Meconium ileus: a fifteen-year experience with forty-two neonates.

From 1969 to 1984, 42 neonates were managed for meconium ileus caused by cystic fibrosis. Simple, uncomplicated meconium ileus occurred in 24 infants (57%) and complicated meconium ileus occurred in 18 (43%). Meglumine diatrizoate (Gastrografin) enema completely relieved the obstruction in 13 patients with simple meconium ileus (54%) and caused colonic and rectal perforations in three (13%). Six operative procedures were used in 29 patients: double enterostomy (seven), resection with primary anastomosis (seven), Bishop-Koop enterostomy (seven), intraluminal lavage (four), colostomy (three), and Mikulicz enterostomy (one). Postoperative complications included malabsorptive diarrhea (nine), pneumonia (three), intestinal obstruction (two), total parenteral nutrition-catheter sepsis (two), and anastomotic leak (one). Infants managed nonoperatively by Gastrografin enema had a significantly shorter hospitalization (average, 15 days) than those undergoing operation for simple meconium ileus (54 days) and complicated meconium ileus (111 days). Postoperative survival rate was 100% with a late survival rate of 86%.

Prediction of heparin requirements in acute thromboplastic venous disease.

It has been suggested that early heparin requirements are greater in patients with acute deep venous thrombosis (DVT) and pulmonary embolism (PE). Heparin requirements were recorded for 73 patients with suspected DVT and PE. The maintenance dosage (days 1 through 4) of heparin sodium required to achieve therapeutic partial thromboplastin times (PTTs) was significantly higher in patients with DVT (n = 54; mean +/- SD dosage, 1,151 +/- 246 units/hr) compared with patients with no DVT (n = 19; mean +/- SD dosage, 952 +/- 190 units/hr). The first posttreatment PTT was significantly lower in patients with DVT (mean +/- SD PTT, 68.74 +/- 27.96 s) compared with control patients (mean +/- SD PTT, 89.41 +/- 23.25 s). This study supports the clinical impression that initial heparin requirements are greater and heparin clearance is more rapid in patients with acute DVT and PE.

Pediatric thoracic trauma.

The majority of chest injuries in children may be effectively diagnosed and treated in the emergency room area, if an organized plan is followed and a high index of suspicion for specific injuries is maintained. Unique features of pediatric anatomy and physiology require innovative adaptation to provide maximal effective resuscitation. Children in this sense are not merely "little adults." Of those few blunt and penetrating injuries that require operative management, operative techniques do not differ from those employed in adult trauma patients.

Differential expression of chemokines in a mouse model of wound healing.

Macrophages have a multifaceted role in wound healing. While their initial activity may be in the degradation and elimination of damaged tissue, macrophages also produce and secrete a variety of mediators that can participate in the repair process as well. To perform these functions, macrophages must be recruited to a wound site. Our purpose was to examine the temporal and spatial expression of macrophage chemoattracting cytokines (chemokines) at a surgical wound site. A surgical wound was prepared on the dorsal aspect of B6AF1/J mice. Biopsies were obtained from the wound and a comparable nonwounded area between 6 and 72 hr after wounding. The presence or absence of various chemokine mRNAs was detected by the reverse transcriptase-polymerase chain reaction (RT-PCR). Immunohistochemical staining and in situ RT-PCR determined localization of cells producing chemokines. In wounded tissue, both macrophage chemoattractant protein-1 (MCP-1) and macrophage inflammatory protein-1 (MIP-1) were detected; however, the time of expression differed for each molecule. MCP-1 mRNA was detected at 6 hr after wounding, with decreased expression at subsequent time periods. In contrast, MIP-1 messages were not observed until 24 hr after wounding, and steadily increased thereafter. MCP-1 and MIP-1 mRNA and protein were localized predominantly in keratinocytes. The rapid and strong expression of MCP-1 and MIP-1 messages within the wound site suggests a pivotal role for these chemokines in the repair process. The differences in appearance and level of expression over time, however, suggest distinctive functions for each chemokine and indicate that the local milieu, rather than a single cytokine, influences macrophage recruitment and/or activation.

Diagnosis of spontaneous perforation of the biliary tract in the newborn.

This report is of a 2-month-old child with spontaneous perforation of the common bile duct diagnosed by 99m-Tc disofenin nuclear hepatobiliary imaging. Of the agents available, the radiopharmaceutical properties of this compound allow the most accurate, safe, high-resolution imaging of the hepatobiliary tree in the diagnostic evaluation of jaundiced infants.

Abdominal injuries in restrained pediatric passengers.

A statewide experience with pediatric abdominal visceral injury in restrained automobile passengers was compiled from the trauma registries of two academic institutions. Retrospective analysis of motor vehicle passenger injuries from 1987 to 1991 included age, sex, mechanism of injury, prehospital care, type of injury, therapeutic interventions, complications, and ultimate outcome. The records of over 2,000 patients evaluated for blunt trauma were reviewed, with 42 children fulfilling the following inclusion criteria: 15 years of age or younger, restrained in an automobile at the time of the accident, and diagnosed with an abdominal injury. Of the 42 patients studied, there were 20 boys and 22 girls; ages ranged from 2 months to 15 years (mean, 7.02 years). Six of 42 patients (14%) required extrication from the vehicle at the scene. Nineteen of 42 patients (45%) sustained belt-related abdominal wall bruising or erythema. The specific blunt visceral injuries noted were as follows: splenic 5, hepatic 5, bowel 6, renal 3, combined 6 (stomach, diaphragm, pancreas, or retroperitoneum). Twenty-three children (55%) had abdominal visceral injuries without external seat belt marks. Operative intervention was necessary in seven patients. A delay in diagnosing visceral injury occurred in 4 of 42 (10%) cases. One patient developed abdominal symptoms 72 hours after the accident. Length of hospital stay ranged from 1 to 45 days. Complications occurred in 4 (10%) of patients. There were two deaths due to injuries. Hollow and solid visceral injuries can occur in belted pediatric passengers during vehicular accidents. Both are a source of significant morbidity, and the patient should be evaluated carefully.(ABSTRACT TRUNCATED AT 250 WORDS)

Penetrating neck trauma in children: a reappraisal.

The management of penetrating neck injuries in adults is controversial, with a trend toward selective neck exploration. These injuries are uncommon in children, and only limited information exists regarding their management. To assess the management of these injuries in the authors' geographic region, they reviewed the records of children with injuries penetrating the platysma muscle who were treated between 1980 and 1994. Forty-six children (aged 2 to 16 years) suffered a total of 55 penetrating neck injuries. The injuries were classified according to type and location. Fifty-two percent were caused by missiles, 30% by stab wounds, and 18% by dog bites. Fifty-eight percent of injuries were in zone II, 31% in zone I, and only 11% in zone III. The diagnostic workup, including arteriography, esophagography, or endoscopy, was performed preoperatively in 10 patients. Overall, 21 patients had exploration, and the rate of negative explorations was 48%. All cases explored for bleeding or a positive diagnostic workup result were found to have significant injury. On the other hand, all neck explorations performed solely because of injury to zone II were negative. The overall morbidity and mortality rates were 31% and 7%, respectively. A more selective approach, similar to that used for adult patients, emphasizing preoperative diagnostic evaluation, is recommended to decrease the rate of negative neck explorations among children.

Ectopic calcitonin in adrenocortical carcinoma: a new tumor marker.

Ectopic calcitonin has never before been described in association with pediatric malignancy. This is the first report of ectopic calcitonin in a child with adrenocortical carcinoma. It may prove to be a useful tumor marker in this, as well as other childhood malignancies.

Characteristics of pediatric firearm fatalities.

An increase in the awareness of the problem of gunshot fatalities in children has occurred nationwide over the last year. Unintentional firearm deaths are more common among children and young adults. These deaths may be addressed by preventive measures beyond those available for pediatric firearm suicide and homicide. This study focuses on the incidence of fatal gunshot injuries in children under 16 years of age during the years 1979 through 1987 in our state. Over the past 9 years 132 children (0 to 16 years) were shot and killed as a result of firearm injuries (M:F ratio, 3:1). No difference in absolute number in racial distribution existed. Deaths were classified as homicide, 61 (46%); accidental, 33 (25%); suicide, 29 (22%); undetermined, 7 (5%); and other, 2 (1.5%). Over 70% of these fatal injuries occurred in the home environment. Types of weapons involved included handguns (48%), shotguns (22%), rifles (17%), unspecified weapon (12%), and air rifle (1%). In a large number of cases, guns were found in the home unsecured. The perpetrator was known by the victim in 64 instances, while unknown in 27. Thirty-nine self-inflicted wounds and two shotgun blasts in the line of fire accounted for the remaining deaths. The most common anatomical injury and ultimate cause of death was cranial central nervous system (CNS) (62%), followed by chest/mediastinum (20%), abdomen (10%), and other (8%). A child who has sustained a firearm injury is more likely to know the perpetrator, be killed in the home by a readily available unsecured firearm, and die from severe head injury.

The nephroblastomatosis complex and its relationship to Wilms' tumor.

Nephroblastomatosis (NB), a persistence of abnormal embryonal renal tissue beyond 36 weeks' gestation, is often associated with Wilms' tumor. The exact relationship of NB to the development of Wilms' tumor is unclear. Four cases are presented that elucidate the entire morphological spectrum of this disease. Analyses of these cases suggest these conclusions: (1) the NB complex is a spectrum of lesions from benign multifocal nodular renal blastema, resembling residual nephrogenic zones of immature fetal kidney, to Wilms' tumor; (2) infantile NB is a premalignant variant of Wilms' tumor with a favorable outcome usually, when treated early; (3) neonatal nephromegaly requires a complete evaluation and follow-up imaging; persistence mandates biopsy; (4) "second-look" laparotomy is unnecessary with state-of-the-art imaging; and (5) standardization of terminology is essential.

Does handgun legislation change firearm fatalities?

When comparing firearm fatalities for children under 16 years of age before and after handgun legislation enactment in Maryland, firearm fatalities increased overall. A decrease in accidental deaths in the home perhaps reflects a response to public education and awareness. More aggressive handgun legislation is imperative to reverse this public health trend.

Efficacy of emergency room thoracotomy in pediatric trauma.

With improved rapid transportation systems, an increasing number of children may arrive at the emergency room (ER) without detectable vital signs and may undergo vigorous resuscitation, including emergency room thoracotomy, aortic cross clamping, and open cardiac massage. Of 1,287 pediatric trauma admissions between 1980 and 1985, 101 deaths were recorded. Fifty (50%) of the deaths occurred in the ER. Thirty-three of the patients were pronounced dead with obvious irreversible injuries, while 17 (34%) with suspected thoracoabdominal injuries underwent ER thoracotomy during resuscitation. None of the 17 patients had detectable vital signs upon arrival to the ER. Fifteen patients had multisystem injuries associated with blunt trauma and two with isolated penetrating injuries. Despite maximal conventional resuscitation and ER thoracotomy, none of the 17 patients survived. In this group of pediatric blunt trauma victims who appear initially salvageable, and present in the ER with no detectable vital signs, ER resuscitative thoracotomy did not influence survival. ER thoracotomy in children, therefore, should be reserved for patients presenting with penetrating thoracic injuries or blunt injuries associated with detectable vital signs and deterioration despite maximal conventional therapy.

The efficacy of computed tomography in evaluating abdominal injuries in children with major head trauma.

Physical examination may be unreliable in the evaluation of children with blunt abdominal trauma particularly in those with associated major head injuries. In the absence of obvious clinical signs or physical findings of intraabdominal injury, the usefulness of abdominal computed tomography in children is controversial. To test the efficacy of CT scans, a 12-month prospective study of computed tomography for the initial assessment of children with blunt abdominal trauma and major head injuries was carried out. Of 320 pediatric trauma admissions to our regional trauma center, 65 consecutive patients with Glasgow Coma Scores less than ten were managed with sequential head and abdominal computed tomography in the emergency room for (1) closed head injury and (2) suspected abdominal trauma. Fifteen patients (23%) were found to have significant intraabdominal injury. Only two required operative intervention. No patients died as a result of the abdominal injuries. In children with significant head trauma and suspected abdominal trauma, combined head and abdominal CT proved to be reliable.

Neonatal diagnosis of a presacral mass in the presence of congenital anal stenosis and partial sacral agenesis.

The simultaneous presentation of clinically symptomatic anal anomalies and roentgenographically demonstrated sacral dysgenesis should alert the pediatric surgeon to investigate for the presence of a presacral malformation. We report on such a case to illustrate a new radiographic technique that facilitates diagnosis and management of complex congenital malformations. A 1-day-old white boy presented with anal stenosis, a scimitar-shaped sacrum, and large anterior and posterior meningoceles. In addition, a distinct presacral tumor--a teratoma--was identified. These malformations were identified utilizing metrizamide myelography and three-dimensional reconstruction computed tomography (CT) scanning. The meningoceles and a tethered cord were successfully corrected utilizing a posterior approach. A diverting colostomy was performed and subsequently taken down. Two years postoperatively, the patient continues to do well. This case demonstrates that this triad of anomalies (presacral mass, sacral dysgenesis, and anorectal malformation), once considered, can be safely detected with modern radiologic techniques and can be expeditiously corrected during infancy before further deterioration occurs.

Pediatric all-terrain vehicle trauma: a 5-year statewide experience.

BACKGROUND/PURPOSE: This is a retrospective review of the pediatric all-terrain vehicle trauma victims who presented to the five major trauma centers serving the state of West Virginia during the 5-year period from January 1991 to December 1995. The purpose of this research is to characterize the nature of the injuries and the individuals injured to better appreciate the magnitude of the problem of ATV-related injuries in the pediatric population. METHODS: This study is a retrospective review of these 218 consecutive pediatric patients from trauma registry data and their medical records. RESULTS: Two hundred eighteen patients between the ages of 2 years and 16 years presented during the study period. Boys outnumbered girls three to one. The average Injury Severity Score (ISS) was 8.76, the average Glasgow Coma Score (GCS) was 14.4, and the average Trauma Score (TS) was 15.2. The most common injuries were orthopedic followed by head and facial injuries. The majority of the children did not wear helmets, and their injuries resulted in an average hospital length of stay of 4.3 days. Thirty-eight percent of the children required surgery. There were a total of four deaths for a mortality rate of 1.8%. The estimated total hospitalization cost for the 218 patients was $1,918,400.00. CONCLUSIONS: All-terrain vehicle-related trauma remains an ongoing safety concern facing society today. Every physician who cares for children should address this important issue when talking to children and parents about safety issues and injury prevention.

Surgical intervention in children with human immunodeficiency virus infection.

Twenty-one children with human immunodeficiency virus (HIV) infection required surgical intervention during the course of their disease. There were 11 females and 10 males (age range, 3 months to 6 years). The children underwent 54 operative procedures after diagnosis of their disease. These included placement of central venous catheter (23 patients), open lung biopsy (11), incision and drainage of perirectal abscess (4), incision and drainage of soft tissue abscess (5), myringotomy (2), diverting colostomy (3), Nissen fundoplication (1), and other (5). All 21 patients had clinical AIDS by the Centers for Disease Control CDC classification. To date, there have been 12 deaths in the 21 patients (57%) due to progressive deterioration with the patient's disease. Most procedures were adjuncts for diagnostic and therapeutic intervention in a population of children with a uniformly fatal disease. The knowledge of various high risk groups for AIDS must heighten the surgeon's awareness to the growing and significant pediatric segment of the HIV population, the complications of their disease, and the surgeon's limited role in treating these problems.

Blunt traumatic subclavian artery injury.

Subclavian artery injury secondary to blunt trauma is uncommon, accounting for only 3% of traumatic injuries of the upper extremity. Associated injuries of nerve, bone and joint are common. Early recognition and appropriate surgical intervention are essential to reduce disability. Long-term limb dysfunction usually results from concomitant nerve injury. This article describes our experiences treating four patients at two Level II trauma centers in Huntington, W.Va., and reviews the literature on the subject of subclavian artery injury secondary to blunt trauma.

Metastatic breast carcinoma of the gallbladder.

Metastasis of breast carcinoma to the gallbladder, not hitherto reported, occurred in a 73-year-old woman who had acute cholecystitis. After cholecystectomy was performed, pathologic examination of the specimen demonstrated tumor morphologically identical to the breast carcinoma for which the patient had undergone right mastectomy 3 years earlier.

Child abuse. An update on surgical management in 256 cases.

In the period January 1982-July 1984, 1512 cases of suspected child abuse were evaluated in the emergency department of a major children's hospital, of which 256 (17%) required hospitalization. Failure-to-thrive with caloric malnutrition was present in 66 (26%), burns in 56 (22%), central nervous system injury in 53 (22%), soft tissue trauma in 21 (8%), ingestions in 20 (8%), skeletal injury in 15 (6%), neglect of an underlying disease in 10 (4%), sexual abuse in nine (3%), near-drowning in four (1%), and abdominal trauma in two (1%). Two-thirds of the children required surgical care and one-third of the surgical group needed operations. The majority of the patients were toddlers between 18 and 36 months of age. A long hospitalization occurred with a mean stay of 9.3 days. Mortality was 7% for the entire group, but children with central nervous system injury had a much higher mortality (26%) and morbidity (21%).