Pediatric pancreatic trauma: predictors of nonoperative management failure and associated outcomes.

BACKGROUND: Nonoperative management (NOM) is an accepted treatment of pediatric solid organ injuries and is typically successful. Blunt pancreatic trauma tends to require operative intervention more frequently. We sought to identify predictors of failure of NOM and compare the outcome of operative management against NOM. METHODS: A retrospective analysis was performed from January 1993 to December 2002 of all children with blunt pancreatic injuries from the trauma registries of 7 designated level 1 pediatric trauma centers. Failure of NOM was defined as the need for intraabdominal operative intervention. Injuries were graded I to V, and ductal injury was defined as grades III to V. Parameters included mechanism of injury, injury severity score (ISS), organ grade, Glasgow Coma Scale score, and outcome. Data were analyzed by Fisher exact test and Mann-Whitney U test, with mean values +/- SD and significance of P < .05. RESULTS: Pancreatic injuries were present in 173 (9.2%) of 1823 patients. Of these, 43 (26.0% [43/173]) required an operation. Valid morbidity data was obtained in 118 of 173 patients. ISS was significantly higher in all patients treated operatively. Patients with an injury of grade III to V failed NOM more frequently than all patients with pancreatic injury (P =.0169). Length of stay was longer, and the incidence of pseudocysts, drainage procedures, and pancreatitis was higher in NOM patients, although not significant. CONCLUSIONS: Patients with pancreatic injuries had a NOM failure rate of 26.0%. ISS and injury grades III to V were predictors of NOM failure. Patients with pancreatic ductal injury require more aggressive management.

Inflammatory myofibroblastic tumor following hematopoietic stem cell transplantation: report of two pediatric cases.

Inflammatory myofibroblastic tumors are benign neoplasms histologically composed of lymphocytes, histiocytes, macrophages, foam cells, and plasma cells among a spindle-shaped stroma. Their etiology and potential for metastatic spread is controversial. Numerous predisposing factors have been suggested, including preceding infections, radiotherapy, and local trauma. We present two cases of pseudotumors that developed in children following hematopoietic stem cell transplantation. These are the first cases after hematopoietic transplant reported in the literature. As these neoplasms are difficult to diagnose and are often confused with highly aggressive tumors, our cases demonstrate that a high index of suspicion for such lesions must be maintained when evaluating masses in post transplant patients.

Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma.

BACKGROUND: Focused abdominal sonography for trauma (FAST) has been well reported in adults, but its applicability in children is less well established. We decided to test the hypothesis that FAST and computed tomography (CT) are equivalent imaging studies in the setting of pediatric blunt abdominal trauma. METHODS: One hundred seven hemodynamically stable children undergoing CT for blunt abdominal trauma were prospectively investigated using FAST. The ability of FAST to predict injury by detecting free intraperitoneal fluid was compared with CT as the imaging standard. RESULTS: Thirty-two patients had CT documented injuries. There were no late injuries missed by CT. FAST detected free fluid in 12 patients. Ten patients had solid organ injury but no free fluid and, thus, were not detected by FAST. The sensitivity of FAST relative to CT was only 0.55 and the negative predictive value was only 0.50. CONCLUSION: FAST has insufficient sensitivity and negative predictive value to be used as a screening imaging test in hemodynamically stable children with blunt abdominal trauma.

The impact of a brief intervention on maternal smoking behavior.

OBJECTIVE: To determine if mothers receiving a smoking cessation intervention emphasizing health risks of environmental tobacco smoke (ETS) for their children have a higher quit rate than 1) mothers receiving routine smoking cessation advice or 2) a control group. DESIGN: Randomized, controlled trial. SETTING: Primary care center in a large urban children's hospital. INTERVENTION: Four hundred seventy-nine mothers were randomly assigned to a smoking cessation intervention either aimed at their child's health or their own health, or to a control group receiving safety information. OUTCOME MEASURES: Smoking status, stage of change, cigarettes/day, location smoking occurred, and knowledge of ETS effects. RESULTS: Complete data (baseline and both follow-ups) were available for 166 subjects. There was no impact of group assignment on the quit rate, cigarettes/day, or stage of change. The Child Health Group intervention had a sustained effect on location where smoking reportedly occurred (usually outside) and on improved knowledge of ETS effects. CONCLUSIONS: Further research is needed to devise more effective methods of using the pediatric health care setting to influence adult smoking behaviors.

A cost-effective thoracoscopic treatment strategy for pediatric spontaneous pneumothorax.

BACKGROUND: Recent data suggest that children have a higher incidence of recurrence than adults after nonoperative treatment of primary spontaneous pneumothorax (PSP). Video-assisted thoracoscopic surgery (VATS) allows efficacious therapy with significantly less morbidity. We attempt to define the most cost-effective clinically efficacious strategy using VATS to manage pediatric PSP. METHODS: We retrospectively reviewed all admissions to a tertiary care children's hospital for PSP between January 1, 1991 and June 30, 1996. RESULTS: Fifteen children had 29 primary or recurrent PSPs. Mean patient age was 14.8 +/- 1.1 years, boy-girl ratio 4:1, median body mass index 18 (normal, 20-25), and 67% of pneumothoraces left sided. All patients were managed initially nonoperatively: 14 with tube thoracostomy drainage and 1 with oxygen alone. Of the children initially managed nonoperatively, 57% had a recurrent pneumothorax, and 50% of these patients eventually developed contralateral pneumothoraces. Nonoperative treatment for recurrence resulted in a 75% second recurrence rate. In contrast, eight children who underwent operative management had a 9% incidence of recurrence. The total for charges accrued in treating 29 pneumothoraces in these 15 patients was approximately $315,000. In the same population, the estimated charges for initial nonoperative therapy followed by bilateral thoracoscopy after a single recurrence would be $230,000. CONCLUSIONS: A cost-effective treatment strategy for pediatric primary spontaneous pneumothorax is tube thoracostomy at first presentation, followed by VATS with thoracoscopic bleb resection and pleurodesis for patients who experience recurrent pneumothorax.

Latex sensitization in general pediatric surgical patients: a call for increased screening of patients.

BACKGROUND/PURPOSE: Latex sensitization is a well-documented occurrence in children with myelodysplastic and urologic anomalies. The incidence of latex allergy in general pediatric surgical patients, however, has not been previously addressed. The purpose of this study was to examine the risk of perioperative latex reactions in a general pediatric surgical practice over a 1-year period. METHODS: This study examined the occurrence of latex sensitization using two methods. First, the preoperative anesthesia records of patients that have undergone surgery from October 1995 through September 1996 at Mott Children's Hospital were reviewed retrospectively. Second, all patients who had intraoperative anaphylaxis attributable to latex sensitization, including those from three additional hospitals, were evaluated. RESULTS: During a 12-month period, 1,523 pediatric general surgical operations were performed at the C.S. Mott Children's Hospital. Of these, only 11 operations on five patients were performed under latex precautions. All of these patients had a preoperative diagnosis of latex sensitivity. During the same period, intraoperative anaphylactic reactions caused by latex allergy occurred in two of the general surgical patients (0.13%) at the C.S. Mott Hospital. Four additional cases are also reported from other study hospitals. None of these patients were suspected, based on current screening methods, of having a latex allergy before their surgery. CONCLUSIONS: Latex allergy is a potentially life-threatening condition in the pediatric general surgical population. Further study is needed to develop criteria to preoperatively identify patients at risk for latex sensitization.

Smoking behaviors of women whose children attend an urban pediatric primary care clinic.

OBJECTIVE: To characterize smoking behaviors of caregivers whose children attend a large urban pediatric primary care center. DESIGN: Descriptive survey. Women (n = 479) classified as smokers completed a questionnaire including demographics, smoking habits, measures of addiction, social reinforcers for smoking, attitudes and knowledge, other health and safety habits, and the pediatrician's role in smoking cessation counseling. RESULTS: Of 1421 women surveyed, 36.6% (517) were classified as daily smokers. Four hundred and seventy-nine (93%) were enrolled in the study. Thirty-eight (7%) refused or were ineligible. Smokers differed significantly from non-smokers, with smokers more likely to have lower incomes (p<.03), lower educational attainment (p<.001), and were more likely to be white than non-smokers (p<.001). The average smoker smoked 14 cigarettes per day for 10 years. Half of the subjects had not considered quitting smoking in the near future. The majority of subjects (66%) lived with at least one other smoker, and reported that more than half of their friends smoked. Most (79%) participants agreed that pediatricians should give smoking cessation advice to parents of their patients. However, only 19% recalled being counseled to quit, and 55% recalled their child's doctor discussing the danger of environmental tobacco smoke. CONCLUSION: The pediatric visit is an excellent opportunity for identifying women who smoke. Efforts to assist women with smoking cessation in similar settings will need to take into account their poverty and the high degree of social support for their continued smoking.

Endotoxin and transient hypoxia cause severe acidosis in the piglet.

PURPOSE: Both hypoxia and gram-negative sepsis are thought to play a role in the development of necrotizing enterocolitis (NEC). Endotoxin, a lipopolysaccharide (LPS), is a potent mediator of gram-negative sepsis. The author investigated the effect of LPS and hypoxia on arterial and mesenteric venous blood gas values in a piglet model. METHODS: 16 piglets (mean age, 9 days; mean weight, 3.2 kg) were anesthetized and mechanically ventilated. Catheters were placed in the aorta and the superior mesenteric vein (SMV). After a 30-minute stabilization period, piglets were randomly assigned to four experimental groups: normoxic ventilation (FIO2, 0.21), normoxic ventilation and LPS infusion (200 microg/kg, intravenously), hypoxic ventilation (FIO2, 0.10 for 20 minutes), or hypoxic ventilation and LPS infusion. All subjects were then monitored for an additional 30 minutes (recovery period). Multiple, paired blood gas samples were obtained from the aorta and SMV during the stabilization, experimental, and recovery periods. RESULTS: Piglets subjected to both hypoxia and LPS experienced a much more severe acidosis in both the aorta (pH, 7.10 +/- 0.08) and SMV (pH, 7.03 +/- 0.09) than piglets subjected to either hypoxia or LPS alone (P < .05). In addition, LPS lowered the arterial oxygen saturation in piglets exposed to acute, transient hypoxia (36 +/- 4% v 59 +/- 12%, P < .05). CONCLUSION: This study suggests that the combination of transient hypoxia and gram-negative sepsis may act synergistically to produce both a severe acidosis and decreased tissue oxygenation.

Massive hemoptysis as the presenting manifestation in a child with histoplasmosis.

A previously healthy and asymptomatic 7-year-old white boy presented with a history of two episodes of hemoptysis productive of bright red blood in the 5 days preceding admission. After admission he developed massive hemoptysis that, on bronchoscopy, was noted to be emanating from the right lower lobe. An emergency right lower lobe resection was done. Pathological examination revealed hilar adenopathy and peripheral lesions with caseating granulomas containing yeast, morphologically consistent with Histoplasma capsulatum.

Dicephalus dipus dibrachius: an unusual case of conjoined twins.

Conjoined twinning is a rare anomaly, occurring in one of every 50,000 births. Dicephalus dipus dibrachius is an extremely rare form of conjoined twinning in which the infant has two arms, two legs, one trunk, but two heads. These infants are often stillborn or die shortly after birth. The authors describe a case of dicephalus twinning with 11-day survival. A thorough investigation using multiple imaging modalities (plain radiographs, contrast studies, ultrasonography, and magnetic resonance imaging) demonstrated that these twins had separate spinal columns but shared multiple internal organs including heart, liver, pancreas, intestine and bladder. Based on the anatomy of this case, the authors conclude that separation of dicephalus dipus dibrachius twins should not be attempted.

Congenital diaphragmatic hernia and profound prematurity: report of a survivor.

Congenital diaphragmatic hernia (CDH) continues to be one of the most challenging problems in pediatric surgery. The overall mortality rate remains at 40%, and death is caused by pulmonary hypoplasia and persistent pulmonary hypertension. It has been suggested that in utero repair of the defect should be performed to allow the lungs to grow and develop, in the hope of preventing fatal pulmonary insufficiency. The authors report the survival of a 960-g premature infant with CDH, suggesting that ex utero repair is possible in a very low birth weight infant.

Presence of growth factors in palmar and plantar fibromatoses.

Palmar and plantar fibromatoses are disease processes in which the presence of certain growth factors has not been defined. Monoclonal antibodies against transforming growth factor-beta, epidermal growth factor, procollagen type 1, fibronectin, phosphotyrosine residues, and CD41 platelet antigen were used in standard immunoperoxidase staining to study 36 nodules and 24 cords obtained from patients with fibromatoses. The specimens were studied via light microscopy, and staining intensity was quantitated using a computer-enhanced video system. Transforming growth factor-beta staining paralleled procollagen I, fibronectin, and phosphotyrosine staining within the nodule (early stages) but not the cord (late stages) tissue. These factors showed significant increased staining in the early stage of fibromatosis when compared to the late stage. This study is a preliminary demonstration of the presence of transforming growth factor-beta in palmar and plantar fibromatoses.

Experimental study of the influence of arterial trauma on dependent distal tissue survival.

An experimental model was developed combining arterial trauma with island flap creation using the rat groin flap system. Flap arteries were subjected to crush/avulsion injuries with subsequent microvascular repair. A second series involved resection 4 hr after thrombosis of injured flap arteries and interpositional vein grafting to reestablish circulation. A single bolus of systemic heparin was administered to half of the animals from each series on a blinded, randomized basis. Arterial patency at 7 days correlated with flap survival. There was no case of partial flap loss. Patencies improved in the first series from 31% to 71% with heparin administration (P less than 0.05) and from 58% to 90% in the second (not significantly different). A third series involving immediate resection of traumatized vessel and vein graft replacement achieved a patency of 92% (without heparinization). These results support the value of replacement of all traumatized arterial tissue with vein grafts and indicate the efficacy of systemic heparin (in single bolus) for enhancing the likelihood of maintaining patency. Furthermore, it is suggested that the occurrence of a thrombogenic site in the arterial inflow to a region of dependent tissue does not lead to partial tissue loss, and thus thromboembolic events may not be responsible for this clinical phenomenon.

The newborn piglet: a model of neonatal gastrointestinal motility.

Small intestinal myoelectric activity has been studied extensively in adult humans and in many animal models. However, little is known about gut myoelectrical activity in newborns, a population susceptible to primary and secondary motility disorders. We report the development of a chronic neonatal piglet model for assessment of gastric and small intestinal myoelectric activity. Six piglets aged 12 to 27 days and weighing 2.3 to 4 kg underwent laparotomy and implantation of four to six bipolar serosal electrodes along the small intestine; and selectively on the gastric antrum. Myoelectric records were obtained daily after operation in awake animals using low (0.16 Hz) and high (30 Hz) frequency filters. Electrical control activity (ECA) was observed in the stomach (4 to 5 cycles per minute) and in the duodenum (14 to 15 cycles per minute) on postoperative day 1; along with random bursts of spiking activity. The migrating myoelectric complex (MMC) appeared on postoperative day 2 or 3. In piglets followed for a week or more, the MMC cycle duration and phase III duration (period of maximal spiking activity) were longer in the proximal small intestine than at the terminal ileum (80 +/- 5 versus 47 +/- 3 minutes and 5.1 +/- 0.3 versus 3.7 +/- 0.1 minutes, respectively; mean +/- SEM, P less than .005), suggesting that some MMCs arise spontaneously in the distal small bowel without traversing the upper intestine. The antral and duodenal ECA frequencies are similar to values reported in human adults; the MMC cycle duration is slightly shorter.(ABSTRACT TRUNCATED AT 250 WORDS)

Resting energy expenditure in children following major operative procedures.

Resting energy expenditure (REE) is reported to increase by 24% in adults following elective operations; however, similar data are not available for children. We studied REE in 12 children (14 operative procedures) to test the hypothesis that children experience a similar rise in REE as adults following operation. The operations included endorectal pull-through, gastric resection, ileostomy closure, and other major abdominal procedures. REE was measured daily by indirect calorimetry using a computerized bedside metabolic cart. All subjects (7 males, 5 females; age range, 8 to 19 years; mean age, 14.7 years) were measured supine, in bed, and after an overnight fast. REE was expressed as kilocalories per unit body surface area (BSA) per day. In addition, respiratory quotient (RQ) was calculated for each patient. Contrary to adults, these children did not demonstrate a significant increase in REE following major operative procedures. Furthermore, there was no change in RQ postoperatively. These data demonstrate that children might have a different response to surgical stress than adults. We theorize that children are able to convert energy expended on growth to energy spent on wound repair and healing, thus avoiding the overall increase in energy expenditure seen in the adult population.

The efficacy of oral antimicrobials in reducing aerobic and anaerobic colonic mucosal flora.

We investigated the impact of intestinal antisepsis on the colonic mucosa-associated flora. Four groups of dogs were studied: group A received no bowel preparation, group B received a three-day clear-liquid diet, group C underwent mechanical cleansing of the bowel, and group D had mechanical cleansing followed by oral neomycin and erythromycin. Mucosal biopsy specimens were obtained for bacteriologic and scanning electron microscopic (SEM) studies. No significant difference in recovery of mucosal bacteria was observed between groups A and B. A significant decrease in recovery of aerobes was observed in group C, and a significant decrease in both aerobes and anaerobes was observed in group D compared with group A; Enterobacteriaceae and Bacteroides were either eliminated or greatly reduced. The SEM analysis of group D revealed a marked decrease in mucosa-associated microflora compared with groups B and C. Oral neomycin-erythromycin produced a significant quantitative reduction in the colonic mucosa-associated bacterial population, including the potentially pathogenic Escherichia coli and Bacteroides fragilis group isolates. These mucosa-associated bacteria are a likely source of contamination of the abdominal cavity and wound at the time of colon surgery.

A randomized trial of oral iron on tests of short-term memory and attention span in young pregnant women.

Recent studies suggest that infant behavior and psychological test performance are impaired by iron deficiency and may be improved by iron. Comparable studies have not been performed in older populations. Young women early in pregnancy whose nutritional intake may be impaired by poverty constitute a high-risk population. Women aged 14-24 years coming for prenatal care at or before 16 weeks gestation whose hematocrits were greater than or equal to 31% were randomized in a double-blind trial to receive vitamins supplemented with iron (experimental group) or vitamins alone (controls). Hematologic status and tests of short-term memory and attention span were assessed at entry and conclusion of the one-month treatment period. The experimental group showed significant improvement on the most sensitive measure of short-term memory and three subtests. On comparison of the change between initial and final scores, the experimental group showed significant or borderline greater improvement than controls on three tests. These results indicated a beneficial effect of iron therapy on psychometric test-score performance.