Is routine preoperative screening echocardiogram indicated in all children with congenital duodenal obstruction?

INTRODUCTION: Congenital duodenal obstruction (DO) is frequently associated with congenital heart disease (CHD). Operative repair of DO is often postponed until an echocardiogram is completed, which may result in unnecessary delays. We aimed to identify and characterize CHD in children with DO to determine if appropriately selected patients could forego preoperative echocardiogram. METHODS: A two-center retrospective review of all infants with DO undergoing operative repair with completed echocardiograms was included (2003-2011). Demographics, co-morbid conditions, clinical exam findings, radiologic imaging, and need for cardiac surgery were recorded. RESULTS: 67 children were identified. 47 (70.1%) had CHD on echocardiogram of which 19 (40.5%) had significant CHD. Children without clinical findings, abnormalities on physical examination, and/or abnormal chest x-ray were unlikely to have CHD; i.e., no asymptomatic child had significant CHD. Sensitivity and specificity of clinical findings, physical exam, and/or chest x-ray for significant CHD were 100% (95% CI 0.79-1.0) and 37.5% (95% CI 0.24-0.53), respectively, for major CHD and 87.2% (0.74-0.95) and 60% (0.36-0.80) for any CHD. CONCLUSION: Careful clinical assessment, evaluation with pulse oximetry, and chest x-ray may be sufficient to exclude significant CHD in children with DO. Identifying children at low risk for cardiac lesions may prevent unnecessary delays to operative intervention and may limit medical expenses.

Delayed family reunification of pediatric disaster survivors increases mortality and inpatient hospital costs: a simulation study.

BACKGROUND: Disasters occur randomly and can severely tax the health care delivery system of affected and surrounding regions. A significant proportion of disaster survivors are children, who have unique medical, psychosocial, and logistical needs after a mass casualty event. Children are often transported to specialty centers after disasters for a higher level of pediatric care, but this can also lead to separation of these survivors from their families. In a recent theoretical article, we showed that the availability of a pediatric trauma center after a mass casualty event would decrease the time needed to definitively treat the pediatric survivor cohort and decrease pediatric mortality. However, we also found that if the pediatric center was too slow in admitting and discharging patients, these benefits were at risk of being lost as children became "trapped" in the slow center. We hypothesized that this effect could result in further increased mortality and greater costs. METHODS: Here, we expand on these ideas to test this hypothesis via mathematical simulation. We examine how a delay in discharge of part of the pediatric cohort is predicted to affect mortality and the cost of inpatient care in the setting of our model. RESULTS: We find that mortality would increase slightly (from 14.2%-16.1%), and the cost of inpatient care increases dramatically (by a factor of 21) if children are discharged at rates consistent with reported delays to reunification after a disaster from the literature. CONCLUSIONS: Our results argue for the ongoing improvement of identification technology and logistics for rapid reunification of pediatric survivors with their families after mass casualty events.

Emergency management of pancreatic injury in a 5-year-old.

Pediatric pancreatic injuries are less common than many other intra-abdominal organ traumatic injuries; failure to identify pancreatic injury during the emergency phase will result in delayed diagnosis, delayed treatment, and potentially poor health outcomes. Injured children may present to nontrauma center/nonpediatric hospitals or urgent care settings where practitioners may not be experienced in diagnosing and treating pediatric pancreatic injuries. This case study explores the medical course of a child with persistent abdominal pain after a fall from a horse. He was evaluated in a nonpediatric trauma center and was discharged home, continued with symptoms, presented to a different community emergency department, and then transferred to the emergency department at a Level 1 pediatric trauma center. Educating health care providers about pediatric pancreatic injuries in emergency or urgent care settings will help improve quality of care for injured children who are not initially evaluated in a pediatric specific hospital or trauma center.

Congenital heart disease and heterotaxy: upper gastrointestinal fluoroscopy can be misleading and surgery in an asymptomatic patient is not beneficial.

PURPOSE: Heterotaxy syndrome is associated with intestinal abnormalities. We sought to define the gastrointestinal anatomy and determine both the risk of volvulus and benefit of screening upper gastrointestinal fluoroscopy (UGI) in these patients. METHODS: Medical records from 2003 until 2011 at Children's Hospital Los Angeles were reviewed in patients with heterotaxy for cardiovascular diagnosis, gastrointestinal symptoms, imaging and surgical arrangement of viscera, perioperative morbidities, and overall mortality. RESULTS: 224 patients were identified. Fifteen had polysplenia, 41 had asplenia, 50 had normal splenic morphology, 13 had inversus, and 104 were uncharacterized. UGI was performed in 4 patients for suspected volvulus and 20 for obstructive symptoms. Sixty-two had "screening" UGIs. Of 138 asymptomatic patients without imaging, none developed volvulus during the study period. In 30 patients with duodenojejunal malposition (DJM) who underwent surgery, none had malrotation or narrow mesentery. Eleven developed complications, with 8 requiring reoperation for obstruction. Of 8 patients with malrotation, 7 received a Ladd's procedure, and 2 had volvulus with viable bowel. One patient required reoperation and resection for obstruction. CONCLUSION: While rotational abnormalities are common in heterotaxy, risk of volvulus is low. Following operation, the risk of bowel obstruction and of need for reoperation is higher. We advocate avoiding operation in the asymptomatic patient.

Intraoperative hypercyanosis in a patient with pulmonary artery band: case report and review of the literature.

A case of intraoperative cyanosis in a patient with a common atrioventricular canal palliated with a pulmonary artery (PA) band is presented. The patient's physiology was consistent with cyanosis due to inadequate pulmonary blood flow, and responded quickly to typical interventions used for a hypercyanotic episode in a patient with unrepaired Tetralogy of Fallot. Differences and similarities in the physiology of PA banding compared with Tetralogy of Fallot are presented, including a rationale for treatment options for hemodynamic decompensation occurring in the setting of anesthesia and surgery.

Calcified gallstone in a 3 year-old boy: a case report.

BACKGROUND: Gallstones are relatively rare in children. At-risk populations include patients suffering from hemolysis syndromes. Regardless of etiology, these patients usually will present with postprandial abdominal pain, and ultrasonography is the mainstay of diagnosis. However, some gallstones are radiopaque and can be visualized on plain abdominal radiography. CASE PRESENTATION: We present the uncommon but classic plain x-ray finding of a calcified gallstone in a 3 year-old Hispanic boy. He was treated with elective laparoscopic cholecystectomy. CONCLUSIONS: Cholelithiasis is rare in children, and calcified stones that will appear on plain abdominal x-rays are even rarer. If symptomatic, cholecystectomy by a pediatric surgeon is the treatment of choice. We discuss some of the recent developments in treatment of this condition in this patient population.

Can a pediatric trauma center improve the response to a mass casualty incident?

UNLABELLED: Recent events including the 2001 terrorist attacks on New York; Hurricane Katrina; the 2010 Haitian and Chilean earthquakes; and the 2011 earthquake, tsunami, and nuclear disaster in Japan have reminded disaster planners and responders of the tremendous scale of mass casualty disasters and their resulting human devastation. Although adult disaster medicine is a well-developed field with roots in wartime medicine, we are increasingly recognizing that children may comprise up to 50% of disaster victims, and response mechanisms are often designed without adequate preparation for the number of pediatric victims that can result. In this short educational review, we explore the differences between the pediatric and adult disaster and trauma populations, the requirements for designation of a site as a pediatric trauma center (PTC), and the magnitude of the problem of pediatric disaster patients as described in the literature, specifically as it pertains to the availability and use of designated PTCs as opposed to trauma centers in general. We also review our own experience in planning and simulating pediatric mass casualty events and suggest strategies for preparedness when there is no PTC available. We aim to demonstrate from this brief survey that the availability of a designated PTC in the setting of a mass casualty disaster event is likely to significantly improve the outcome for the pediatric demographic of the affected population. We conclude that the relative scarcity of disaster data specific to children limits epidemiologic study of the pediatric disaster population and offer suggestions for strategies for future study of our hypothesis. LEVEL OF EVIDENCE: Systematic review, level III.

Steady-state and time-dependent thermodynamic modeling of the effect of intravenous infusion of warm and cold fluids.

BACKGROUND: Hypothermia results in vital sign lability, coagulopathy, wound infections, and other sequelae. Normothermia can be restored by several modalities, including passive blanket heating, warm forced-air devices, and active fluid warming (AFW). In AFW, intravenously administered fluids are heated to 40 to 45 °C to minimize net thermal losses and to raise body temperature. Clinical studies have demonstrated the efficacy of AFW as part of a strategy encompassing several methods, but the isolated contribution of AFW to warming has not been theoretically examined in detail. METHODS: A calorimetric model is derived to determine the functional dependence of warming on patient weight, hypothermia severity, infusion temperature, and volume infused. A second heat transfer model is derived to describe the time-dependent temperature changes of the periphery and core after warmed-fluid infusion. RESULTS: There is an inverse linear relationship between the patient's initial temperature and the amount of warming achieved with a given volume. In contrast, as the temperature of the infusion approaches the desired final temperature, the volume required for a fixed temperature change increases nonlinearly. For weight-based boluses, the temperature change scales appropriately with patient mass. Infusion of 2 L of room-temperature crystalloid results in a decrease in body temperature of approximately one-third degree Celsius in the average normothermic adult. For the heat transfer model, previously reported rates of temperature drop and recovery after the intravenous infusion of cold fluids are qualitatively reproduced with a blood mixing time of approximately 15 minutes. CONCLUSION: Our calculations reveal that AFW has a larger measurable beneficial effect for patients with more severe hypothermia, but true rewarming of the patient with AFW alone would require prohibitively large fluid volumes (more than 10 L of 40 °C fluid) or dangerously hot fluid (20 mL/kg of 80 °C fluid for a 1 °C increase). The major beneficial effect of AFW is the prevention of further net heat loss.

Colonic venous malformation and portal hypertension: association, management, and review of the literature.

We present a case of an adolescent with lower gastrointestinal bleeding caused by a colorectal venous malformation (VM) with concomitant portal hypertension. After an episode of massive gastrointestinal bleeding, we performed an extended right hemicolectomy and resection of the VM and selective portosystemic shunt. Here, we present the case and review the literature regarding portal hypertension and gastrointestinal vascular malformations. Additionally, we discuss the physiologic and hemodynamic effects of gastrointestinal vascular malformations on the portal system.

Sigmoid perforation and bucket-handle tear of the mesocolon after bicycle handlebar injury: a case report and review of the literature.

We describe an unusual case of sigmoid colon perforation secondary to a bicycle handlebar injury. Because the patient presented 2 days after the initial injury, we suspected that the colon perforation was not the immediate result of the bicycle accident but, rather, was secondary to devascularization. At operation, we found a bucket-handle tear of the colonic mesentery, which was the patient's primary injury and cause of the perforated colon.

Pneumatosis intestinalis after laparoscopic appendectomy: case report and review of the literature.

Pneumatosis intestinalis (PI) is the presence of intraluminal gas within the wall of the intestine. As a marker for bowel injury owing to mucosal injury, PI may herald a severe underlying disease process in patients without a significant medical history. In other cases, PI is a benign process, and expectant management is appropriate. Here, we present the first reported case of pneumatosis associated with postoperative abscess after appendectomy and its successful management. Then, we describe the pathophysiology of pneumatosis and review the literature regarding its origin and management.

Availability of a pediatric trauma center in a disaster surge decreases triage time of the pediatric surge population: a population kinetics model.

BACKGROUND: The concept of disaster surge has arisen in recent years to describe the phenomenon of severely increased demands on healthcare systems resulting from catastrophic mass casualty events (MCEs) such as natural disasters and terrorist attacks. The major challenge in dealing with a disaster surge is the efficient triage and utilization of the healthcare resources appropriate to the magnitude and character of the affected population in terms of its demographics and the types of injuries that have been sustained. RESULTS: In this paper a deterministic population kinetics model is used to predict the effect of the availability of a pediatric trauma center (PTC) upon the response to an arbitrary disaster surge as a function of the rates of pediatric patients' admission to adult and pediatric centers and the corresponding discharge rates of these centers. We find that adding a hypothetical pediatric trauma center to the response documented in an historical example (the Israeli Defense Forces field hospital that responded to the Haiti earthquake of 2010) would have allowed for a significant increase in the overall rate of admission of the pediatric surge cohort. This would have reduced the time to treatment in this example by approximately half. The time needed to completely treat all children affected by the disaster would have decreased by slightly more than a third, with the caveat that the PTC would have to have been approximately as fast as the adult center in discharging its patients. Lastly, if disaster death rates from other events reported in the literature are included in the model, availability of a PTC would result in a relative mortality risk reduction of 37%. CONCLUSIONS: Our model provides a mathematical justification for aggressive inclusion of PTCs in planning for disasters by public health agencies.

Numerical modeling of ferrous-ion oxidation rate in Acidithiobacillus ferrooxidans ATCC 23270: optimization of culture conditions through statistically designed experiments.

Statistically designed experimental strategy has been performed in order to evaluate and optimize nutritional and environmental parameters that affect ferrous ion oxidation rate in Acidithiobacillus ferrooxidans ATCC 23270. Plackett-Burman design was carried out to evaluate efficiently the biological significance of 10 culture conditions influencing ferrous-ion oxidation rate of A. ferrooxidans grown for 5 days in shake-flask batch mode on the newly modified 9-K media. Among ten fermentation factors examined, the most significant variables influencing ferrous-ion oxidation rate were statistically elucidated to be pH and calcium nitrate as positive contributors, whereas trace metals solution and potassium chloride were the most significant negative contributors. The optimal levels of the most significant three nutritional factors were further predicted from a polynomial model created from the data obtained from three level factorial design, a Box-Behnken design. Predicted optimal ferrous-ion oxidation rate Q(Fe2+) was recorded to be 0.148 (g Fe2+/l/hr). On verifying the predicted value, an experiment was performed under optimal predicted conditions and showed an actual experimental Q(Fe2+) of 0.152 g/l/hr, which was 2.7% over the predicted value. Our optimized medium formula gave overall five folds increase in ferrous-ion oxidation rates over the previously published data of standard 9-K medium on batch culture of A. ferrooxidans ATCC 23270 with higher mu(max) (hr(-1)) of 0.177 which was achieved within 75 h incubation in shake-flask culture.