Needle core biopsy in the diagnosis of pediatric thyroid neoplasms: a single institution retrospective review.

PURPOSE: Our institution routinely utilizes needle core biopsy (NCB), instead of fine needle aspiration, in the evaluation of pediatric thyroid nodules. This practice initially arose from limited cytopathology services in our hospital. Given the lack of information regarding the utility of NCB in diagnosing pediatric thyroid neoplasms, we set out to review our institution's experience with this technique. METHODS: We performed a single institution retrospective chart review of all children who underwent thyroidectomy for primary thyroid pathology. RESULTS: Seventy-four patients, with a mean age of 12.9 ± 4.5 (SD) years, underwent partial or total thyroidectomy between 2002 and 2010. Seven of these patients had medically refractive hyperthyroidism. The remaining 67 patients had one or more thyroid nodules as identified by ultrasound. 24 (36 %) of these cases were malignant on final pathology. 14 (58 %) of the malignant cases were papillary thyroid carcinoma. 46 of the thyroid nodule cases underwent pre-operative NCB. Biopsy results for these patients were non-diagnostic in 6 (13 %), benign in 11 (24 %), atypical in 17 (37 %), and malignant in 12 (26 %). There were no complications arising from NCB. Sensitivity of NCB for diagnosing papillary carcinoma (PC) and follicular neoplasm was calculated at 0.88 (0.47-1.0, 95 % CI) and 0.84 (0.60-0.97, 95 % CI), respectively. Of the 28 patients not undergoing preoperative NCB, 12 underwent hemithyroidectomy, with one patient (8 %) requiring completion thyroidectomy for PC. Overall, the sensitivity of NCB in diagnosing PC and follicular thyroid neoplasms was 0.85 (0.55-0.99, 95 % CI), while the specificity was 0.63 (0.42-0.82, 95 % CI). CONCLUSIONS: Needle core biopsy appears to have a low rate of associated complications, and its sensitivity for diagnosing PC and follicular neoplasm is comparable to what has been reported for fine needle aspiration biopsy in a similar patient population.

Endogenous endothelins mediate increased distal tubule acidification induced by dietary acid in rats.

We examined if endogenous endothelins mediate the decreased HCO3 secretion and increased H+ secretion in in vivo-perfused distal tubules of rats fed dietary acid as (NH4)2SO4. Animals given (NH4)2SO4 drinking solution had higher endothelin-1 addition to renal interstitial fluid than those given distilled H2O (480+/-51 vs. 293+/-32 fmol g kidney wt(-1) min(-1), respectively, P < 0.03). (NH4)2SO4-ingesting animals infused with bosentan (10 mg/kg) to inhibit A- and B-type endothelin receptors had higher HCO3 secretion than baseline (NH4)2SO4 animals (-4.7+/-0.4 vs. -2.4+/-0.3 pmol mm(-1) min(-1), P < 0.01), but (NH4)2SO4 animals given a specific inhibitor of A-type endothelin receptors (BQ-123) did not (-2.0+/-0.2 pmol mm(-1) min(-1), P = NS vs. baseline). H+ secretion was lower in bosentan-infused compared with baseline (NH4)2SO4 animals (27.7+/-2.5 vs. 43.9+/-4.0 pmol mm(-1) min(-1), P < 0.03), but that for BQ-123-infused (NH4)2SO4 animals was not (42.9+/-4.2 pmol mm(-1) min(-1), P = NS vs. baseline). Bosentan had no effect on distal tubule HCO3 or H+ secretion in control animals. The data show that dietary acid increases endothelin-1 addition to renal interstitial fluid and that inhibition of B- but not A-type endothelin receptors blunts the decreased HCO3 secretion and increased H+ secretion in the distal tubule of animals given dietary acid. The data are consistent with endogenous endothelins as mediators of increased distal tubule acidification induced by dietary acid.

Augmented bicarbonate reabsorption by both the proximal and distal nephron maintains chloride-deplete metabolic alkalosis in rats.

Whether augmented bicarbonate reabsorption by renal tubular epithelium contributes to the maintenance of chloride-deplete metabolic alkalosis is not clear. This study used free-flow micropuncture to investigate bicarbonate reabsorption by surface nephron segments in a rat model of diuretic-induced alkalosis compared to control. The proximal and distal nephron of the alkalotic animals had higher values for both delivered load to and absolute reabsorption from these segments. The proximal tubules of alkalotic and control animals had similar values for the slopes of the linear regression of delivered load vs. reabsorption and for the bicarbonate tubular fluid to plasma (TF/P) ratio at the late proximal tubule. By contrast, the corresponding analysis for the distal segment of alkalotic animals revealed a greater slope (0.98 vs. 0.81, P less than 0.003) and a smaller bicarbonate TF/P ratio at the late distal tubule (0.10 vs. 0.16, P less than 0.006). The data indicate that augmented bicarbonate reabsorption by both the proximal and distal nephron contributes to maintaining the alkalosis of this model. The data suggest primary stimulation of bicarbonate reabsorption in the distal nephron and load-dependent reabsorption in the proximal tubule.

Reduced extracellular pH increases endothelin-1 secretion by human renal microvascular endothelial cells.

Because dietary acid increases renal secretion of endothelin-1 (ET-1) which is synthesized by renal microvascular endothelium, we examined if reduced extracellular pH increases ET-1 secretion by cultured human renal microvascular endothelial cells (RMVECs). Confluent cells were exposed to serum-free media for 24 h, then incubated in either control, acid, or alkaline serum-free media for 12 h. Standard growth media pH was 7.2 after equilibration with 5% CO2 at 37 degrees C and was made the pH of control media. Acid and alkaline media pH were 7.0 and 7.4, respectively. Added Hepes and Tris maintained all assigned pHs. Media ET-1 measured by RIA after column extraction was higher for RMVECs exposed to acid compared with control media (170.0+/-17.1 vs. 64.6+/-9.6 pM, P < 0.004) but those exposed to alkaline media (56.6+/-25.1 pM, P = NS vs. control) were not. Human aortic endothelial cells exposed to control, acid, and alkaline media had similar ET-1 (166.6+/-18.1, 139.3+/-18.5, and 205.9+/-25.3 pM, P = NS). The data show acid-stimulated ET-1 secretion by RMVECs but not aortic endothelial cells, demonstrating a new environmental factor that influences ET-1 secretion by renal microvascular endothelium and thereby possibly modulates endothelin-dependent processes in vivo.

Internephron heterogeneity for carbonic anhydrase-independent bicarbonate reabsorption in the rat.

The present experiments were designed to localize the sites of carbonic anhydrase-independent bicarbonate reabsorption in the rat kidney and to examine some of its mechanisms. Young Munich-Wistar rats were studied using standard cortical and papillary free-flow micropuncture techniques. Total CO2 (tCO2) was determined using microcalorimetry. In control rats both superficial and juxtamedullary proximal nephrons reabsorbed approximately 95% of the filtered load of bicarbonate. The administration of acetazolamide (20 mg/kg body weight [bw]/h) decreased proximal reabsorption to 65.6% of the filtered load in superficial nephrons (32% was reabsorbed by the proximal convoluted tubule while 31.7% was reabsorbed by the loop segment), and to 38.4% in juxtamedullary nephrons. Absolute reabsorption of bicarbonate was also significantly higher in superficial than in juxtamedullary nephrons after administration of acetazolamide (727 +/- 82 vs. 346 +/- 126 pmol/min; P less than 0.05). The infusion of amiloride (2.5 mg/kg bw/h) to acetazolamide-treated rats increased the fractional excretion of bicarbonate as compared with animals treated with acetazolamide alone (34.9 +/- 1.9 vs. 42.9 +/- 2.1%; P less than 0.01), and induced net addition of bicarbonate between the superficial early distal tubule and the final urine (34.8 +/- 3.0 vs. 42.9 +/- 2.1%; P less than 0.05). Amiloride at this dose did not affect proximal water or bicarbonate transport; our studies localize its site of action to the terminal nephron. Vasa recta (VR) plasma and loop of Henle (LH) tubular fluid tCO2 were determined in control and acetazolamide-treated rats in order to identify possible driving forces for carbonic anhydrase-independent bicarbonate reabsorption in the rat papilla. Control animals showed a tCO2 gradient favoring secretion (LH tCO2, 7.4 +/- 1.7 mM vs. VR tCO2, 19.1 +/- 2.3 mM; P less than 0.005). Acetazolamide administration reversed this chemical concentration gradient, inducing a driving force favoring reabsorption of bicarbonate (LH tCO2, 27.0 +/- 1.4 mM vs. VR tCO2, 20.4 +/- 1.0 mM; P less than 0.005). Our study shows that in addition to the superficial proximal convoluted tubule, the loop segment and the collecting duct show acetazolamide-insensitive bicarbonate reabsorption. No internephron heterogeneity for bicarbonate transport was found in controls. The infusion of acetazolamide, however, induced significant internephron heterogeneity for bicarbonate reabsorption, with superficial nephrons reabsorbing a higher fractional and absolute load of bicarbonate than juxtamedullary nephrons. We think that the net addition of bicarbonate induced by amiloride is secondary to inhibition of voltage-dependent, carbonic anhydrase-independent bicarbonate reabsorption at the level of the collecting duct, which uncovers a greater delivery of carbonate from deeper nephrons to the collecting duct. Finally, our results suggest that carbonic anhydrase-independent bicarbonate reabsorption is partly passive, driven by favorable chemical gradients in the papillary tubular structures, and partly voltage-dependent, in the collecting duct.

Monitoring performance: longterm impact of trauma verification and review.

BACKGROUND: This study documents how the verification process at a Level I pediatric trauma center affected patient care through changes in care indicators (CIs) from predesignation through four postverification time frames. An important component of any verification program is its effectiveness, not only at the time of verification but during the time between "examinations." To date, few data exist describing the interval periods and the progression and maturation of a trauma program after initial verification. STUDY DESIGN: Forty-seven distinct CIs were monitored monthly through data generated from the trauma registry. Six distinct time periods were identified. PRE (January, June, October 1997), trauma care without monitoring; VER (November 1999 to September 2000), preparation for verification; and four postverification periods: P1 (January to June 2001), P2 (July to December 2001), P3 (January to June 2002), and P4 (July to September 2002). RESULTS: Between 1997 and 2002, trauma admissions increased from 200 per year to 313 per year. Mortality rate and Injury Severity Score distributions remained unaltered. Statistically significant (p < 0.05) quantitative and qualitative changes were observed in numbers (percent) of patients reaching clinical criteria. These included prehospital, emergency department, and hospital-based trauma competencies. Trauma patient evaluation (including radiology) and disposition out of the emergency department (<120 minutes) improved in each study section and remained high during the postverification time period. There was a strong pair-wise correlation (p < 0.005, Cronbach alpha 0.8) between CNS charting and acquisition of head CAT scans. Pediatric ICU duration of stay increased in both the (summer) P2 and P4 time periods. Prehospital and emergency department fluid monitoring remained unsatisfactory. CONCLUSIONS: Statistically significant changes in patient care indicators were noted to improve during the trauma center designation process, and other key deficiencies were identified and addressed. Maintaining these improvements requires constant monitoring or performance may revert below accepted levels.

Vascular relaxation probably mediates the antihypertensive effect of a high-potassium diet: a role for enhanced vascular Na,K-ATPase activity.

OBJECTIVE: to evaluate the effect of dietary potassium on blood pressure and vascular contractility in adult rats of two strains, spontaneously hypertensive rats (SHR) and normotensive Wistar-Kyoto (WKY) rats. DESIGN: 'Potassium-induced relaxation' was evaluated in aortic rings as a functional measure of Na,K-ATPase activity in the vascular wall. The rats were fed one of three diets: regular (American Institute of Nutrition-76 rat chow); high-sodium (7% sodium chloride) or high-sodium plus potassium (7% sodium chloride and 13.4% potassium citrate) for 12 +/- 1 weeks. RESULTS: SHR fed the high-sodium diet had a mean blood pressure of 157 +/- 8 mmHg, as compared with 130 +/- 9 mmHg for those on a regular diet (P < 0.01). SHR fed the potassium-supplemented diet had a blood pressure of 122 +/- 9 mmHg (P < 0.01 versus the high-sodium diet group). The mean blood pressure of WKY rats was 78 +/- 3 mmHg and did not differ among the dietary groups. The 'potassium-induced relaxation' response of aortic rings from SHR and WKY rats fed a potassium-supplemented diet was significantly higher (P < 0.05) than that in animals in the corresponding high-sodium dietary group. This observation in potassium-supplemented rats is interpreted as indicative of increased Na,K-ATPase activity in the vascular wall. CONCLUSIONS: A potassium-rich diet in SHR receiving a high sodium intake was associated with lower blood pressure and higher vascular Na,K-ATPase activity. A similar effect of this diet on vascular Na,K-ATPase was observed in WKY. We propose that the antihypertensive effect of a potassium-rich diet is mediated, at least in part, by stimulation of vascular Na,K-ATPase activity.

Evaluation of a subsidy program to increase bicycle helmet use by children of low-income families.

OBJECTIVE: We have previously shown that an educational program was not effective in increasing bicycle helmet use in children of low-income families. The objective of this study was to evaluate a combined educational and helmet subsidy program in the same population, while controlling for secular trends. The secondary objective was to complete a third year of surveying children's bicycle helmet use throughout the study community. DESIGN: A prospective, controlled, before-and-after study. SUBJECTS: Bicycling children 5 to 14 years of age from areas of low average family income. SETTING: A defined geographic community within a large urban Canadian city. INTERVENTION: In April 1992, students in three schools located in the area of lowest average family income were offered $10 helmets and an educational program; three other low-income areas served as control areas. MAIN OUTCOME MEASURE: Helmet use was determined by direct observation of more than 1800 bicycling children. RESULTS: Nine hundred ten helmets were sold to a school population of 1415 (64%). Reported helmet ownership increased from 10% to 47%. However, observed helmet use in the low-income intervention area was no different from the rate in the three low-income control areas (18% versus 19%). There was no difference in the trend in helmet use during the period of 1990 through 1992 in the intervention area (4% to 18%) compared with the control areas (3% to 19%). Helmet use rates from all income areas have increased from 3.4% in 1990, to 16% in 1991, to 28% in 1992. In 1992, helmet use in the high-income areas was 48% and in the low-income areas was 20%. CONCLUSIONS: There has been a trend toward increasing helmet use in all income areas during the 3-year period. Despite encouraging helmet sales and increases in reported helmet ownership, the results of the observational study do not support the efficacy of a helmet subsidy program in increasing helmet use in children residing in areas of low average family income. Strategies to increase helmet use in children of low average family income remain a priority.

Evaluation of a promotional strategy to increase bicycle helmet use by children.

Bicycle-related head injuries are an important cause of death and disability, despite the availability of helmets. The objective of this study was to evaluate the effectiveness of a school-based bicycle helmet promotion program in increasing helmet use by children while controlling for secular trends. Two high-income and two low-income schools in an urban Canadian community were selected to receive a bicycle helmet promotion intervention, with the remaining 18 schools serving as controls. Approximately 1800 observations of bicycling children were made at randomly selected observational sites 2 to 5 months after the intervention to assess changes in behavior. Helmet use at all observation sites tripled from 3.4% (1990, preintervention) to 16% (1991, postintervention). In the high-income intervention area, observed helmet use rose dramatically from 4% to 36% in contrast to the more modest increase in the high-income control area from 4% to 15%. In the low-income intervention area, there was a modest increase from 1% to 7%, but it did not differ from the increase in the low-income control area from 3% to 13%. The program was highly successful in children of high-income families but not in children of low-income families. Developing strategies for low-income families remains a priority.

Cigarette smoking is associated with augmented progression of renal insufficiency in severe essential hypertension.

Hypertension-associated renal disease is a major cause of end-stage renal disease (ESRD) in the United States, but its risk factors remain incompletely defined. Identification and correction of amendable ESRD risk factors among patients with essential hypertension could reduce ESRD prevalence. Patients referred by their primary care physician for hypertension management to an academic nephrology clinic during calendar year 1995 were followed up prospectively. Studied patients had no evidence of secondary hypertension, diabetes, or primary renal disease. All were treated pharmacologically toward a target mean blood pressure (MBP) of 100 mm Hg or less. The course of renal function during follow-up was assessed as the slope of the reciprocal of plasma creatinine concentration (1/P(cr)) plotted against months of follow-up and as the change in calculated glomerular filtration rate (GFR) in milliliters per minute per month. The following patient characteristics were prospectively examined as possible predictive factors for altered renal function: age, sex, ethnicity, initial MBP, initial P(cr) level, initial level of urine protein excretion, and smoking status. Fifty-three patients were enrolled, and follow-up data were available for 51 patients after a mean follow-up of 35.5 months. Despite MBP reduction from 126.8 +/- 1.3 to 96.5 +/- 1.1 mm Hg (P < 0.0001), P(cr) level increased from 1.5 +/- 0.1 to 1.9 +/- 0. 2 mg/dL (P < 0.01). Multivariate regression analysis showed that smoking, greater initial P(cr) level, and black ethnicity were the only examined parameters that independently predicted both a decrease in the 1/P(cr) slope and calculated GFR with at least 95% confidence. Smoking was by far the most powerful of the examined factors, with initial P(cr) and ethnicity being much less predictive. These studies show for the first time that smoking is an independent risk factor for renal function decline in patients with severe essential hypertension.

Prokinetic agents increase plasma albumin in hypoalbuminemic chronic dialysis patients with delayed gastric emptying.

Hypoalbuminemia is a surrogate of malnutrition in patients with end-stage renal disease undergoing chronic dialysis and commonly improves with prescription of adequate nutrition and dialysis. Nevertheless, some patients remain hypoalbuminemic for poorly understood reasons. We tested the hypotheses that chronic dialysis patients who remain hypoalbuminemic despite prescription of adequate nutrition and dialysis (1) have delayed gastric emptying, and (2) that prokinetic agents will increase plasma albumin (P(alb)) levels in patients with delayed gastric emptying. We retrospectively identified 99 of 343 hemodialysis and peritoneal dialysis patients with hypoalbuminuria (P(alb) < 3.5 mg/dL) and studied those who did not (hypoalbuminemic, n =15) and did (normoalbuminemic, n = 15) increase their P(alb) levels over the subsequent 6 months and met inclusion and exclusion criteria. Gastrointestinal symptom scores determined by an administered questionnaire were not different in hypoalbuminemic and normoalbuminemic patients. Conversely, the half-time (T(1/2)) for radionuclide gastric emptying was longer in hypoalbuminemic than normoalbuminemic patients (74.5 +/- 7.4 versus 46.7 +/- 4.6 minutes; P < 0.004). Hypoalbuminemic patients were prescribed prokinetics and followed prospectively for 6 months, during which time gastric T(1/2) decreased to 53.9 +/- 3.3 minutes (P < 0.01 versus initial) and P(alb) increased from 3.1 +/- 0.2 to 3.5 +/- 0.2 mg/dL (P < 0.004). The net increase in P(alb) level correlated with the net decrease in gastric T(1/2) (r(2) = 0.4; P < 0.04) by linear regression. The data show that some persistently hypoalbuminemic chronic dialysis patients have poor gastric emptying and increase their P(alb) levels in response to prokinetic agents.

Role of dietary factors in the hypertension of African Americans.

Epidemiological and experimental data suggest that dietary constituents are among the causative factors that contribute to the higher prevalence and severity of hypertension in African Americans as compared with European Americans. Given the difficulty of cleanly separating a change in one dietary nutrient from concomitant changes in others, it has been difficult to reliably attribute an observed effect on blood pressure level and hypertension prevalence to the specific dietary constituent under study. Nevertheless, because hypertension is virtually nonexistent in societies whose dietary sodium chloride intake is very low, it appears that a sodium chloride intake in excess of that required to maintain adequate extracellular fluid volume is necessary but not sufficient for hypertension to be manifest. Additional factors are clearly necessary in the development of hypertension because most individuals, including African Americans, can ingest a high sodium chloride diet without developing hypertension. Evidence for the potential importance of other dietary constituents is also discussed, as are dietary strategies that effectively reduce blood pressure in hypertensive individuals. The data presented support the need for continued research into dietary constituents as potential factors contributing to the etiology of hypertension, as well as effective adjuncts to the management of this very common health problem.

Bicycling exposure and severe injuries in school-age children. A population-based study.

OBJECTIVES: To examine exposure to bicycling and its association with severe bicycle injuries in school-age children in a defined population. DESIGN: Random-digit dialing telephone survey and analysis of hospital discharge records. SETTING: Metropolitan Toronto, Ontario. SUBJECTS: Sample of parents of children aged 5 to 17 years who owned a bicycle; all children who were admitted to hospitals with bicycle-related injuries from April 1989 to March 1991. MAIN OUTCOMES: Median annual bicycling hours and distance by age and sex; age- and sex-specific incidence rates by population at risk, cumulative exposure hours, and riding distances. RESULTS: More than half of the children of all age groups were exposed to bicycling more than 100 hours per year. Boys spent more hours and rode longer distances than girls in every age group. The overall annual injury rates were 8.1 and 3.4 per 10,000 population at risk for boys and girls, respectively. About half of the injuries suffered were head injuries. When rates were estimated on the basis of exposure, boys still experienced a higher injury rate than girls. Boys displayed a slight increase with age in rates per unit of exposure hours. Conversely, age appeared to be negatively associated with overall and head injury rates when exposure was expressed by distance ridden. CONCLUSIONS: Boys had a higher injury rate than girls, and bicycle-related injuries are more likely to be associated with exposure time than distance ridden.

Esophageal atresia and tracheoesophageal fistula: surgical experience over two decades.

BACKGROUND: Despite improvements in survival, for infants born with esophageal atresia tracheoesophageal fistula, or both, the morbidity associated with repair of these anomalies remains high. METHODS: This report retrospectively analyzes 81 patients with esophageal atresia, tracheoesophageal fistula, or both presenting to our institution between 1975 and 1995, with a focus on anastomotic complications. RESULTS: There were 46 male and 35 female patients with a mean gestational age of 37 weeks and mean birth weight of 2443 g. Forty-four patients underwent primary esophageal anastomoses, 7 underwent delayed primary anastomoses, 12 patients underwent staged repairs, and 5 underwent repair of H-type fistulas. Among 62 patients with anastomoses, complications included stricture in 25/62 patients (40%), leakage in 12/62 patients (19%), and recurrent tracheoesophageal fistulas in 6/62 patients (10%). Stricture rates for esophagoclonic anastomoses versus esophagoesophageal anastomoses were 4/8 cases (50%) versus 21/54 cases (39%). This difference was not statistically significant. All esophagoesophageal strictures were managed successfully with dilations; three of four esophagocolonic strictures required anastomotic revision. The leakage rate for esophagocolonic anastomoses versus esophagoesophageal anastomoses was 6/8 cases (75%) versus 6/54 cases (11%). This difference was statistically significant (p = 0.0003). Two patients required revision of their colon grafts secondary to necrosis. Eighteen of 81 patients (22%) died. Operative mortality was 9/74 (12%). Causes of death included associated anomalies (n = 15), recurrent aspiration and sepsis secondary to missed fistula (n = 1), and unknown (n = 2). CONCLUSIONS: Although the morbidity associated with surgical repair of these anomalies is high, this does not affect the overall survival. The high complication rate associated with colonic interposition suggests that one should preserve the native esophagus as a primary conduit whenever feasible.

Artificial beta-cell promotes positive nitrogen balance and whole body protein synthesis in insulin-dependent diabetic subjects.

To assess the effects of artificial beta-cell-directed insulin therapy on protein metabolism in patients with diabetes mellitus, nitrogen balance, urea production, and whole body protein turnover were determined in five type I insulin-dependent subjects and five age- and sex-matched controls. Each diabetic participant was studied over two 4-day periods while receiving conventional insulin therapy (one or two daily injections of short and intermediate acting insulin) or insulin delivered by the artificial beta-cell. While the diabetic participants received conventional insulin therapy, nitrogen balance, urea production, whole body protein turnover, and protein synthesis and breakdown rates did not differ significantly from the control group. However, when the same subjects were on artificial beta-cell-directed insulin therapy, they manifested a significant net positive nitrogen balance of over 2 g/day. This change in nitrogen balance was largely due to a fall in urea nitrogen production from 174 +/- 6 to 140 +/- 13 mg/kg body weight per day (p less than 0.05). In addition, while artificial beta-cell therapy did not affect whole body protein turnover or breakdown rates, a significant rise (2.1 +/- 0.2 to 2.4 +/- 0.1 g/kg per day) in whole body protein synthesis was observed (p less than 0.05). Thus when compared to conventional insulin treatment, artificial beta-cell-directed insulin therapy was associated with a 14% increase in the rate of protein synthesis and a decrease of 20% in urea nitrogen production, leading to a net positive nitrogen balance.

Evaluating the accuracy of nutritional assessment techniques applied to hospitalized patients: methodology and comparisons.

Herein we describe a methodology which can be used to evaluate the predictive accuracy of nutritional assessment techniques. We use this methodology to compare seven techniques of nutritional assessment in terms of their ability to predict one nutrition associated hospital complication (infection) by dividing a sample of 59 surgical patients into high risk and low risk groups. One technique was subjective global assessment (SGA) of the patient's nutritional status on admission to hospital. Five techniques were single objective measurements (albumin, transferrin, delayed cutaneous hypersensitivity, anthropometry, and creatinine-height index). The 7th technique was the prognostic nutritional index. The best combination of sensitivity (0.82) and specificity (0.72) was found with SGA. The second best combination (0.88 and 0.45) was found by using either the prognostic nutritional index or creatinine-height index. We also found that combining the five objective measurements with SGA into a single index did not increase the discriminatory (or predictive) power over that of SGA alone in a clinically significant way. We conclude that a larger study comparing these approaches should be undertaken to confirm these findings and to develop methods which improve the predictive properties of SGA.

A symptomatic atypical mycobacterial infection masquerading as a vascular ring on chest x-ray.

Atypical mycobacterium is rare in children. There are few case reports of childhood pulmonary diseases caused by atypical mycobacterium. The case of a 20-month-old boy who had stridor and respiratory distress is presented. Chest x-ray showed right-sided narrowing of the trachea and left-sided aortic knob. Ziehl-Neelsen stain showed acid-fast bacilli. The culture showed Mycobacterium malmoense.

Risk factors for severe injuries associated with falls from playground equipment.

A case control study design was used to determine the risk factors for severe injuries associated with falls from playground equipment. Children presenting to the Hospital for Sick Children in Toronto because of falls from playground equipment (1995-1996) were identified through daily review of admissions and emergency department visits. Cases were defined as children with a severe injury (AIS > or = 2), whereas, controls were children with a minor injury (AIS < 2). Data on age, sex, socioeconomic status, prior experience on the equipment, previous playground injury, type of equipment, height of fall, undersurface, nature of injury, body part involved, and disposition were collected via telephone interview, field trip measurement, and mailed questionnaire. A total of 126 children were studied--67 cases and 59 controls. There were no differences between the two groups on age, sex, socioeconomic status, prior exposure to the equipment, or previous playground injury. Extremity fractures predominated in the case group, while, facial lacerations predominated in the control group. The median height of fall for cases was 199 cm, compared with 160 cm for controls (P = 0.021). Cases were also more likely to have fallen from a height of > 150 cm (73%), compared with controls (54%), P = 0.027. The majority of cases (82%) and controls (86%) fell onto an impact absorbing undersurface (P = 0.540). The median depth of impact absorbing undersurface, however, for both case and control injuries was 3 cm--well below the recommended safety standards. Height of fall was an important risk factor for severe injury associated with falls from playground equipment. Above 150 cm, the risk of severe injury was increased 2-fold.

Urokinase in the treatment of occluded central venous catheters in children.

Urokinase was used to clear occluded silastic central venous catheters in 14 pediatric patients. The catheters, which had been placed into a neck vein and tunnelled out through the skin of the anterior chest wall, were being used for either long-term parenteral nutrition or chemotherapy. Occluded catheters that could not be cleared by simple flushing with heparinized saline were filled with a solution of urokinase, which was left in place for 2 hours before the catheter was flushed a second time. Twenty-one occluded catheters were managed in this way over a period of 14 months. There were no allergic reactions or bleeding complications. Twelve of the 21 occluded catheters were immediately cleared. Three catheters ruptured during attempted flushing maneuvers but were patent after repair. Two catheters remained partially occluded. Only four catheters were removed because of persistent occlusion. When simpler techniques fail, urokinase instillation appears a safe and effective alternative to the more common practice of removing occluded central venous catheters in children.

Results of bowel resection for Crohn's disease in the young.

Thirty patients (21 boys and 9 girls) underwent bowel resections for Crohn's disease from 1965 to 1979. They ranged in age from 6 to 18 yr. The follow-up period varied from 3 mo to 14 yr. There were no deaths. Seventeen developed clinical or radiologic evidence of recurrent Crohn's disease. Seven of these required reoperation and six are now well without sign of further recurrence. Eleven of 18 achieved catch-up growth in weight; 10 of 15 achieved catch-up growth in height. At the time of follow-up four had active disease, seven had evidence of recurrence but were generally well, and 19 were well without any evidence of recurrence.