Abdominal sonography in examination of children with blunt abdominal trauma.

OBJECTIVE: The objective of our study was to evaluate abdominal sonography for the detection of fluid and organ injury in children with blunt abdominal trauma. SUBJECTS AND METHODS: Fifty-one consecutive children with blunt abdominal trauma requiring abdominal CT were prospectively examined with sonography. Sonograms and CTs were independently evaluated by two radiologists for fluid and organ injury; CT examinations were considered abnormal if either was identified. Differences in CT interpretation were settled by a third observer. Using CT as the truth standard, we calculated the sensitivity, specificity, and negative predictive value of sonography for both observers. Agreement of the sonographic interpretations was evaluated using kappa statistic. RESULTS: In 33.3% of patients, CT revealed fluid, organ injury, or both. The sensitivity and specificity of sonography when detection of fluid was the sole parameter evaluated was 58.8% and 79.4%, respectively, for observer 1 and 47.1% and 79.4%, respectively, for observer 2. In contrast, the sensitivity and specificity of sonography when detection of both fluid and organ injury was evaluated was 64.7% and 79.4%, respectively, for observer 1 and 70.6% and 70.6%, respectively, for observer 2. The negative predictive value of sonography was 79.4% and 75.0% with evaluation limited to detection of fluid and 81.8% and 82.8% with evaluation of fluid and organ abnormality for observers 1 and 2 , respectively. Agreement was excellent for sonographic identification of fluid (kappa = 0.82) but poor for detection of organ injury (kappa = 0.34). CONCLUSION: The low sensitivity and negative predictive value of sonography when assessing for either fluid alone or fluid and organ injury suggest that a normal screening sonography alone in the setting of blunt abdominal trauma fails to confidently exclude the presence of an intraabdominal injury.

Modern treatment modalities for neonatal and pediatric respiratory failure.

BACKGROUND: Respiratory failure secondary to a variety of causes remains a significant cause of morbidity and mortality in the pediatric population. Newer therapies are appearing frequently in an attempt to decrease the number of deaths from this disease state. We briefly review the current literature on some of the newer modalities including: high-frequency ventilation, surfactant, liquid ventilation, and nitric oxide. We then present our experience from the past 11 years in the most invasive, yet successful, therapy for acute respiratory failure-extracorporeal membrane oxygenation (ECMO). METHODS: Retrospective review of all patients treated with ECMO from September 1983 to December 1994 was undertaken. Data were collected from bedside ECMO flow sheets and the standardized data entry forms submitted to the Extracorporeal Life Support Organization. All statistical analyses were performed using a standard statistical software program. RESULTS: During the study period, 194 neonates and 47 pediatric patients were treated with ECMO. The survival rate in the neonatal population is 82% and in the pediatric population it is 40%. The neonatal patients required an average of 153 hours of support while the pediatric patients required 220 hours (P = 0.008). CONCLUSIONS: While the newer treatment modalities discussed may have an important role in treating neonatal and pediatric respiratory failure in the near future, ECMO remains a cornerstone of the modern treatment modalities. Although somewhat invasive, ECMO is effective therapy with increasing survival rates each year.

Trends in pediatric ostomy surgery: intestinal diversion for necrotizing enterocolitis and biliary diversion for biliary hypoplasia syndromes.

Ostomies are placed in children for different indications than in the older population. Many ostomies of childhood are placed because of congenital or neonatal problems that require temporary or long-term diversion to stabilize the neonatal patient. Necrotizing enterocolitis, the most common reason for placement of neonatal colostomies and ileostomies, is increasing in frequency as more prematurely born infants survive. Recently, there has been an increase in treatment of various biliary hypoplasia syndromes with biliary cutaneous diversion. Children with biliary hypoplasia syndromes are a challenging group of patients who frequently can be helped by ostomies. This article reviews current information on biliary cutaneous diversion for the biliary hypoplasia syndromes and intestinal diversion for necrotizing enterocolitis.

Definitive treatment of Hirschsprung's disease in the newborn with a one-stage procedure.

BACKGROUND: The purpose of this study was to review our experience and early follow-up with 15 one-stage pull-through procedures performed at the time of diagnosis in neonates and infants with Hirschsprung's disease. METHODS: Historic chart review of all patients with the new diagnosis of Hirschsprung's disease seen at the C.S. Mott Children's Hospital at the University of Michigan, Ann Arbor, between June 1989 and June 1992 was performed. Progress notes, operative and anesthetic records, pathology reports, and outpatient follow-up notes were used for data collection. RESULTS: Operative technique included a modified endorectal pull-through after determining the presence of ganglion cells by frozen section. No colostomies were performed before or after operation. Three patients had affected family members. All infants were born at term. Operation was performed within 24 hours of diagnosis and as early as 48 hours of age. Twelve patients had standard rectosigmoid disease, two had total colonic disease, and another had long-segment disease. Bowel function returned within 4 days of operation, and feeding was instituted by postoperative day 6 in all patients. All of the patients with rectosigmoid disease are doing well. Patients with long-segment or total colonic disease had more problems but are currently at home and doing well. Morbidity included two postoperative bowel obstructions and three patients with postoperative enterocolitis. CONCLUSIONS: A single definitive operation may be used to treat Hirschsprung's disease diagnosed in the newborn. Long-term follow-up in these patients is required.

Utility of sonography in the diagnosis of bronchopulmonary sequestration.

Sonography in six patients with pulmonary sequestration demonstrated findings associated with and indicative of that diagnosis. The most useful feature, which was seen in three cases and is diagnostic of sequestration, is the identification of an anomalous systemic artery arising from the aorta.

Inflammatory bowel disease.

Inflammatory bowel disease in children encompasses at least two forms of intestinal inflammation: ulcerative colitis and Crohn's disease. These two disease processes are differentiated based on clinical presentation, radiologic findings, endoscopic findings, histologic evaluation, and exclusion of alternative causes. The treatment and operative interventions are reviewed.

Appendiceal transection in a child associated with a lap belt restraint: case report.

The seatbelt syndrome refers to the spectrum of injuries associated with lap belt restraints and includes intestinal tears, perforations, and transections; mesenteric disruptions; and lumbar distractions, dislocations, and fractures. We report a case of appendiceal transection associated with a lap belt restraint in a small child.

Peripheral and central venous access.

Peripheral venous access is indicated for the administration of fluids, drugs, or if nutrients when other routes are unavailable. Central venous access is indicated if peripheral access is unsuccessful or if hypertonic, irritant, or vasoconstrictor solutions are used. Because of anatomical variations, different peripheral cannulation sites are more appropriate in different age groups. The preferred sites for long-term central venous access in infants and children are the external jugular, facial, internal jugular, saphenous veins at the groin, and subclavian veins. The practical aspects of peripheral and central venous access and the complications are discussed.

Fluids and electrolytes in infants and children.

The fluid and electrolyte management of the surgical neonate must take into account the acute transition to extrauterine life superimposed on the gradual changes associated with fetal and neonatal maturation and growth. With this transition, there are acute changes in body water distribution, and a striking increase in evaporative losses from the skin and respiratory tract. These changes, as well as those in renal function and sodium balance in the preterm and full-term infant are discussed.

Calcium homeostasis, bone metabolism and safety aspects during long-term treatment with a GnRH agonist.

Thirty-five women with symptomatic fibroids were treated with monthly injections of 3.2 mg microcapsulated D-Trp-6-LHRH for 6 months. During treatment serum 17 beta-oestradiol levels decreased, falling to castration levels associated with a reduction in the volume of the fibroids. In 16 patients a complete calcium homeostasis and bone metabolism work-up was carried out during treatment and subsequently for a 6-month follow-up period. Bone mineral content (BMC) and Compton bone densitometry readings remained unchanged. There were significant increases in serum calcium phosphate and alkaline phosphatase concentrations. A slight although not significant increase was observed in osteocalcin and parathyroid hormone (PTH) serum levels. Serum 1,25(OH)2D3 values decreased significantly after 3 months of treatment. Urinary hydroxyproline/creatinine and calcium/creatinine ratios as well as 24-h urinary calcium values increased significantly during the treatment period but decreased rapidly to pretreatment values after 3 months in the follow-up period. The endocrine changes induced by the GnRH-agonist treatment were associated with reversible biochemical signs of increased bone turnover and no significant changes in bone mass, suggesting that the treatment can be administered safely for a period of 6 months in patients with oestrogen-dependent diseases.

Effect of swimming on prednisolone-induced osteoporosis in elderly rats.

We investigated the possible ameliorating and preventive effect of swimming on prednisolone-induced osteoporosis in elderly rats. A total of 48 female Sabra strain rats were randomly assigned to the following groups and treatments: (1) control (C), (2) swimming (S), (3) prednisolone-treated (CP), and (4) swimming + prednisolone (SP). An additional 8 rats were sacrificed and examined at the onset of the study. Groups C and S were sham injected; groups CP and SP were injected with prednisolone (Ultracorten), 80 mg/kg three times per week for 10 weeks. Groups S and SP swam 1 h daily, 5 days per week for 10 weeks. SP rats swam simultaneously with prednisolone administration. At the end of the swimming period, in vivo bone mineral content (BMC) measurements were performed on rat vertebrae L4-5 by single-photon absorptiometry. Later, the humerus and femur were removed for the following measurements: morphometric, bone density (BD) by Compton scattering technique, bone ion content by atomic absorption, and hydration fraction by proton magnetic resonance (PMR). We found that the humeral BD of S rats was greater by 14% for group S over C and 3% greater for group SP over CP (P less than 0.05). Vertebral BMC was higher by 15% in group S over C and 11% higher for group SP over CP (P less than 0.05). Femoral calcium (mg/g dry bone) ion content was higher by 5% in group S over C and 8% in group SP over CP group (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of swimming on bone modeling and composition in young adult rats.

The purpose of this study was to investigate the adaptability of long bones of young adult rats to the stress of chronic aquatic exercise. Twenty-eight female Sabra rats (12 weeks old) were randomly assigned to two groups and treatments: exercise (14 rats) and sedentary control (14 rats) matched for age and weight. Exercised animals were trained to swim in a water bath (35 degrees +/- 1 degree C, 1 hour daily 5 times a week) for 12 weeks loaded with lead weights on their tails (2% of their body weight) (BW). At the end of the training period following blood sampling for alkaline phosphatase, all rats were sacrificed and the humeri and tibiae bones were removed for the following measurements: bone morphometry, bone water compartmentalization, bone density (BD), bone mineral content (BMC), and bone ions content (Ca, Pi, Mg, Zn). The results indicate that exercise did not significantly affect the animals' body weight, bone volume, or length and diameters. However, bone hydration properties, BD, bone mass, and mineralization revealed significant differences between swim-trained rats and controls (P less than 0.05). Longitudinal (R1) measurement was higher by 43% for both humerus and tibia, and Transverse (R2) relaxation rates of hydrogen proton were higher by 117 and 76% for humerus and tibia, respectively; fraction of bound water was higher by 36 and 46% for humerus and tibia, respectively. BD, bone weight, and ash were higher by 13%. BMC and bone ions content were higher by 10%, and alkaline phosphatase was higher by 67%.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of zinc therapy on neutrophil chemotaxis in psoriasis.

Neutrophil chemotaxis in patients with psoriasis vulgaris and psoriatic arthritis was investigated before and after 6 weeks of treatment with zinc sulphate (50 mg elementary zinc three times daily). In patients with active psoriasis vulgaris, a significant increase in neutrophil random migration and directed chemotaxis was demonstrated (10.2 +/- 3.1 and 14.1 +/- 4.1 mu, respectively, greater than that of control patients), while in patients with psoriatic arthritis the values were within the normal range (5.8 +/- 3.2 and 1.1 +/- 4.1 mu, respectively, greater than that of control patients). Although the zinc sulphate treatment had little or no effect on the course of either disease, it restored both the random migration and directed chemotaxis to normal values in psoriasis vulgaris patients. These results support the contention that zinc sulphate modifies neutrophil inflammatory potential; however, the lack of a clinical benefit suggests that neutrophils play only a secondary role in the pathogenesis of psoriasis.

Effect of swimming on bone growth and development in young rats.

The effect of chronic swimming on bone modelling was studied. Forty female Sabra rats (5 weeks old) were randomly assigned to the following experimental groups: 30 rats were trained to swim (water bath 35 +/- 1 degree C, one h daily, five times a week) for 20 weeks--20 of them loaded with lead weights (1% body weight) while the rest (10 animals) swam load free. Ten sedentary rats matched for age and weight served as controls. At the end of the twenty-week swimming period, all rats were sacrificed, both humeri bones were dissected and prepared for the following examinations: morphometric, bone density (BD), bone mineral content (BMC), compression tests and cross-sectional geometrical parameters, histomorphometry and biochemical analysis of minerals (Ca, Pi, Mg, Zn). All measured parameters were found to be significantly higher (P less than 0.05) in the swimming rats irrespective of load, as compared with the controls. Bone weight was higher by 19%, bone volume by 11%, bone length by 2.8%, cortical area by 16%, BD by 7% and BMC by 15%. The compression breaking force at the distal shaft of the humerus was higher by 24% in the trained group, while the ultimate compressive stress was not significantly different. Maximal and minimal moment of inertia at the distal diaphysis were 33.4 and 40% higher, respectively, for the swimming groups than the controls. Ca, Pi, Mg and Zn levels per total humeral bone were significantly higher in the exercising rats. The histomorphometry and cross-sectional data emphasize longitudinal and transversal growth. These data indicate that swimming exercise exerts a positive effect on bone growth and development in young rats.

Osteogenic response to marrow aspiration: increased serum osteocalcin and alkaline phosphatase in human bone marrow donors.

It has been shown recently in experimental animals that regeneration of bone marrow after ablation is associated with enhanced osteogenic growth factor activity and a systemic increase in bone formation. To assess the possible occurrence of a similar phenomenon in humans, serum markers of bone formation, osteocalcin and alkaline phosphatase, were measured in marrow donors before the aspiration of large amounts of iliac marrow and 1 day to 5 weeks thereafter. Both osteocalcin and alkaline phosphatase showed significant increases, with peak values 1-3 and 2-4 weeks postaspiration, respectively. The absolute maximal increase in osteocalcin was significantly higher in adolescent and child donors than in adults. When evaluated together with studies on systemic changes during fracture healing and marrow regeneration, these findings suggest that marrow aspiration in humans evokes a systemic osteogenic response.