory markers. This case report reviews the diagnosis and management of IMTs, as well as the histopathologic features of this rare tumor type. Clinicians should be aware of their clinical presentation because early diagnosis and treatment can significantly reduce morbidity and mortality.
Canadian journal of surgery. Journal canadien de chirurgie, 2015
This study describes our experience with the placement of a skin-level gastrostomy device (MIC-KE... more This study describes our experience with the placement of a skin-level gastrostomy device (MIC-KEY) in a single procedure. We identified infants, children and young adults who underwent laparoscopicassisted percutaneous endoscopic gastrostomy (LAPEG) tube insertion between October 2009 and June 2013. The steps of this procedure include upper endoscopy, single-port laparoscopy, gastropexy via percutaneous T-fasteners and placement of a skin-level gastrostomy device (MIC-KEY) using a "push" technique with a tear-away sheath. We included 92 patients in our study. Mean age was 3.7 years (range 3 wk-5 yr), and mean weight was 11.2 (range 2.8-54) kg. Median procedural time was 20 (range 12-76) minutes. Total median duration for the most recent 25 procedures was lower than that of the first 25 (62 v. 79 min, p = 0.004). There were no intraoperative complications or conversions to open surgery. Postoperative complications were observed in 6 (6.5%) patients. Three retained T-fasten...
Beckwith-Wiedemann syndrome (BWS) is an imprinting disorder characterized by overgrowth, congenit... more Beckwith-Wiedemann syndrome (BWS) is an imprinting disorder characterized by overgrowth, congenital malformation, and tumor predisposition. Children with BWS have a higher incidence of tumors, commonly intra-abdominal tumors such as Wilms tumor, hepatoblastoma, and adrenal cortical carcinoma. Here, we describe the first case of a rare hepatic malignancy of nested stromal epithelial tumor (NSET) of the liver in a child with BWS. A 22-month old girl with BWS had a new incidental liver mass. Her alpha-fetoprotein levels were normal. She underwent a liver segmentectomy. Histopathologic features combined with immunohistochemistry results (positivity for pankeratin [AE1/3], CD56, CK19, CD117, CD99 [weak membranous pattern], β-catenin, and WT1-COOH [focal]), were diagnostic of NSET of the liver. This is the first case of NSET of the liver associated with BWS. Its occurrence at such an early age is consistent with the tumor predisposition of BWS.
Background and Objectives: Malignant mesothelioma is a lethal disease. Aggressive multimodality t... more Background and Objectives: Malignant mesothelioma is a lethal disease. Aggressive multimodality treatment protocols are reportedly associated with improved survival, but the apparent survival bene®ts may simply re¯ect patient selection and the variable natural history of this malignancy. Before embarking on our own protocol of experimental treatment for mesothelioma, we sought to identify important prognostic factors and document the survival of patients treated conservatively (with palliative intent only) in our region. Methods: We performed a retrospective review of all patients with a diagnosis of malignant mesothelioma seen at our center between 1987 and 1999. Since curative intent treatment had not been given, we assumed that measured survival would largely re¯ect the natural history of the malignancy. Results: There were 101 patients (80 males and 21 females). Mean age was 65 AE 9.2 years. Symptoms of disease were present for a median time of 5 months before the diagnosis was established. The most common presenting symptoms were dyspnea (46 patients), chest pain (30 patients), and weight loss (22 patients). Sixty-eight patients (68%) had a history of asbestos exposure. Mesothelioma subtypes included epithelial (43 patients), sarcomatous (26 patients), mixed (19 patients), desmoplastic (4 patients), and unspeci®ed (9 patients). All 101 patients were treated with palliative intent. Talc pleurodesis was performed in 70 patients. At the time of analysis, 90 patients had died and 11 remained alive. Median survival was 213 (95% CI 137±289) days. Survival for the three major histological subtypes was signi®cantly different (log rank, P 0.0016). Histological subtype (epithelial favorable) was the only signi®cant independent prognostic factor (Cox proportional hazard regression, P 0.0009). Conclusions: Patients with epithelial mesothelioma survive longer than those with other histological subtypes. Conservatively managed patients with pleural malignant mesothelioma have a median survival of approximately 7 months. These data from conservatively treated patients can serve as baseline information for future studies of experimental treatments.
Journal of Pediatric Endocrinology and Metabolism, 2014
Ectopic ACTH syndrome is a rare but important cause of pediatric Cushing syndrome, for which mana... more Ectopic ACTH syndrome is a rare but important cause of pediatric Cushing syndrome, for which management by a multidisciplinary team is required. Although diagnostic evaluation is similar to that in adults, the variation in epidemiology may sway investigations, leading to inappropriate and/or incomplete diagnostic interventions. We present a case of 15-year-old girl with symptoms of severe ACTH-dependent Cushing syndrome and two pituitary adenomas. The ectopic source of ACTH production was confirmed after petrosal venous sampling was performed. Diagnostics and perioperative management of a pulmonary carcinoid tumor producing ectopic ACTH is reviewed. In pediatric patients, as in adult patients, a pituitary lesion < 6 mm on MRI is not sufficient confirmation of Cushing's disease, and appropriate diagnostic work-up should be performed to assess the source of the ACTH overproduction.
Background: The COVID-19 pandemic had accelerated the adoption of virtual care as an extension ... more Background: The COVID-19 pandemic had accelerated the adoption of virtual care as an extension of routine clinical practice. In addition, pre-clinical undergraduate medical education was affected by the transition to both synchronous and asynchronous online learning. The objective of this study was to assess the current experience and knowledge of medical students with regards to virtual care. A secondary objective was to identify opportunities for improvement in the undergraduate medical curriculum. Methods: An electronic survey was distributed to undergraduate medical students in Canadian medical schools. Main sections of the survey addressed experience with virtual care encounters and perceived impact of virtual learning on medical education. Result: Out of our 53 respondents, the majority (80%) of medical students perceived high educational importance of virtual care encounters. 91% of the students recognized the developing role of virtual care in current and future medical pr...
Background: Literature suggests that teamwork and team performance greatly impact medical trauma ... more Background: Literature suggests that teamwork and team performance greatly impact medical trauma outcomes. While trauma simulations have been shown to improve teamwork and clinical outcomes, there is a need to establish reliable teamwork evaluation tools. This study aims to test the reliability of the Teamwork Emergency Assessment Measure (TEAM), the Trauma Teamwork Assessment Tool (TTAT) and, specifically, the teamwork domain of the TTAT (TTATtw). Methods: An expert and nonexpert panel evaluated 3 prerecorded pediatric trauma in situ simu lations using TEAM and TTAT. Inter-rater reliability was determined using intraclass coefficient (ICC; 95% CI) and Cohen's kappa for TEAM, TTAT and TTATtw. Results: Average measures ICC data for TEAM (expert 0.954, nonexpert 0.941), TTAT (expert 0.851, nonexpert 0.828) and TTATtw (expert 0.964, nonexpert 0.889) proved to be "extremely" reliable for both expert and nonexpert panels. Single measures ICC data for TEAM (expert 0.591, nonexpert 0.676), TTAT (expert 0.326, nonexpert 0.342) and TTATtw (expert 0.445, nonexpert 0.711) demonstrated "fair to good," "poor" and "fair to good" reliability for both panels, respectively. Kappa indicated "moderate" agreement between expert and nonexpert panels for TEAM (0.467) and TTATtw (0.497) and indicated "fair" agreement for TTAT (0.329). Conclusion: The TEAM, TTAT and TTATtw were found to be reliable instruments when used by both a panel of experts and nonexperts. Further validation studies would be beneficial to warrant the tools appropriate for teamwork evaluation in pediatric trauma simulations. The association of etomidate with mortality in trauma patients. C. Hinkewich, R. Green, J. Tallon. From Dalhousie University, Halifax, NS Background: Etomidate is a commonly used medication to facili tate emergent endotracheal intubations in trauma patients, despite concerns regarding its safety. This study examined the association of etomidate use with patient mortality in trauma patients. Methods: This study is a retrospective review of adult trauma patients who required intubation at the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, since 2000. Patients who received etomidate were compared with those who did not, with a primary outcome of 28-day mortality. Secondary outcomes included length of stay in the hospital and intensive care unit (ICU), and mechanical ventilation days. Multivariate logistic models were created adjusting for age, Injury Severity Score (ISS), sex, comorbidities and injury type. Results: We included 315 patients for analysis. Patients who received etomidate had a more recent median arrival date (November 2006 v. February 2005, p = 0.0003) and a higher ISS (23.4 v. 26.8, p = 0.03); 28-day mortality was higher in the etomidate group (20.0% v. 10.8%, p = 0.04). There was no difference in ICU length of stay, hospital length of stay or number of days requiring mechanical ventilation. Etomidate was associated with an increased mortality, with a crude odds ratio of 2.06 (95% CI 1.08-3.91, p = 0.03). After adjustment for age, female sex, ISS and comorbidity, the odds ratio was 2.00 (95% CI 0.91-4.40, p = 0.08). Conclusion: Etomidate administration for emergent endotracheal intubation in trauma patients may be associated with increased mortality. Further investigation is warranted. Definition of isolated hip fractures as an exclusion criterion in trauma centre performance evaluations: a systematic review.
Injury-international Journal of The Care of The Injured, 2014
The purpose of this study was to determine the effective dose of radiation due to computed tomogr... more The purpose of this study was to determine the effective dose of radiation due to computed tomography (CT) scans in paediatric trauma patients at a level 1 Canadian paediatric trauma centre. We also explored the indications and actions taken as a result of these scans. We performed a retrospective review of paediatric trauma patients presenting to our centre from January 1, 2007 to December 31, 2008. All CT scans performed during the initial trauma resuscitation, hospital stay, and 6 months afterwards were included. Effective dose was calculated using the reported dose length product for each scan and conversion factors specific for body region and age of the patient. 157 paediatric trauma patients were identified during the 2-year study period. Mean Injury Severity Score was 22.5 (range 12-75). 133 patients received at least one CT scan. The mean number of scans per patient was 2.6 (range 0-16). Most scans resulted in no further action (56%) or additional imaging (32%). A decision to perform a procedure (2%), surgery (8%), or withdrawal of life support (2%) was less common. The average dose per patient was 13.5mSv, which is 4.5 times the background radiation compared to the general population. CT head was the most commonly performed type of scan and was most likely to be repeated. CT body, defined as a scan of the chest, abdomen, and/or pelvis, was associated with the highest effective dose. CT is a significant source of radiation in paediatric trauma patients. Clinicians should carefully consider the indications for each scan, especially when performing non-resuscitation scans. There is a need for evidence-based treatment algorithms to assist clinicians in selecting appropriate imaging for patients with severe multisystem trauma.
Background: Long-term peritoneal dialysis (PD), especially with nonphysiological solutions, is af... more Background: Long-term peritoneal dialysis (PD), especially with nonphysiological solutions, is afflicted with the severe complication of encapsulating peritoneal sclerosis (EPS). Physiologic PD solutions have been introduced to reduce pH trauma. Data on peritoneal biopsies in pediatrics with long-term PD using physiological solutions are scant. Case Report: We report an adolescent who had been on 10-h continuous hourly cycles using mostly 2.27% Physioneal™ for 5 years. There were two episodes of peritonitis in October 2017 (Klebsiella oxytoca) and May 2018 (Klebsiella pneumoniae), which were treated promptly. This adolescent, who lost two kidney transplants from recurrent focal and segmental glomerulosclerosis, underwent a peritoneal membrane biopsy at the time of a third PD catheter placement, 16 months after the second renal transplant. Laparoscopically, the peritoneum appeared grossly normal, but fibrosis and abundant hemosiderin deposition were noted on histology. The thickness ...
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Purpose: Rapid sequence intubation (RSI) drugs, such as propofol, affect clinical outcomes, but t... more Purpose: Rapid sequence intubation (RSI) drugs, such as propofol, affect clinical outcomes, but this has not been examined in the pediatric population. This descriptive study compares the outcomes associated with intubation drugs used in pediatric traumatic brain injury (TBI) patients. Methods: A retrospective chart review and descriptive analysis of intubated TBI patients, ages 0-17, admitted to Children's Hospital London Health Sciences Centre (LHSC) from January 2006-December 2016 was performed. Results: Out of 259 patients intubated, complete data was available for 107 cases. Average injury severity score was 28; 46 were intubated at LHSC, 55 at primary care site, and 6 on scene. Intubation attempts were recorded in 87 of 107 paper charts. First-pass intubation success rate was 88.5%. Propofol (n = 21), midazolam (n = 31), etomidate (n = 13), and ketamine (n = 7) were the most commonly used intubation drugs. Paralytics were used in 50% of patients. Following use of propofol, Pediatric Adjusted Shock Index was increased as a result of worsening hypotension. Mean total hospital length of stay was 21 days with 7.5 days in ICU. Survival was 87%. Conclusion: Great variability exists in the use of induction agents and paralytics for RSI. Propofol was commonly used and is potentially associated with poorer clinical outcomes. Type of Study: Retrospective.
Background: The objective of our study was to identify the most common mechanisms of injury leadi... more Background: The objective of our study was to identify the most common mechanisms of injury leading to death in our pediatric population. Methods: A retrospective cohort of fatally injured children 0e17 years old treated at our trauma center during 2000e2015. Results: The mortality rate in our population was 8% (n ¼ 103). Fifty-five percent were male. The majority (76%) of fatal injuries were blunt. Overall, motor vehicle collisions (MVCs) were the most common mechanism of injury (61%), followed by assault/abuse (9%). Of the deaths caused by MVCs, 37 (59%) were occupants, 11 (17%) were pedestrians, and 6 (10%) were cyclists. In the infant sub-population, assault/ abuse was the most common mechanism of injury. Conclusion: MVCs were the leading cause of death in this population. In the infant subpopulation (<1 year), abusive head trauma emerged as the leading mechanism. Injury prevention programming should target abusive head trauma in infants and teen road safety. Summary: A 15 year cohort review of pediatric trauma center mortality. Common mechanisms of injury leading to death were identified.
Background: An extra-corporeal (ECA), transumbilical appendectomy has been proposed as a treatmen... more Background: An extra-corporeal (ECA), transumbilical appendectomy has been proposed as a treatment for appendicitis. This study assessed the 30-day peri-operative outcomes and cost between ECA and traditional intra-corporeal (ICA) techniques for acute uncomplicated appendicitis. Methods: IRB approval was obtained for this retrospective cohort study of acute uncomplicated appendicitis in children aged 4 to 17 between April 2014 and April 2017. Patients were grouped based on ICA versus ECA. Operative time, length of stay, and complication rates were recorded. Results: A total of 289 patients were included, and of these 217 underwent ICA, and 72 underwent ECA. Median weight-forage percentile was the only demographic characteristic different between groups (ECA 50 [0.1-100] vs. ICA 71 [0-100]; p <0.01). Median operative time was significantly shorter in the ECA group (21.0 min [8.0-61.0] vs. 38.0 min [19.0-87.0]; p<0.0001). Length of stay and complication rates were similar between groups. The median per case cost was significantly lower in the ECA group (
Spontaneous or non-traumatic common bile duct (CBD) perforation in children is a rare condition l... more Spontaneous or non-traumatic common bile duct (CBD) perforation in children is a rare condition leading to difficulty and delay in diagnosis and resulting in high mortality. Presentation can vary significantly. Patients usually present with sudden obstructive jaundice, acholic stools, and abdominal pain and distension. Treatment tends to be surgical, consisting of CBD exploration, and possibly, repair. We report the case of a 22-month-old female with spontaneous CBD perforation. She presented with a 1-month history of increasing abdominal distension, abdominal pain, and jaundice. On exploratory laparotomy, a large amount of bile-stained ascitic fluid was drained. She was managed conservatively with 3 weeks of external intra-abdominal drains. Follow-up at 6 months showed complete recovery. Due to the rarity of spontaneous bile duct perforation, delayed diagnosis and intervention is common. Physicians must consider this diagnosis in a child with abdominal pain in order to prompt timel...
(IPM). The liver parenchyma was divided by a combination of CUSAÒ;, Thunderbeat (OlympusÒ;) and L... more (IPM). The liver parenchyma was divided by a combination of CUSAÒ;, Thunderbeat (OlympusÒ;) and LigasureÒ; keeping the transaction line as close as possible to the cystic neoplasm. Locking clips and vascular stapler were used to divide the RPPP and branches of RHV in contact with the neoplasm. Results: Operative time was 300 min. Blood loss was 150 ml and IPM was used twice. The patient did not develop any complication. Total hospital stay was five days. The histologic reports confirmed the preoperative diagnosis of BCA with ovarian stroma. Conclusions: The laparoscopic approach is a feasible and safe option to treat patients with large BCA in need for a radical resection even when the lesion is localized in the right posterior segments as far as the surgeon is skilled with advanced minimally invasive liver procedures.
We report a case of a child with a right ventricular inflammatory myofibroblastic tumor (IMT) who... more We report a case of a child with a right ventricular inflammatory myofibroblastic tumor (IMT) who presented with fever, viral symptoms, and abdominal discomfort. Including this case, 49 intracardiac tumors have been previously reported in all age groups. The majority of intracardiac IMTs occur in pediatric patients, with approximately half presenting in children aged <12 months. Intracardiac IMTs are generally described as benign tumors; however, depending on their location, the initial presentation may involve heart failure or sudden death.(1) In addition to cardiac signs and symptoms, the clinical presentation of IMTs may also include constitutional signs such as fever, anemia, and elevated inflammatory markers. This case report reviews the diagnosis and management of IMTs, as well as the histopathologic features of this rare tumor type. Clinicians should be aware of their clinical presentation because early diagnosis and treatment can significantly reduce morbidity and mortality.
Canadian journal of surgery. Journal canadien de chirurgie, 2015
This study describes our experience with the placement of a skin-level gastrostomy device (MIC-KE... more This study describes our experience with the placement of a skin-level gastrostomy device (MIC-KEY) in a single procedure. We identified infants, children and young adults who underwent laparoscopicassisted percutaneous endoscopic gastrostomy (LAPEG) tube insertion between October 2009 and June 2013. The steps of this procedure include upper endoscopy, single-port laparoscopy, gastropexy via percutaneous T-fasteners and placement of a skin-level gastrostomy device (MIC-KEY) using a "push" technique with a tear-away sheath. We included 92 patients in our study. Mean age was 3.7 years (range 3 wk-5 yr), and mean weight was 11.2 (range 2.8-54) kg. Median procedural time was 20 (range 12-76) minutes. Total median duration for the most recent 25 procedures was lower than that of the first 25 (62 v. 79 min, p = 0.004). There were no intraoperative complications or conversions to open surgery. Postoperative complications were observed in 6 (6.5%) patients. Three retained T-fasten...
Beckwith-Wiedemann syndrome (BWS) is an imprinting disorder characterized by overgrowth, congenit... more Beckwith-Wiedemann syndrome (BWS) is an imprinting disorder characterized by overgrowth, congenital malformation, and tumor predisposition. Children with BWS have a higher incidence of tumors, commonly intra-abdominal tumors such as Wilms tumor, hepatoblastoma, and adrenal cortical carcinoma. Here, we describe the first case of a rare hepatic malignancy of nested stromal epithelial tumor (NSET) of the liver in a child with BWS. A 22-month old girl with BWS had a new incidental liver mass. Her alpha-fetoprotein levels were normal. She underwent a liver segmentectomy. Histopathologic features combined with immunohistochemistry results (positivity for pankeratin [AE1/3], CD56, CK19, CD117, CD99 [weak membranous pattern], β-catenin, and WT1-COOH [focal]), were diagnostic of NSET of the liver. This is the first case of NSET of the liver associated with BWS. Its occurrence at such an early age is consistent with the tumor predisposition of BWS.
Background and Objectives: Malignant mesothelioma is a lethal disease. Aggressive multimodality t... more Background and Objectives: Malignant mesothelioma is a lethal disease. Aggressive multimodality treatment protocols are reportedly associated with improved survival, but the apparent survival bene®ts may simply re¯ect patient selection and the variable natural history of this malignancy. Before embarking on our own protocol of experimental treatment for mesothelioma, we sought to identify important prognostic factors and document the survival of patients treated conservatively (with palliative intent only) in our region. Methods: We performed a retrospective review of all patients with a diagnosis of malignant mesothelioma seen at our center between 1987 and 1999. Since curative intent treatment had not been given, we assumed that measured survival would largely re¯ect the natural history of the malignancy. Results: There were 101 patients (80 males and 21 females). Mean age was 65 AE 9.2 years. Symptoms of disease were present for a median time of 5 months before the diagnosis was established. The most common presenting symptoms were dyspnea (46 patients), chest pain (30 patients), and weight loss (22 patients). Sixty-eight patients (68%) had a history of asbestos exposure. Mesothelioma subtypes included epithelial (43 patients), sarcomatous (26 patients), mixed (19 patients), desmoplastic (4 patients), and unspeci®ed (9 patients). All 101 patients were treated with palliative intent. Talc pleurodesis was performed in 70 patients. At the time of analysis, 90 patients had died and 11 remained alive. Median survival was 213 (95% CI 137±289) days. Survival for the three major histological subtypes was signi®cantly different (log rank, P 0.0016). Histological subtype (epithelial favorable) was the only signi®cant independent prognostic factor (Cox proportional hazard regression, P 0.0009). Conclusions: Patients with epithelial mesothelioma survive longer than those with other histological subtypes. Conservatively managed patients with pleural malignant mesothelioma have a median survival of approximately 7 months. These data from conservatively treated patients can serve as baseline information for future studies of experimental treatments.
Journal of Pediatric Endocrinology and Metabolism, 2014
Ectopic ACTH syndrome is a rare but important cause of pediatric Cushing syndrome, for which mana... more Ectopic ACTH syndrome is a rare but important cause of pediatric Cushing syndrome, for which management by a multidisciplinary team is required. Although diagnostic evaluation is similar to that in adults, the variation in epidemiology may sway investigations, leading to inappropriate and/or incomplete diagnostic interventions. We present a case of 15-year-old girl with symptoms of severe ACTH-dependent Cushing syndrome and two pituitary adenomas. The ectopic source of ACTH production was confirmed after petrosal venous sampling was performed. Diagnostics and perioperative management of a pulmonary carcinoid tumor producing ectopic ACTH is reviewed. In pediatric patients, as in adult patients, a pituitary lesion < 6 mm on MRI is not sufficient confirmation of Cushing's disease, and appropriate diagnostic work-up should be performed to assess the source of the ACTH overproduction.
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Papers by Neil Merritt