Hydrostatic balloon dilation of congenital esophageal stenoses associated with esophageal atresia.

It has been stated that congenital cartilage rings in the esophagus do not respond to dilation and should be resected. The authors report on 3 infants with congenital esophageal stenoses who were treated successfully with hydrostatic balloon dilation. Based on the appearance during dilation the authors believe that these stenoses were cartilage rings. The technique is described in detail. Balloon dilation is the treatment of choice for these patients. Resection should be reserved for those who do not respond to this form of therapy.

Extralobar pulmonary sequestration receiving its arterial supply from the innominate artery.

Pulmonary sequestration is a rare bronchopulmonary foregut malformation, for which the arterial blood supply is usually derived from the descending thoracic or abdominal aorta. A 5-week-old infant is described with an extralobar pulmonary sequestration supplied by a large artery originating from the innominate artery, an arrangement only described once previously. Helical CT scan now makes arteriography unnecessary in the evaluation of these malformations.

The posterior approach to pyloric sonography.

Overlying bowel gas or gastric distension may occasionally hinder the sonographic diagnosis of hypertrophic pyloric stenosis. To address this problem, a novel approach for obtaining posterior views of the pylorus is reported. Utilizing this approach may decrease the incidence of nondiagnostic pyloric ultrasonography.

Prolonged intestinal exposure to amniotic fluid does not result in peel formation in gastroschisis.

The etiology of bowel wall changes in infants with gastroschisis remains unknown. Currently, debate focuses on the relative roles of amniotic fluid exposure versus that of intestinal ischemia. The authors report five cases of prenatally diagnosed gastroschisis in which the bowel was exposed to amniotic fluid for up to 21.3 weeks without developing any visible intestinal peel. These cases appear to minimize the role of prolonged amniotic fluid exposure in the development of bowel wall changes in gastroschisis.

Snowboarding injuries in children and adolescents.

To study snowboarding injuries in children and adolescents, a 6-year retrospective study was conducted of patients 18 years old and younger admitted to a pediatric trauma center after snowboarding accidents. The study was designed to identify the most severely injured patients. Comparison was made to data from a recent comparable study of skiing injuries. Twenty-seven patients were identified, all but one male and none under 10 years old. Nineteen were injured in a fall, 6 collided with a stationary object, one collided with a skier, and in one case the mechanism of injury was unclear. The average pediatric trauma score was 10.5, and the average injury severity score 10.2. Most of the 12 head injuries were minor. Most extremity fractures were to the upper extremity. There were two lumbar vertebral burst fractures, suggesting that the sport may predispose to this injury. There were no deaths. When compared with skiing, in snowboarding the overall severity of injury is lower, collision is a less common mechanism of injury and results in less serious injury, head injuries are less severe, the relative frequency of upper extremity fracture is higher, abdominal injuries are caused by falls rather than collisions, and facial injuries are less common. These differences are predictable on the basis of differences in the equipment. However, it is too early to say that snowboarding has less potential for life-threatening injury than skiing. Expected changes in the mix of participants, with an increase in the average skill level over time, may well result in different patterns, mechanisms, and severity of injury.

Indomethacin-associated bowel perforations: a study of possible risk factors.

BACKGROUND: The association between indomethacin administration and bowel perforation in premature infants is well known. The goal of this study was to examine possible risk factors for this complication. METHODS: Fifteen cases of indomethacin-associated bowel perforation occurred from 1993 to 1996. All had a birth weight < or = 1,100 g. These patients were compared with a control group of 51 infants who were cared for contemporaneously, had birth weights < or = 1,100 g and received indomethacin. RESULTS: Survival rate in the control group was 96%. For the group with perforations, it was 53%. Two types of perforation were seen, one occurring in the setting of necrotizing enterocolitis, and the other, a simple perforation in an otherwise normal-appearing bowel. For the latter group, the survival rate was 86%, and, when possible, primary repair was the procedure of choice. Use of aminophylline was greater in the control group. Otherwise, there were no significant differences between the two groups in any of the variables observed. However, when the simple perforations were observed separately, these patients had, on average, received indomethacin at a younger age than the controls (P < .05). The clustering of perforation cases from May through August suggests an infectious agent might be involved. CONCLUSIONS: Earlier administration of indomethacin correlates with an increased risk of focal perforation. It is unclear, however, whether the risk factor is the drug itself or the earlier need for it. Aminophylline use was somewhat more in the control group, but this is not likely to reflect a protective role for that drug. The possible involvement of an infectious agent should be considered.

Childhood sledding injuries.

Sledding is only rarely thought of as a potentially dangerous childhood activity. However, serious injuries and occasional deaths do occur. A review of patients 18 years old and younger admitted to a pediatric trauma center following a sledding accident from 1991 to 1997 was conducted. By design this study was expected to identify the most seriously injured patients. Twenty-five patients were identified, all but four younger than 13. Seventeen were boys. The mechanisms of injury were: collision with stationary object, 15; sled-sled collision, 1; struck by sled, 2; going off jump, 3; foot caught under sled or on ground, 3; fall off sled being towed by snowmobile, 1. The average pediatric trauma score was 10.5, and the average injury severity score 10.6. There were no deaths. The injuries were: head, 11; long bone/extremity, all lower, 10; abdomen, 5; chest, 1; facial, 2; spinal, 1. Five patients sustained multiple injuries. A surprisingly high number, 5, had pre-existing neurological conditions that could have played a contributory role in the accident. Sledding is predominantly an activity of children, and occasional serious injuries occur. Most are preventable. Obeying the simple caveat that sledding should only be done in clear areas away from stationary objects would eliminate the great majority of serious injuries.

Variation in the management of pediatric splenic injuries in New Hampshire.

PURPOSE: The aim of this study was to determine if variation in the management of pediatric splenic injuries occurs among hospitals in New Hampshire. METHODS: Data accrued for each patient less than 18 years of age discharged from an acute care hospital in New Hampshire with a splenic injury diagnosis code or splenic procedure code were analyzed for the years 1991 through 1994. The splenectomy, splenorrhaphy, and nonoperative management rates of each hospital were analyzed and adjusted for case mix using direct standardization. Management rates were determined for patients with isolated splenic injuries, which were then adjusted for case mix. RESULTS: Variation in the management of pediatric splenic injuries was found to occur among hospitals in New Hampshire. Management variation persisted despite adjustment for case mix. Variation was also noted in the management of patients with isolated splenic injuries and persisted after case mix adjustment. CONCLUSION: Even after adjustment for case mix, if all children with splenic injuries in New Hampshire were treated in the same fashion as at the state's children's hospital, over 73% of splenectomies and 70% of splenorrhaphies performed for trauma may have been avoided.

Teenage driving fatalities.

BACKGROUND/PURPOSE: A recent legislative effort in New Hampshire to institute a graduated licensing system for teenagers (TA) led to an analysis of state data on fatal crashes involving TA drivers. This provides an overview of these events and suggests possible prevention strategies. METHODS: Data on fatal crashes involving TA drivers was obtained for the years 1991 through 1996 from the Fatal Accident Unit, Division of State Police, New Hampshire Department of Safety. RESULTS: From 1991 through 1996, there were 100 events resulting in 109 total deaths, of which 76 were TA. Five involved motorcycles. Four drivers struck pedestrians, and two struck children on bicycles. In one case, an object fell from a truck, crushing a car. The remaining 88 were single- or multiple-car crashes, and these were analyzed further. Two thirds of the drivers were boys. The driver breakdown by age was 15 years, 3; 16 years, 21; 17 years, 26; 18 years, 20; 19 years, 18. The TA driver was killed in 47% of the events. Nineteen percent resulted in the death of the driver of another car. In 62 events, there were passengers in the TA's car, and in 55% of these, a passenger was killed. Twenty percent of the crashes involved drugs or alcohol, and almost two thirds of these occurred between 10:00 PM and 6:00 AM. Seat belts were not used by at least 72% of those injured fatally. In 59%, known traffic violations, usually speeding, contributed. More detailed data were available for 1995 through 1996, during which there were 30 crashes resulting in 33 deaths. Speed limit did not correlate with number of crashes. One-car crashes outnumbered multiple-car, 57% to 43%. Ninety percent occurred on single-lane roads. Most significantly, 63% of the drivers had been licensed less than 1 year and 47% less than 6 months. In this latter group, drugs and alcohol played no role, and none occurred between 11:00 PM and 6:00 AM. CONCLUSIONS: Two at-risk groups exist. The first is inexperienced sober TA drivers on single-lane roads during conventional hours. As experience increases, the second group appears: TA who have been drinking and are out late at night. Prevention strategies must take into account these two groups.

Surgical aspects of an outbreak of Yersinia enterocolitis.

Eleven patients with Yersinia enterocolitica infections were identified in the Upper Valley of New Hampshire and Vermont during October and November of 1995. Three children presented with an appendicitis-like picture. Two underwent appendectomy, one of whom was the outbreak's index case. Both appendectomy patients presented with lower abdominal pain, fever, vomiting, and a right lower quadrant mass associated with leukocytosis. Both had terminal ileitis, and in both, cultures of peritoneal fluid and a mesenteric lymph node grew Y. enterocolitica. Even during an outbreak there is no consistently reliable nonoperative way to separate a sporadic case of appendicitis from one whose appendicitis-like symptoms are due to Yersinia. In addition, a small percentage of Yersinia patients will present with true appendicitis as a complication of their disease.

Slipping rib syndrome in childhood.

Slipping rib syndrome is an unusual cause of lower chest and upper abdominal pain in children not mentioned in major pediatric surgical texts. The syndrome occurs when the medial fibrous attachments of the eighth, ninth, or tenth ribs are inadequate or ruptured, allowing their cartilage tip to slip superiorly and impinge on the intervening intercostal nerve. This may cause a variety of somatic and visceral complaints. Although the diagnosis may be made based on history and physical examination, lack of recognition of this disorder frequently leads to extensive diagnostic evaluations before definitive therapy. The authors report on four children who have this disorder.

Modifications of Bishop's method for pediatric gastrostomy closure.

In 1981, H.C. Bishop described a simple and effective method for pediatric gastrostomy closure. We have modified this approach in order to simplify and shorten the period of postoperative management.

Retinoic acid-induced regulation of neuropeptide Y receptor expression and function in the neuroepithelioma line SK-N-MC.

UNLABELLED: Neuropeptide Y (NPY) acts through specific receptors to inhibit adenyl cyclase and may have a role in neuroblastomas and neuroepitheliomas (NE) as a regulator of cell growth and differentiation. The authors have examined the status of NPY receptors in the NE cell line SK-N-MC and the effect of retinoic acid (RA), a known differentiating agent, on their expression and function. METHODS: Competitive NPY binding studies were performed on normal and RA-treated cells, followed by Scatchard analysis. NPY receptor function in the absence of or following RA treatment was determined by the ability of various concentrations of NPY to attenuate the forskolin-stimulated accumulation of intracellular cAMP. The mitogenic effect of NPY was evaluated by growing normal or RA-treated cell in the presence of various concentrations of NPY. RESULTS: Scatchard analysis showed a Kd of 2.3 nmol/L and a Bmax of 91,000 receptors per cell for untreated cells. RA treatment decreased receptor expression to 11,700 per cell without a significant change in receptor affinity (3.6 nmol/L). The effect of forskolin was inhibited by NPY in a dose-dependent fashion in both untreated and treated cells indicating functional receptors in both NPY stimulates the growth of normal SK-N-MC cells. NPY stimulated growth was significantly attenuated after RA treatment, possibly as a result of decreased NPY receptor expression. CONCLUSIONS: Treatment of SK-N-MC cells with RA, a known differentiating agent, leads to decreased expression of functional NPY receptors and a concomitant decrease in the mitogenic effect of NPY. This supports the role for NPY in the pathogenesis of NE.

Prenatal ultrasound characterization of the suprarenal mass: distinction between neuroblastoma and subdiaphragmatic extralobar pulmonary sequestration.

With the increased routine use of prenatal ultrasonography, subdiaphragmatic masses in the fetus are identified more frequently. Suprarenal masses often are presumed to be neuroblastoma and are removed surgically postnatally. We sought to better understand the natural history of subdiaphragmatic extralobar pulmonary sequestration, and to determine if subdiaphragmatic extralobar pulmonary sequestration can be distinguished preoperatively from neuroblastoma. The literature was reviewed for cases of prenatally diagnosed suprarenal masses that proved ultimately to be either subdiaphragmatic extralobar pulmonary sequestration or neuroblastoma. The distinguishing features of the two lesions were identified and an algorithm was created on the basis of these distinctions. Prenatally diagnosed subdiaphragmatic extralobar pulmonary sequestration is no longer rare, with one case being reported for every 2.5 cases of neuroblastoma. On prenatal ultrasonography subdiaphragmatic extralobar pulmonary sequestration usually is echogenic, is left-sided, and can be identified in the second trimester. Neuroblastoma is most often cystic, right-sided, and identified in the third trimester. In summary, subdiaphragmatic extralobar pulmonary sequestration must be considered in the differential diagnosis of the suprarenal mass identified on prenatal ultrasonography. Using the algorithm which we propose, the correct diagnosis can be determined prenatally in 95% of patients.

Skiing injuries in children and adolescents.

OBJECTIVE: A study of major skiing injuries in children and adolescents. DESIGN AND MATERIALS AND METHODS: A 5-year retrospective study of patients 18 years old and under admitted to a pediatric trauma center after skiing accidents. A follow-up questionnaire was used to obtain additional information. MEASUREMENTS AND MAIN RESULTS: Thirty-eight patients, of which 34 were male. Age range was 5 to 18 years. Fifty-eight percent of the accidents were collisions with stationary objects. Alcohol and drugs were not implicated. Helmet use was negligible. Head injuries, especially skull fractures, were very common (27), followed by extremity fractures (13), facial fractures (8), and abdominal (6), thoracic (5), and spinal injuries (2). One third had multiple injuries. The average cost was $22,000. There were no deaths, but 26% had long-term sequelae. The skill breakdown was 26% beginner, 29% intermediate, 45% advanced. Willingness to accept responsibility for the accident correlated inversely with skill level. CONCLUSIONS: Prevention efforts must target excessive speed and loss of control. Beginners must be well supervised on appropriate terrain. The frequency of skull fractures suggests that helmet use should be encouraged for young recreational skiers.

Perinatal intussusception in premature infants.

Intussusception is common in infants aged 5 to 18 months, but there have been only 12 reports of its occurrence among premature infants. Nine of these previously reported cases with adequate data and one new case are reviewed. Many of the infants were believed to have necrotizing enterocolitis, leading to an average 12-day interval between the onset of signs and the operation. Bilious emesis or nasogastric contents, bloody stool, and intestinal dilation without pneumatosis intestinalis were common. A contrast enema showed the intussusception in only 1 of 7 cases. Most cases were diagnosed in the operating room and underwent successful primary anastomosis, with no recurrences. A pathological lead point was identified in 2 of the 10 cases. The overall mortality rate was 23%; the one death since 1970 was secondary to attempted hydrostatic reduction. These cases may represent what, in the absence of premature delivery, would have been the intrauterine development of intussusception likely leading to small bowel atresia.

An unusual cause of penetrating cardiac injury in a child.

The authors report on a 7-year-old boy who suffered an unintentional penetrating cardiac injury while misusing a lawn toy in a predictable way. The boy was hemodynamically stable, with abdominal pain and tenderness. The pericardial effusion was first noted on upper abdominal computerized tomographic images and was confirmed by echocardiography. A puncture wound of the anterior right ventricle was found. As in this case, children may not have the typical signs and symptoms of cardiac tamponade, making the diagnosis difficult and delaying appropriate care. This child's injury could have been prevented through increased parental supervision or a modified toy design that takes into account predictable patterns of misuse.

The role of surgery in the management of stage IV neuroblastoma: a single institution study.

The role of surgery in the management of Stage IV neuroblastoma is still far from clear. Seventy-nine patients with this diagnosis presented to the Children's Hospital of Philadelphia during the 10-year period, 1977 to 1986. Four-year survival was 23%. A major resection of the primary tumor was undertaken in 54 patients. The timing of the procedure (at presentation or delayed) had no effect on survival. The patients were divided into three groups based on the extent of surgical resection: Group 1, no surgery or biopsy only (25); Group 2, complete gross resection (34); Group 3, incomplete resection with residual gross disease (20). Four-year survival was 16, 15, and 45%, respectively. The patients were then classified as favorable or unfavorable, on the basis of biological prognostic factors at presentation. When this analysis was combined with the extent of surgery it was discovered that Group 3 contained a higher proportion of favorable patients, accounting for the better survival. Within each group survival correlated with the expected prognosis. The outcome for a patient with Stage IV neuroblastoma depends on the biological characteristics of the tumor, and there is currently no evidence that these can be favorably altered by the timing or extent of surgical resection. Defining the appropriate role of surgery in the management of these patients will require a prospective randomized study which takes into account the inherent biological variability of the disease.