Hepatic angiosarcoma is a rare, aggressive, malignant neoplasm with fewer than 50 cases reported in children. Prognosis is poor, with a minority surviving beyond 2 years after diagnosis. We report eight cases of pediatric hepatic angiosarcoma, diagnosed at a mean age of 3 years. Seven were initially diagnosed with an infantile hepatic hemangioendothelioma (IHHE) or hemangioma and the eighth with a "vascular tumor." Two patients, who received liver transplant, survived. We suggest hepatic hemangiomas can rarely transform into angiosarcomas and a subset of IHHEs (Type II) are actually a low-grade form of angiosarcoma rather than a benign lesion.

BACKGROUND:Tracheostomy placement is much more common in adults than children following severe trauma. We evaluated whether tracheostomy rates and outcomes differ for pediatric patients treated at trauma centers that primarily care for children versus adults. METHODS:We conducted a retrospective cohort study of patients younger than 18 years in the National Trauma Data Bank from 2007 to 2016 treated at a Level I/II pediatric, adult, or combined adult/pediatric trauma center, ventilated >24 hours, and who survived to discharge. We used multivariable logistic regression adjusted for age, insurance, injury mechanism and body region, and Injury Severity Score to estimate the association between the three trauma center types and tracheostomy. We used augmented inverse probability weighting to model the likelihood of tracheostomy based on the propensity for treatment at a pediatric, adult, or combined trauma center, and estimated associations between trauma center type with length of stay and postdischarge care. RESULTS:Among 33,602 children, tracheostomies were performed in 4.2% of children in pediatric centers, 7.8% in combined centers (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.20-1.81), and 11.2% in adult centers (aOR, 1.81; 95% CI, 1.48-2.22). After propensity matching, the estimated average tracheostomy rate would be 62.9% higher (95% CI, 37.7-88.1%) at combined centers and 85.3% higher (56.6-113.9%) at adult centers relative to pediatric centers. Tracheostomy patients had longer hospital stay in pediatric centers than combined (−4.4 days, −7.4 to −1.3 days) or adult (−4.0 days, −7.2 to −0.9 days) centers, but fewer children required postdischarge inpatient care (70.1% pediatric vs. 81.3% combined [aOR, 2.11; 95% CI,] and 82.4% adult centers [aOR, 2.51; 95% CI,). CONCLUSION:Children treated at pediatric trauma centers have lower likelihood of tracheostomy than children treated at combined adult/pediatric or adult centers independent of patient or injury characteristics. Better understanding of optimal indications for tracheostomy is necessary to improve processes of care for children treated throughout the pediatric trauma system.

Background Background Lower respiratory tract diseases remain significant causes of pediatric mortality in lowand middle-income countries. In these settings, staff must quickly triage patients for timely initiation of treatment and potential transfer to higher levels of care. World Health Organization (WHO) guidelines focus on two physical exam findings-tachypnea and chest indrawing-without addressing the multitude of other respiratory assessment tools used by healthcare workers. This lack of additional validated markers makes triage of patients challenging. The aim of this study was to systematically review respiratory assessments in children under five years of age that have been associated with poor clinical outcomes in resource limited settings. Methods Methods We conducted a systematic search for studies published between January 1, 2008 and January 21, 2018 using Ovid MEDLINE and Embase including patients five years of age and younger. Major categories of search terms were "respiratory distress", "respiratory symptoms", "low-and middle-income countries" and "clinical assessment". We extracted data relevant to study characteristics, respiratory assessments and clinical outcomes. Findings Findings Out of 2317 identified publications, 63 full text articles fit inclusion criteria, 56 reported statistically significant associations and were included in analyses and these publications included 53 unique study populations. Publications were from: low-income countries (26%), lower middle-income countries (55%) and upper middle-income countries (19%). The most common respiratory assessments were hypoxia (50%), tachypnea (46%) and chest indrawing/retractions (38%). Death was the most frequently reported clinical outcome (54%), followed by hypoxia (23%). Hypoxia, chest indrawing/retractions and tachypnea were the most commonly reported risk factors for mortality. Hedstrom AB, von Saint Andre-von Arnim AO, Grassia KL, Nielsen KR. Markers of pediatric respiratory distress predictive of poor outcome in low-and middle-income countries: a systematic review.