Appendiceal fecalith is associated with early perforation in pediatric patients.

PURPOSE: A fecalith is a fecal concretion that can obstruct the appendix leading to acute appendicitis. We hypothesized that the presence of a fecalith would lead to an earlier appendiceal perforation. METHODS: Between January 2001 and December 2005, the charts of all patients younger than 18 years old who underwent appendectomy at our institution were reviewed. Duration of symptoms and timing between presentation and operation were noted along with radiologic, operative, and pathologic findings. RESULTS: There were 388 patients who met the study criteria. A fecalith was present in 31% of patients (n = 121). The appendix was perforated in 57% of patients who had a fecalith vs 36% in patients without a fecalith (P < .001). The overall rate of interval appendectomies was 12%. A fecalith was present on the initial radiologic studies of 36% of the patients who had interval appendectomies, and the appendix was perforated significantly sooner in these patients when compared to those without a fecalith (91 vs 150 hours; P = .036). CONCLUSION: The presence of fecalith is associated with earlier and higher rates of appendiceal perforation in pediatric patients with acute appendicitis. An expedient appendectomy should therefore be performed in the pediatric patient with a radiologic evidence of fecalith.

Gastric bypass surgery in a paraplegic morbidly obese patient.

The complications of spinal cord injury are exaggerated with obesity, and create complex medical and socioeconomic issues. Despite the well-documented advantages of bariatric surgery in reducing the morbidity of obesity, this option has not been routinely offered to obese patients with spinal cord injuries. We describe the first case of a morbidly obese male with a spinal cord injury who underwent a successful Roux-en-Y gastric bypass.

Total parenteral nutrition-associated hyperglycemia correlates with prolonged mechanical ventilation and hospital stay in septic infants.

PURPOSE: We studied the effects of total parenteral nutrition (TPN)-associated hyperglycemia on the clinical outcome in premature septic infants in the neonatal intensive care unit. METHODS: The charts of all premature infants weighing less than 1500 g upon admission to the neonatal intensive care unit between January 1, 2002, and December 31, 2002, with sepsis, ventilator dependence, and feeding intolerance were studied. Maximum serum glucose concentrations were compared with duration of TPN, mechanical ventilation, hospital length of stay, and survival using Pearson regression analysis and Student's t test. RESULTS: Thirty-seven patients met the search criteria. The average caloric intake for all infants at the time of blood culture-proven sepsis was 83 +/- 19 kcal/kg per day. The maximum serum glucose concentration (milligrams per deciliter) after having positive blood cultures (sepsis) was positively correlated with the duration of TPN (r = 0.45, P = .005), length of dependence on mechanical ventilation (r = 0.45, P = .006), and hospital length of stay (r = 0.36, P = .03). The average maximum serum glucose level was significantly higher in the nonsurviving infants (241 +/- 46 vs 141 +/- 48, P < .0001). CONCLUSION: Hyperglycemia correlated with prolonged ventilator dependency and increased hospital length of stay in premature septic infants. Avoidance of excessive nutrient delivery and tight glycemic control during periods of acute metabolic stress may improve outcome in this patient population.

Fine-needle aspiration biopsy specimen with a predominance of Hürthle cells: a dilemma in the management of nodular thyroid disease.

BACKGROUND: A fine-needle aspiration biopsy (FNAB) specimen of a thyroid nodule with a predominance of Hürthle cells usually is indicative of a Hürthle cell neoplasm, but it also may occur with nonneoplastic disease. METHODS: A prospective nodular thyroid disease database was used to identify patients with a FNAB specimen consisting of a predominance of Hürthle cells. Clinical factors were investigated and FNAB specimens were examined in a blinded fashion by a single cytopathologist to determine if there were specific factors that could be used to distinguish nonneoplastic from neoplastic disease. RESULTS: Of the 738 patients with nodular thyroid disease, 622 had a FNAB specimen. The FNAB specimen was interpreted as consistent with a Hürthle cell neoplasm in 45 (7%) patients, 7 (16%) with carcinoma, 21 (47%) with adenoma, 12 (27%) with adenomatous hyperplasia, and 5 (11%) with thyroiditis. Extensive cellularity and absent colloid were associated with neoplastic disease (P < .05). No cytologic feature reliably excluded neoplastic disease (P > .05). No significant differences in age (x +/- SD) (51 +/- 17 vs 54 +/- 17 y), sex (female/male ratio, 6/1 vs 15/2), nodule size (3.9 +/- 1.9 vs 3.4 +/- 2.0 cm), weight of excised thyroid tissue (42 +/- 27 vs 33 +/- 30 g), or functional status of the thyroid gland was observed between patients with neoplastic (n = 28, 62%) versus nonneoplastic (n = 17, 38%) disease. CONCLUSIONS: Neoplastic disease accounts for two thirds of the pathology in patients with a predominance of Hürthle cells on FNAB specimen and neither clinical nor cytologic features reliably exclude Hürthle cell adenoma or carcinoma. As a result, thyroidectomy is recommended for all patients with a thyroid nodule and a predominance of Hürthle cells on FNAB specimen.

C-Reactive protein-determined injury severity: length of stay predictor in surgical infants.

BACKGROUND/PURPOSE: Serum C-reactive protein (CRP) levels reflect the severity of the metabolic response to injury in critically ill children. During this period, caloric overfeeding can increase complications and delay recovery. The authors hypothesized that by avoiding excessive caloric delivery, the effect of injury severity would be the major factor determining clinical outcome. METHODS: Twenty-eight surgical infants who had indirect calorimetry measurements while in the Neonatal Intensive Care Unit between August 2000 and January 2002 were studied. Serum CRP concentrations, mean energy expenditure (MEE), respiratory quotient (RQ), length of hospital stay (LOS), and caloric intake (I) at the time of indirect calorimetry were recorded. Data were analyzed using the Pearson product-moment correlation. RESULTS: Peak serum CRP was significantly correlated to LOS in all patients (r = 0.79, P < .0001). When net caloric balance (I-MEE) did not exceed 5 kcal/kg/d (n = 9), peak serum CRP was correlated positively with RQ (r = 0.66, P = .05). When I-MEE exceeded 5 kcal/kg/d (n = 19), the positive correlation of serum CRP with RQ was diminished (r = 0.23, P = .33). CONCLUSIONS: CRP-measured injury severity is a major determinant of clinical outcome in surgical infants. In addition, overfeeding causes additional RQ elevation.