Spatial and Temporal Clustering of Chikungunya Virus Transmission in Dominica.

Using geo-referenced case data, we present spatial and spatio-temporal cluster analyses of the early spread of the 2013-2015 chikungunya virus (CHIKV) in Dominica, an island in the Caribbean. Spatial coordinates of the locations of the first 417 reported cases observed between December 15th, 2013 and March 11th, 2014, were captured using the Global Positioning System (GPS). We observed a preponderance of female cases, which has been reported for CHIKV outbreaks in other regions. We also noted statistically significant spatial and spatio-temporal clusters in highly populated areas and observed major clusters prior to implementation of intensive vector control programs suggesting early vector control measures, and education had an impact on the spread of the CHIKV epidemic in Dominica. A dynamical identification of clusters can lead to local assessment of risk and provide opportunities for targeted control efforts for nations experiencing CHIKV outbreaks.

Splenic cysts in the pediatric population: a report of 21 cases with review of the literature.

Splenic cysts are rare lesions that can occur in parasitic and non-parasitic forms. Because they are uncommon, the classification, pathogenesis, and management techniques are still debated. The continual review of splenic cyst cases in the pediatric population is essential for establishing a clear diagnosis and course of treatment. This report presents 21 cases of pediatric splenic cysts observed at Children's Healthcare of Atlanta over an 18 year period (1993-2011). The cases include both parasitic and and nonparasitic cysts. The current splenic cyst classification and treatment methods are analyzed through a review of the current theories and based on our experiences.

Leiomyoma at the site of esophageal atresia repair.

Esophageal leiomyomas are rare in the pediatric population. They frequently occur in association with other anomalies, such as Alport's syndrome, osteoarthropathy, and leiomyomas elsewhere in the body. The authors describe the case of a focal esophageal leiomyoma in a 12-month-old girl with a history of long-gap esophageal atresia. The patient initially underwent bouginage of the proximal pouch while awaiting definitive repair. After esophageal repair, the patient required multiple dilatations for anastomotic strictures. A segmental resection of the esophagus was performed because of recurrent strictures. A leiomyoma, arising from the site of the previous esophageal atresia repair, was noted on histologic evaluation. Esophageal leiomyomas have not been reported previously in a child with esophageal atresia. J Pediatr Surg 36:1832-1833.

Kasai portoenterostomy: differences related to race.

PURPOSE: The aim of this study was to evaluate the Kasai portoenterostomy in African-American and white children with respect to differences in presentation and outcome. METHODS: A retrospective review of all children with biliary atresia who underwent a portoenterostomy at our institution over the last 15 years (n = 63) was performed. Sex, age at the time of Kasai, preoperative laboratory tests, success rates (defined as postoperative total serum bilirubin < or = 2.0 mg/dL), and survival rate were recorded. Differences between African-American (AA; n = 30) and white (W; n = 33) children were analyzed. Long-term follow-up was available on 59 of 63 patients. RESULTS: Sixty-three percent of all patients (40 of 65) were girls, and 48% were AA (30 of 63). A higher percentage of AA children (73%) were girls than were white children (55%), although this difference did not achieve statistical significance. African-Americans underwent portoenterostomy at a later age, had higher alkaline phosphatase levels, and higher AST. These differences were statistically significant. Preoperative ALT, total bilirubin level, and GGTP levels all were greater in African-Americans, although these differences did not achieve statistical significance. There was a trend toward decreased success and survival rate, although these results also were not statistically significant. CONCLUSIONS: African-Americans underwent primary therapeutic intervention for biliary atresia at an older age than white children with a trend toward less favorable results. These differences related to race may be attributed to greater difficulty in diagnosing jaundice or poorer access to health care in this patient population. Increased effort at identifying biliary atresia in AA children may lead to earlier diagnosis and treatment and improved outcomes.

Clinical management of anterior mediastinal tumors in children.

The majority of anterior mediastinal tumors in children are malignant. The most common tumors in this location are lymphomas, germ cell tumors, and thymic masses. Most require an operation, either a biopsy or a resection, for cure. Because of their size and location, patients with these masses are at significant risk for cardiopulmonary complications when general anesthesia is administered. Of the many clinical, functional, and radiologic criteria used to identify the children at greatest risk for anesthetic complications, the peak expiratory flow rate (PEFR) and the tracheal cross-section area seem to be the most reliable. General anesthesia should not be administered to children if the PEFR and a tracheal cross section area are both less than 50% of predicted values. If both are greater than 50% of predicted values, general anesthesia can be administered safely. An algorithm is proposed for the preoperative evaluation and management of children with anterior mediastinal tumors.

Statistical models to predict the need for postoperative intensive care and hospitalization in pediatric surgical patients.

OBJECTIVE: To develop statistical models for predicting postoperative hospital and ICU stay in pediatric surgical patients based on preoperative clinical characteristics and operative factors related to the degree of surgical stress. We hypothesized that preoperative and operative factors will predict the need for ICU admission and may be used to forecast the length of ICU stay or postoperative hospital stay. DESIGN: Prospective data collection from 1,763 patients. SETTING: Tertiary care children's hospital. PATIENTS AND PARTICIPANTS: All pediatric surgical patients, including those undergoing day surgery. Patients undergoing dental or ophthalmologic surgical procedures were excluded. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: A logistic regression model predicting ICU admission was developed from all patients. Poissonregression models were developed from 1,161 randomly selected patients and validated from the remaining 602 patients. The logistic regression model for ICU admission was highlypredictive (area under the receiver operating characteristics (ROC) curve = 0.981). In the data set used for development of Poisson regression models, significant correlations occurred between the observed and predicted ICU stay (Pearson r = 0.468, p < 0.0001, n = 131) and between the observed and predicted hospital stay for patients undergoing general (r = 0.695, p < 0.0001), orthopedic (r = 0.717, p < 0.0001), cardiothoracic (r = 0.746, p < 0.0001), urologic (r = 0.458, p < 0.0001), otorhinolaryngologic (r = 0.962, p < 0.0001), neurosurgical (r = 0.7084, p < 0.0001) and plastic surgical (r = 0.854, p < 0.0001) procedures. In the validation data set, correlations between predicted and observed hospital stay were significant for general (p < 0.0001), orthopedic (p < 0.0001), cardiothoracic (p = 0.0321) and urologic surgery (p = 0.0383). The Poisson models for length of ICU stay, otorhinolaryngology, neurosurgery or plastic surgery could not be validated because of small numbers of patients. CONCLUSIONS: Preoperative and operative factors may be used to develop statistical models predicting the need for ICU admission in pediatric surgical patients, and hospital stay following general surgical, orthopedic, cardiothoracic and urologic procedures. These statistical models need to be refined and validatedfurther, perhaps using data collection from multiple institutions.

The Kasai portoenterostomy: when is it too late?

BACKGROUND/PURPOSE: Kasai portoenterostomy is recommended as the primary initial therapy for extrahepatic biliary atresia if the procedure can be performed within 10 to 12 weeks of life. The optimal management for infants with delayed presentation of biliary atresia remains controversial. The purpose of this study was to determine the success rate and outcome for patients who underwent a "late" Kasai portoenterostomy. METHODS: The authors conducted a retrospective review of the medical records of all patients with biliary atresia who underwent a Kasai portoenterostomy at their institution from 1986 to 1999 (n = 31). The authors analyzed success rates compared with age at the time of the Kasai procedure and the association with patient demographics. Surgical success was defined as achievement of a total serum bilirubin < or = 2 mg/dL. Long-term follow-up assessments included the need for liver transplantation and patient survival rate. RESULTS: The demographics of this study cohort showed a predominance of African-Americans, 19 of 31 (61%), and girls, 23 of 31 (74%). Assessment of success compared with subject age at the time of the initial portoenterostomy showed that 52% (13 of 25) had successful Kasai procedure at 0 to 75 days, compared with 83% success rate (5 of 6) at age 76 days or older (P = .359). Liver transplantation was performed in 16 of 31 patients (45%). Overall survival rate for the entire cohort is 23 of 31 (74%), whereas 12 of 31 (39%) are currently alive without a liver transplant. CONCLUSION: These data suggest that there is no contraindication to performing a Kasai portoenterostomy for biliary atresia in children over 75 days of age.

Esophageal atresia in infants with very low birth weight.

Infants with esophageal atresia (EA), with or without a tracheoesophageal fistula (TEF) frequently are of low birth weight. With advances in neonatal, respiratory, surgical, and anesthetic care, more infants with very low birth weight (VLBW; birth weight less than 1.5 kg) are surviving. The therapy of the VLBW neonate with EA is not longer automatically staged. Primary or delayed primary anastomosis can be performed safely if the patient is stable. This report will review the epidemiology, pathophysiology, treatment, and prognosis of EA in VLBW infants. The authors present their own experience in dealing with the VLBW with EA and review the world literature.

Resuscitation of the surgical neonate.

This article reviews the general principles of resuscitation of a neonate with a surgical disorder. These principles include careful attention to critical management issues of the airway, ventilation, perfusion, nutritional support and thermogenesis. In addition, a variety of surgical disorders in the neonatal period are discussed. For each disorder, early recognition of presentation patterns, efficient work-up strategy, initial management steps, and basic surgical principles are stressed. This framework can provide a basis for successful cooperation between the neonatologist and the pediatric surgeon for the initial care of the neonate requiring surgery.

Use of the aortic homograft in the reconstruction of complex tracheobronchial tree injuries.

BACKGROUND/PURPOSE: The repair of complex tracheobronchial tree injuries often is associated with complications including stenosis and excessive granulation tissue formation. Patch reconstruction using pericardium or synthetic material decreases the incidence of stenosis. The authors report on the use of the ascending aorta cryopreserved homograft in reconstructing the tracheobronchial tree of three children. RESULTS: A 10 year old had a through-and-through gun shot wound to the left main stem bronchus with cartilaginous loss. A 12 year old double lung transplant recipient had a breakdown of one bronchial anastomosis after stent placement. A 1 year old had an acquired tracheoesophageal fistula secondary to a long standing foreign body. In all three patients, the aortic patches were secured with interrupted sutures. All three had uneventful recoveries, and postoperative bronchoscopy showed the patches to be completely covered with epithelium without stenosis or granulation tissue. CONCLUSIONS: This is the first report of the use of the cryopreserved ascending aorta homograft in the reconstruction of the tracheobronchial tree. The homograft is strong yet malleable. It gets completely covered with epithelium and results in no stenosis because of the lack of tension. These characteristics make it an attractive alternative for the patch reconstruction of complex tracheobronchial tree injuries.

Neonatal gastric perforation and necrosis with Hunt-Lawrence pouch reconstruction.

This report describes a newborn infant girl who presented with abdominal distension and pneumoperitoneum. At operation, near total necrosis of the stomach was observed. The esophagus was ligated, the stomach resected. The baby was fed by an transpyloric feeding tube. At 8 weeks, an esophagojejunal anastomosis was performed with a Hunt-Lawrence Pouch. A good outcome was achieved.

Mesenchymal hamartoma of the liver.

Mesenchymal hamartomas of the liver are the second most common benign liver tumor of childhood. The experience with this tumor at Egleston's Children Hospital at Emory University from 1989 to 1994 is reviewed. Eight patients presented with abdominal distention or an upper abdominal mass. Six patients presented at a mean age of 8 months, and two patients presented at 17 and 23 years of age, respectively. Four patients displayed normal alpha-fetoprotein levels, whereas one patient had an elevated level. Liver function studies were normal in all patients. Abdominal ultrasonography and CT scans revealed a cystic, septated mass within the liver or on a pedicle in all patients. Five patients had simple excision of the tumor, and two had major hepatic resections. The cysts were multiloculated and lined with cuboidal bile duct epithelium surrounded by stroma containing proliferating bile ducts, blood vessels, and compressed liver tissue with no calcifications. In one patient, some pathologists favored the diagnosis of malignant myxoid fibrous histiocytoma because of similar-appearing stroma. Follow-up (mean, 35 months) revealed one symptomatic recurrence after initial resection was incomplete. There were no other recurrences and no malignant transformations. A septated, noncalcified, cystic hepatic mass in an infant with normal liver function studies and characteristic ultrasound or CT is likely a benign mesenchymal hamartoma that can be cured by total local excision.

Presacral neuroenteric fistula presenting with meningitis and vaginal fistula: a case report.

Neuroenteric fistulas are rare congenital malformations arising from a persistent connection between the embryonic neural and intestinal tissues; they are extremely rare in the lumbosacral area. Neuroenteric fistulas should be suspected whenever children present with anaerobic meningitis in the absence of brain abscesses or respiratory infections. This patient is the first patient who presented with a presacral cyst that separately connected to the nervous system and the vagina. It is thought that the rape of this 12-year-old patient resulted in soilage of the spinal fluid through dual fistulae, causing anaerobic meningitis without an abscess.

A modification of the Bianchi intestinal lengthening procedure with a single anastomosis.

BACKGROUND/PURPOSE: Intestinal lengthening, as described by Bianchi, is the most commonly used method of gastrointestinal reconstruction for the therapy of short bowel syndrome. It divides the bowel in two longitudinal halves based on the bifurcated mesenteric blood supply, then reconnects the two halves in series with the rest of the small intestine. This requires three end-to-end narrow anastomoses in addition to the two longitudinal sutures lines. The authors describe a modification of the Bianchi procedure that lengthens the small intestine with a single wide end-to-end anastomosis thus avoiding two suture lines and their potential complications. METHODS: The anatomic principle used in this modification is the same as that described by Bianchi. The mesentery is separated based on the bifurcated vessels. With sequential firings of the stapler, the division of the intestine begins obliquely, proceeds longitudinally as in the Bianchi procedure, then ends obliquely at the other end of the intestine. This results in two divided segments that remain attached to the proximal and distal intestine and end in tapered staple lines. The two ends are sewn into a wide tapered anastomosis, reestablishing intestinal continuity with a single anastomosis instead of three. CONCLUSIONS: This simple modification, which we have used on two patients so far, decreases the number of anastomoses in an intestinal lengthening procedure from three narrow ones to one that is wider and tapered, thus reducing the risk of leaks and strictures. Because the end result is a lengthened intestinal segment similar to the Bianchi procedure, it should be equally effective in the therapy of short bowel syndrome.

Prosthetic patch stabilization of crural repair in antireflux surgery in children.

Nissen fundoplication is a frequently performed procedure by pediatric surgeons for the treatment of gastroesophageal reflux. Reoperation for failed fundoplication is necessary in 10 per cent of children and in 25 per cent of neurologically impaired children. In an attempt to reduce the postoperative recurrence of gastroesophageal reflux and wrap herniation, we have modified our Nissen fundoplication by reinforcing the crural repair with a horseshoe-shaped prosthetic patch. Between 1993 and 1995, 38 children underwent a Nissen fundoplication with prosthetic patch crural repair. Tension-free crural repair was performed over an esophageal dilator by suturing a horseshoe-shaped Dacron patch posterior to the esophagus. After crural repair, the standard Nissen 360 degrees wrap was constructed. Of the 38 children, 56 per cent (n = 21) were neurologically impaired. In 18 per cent of patients, the operation was performed for recurrent reflux due to wrap herniation after a Nissen fundoplication without prosthetic patch repair. One child required esophageal dilatation postoperatively for dysphagia related to esophageal stenosis. After a mean follow-up of 15 months, all patients were without symptomatic reflux or had no radiographic evidence of recurrent reflux or wrap herniation. Tension-free crural repair with a prosthetic patch may decrease postoperative reflux and wrap herniation, particularly in neurologically impaired children and in children requiring reoperation for recurrent reflux.

The wisdom of the bioprogressive philosophy.

This article provides a brief overview of the history of orthodontic practice and comments on the "era of limitations" that exemplified orthodontic thinking in the 1930s. In contrast, the Bioprogressive philosophy of orthodontic treatment which developed 2 decades later resulted from an attitude of academic and clinical freedom. The Bioprogressive philosophy brought many aspects of biology and function into the arena of orthodontic therapy. This technique does not follow a series of rigidly fixed treatment steps, but rather stresses a number of orthodontic principles that have stood the test of time. This article revisits and updates the Bioprogressive principles in line with the latest developments in biology and orthodontic materials.

Inflammatory pseudotumor of the spleen in a young child.

We describe a case of an inflammatory pseudotumor of the spleen in a 5-year-old boy, found incidentally during a physical examination. The boy underwent a hemisplenectomy. The problems in differentiating this disease from lymphoma of the spleen before surgery and the advantages of hemisplenectomy are discussed. This rare disease has previously been described in the spleen in only 28 cases, the youngest being a 16-year-old patient.