Significance of chest trauma in children.

Chest trauma in children is a marker of injury severity and is associated with a high mortality rate. This retrospective study of 1,356 trauma patients from a private pediatric hospital over a 2.5-year period identified 82 patients with chest injuries and a mortality rate of 22%. Results of Injury Severity Score, Glasgow Coma Scale, and Revised Trauma Score all indicated that children with chest injuries sustained more severe injuries. The presence of any extrathoracic injury was associated with a higher mortality (29%) than chest injury alone (4.3%). The type of extrathoracic injury was important, with head and neck injuries resulting in the highest mortality. Specific chest injuries, such as rib fractures and pulmonary contusions, were not related to increased mortality unless there was an associated extrathoracic injury. Many reports have shown a high mortality associated with chest trauma. This study suggests that it is the associated extrathoracic injury, rather than the chest injury itself, that is the real cause of the high mortality.

A combined hospital experience with fundoplication and gastric emptying procedure for gastroesophageal reflux in children.

BACKGROUND: Operative treatment of symptomatic gastroesophageal reflux (GER), often together with neurologic feeding disorders, is very common in infancy and childhood. Delayed gastric emptying (DGE) has been observed frequently in association with GER in children. STUDY DESIGN: A retrospective review was performed on 1,200 consecutive patients 18 years of age and younger operated upon for symptomatic GER or neurologic feeding disorders, or both, at two pediatric surgery centers in widely separated geographic areas in the United States of America, to compare the results after fundoplication with or without a gastric emptying procedure (GEP). RESULTS: Operations included gastroesophageal fundoplication (GEF) alone (871 patients), GEF plus GEP (286 patients), reoperative GEF plus GEP (30 patients), and GEP alone (13 patients). Thus, 27 percent of the total and 40 percent of the last 494 children with reflux had a GEP. Delayed gastric emptying with retention of more than 60 percent of an isotope meal appropriate for age at 90 minutes was present in 241 of the 451 children with reflux studied. Major neurologic disorders were present in 219 (25 percent) of 871 children who underwent GEF alone and in 247 (75 percent) of 329 children who had a GEP. All patients operated upon from both hospitals were relieved of recurrent emesis, and those with failure to thrive showed significant weight gain; pulmonary symptoms were relieved in 94 percent. Recurrent GER developed in 47 (5.2 percent) of 901 children who had GEF alone, but in only four (1.2 percent) of 329 patients who had a GEP. CONCLUSIONS: The excellent clinical results with low morbidity in this largest reported clinical experience with GEP in childhood suggest that a GEP should be combined with GEF for symptomatic children who have both GER and DGE. Minimal investigative studies are necessary for most neurologically impaired children who require a feeding gastrostomy.

Degradation of the interferon-induced 68,000-M(r) protein kinase by poliovirus requires RNA.

Control of the interferon-induced double-stranded RNA (dsRNA) activated protein kinase (referred to as P68 because of its M(r) of 68,000 in human cells) by animal viruses is essential to avoid decreases in protein synthetic rates during infection. We have previously demonstrated that poliovirus establishes a unique way of regulating the protein kinase, namely by inducing the specific degradation of P68 during infection (T. L. Black, B. Safer, A. Hovanessian, and M. G. Katze, J. Virol. 63:2244-2251, 1989). In the present study we investigated the mechanisms by which P68 degradation occurred. To do this we used an in vitro degradation assay which faithfully reproduced the in vivo events. Although viral gene expression was required for P68 degradation, the major poliovirus proteases, 2A and 3C, were found not to be directly involved with P68 proteolysis. However, the protease responsible for P68 degradation required divalent cations for maximal activity and probably has both an RNA and a protein component since trypsin and ribonuclease abrogated the activity. Despite this requirement for divalent cations and RNA, activation of the kinase was not required for proteolysis since a catalytically inactive P68 was still degraded. Mapping of P68 protease-sensitive sites by using in vitro translated truncation and deletion mutants revealed that sites required for degradation resided in the amino terminus and colocalized to dsRNA-binding domains. Finally, we found that preincubation of cell extracts with the synthetic dsRNA poly(I-C) largely prevented P68 proteolysis, providing additional evidence for the critical role of RNA. On the basis of these data, we present a hypothetical model depicting possible mechanisms of P68 degradation in poliovirus-infected cells.

Federal early childhood special education policy: a model for the improvement of services for children with disabilities.

Services in early childhood special education for children with disabilities, birth through 5 years, and their families have expanded and improved substantially in the past 25 years. The federal government, through legislation, regulation, and a variety of incentives, has played an integral role in this progress. The authors review the evolution of federal education policy in early childhood and the accomplishments achieved, including the development of the Handicapped Children's Early Education Program, the Early Childhood Research Institutes, and Public Law 99-457, the Handicapped Infant and Toddler Program (Part H). This history can serve as a model for federal involvement in the improvement of services for other groups of individuals with special needs.

The effect of tube gastrostomy on gastroesophageal reflux in patients with esophageal atresia.

Gastroesophageal reflux (GER) occurs frequently in infants with esophageal atresia (EA). The definitive management is primary repair and often includes tube gastrostomy. The recent finding of lower esophageal sphincter (LES) pressure changes with tube gastrostomy suggests that GER might be related to gastrostomy rather than EA per se. To evaluate this thesis, two populations of patients from different children's hospitals were reviewed: EA with and without routine gastrostomy. The two populations were similar with respect to number of infants, associated anomalies, distribution in the Waterston classification, morbidity, and mortality. One hundred sixteen patients were studied. Of the 66 survivors who underwent gastrostomy and repair of EA, 30 were found to have GER (45.5%) and 12 required fundoplication (18.2%). Of 31 surviving patients who underwent repair of EA without gastrostomy, 11 had GER (35.5%) and four required fundoplication (12.9%). These data suggest that tube gastrostomy does not significantly contribute to the GER associated with EA.

Necrotizing enterocolitis: improving survival within a single facility.

Necrotizing enterocolitis (NEC), a disease associated with prematurity, carries a significant morbidity and mortality. This study was designed to evaluate our progress in dealing with NEC both medically and surgically in a single large neonatal intensive care unit (NICU). We also sought to confirm the relation of birth weight and particular indications for operation to outcome. Over 6 1/2 years, there were 7,807 admissions to a large NICU. Though there has been a steady increase in total admissions, especially of infants weighing less than 1,000 gm, survival has improved significantly in all groups (mean 89.1%). NEC occurred in 358 infants (4.6%), and 115 (32%) required surgical intervention. Infants weighing between 751 and 1,000 gm had the highest incidence of NEC. There has been a significant decrease in the mortality of both medically and surgically treated infants with NEC; in both cases, this decrease is weight-dependent. We found that using erythema and edema of the abdominal wall and a fixed-loop roentgenographic pattern as early indicators of necrotic bowel significantly improves survival in surgically treated infants.

The cellular 68,000-Mr protein kinase is highly autophosphorylated and activated yet significantly degraded during poliovirus infection: implications for translational regulation.

We investigated the possible translational regulatory roles played by the interferon-induced, double-stranded-RNA-activated protein kinase (P68) and its natural substrate, eucaryotic initiation factor 2 (eIF-2), in poliovirus-infected cells. We demonstrated that protein kinase P68 was both highly autophosphorylated and activated during poliovirus infection. In accordance with these results, immunoprecipitation analysis revealed that phosphorylation of the endogenous eIF-2 alpha subunit also increased in poliovirus-infected cells. We found that double-stranded RNA synthesized during infection likely induced the high levels of P68 autophosphorylation. To determine whether the increase in kinase activity also could be attributed to induction of P68 synthesis, physical levels of protein kinase were measured. It was unexpectedly found that P68 protein levels did not increase but rather dramatically declined in poliovirus-infected cells. Pulse-chase experiments confirmed that the protein kinase was significantly degraded during virus infection. We corroborated our in vivo observations by developing an in vitro assay for P68 degradation using cell extracts. The possible consequences of P68 degradation and increased eIF-2 alpha phosphorylation for protein synthesis regulation in poliovirus-infected cells are discussed.

Extralobar pulmonary sequestration and mediastinal bronchogenic cyst.

A child with coexisting mediastinal bronchogenic cyst and extralobar pulmonary sequestration is presented. Two distinct lesions were suggested by barium esophagram and confirmed by a chest computed tomography scan. The diagnostic and embryologic relationship of the two lesions is discussed.

Preventing accidental decannulations following tracheostomy.

Tracheostomy in infants and children is associated with a high rate of accidental decannulation in the early postoperative period. Eighty-eight patients underwent tracheostomy from 1980 to 1985, and 22 were sutured in place. Accidental decannulation occurred in 31.8% of the nonsutured and 4.5% of the sutured tracheostomies. We advocate suturing tracheostomy tubes in place in infants and children and describe a simple suture technique for this purpose.

Delayed presentation of traumatic intraperitoneal bladder rupture.

A child with urine ascites as a delayed manifestation of post-traumatic intraperitoneal bladder rupture is presented. The diagnosis was suggested by abdominal CT scan and confirmed with a cystogram. While uncommon, late presentation of intraperitoneal bladder rupture following trauma may occur from masking of a primary laceration or development of secondary rupture at the site of a hematoma in the bladder wall. Since CT may be a primary diagnostic study performed following abdominal trauma, the radiologist should be aware of CT findings suggesting bladder rupture and of the possibility of delayed presentation of this injury.

Thyroid dysfunction and neoplasia in children receiving neck irradiation for cancer.

The reported relationship of radiation exposure and thyroid carcinoma stimulated this retrospective study of 298 patients treated at St. Jude Children's Hospital with radiation therapy to the neck for childhood cancer to identify patients who developed subsequent thyroid abnormalities. This series includes 153 patients with Hodgkin's disease, 95 with acute lymphocytic leukemia, 28 with lymphoepithelioma, and 22 with miscellaneous tumors. Inclusion in the study required 5 years of disease-free survival following therapy for their original tumor, which included thyroid irradiation. Follow-up has been 100%. Most patients also received chemotherapy. Seventeen patients were found to have decreased thyroid reserve with normal levels of free triiodothyroxine (T3) or free thyroxin, (T4) and an elevated level of thyroid-stimulating hormone (TSH). In nine patients hypothyroidism developed, with decreased T3 or T4 levels and an elevated level of TSH. One hyperthyroid patient was identified. Two patients had thyroiditis, and seven had thyroid neoplasms: (carcinoma in two, adenoma in two, colloid nodule in one, and undiagnosed nodules in two). This survey has demonstrated an increased incidence of thyroid dysfunction and thyroid neoplasia when compared to the general population. The importance of long-term follow-up for thyroid disease is emphasized in patients who have received thyroid irradiation. The possible role of subclinical hypothyroidism with TSH elevation coupled with radiation damage to the thyroid gland as a model for the development of neoplastic disease is discussed.