Amylase and lipase measurements in paediatric patients with traumatic pancreatic injuries.

INTRODUCTION: Pancreatic injuries occur in up to 10% of paediatric patients who suffer blunt trauma. Initial amylase and lipase measurements have not been helpful as a screening tool to detect pancreatic injuries. However, one primarily adult study suggests that a delayed measurement may be useful. MATERIALS AND METHODS: A retrospective chart review was conducted of patients admitted to a Level I paediatric trauma centre from April 1996 to November 2006 with traumatic pancreatic injuries. RESULTS: The trauma database identified 51 patients with traumatic pancreatic injuries. Inclusion and exclusion criteria were met by 26 patients. Patients with initial amylase and lipase levels measured greater than 2h post-injury were more consistently elevated compared to those patients who had levels measured at 2h or less post-injury. There was a significant association between time of measurement and an increased amylase level (p=0.012). No significant association was found for lipase measurements (p=0.178). DISCUSSION AND CONCLUSIONS: In children with blunt pancreatic injury, elevated serum amylase levels were seen in a significantly higher percentage of patients with initial measurements at greater than 2h post-injury compared to those measured at 2h or less. Lipase measurements demonstrated a similar trend. Delayed amylase and lipase measurements may be helpful to detect pancreatic injuries, but further study is needed.

Low-dose ketamine: efficacy in pediatric sedation.

OBJECTIVES: Intravenous (IV) ketamine has gained widespread use in the emergency department (ED) for procedural sedation. The most commonly recommended starting dose is 1.5 mg/kg. We examined whether lower doses of ketamine in the range of 0.5 to 1.0 mg/kg could successfully sedate pediatric patients. METHODS: We retrospectively reviewed quality assurance data of patients sedated with IV ketamine in a pediatric ED. Patients were administered 0.02 mg/kg of IV atropine, 0.05 mg/kg of IV midazolam, and then 0.5 mg/kg of IV ketamine. Additional aliquots of 0.25 to 0.5 mg/kg of ketamine were given as necessary, to a maximum of 2.0 mg/kg. Efficacy of sedation was assessed after every dose by pediatric emergency medicine attendings or fellows. RESULTS: Seventy-two patients had quality assurance forms completed. The total ketamine dose administered ranged from 0.5 to 2 mg/kg. Adequate procedural sedation was obtained for 70 (97%) of 72 patients. Forty-four percent of patients required 0.75 mg/kg or less of ketamine to obtain adequate initial sedation; 25% of subjects required only 0.5 mg/kg; 43% of patients required 1.0 mg/kg of IV ketamine. We found that 88% of our patients could be successfully sedated at initial doses of 1 mg/kg or less. CONCLUSIONS: Our study suggests a potential role for low-dose IV ketamine in the range of 0.5 to 1.0 mg/kg for pediatric procedural sedation. Most pediatric ED patients can be successfully sedated with 1 mg/kg of ketamine.

Phosphorylated histone H3, Ki-67, p21, fatty acid synthase, and cleaved caspase-3 expression in benign and atypical granular cell tumors.

CONTEXT: Granular cell tumors (GCTs) are classified as benign when none of the following features is present: spindling of the tumor cells, necrosis, diffuse pleomorphism, prominent nucleoli, high nuclear-cytoplasmic ratio, and mitotic rate >2 per 10 high-power fields. It has been suggested that a GCT be classified as atypical when 1 or 2 of these features are seen and as malignant when 3 or more of these are present. In our practice, we do not classify GCTs as malignant in the absence of metastasis. OBJECTIVE: To compare immunohistochemical staining for phosphorylated histone H3 (PHH3), Ki-67 (MIB-1), p21, fatty acid synthase, and cleaved caspase-3 in histologically classified benign and atypical GCTs. DESIGN: We reviewed 25 cases of GCT from our archives and classified 14 as atypical based on histologic features. Immunohistochemical staining for PHH3, Ki-67, p21, fatty acid synthase, and cleaved caspase-3 was performed using standard methods. The number of positive cells for Ki-67, p21, and PHH3 was calculated in 10 consecutive high-power fields in a hot spot. Fatty acid synthase and cleaved caspase-3 cytoplasmic expression was graded from 1 to 3. RESULTS: Ki-67 and PHH3 scores were significantly higher in atypical GCTs. The expression of p21, fatty acid synthase, and cleaved caspase-3 was not significantly different between atypical and benign GCTs. CONCLUSIONS: This study shows that histologic features are reliable in identifying GCTs that have a higher proliferative potential as shown by higher immunoreactivity for Ki-67 and PHH3. These immunostains may help in classifying GCTs in cases where a thorough histologic evaluation is precluded by the small size of a biopsy specimen.

Increased ratio of saturated to unsaturated C18 fatty acids in colonic adenocarcinoma: implications for cryotherapy and lipid raft function.

Mammalian fatty acid synthase (FASE) overexpression has been shown in a number of human malignancies including colonic adenocarcinoma. Since FASE synthesizes only saturated fatty acids, we hypothesized that cancer cells have a greater proportion of long-chain saturated fatty acids. We studied and found an unequivocal increase in saturated C18 fatty acid (stearic acid) in colonic adenocarcinoma compared to adjacent normal colonic mucosa. The increase is even more striking when measured as a ratio of stearic acid to the unsaturated C18 fatty acids (oleic acid and linoleic acid). This change in fatty acid composition of the cancer cells should significantly alter their physical and biological properties. The increase in relative proportion of saturated fatty acids should make the cancer cells more susceptible to cryodamage and measurement of fatty acid composition of cancer cells may help individualize the temperature for cryotherapy. Also, the lipid alterations may affect the structure and functions of lipid rafts, which may enable the cancer cells to affect signaling mechanisms such as those involved in cell growth and apoptosis. Dietary or therapeutic interventions targeting lipid rafts may thus be an option for cancer treatment.

Fatty acid synthase expression in cutaneous melanocytic neoplasms.

Mammalian fatty acid synthase is a multifunctional enzyme complex involved in de novo synthesis of saturated fatty acids, and inhibitors of fatty acid synthase are being evaluated as potential therapeutic agents. Increased fatty acid synthase expression has been demonstrated in subsets of malignancies, including colon, breast, endometrium, prostate and ovarian carcinomas, and recently malignant melanomas. We evaluated the immunohistochemical expression of fatty acid synthase in 155 cutaneous melanocytic lesions. They included 30 congenital nevi, 19 compound nevi, 40 Spitz nevi, 48 primary melanomas, and 18 metastatic melanomas. Fatty acid synthase expression was stronger in malignant melanomas in comparison to conventional nevi and Spitz nevi, and was the highest for metastatic melanoma. Of the primary malignant melanomas, mean fatty acid synthase scores were significantly greater for Clark levels IV and V compared to Clark levels I and II (P<0.001). In addition, melanomas with Breslow thickness 0.75-1.50 mm and >1.50 mm showed significantly higher mean fatty acid synthase scores compared with those with Breslow thickness <0.75 mm (P=0.013 and <0.001, respectively). Of interest, congenital melanocytic nevi also showed strong fatty acid synthase expression, similar to that seen in metastatic melanoma. This may represent persistence of or regression to a fetal phenotype since normal fetal tissues are known to express high levels of fatty acid synthase.

Spitz nevi and atypical Spitz nevi/tumors: a histologic and immunohistochemical analysis.

A subset of Spitz nevi poses substantial diagnostic difficulty, even among experts, due to its resemblance to malignant melanoma. These lesions are termed atypical Spitz nevi/tumors and there is currently a lack of objective criteria for predicting their biologic behavior. We compared the expression of Ki-67, p21, and fatty acid synthase by immunohistochemistry in 10 atypical Spitz nevi, 28 typical Spitz nevi, 19 compound melanocytic nevi and 18 invasive malignant melanomas. There was a progressive increase in fatty acid synthase cytoplasmic expression with statistically significant differences observed between Spitz nevi and atypical Spitz nevi (P=0.003) and between atypical Spitz nevi and malignant melanoma (P<0.050). Ki-67 nuclear staining was lower in both typical and atypical forms of Spitz lesions than in malignant melanoma (P<0.001). The degree of P21 nuclear expression in atypical Spitz nevi was not significantly different than in Spitz nevi, but was significantly greater than expression in conventional nevi and approached significance after multiple comparisons corrections for malignant melanoma. Thus, a high level of P21 expression makes a tumor more likely to be a typical or atypical Spitz nevus than a malignant melanoma, especially when coupled with a low Ki-67 index and weak expression of fatty acid synthase. These immunohistochemical observations support the concept that atypical Spitz nevi are distinct lesions of borderline biologic behavior residing between Spitz nevi and malignant melanoma. The study also compared a large array of histologic features of 16 cases of typical Spitz nevi in children with 12 typical Spitz nevi in adults. The adult lesions were significantly more likely to be intradermal and to display dermal fibroplasia, but were histologically similar to their pediatric counterparts in all other respects.

Fresh whole blood versus reconstituted blood for pump priming in heart surgery in infants.

BACKGROUND: In an attempt to reduce the coagulopathic and inflammatory responses seen after cardiopulmonary bypass, the use of fresh whole blood during heart operations has become the standard of care for neonates and infants at many institutions. We compared the use of fresh whole blood with the use of a combination of packed red cells and fresh-frozen plasma (reconstituted blood) for priming of the cardiopulmonary bypass circuit. METHODS: We conducted a single-center, randomized, double-blind, controlled trial involving children less than one year of age who underwent open-heart surgery. Patients were assigned to receive either fresh whole blood that had been collected not more than 48 hours previously (96 patients) or reconstituted blood (104 patients) for bypass-circuit priming. Clinical outcomes and serologic measures of systemic inflammation and myocardial injury were compared between the groups. RESULTS: The group that received reconstituted blood had a shorter stay in the intensive care unit than the group that received fresh whole blood (70.5 hours vs. 97.0 hours, P=0.04). The group that received reconstituted blood also had a smaller cumulative fluid balance at 48 hours (-6.9 ml per kilogram of body weight vs. 28.8 ml per kilogram, P=0.003). Early postoperative chest-tube output, blood-product transfusion requirements, and levels of serum mediators of inflammation and cardiac troponin I were similar in the two groups. CONCLUSIONS: The use of fresh whole blood for cardiopulmonary bypass priming has no advantage over the use of a combination of packed red cells and fresh-frozen plasma during surgery for congenital heart disease. Moreover, circuit priming with fresh whole blood is associated with an increased length of stay in the intensive care unit and increased perioperative fluid overload.

A comparison of the influence of hospital-trained, ad hoc, and telephone interpreters on perceived satisfaction of limited English-proficient parents presenting to a pediatric emergency department.

BACKGROUND: Latinos are the fastest growing minority group in the United States with a significant percentage of this population having limited English proficiency. OBJECTIVE: To determine whether mode of interpretation influences satisfaction of limited English-proficient parents presenting to a tertiary care pediatric emergency department. DESIGN: One hundred eighty parents of patients presenting to a pediatric emergency department were surveyed after receiving services from one of the following interpreters: hospital-trained, ad hoc, or telephone. An English-proficient comparison group of 60 parents of any ethnicity was also surveyed (total N = 240). RESULTS: Parents were significantly more satisfied (P < 0.001) with hospital-trained interpreters. While no significant difference was found in overall visit satisfaction, there were significant differences in several other outcome variables. When hospital-trained interpreters were used, parents were significantly more satisfied (P < 0.001) with their physicians and nurses. With regard to the ability to communicate with pediatric emergency department personnel, parents using hospital-trained interpreters averaged significantly higher scores (P < 0.001) than the telephone group. Quality-of-care scores were significantly higher (P < 0.001) for parents assigned to hospital-trained interpreters than for the other forms of interpretation. English-proficient parents scored highest in the following categories: ability to communicate, quality of care, and overall visit satisfaction. Parents using hospital-trained interpreters scored higher than English-proficient parents when questioned about physician and nursing satisfaction. CONCLUSION: Hospital-trained interpreters are a valuable and needed resource to facilitate communication with limited English-proficient patients and families. Other interpretation services are useful but have limitations.

Ethnicity, traditional health beliefs, and health-seeking behavior: guardians' attitudes regarding their children's medical treatment.

INTRODUCTION: The purpose of this research was to examine ethnic variation in attitudes about traditional health beliefs concerning the use of home remedies and self-medicating behavior among guardians for their children. METHOD: As part of a community health care utilization study of children, questions were included regarding guardians' traditional health beliefs. Survey questions were adapted from the National Health Interview Survey or developed by the researchers. A cross-sectional stratified sample of households with children (n = 1606) were surveyed by random digit dialing. RESULTS: Two of four traditional health belief questions were significantly associated with ethnicity. Differences were observed for (a) guardians' willingness to treat their children with home remedies rather than use a health care provider if the condition was nonemergent and (b) their belief that some home remedies are better than prescribed drugs for curing illness (P <.01). DISCUSSION: Some traditional health beliefs among guardians differed by ethnicity. However, differences between the two minority groups were as pronounced as differences between minority and nonminority guardians. An understanding of the diversity of ethnic attitudes about traditional health beliefs is necessary for those involved in the delivery of health care. A stereotypical view that larger proportions of minorities subscribe to traditional health beliefs than do Whites is not supported in this research.