Clinical outcomes and protocol for the management of isolated congenital diaphragmatic hernia based on our prenatal risk stratification system.

BACKGROUND/PURPOSE: The aim of this study was to evaluate our prenatal risk stratification system for risk-adjusted management in fetuses with isolated congenital diaphragmatic hernia (CDH). METHODS: Ninety-four infants prenatally diagnosed with isolated CDH treated between 1998 and 2017 at our institution were included in this retrospective single-center cohort study. RESULTS: The patients were prenatally classified into four risk groups: Group A (n = 54), which consisted of infants with neither liver-up nor a contralateral lung-to-thorax transverse area (L/T) ratio <0.08. The infants in group A were divided into two subgroups: Group A-1 (n = 24) consisted of mild conditions; and Group A-2 (n = 30) consisted of severe conditions; Group B (n = 23), which consisted of infants with either liver-up or L/T ratio <0.08; and Group C (n = 17), which consisted of infants with both liver-up and L/T ratio <0.08. The rates of survival to discharge in Groups A-1, A-2, B, and C were 100.0%, 100.0%, 87.0%, and 58.8%, respectively. The rates of intact discharge were 91.7%, 90.0%, 52.1%, and 23.5%, respectively. CONCLUSIONS: Our prenatal risk stratification system demonstrated a significant difference in the severity of postnatal status and clinical outcomes between the groups. STUDY TYPE: Case Series, Retrospective Review. LEVELS OF EVIDENCE: LEVEL IV.

Antibiotic Prophylaxis for Open Chest Management After Pediatric Cardiac Surgery.

OBJECTIVES: Although open chest management optimizes hemodynamics after cardiac surgery, it increases postoperative infections and leads to increased mortality. Despite the importance of antibiotic prophylaxis during open chest management, no specific recommendations exist. We aimed to compare the occurrence rates of bloodstream infection and surgical site infection between the different prophylactic antibiotic regimens for open chest management after pediatric cardiac surgery. DESIGN: Retrospective, single-center, observational study. SETTING: PICU at a tertiary children's hospital. PATIENTS: Consecutive patients younger than or equal to 18 years old with open chest management after cardiac surgery followed by delayed sternal closure, between January 2012 and June 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We compared the composite occurrence rate of postoperative bloodstream infection and surgical site infection within 30 days after cardiac surgery between three prophylactic antibiotic regimens: 1) cefazolin, 2) cefazolin + vancomycin, and 3) vancomycin + meropenem. In 63 pediatric cardiac surgeries with open chest management, 17 bloodstream infections, and 12 surgical site infections were identified postoperatively. The composite occurrence rates of bloodstream infection and surgical site infection were 10 of 15 (67%), 10 of 19 (53%), and nine of 29 (31%) in the cefazolin, cefazolin + vancomycin, and vancomycin + meropenem regimens, respectively (p = 0.07). After adjusting for age, open chest management duration, extracorporeal membrane oxygenation use, and nasal methicillin-resistant Staphylococcus aureus colonization in multivariable analysis, there was no significant difference between the cefazolin and the cefazolin + vancomycin regimens (p = 0.19), while the vancomycin + meropenem regimen had a lower occurrence rate of bloodstream infection and surgical site infection than the cefazolin regimen (odds ratio, 0.0885; 95% CI, 0.0176-0.446; p = 0.003). CONCLUSIONS: In this study, a lower occurrence rate of postoperative bloodstream infection and surgical site infection was observed among patients with broad-spectrum antibiotic regimen after pediatric cardiac surgery with open chest management. Further studies, ideally randomized controlled studies investigating the efficacy of broad-spectrum antibiotics and their complications, are warranted before routine implementation of broad-spectrum prophylactic antibiotic regimen.

Risk Factors for Healthcare-Associated Infections After Pediatric Cardiac Surgery.

OBJECTIVES: Healthcare-associated infections after pediatric cardiac surgery are significant causes of morbidity and mortality. We aimed to identify the risk factors for the occurrence of healthcare-associated infections after pediatric cardiac surgery. DESIGN: Retrospective, single-center observational study. SETTING: PICU at a tertiary children's hospital. PATIENTS: Consecutive pediatric patients less than or equal to 18 years old admitted to the PICU after cardiac surgery, between January 2013 and December 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All the data were retrospectively collected from the medical records of patients. We assessed the first surgery during a single PICU stay and identified four common healthcare-associated infections, including bloodstream infection, surgical site infection, pneumonia, and urinary tract infection, according to the definitions of the Centers for Disease Control and Prevention and National Healthcare Safety Network. We assessed the pre-, intra-, and early postoperative potential risk factors for these healthcare-associated infections via multivariable analysis. In total, 526 cardiac surgeries (394 patients) were included. We identified 81 cases of healthcare-associated infections, including, bloodstream infections (n = 30), surgical site infections (n = 30), urinary tract infections (n = 13), and pneumonia (n = 8). In the case of 71 of the surgeries (13.5%), at least one healthcare-associated infection was reported. Multivariable analysis indicated the following risk factors for postoperative healthcare-associated infections: mechanical ventilation greater than or equal to 3 days (odds ratio, 4.81; 95% CI, 1.89-12.8), dopamine use (odds ratio, 3.87; 95% CI, 1.53-10.3), genetic abnormality (odds ratio, 2.53; 95% CI, 1.17-5.45), and delayed sternal closure (odds ratio, 3.78; 95% CI, 1.16-12.8). CONCLUSIONS: Mechanical ventilation greater than or equal to 3 days, dopamine use, genetic abnormality, and delayed sternal closure were associated with healthcare-associated infections after pediatric cardiac surgery. Since the use of dopamine is an easily modifiable risk factor, and may serve as a potential target to reduce healthcare-associated infections, further studies are needed to establish whether dopamine negatively impacts the development of healthcare-associated infections.

Predicting extubation readiness by monitoring the electrical activity of the diaphragm after prolonged mechanical ventilation: a pediatric case report.

BACKGROUND: The intensity of the electrical activity of the diaphragm (Edi) correlates with inspiratory effort. The ratio of tidal volume to the Edi is known as neuroventilatory efficiency (NVE) and is used as an index for ventilation efficiency. Here, we present a case showing that Edi and NVE may be effective parameters to predict successful extubation. CASE PRESENTATION: A 6-month-old female infant required prolonged mechanical ventilation after cardiac surgery. Fifty-two days after surgery, her trachea was extubated but required reintubation. Edi monitoring was initiated to assess diaphragm function. The Edi was > 70 mcV just after the reintubation, and her NVE was 1.0 mL/mcV, but gradually decreased. On day 59, her Edi values during the spontaneous breathing trials were 13 mcV with the improvement of NVE (2.5 mL/mcV) and her trachea was extubated without complications. CONCLUSIONS: The Edi and NVE were valuable for deciding the extubation readiness in a long-term mechanically ventilated patient.

[A case of bone metastases from hepatocellular carcinoma presenting with erythrocytosis after hepatectomy].

A 57-year-old man was admitted for careful examination of lower limb edema. Abdominal computed tomography(CT) showed hepatocellular carcinoma(HCC), 2 cm in diameter, arising in liver segment S6. Posterior segmentectomy was performed, and histological examination of the specimen revealed poorly differentiated HCC. Nine months after surgery, a metastatic tumor was detected in the left scapula, and the patient gradually began to show a high blood concentration of hemoglobin and erythropoietin(Epo). Sorafenib was started but was discontinued because of intractable diarrhea. The patient died of the metastatictumor 15 months after surgery. This is the first case report of a patient with metastaticHCC developing erythrocytosis associated with a high concentration of Epo.

Laparoscopic-assisted percutaneous endoscopic gastrostomy: a simple and efficient technique for disabled elderly patients.

BACKGROUND/PURPOSE: Percutaneous endoscopic gastrostomy (PEG) is a simplified catheter placement procedure for alimentation. Although the endoscopic approach to gastrostomy tube placement is a safe and well-tolerated procedure in most patients, the PEG procedure is difficult in elderly patients disabled since childhood who have severe scoliosis and malpositioning of the stomach. We describe a simple and effective laparoscopic-assisted PEG (LAPEG) technique that can be used for catheter placement in severely disabled patients. METHODS: Thirteen severely disabled patients aged 14-57 years underwent gastrostomy tube placement with the LAPEG technique. After general anesthesia was achieved, an endoscope was placed into the stomach. Then, a 5-mm camera port was inserted at the umbilicus, and a 3-mm working port was inserted to identify and lift the optimal site for gastrostomy tube placement. After the 4-point fixation of the stomach, the 20-Fr gastrostomy tube was placed under endoscopic and laparoscopic observation. RESULTS: All patients tolerated the procedure well, and there were no major complications. The procedure was successful, and all patients could feed via the tube. CONCLUSIONS: Elderly disabled patients who have been bedridden since childhood often have severe scoliosis and malpositioning of the stomach. Our LAPEG procedure is effective, well tolerated, and safe for gastrostomy tube placement in such elderly patients.

Periodontal tissue activation by vibration: intermittent stimulation by resonance vibration accelerates experimental tooth movement in rats.

INTRODUCTION: Accelerating the speed of orthodontic tooth movement should contribute to the shortening of the treatment period. This would be beneficial because long treatment times are a negative aspect of orthodontic treatment. In this study, we evaluated the effects of mechanical stimulation by resonance vibration on tooth movement, and we showed the cellular and molecular mechanisms of periodontal ligament responses. METHODS: The maxillary first molars of 6-week-old male Wistar rats were moved to the buccal side by using an expansive spring for 21 days (n = 6, control group), and the amount of tooth movement was measured. Additional vibrational stimulation (60 Hz, 1.0 m/s(2)) was applied to the first molars by using a loading vibration system for 8 minutes on days 0, 7, and 14 during orthodontic tooth movement (n = 6, experimental group). The animals were killed under anesthesia, and each maxilla was dissected. The specimens were fixed, decalcified, and embedded in paraffin. Sections were used for immunohistochemical analysis of receptor activator of NF kappa B ligand (RANKL) expression. The number of osteoclasts in the alveolar bone was counted by using TRAP staining, and the amount of root resorption was measured in sections stained with hematoxylin and eosin. RESULTS: The average resonance frequency of the maxillary first molar was 61.02 +/- 8.38 Hz. Tooth movement in the experimental group was significantly greater than in the control group (P <.05). Enhanced RANKL expression was observed at fibroblasts and osteoclasts in the periodontal ligament of the experimental group on day 3. The number of osteoclasts in the experimental group was significantly increased over the control group on day 8 (P <.05). Histologically, there were no pathological findings in either group or significant differences in the amount of root resorption between the 2 groups. CONCLUSIONS: The application of resonance vibration might accelerate orthodontic tooth movement via enhanced RANKL expression in the periodontal ligament without additional damage to periodontal tissues such as root resorption.

Cow's milk protein allergy presenting with Hirschsprung's disease-mimicking symptoms.

BACKGROUND: Pediatric surgeons often encounter neonates who present with Hirschsprung's disease (HD)-like symptoms and plain x-ray findings, but respond well to conservative treatment. During our investigation of the etiology of this condition, which we named "benign transient nonorganic ileus of neonates" (BTNIN), we noticed that BTNIN included cases of cow's milk allergy (CMA). Therefore, a prospective study of the identity of BTNIN and CMA was conducted. METHODS: Cow's milk allergy was diagnosed when a baby showed HD-like symptoms after oral feeding, and a drug-induced lymphocyte stimulation test was positive for cow's milk with a titer of more than 300%. MATERIALS: Of 38 neonates with suspected HD, a surgical disorder was excluded by plain x-ray in 9, intestinal atresia was diagnosed in 3, and the remaining 26 were enrolled in this study. RESULTS: Of 26 cases, 9 were diagnosed as HD by manometric studies and 17 as CMA. Thirteen of 17 CMA cases had been fed with breast milk and 4 with formula milk. CONCLUSION: The proportion of CMA in the cases presenting with HD-like symptoms in the neonatal period is much higher than what we expected, and most cases of BTNIN are caused by CMA. If HD is ruled out, CMA should be considered.

One-trocar laparoscopy-aided gastrostomy in handicapped children.

BACKGROUND/PURPOSE: Percutaneous endoscopic gastrostomy has become a common technique to provide nutritional support to handicapped children with swallowing disorders; however, this technique is sometimes associated with serious complications. We report a novel method of 1-trocar laparoscopy-aided gastrostomy with special reference to its influence on gastroesophageal reflux (GER). METHODS: The subjects consisted of 22 profoundly handicapped children, aged from 1 to 14 years (median, 7 years). Twenty-four-hour esophageal pH monitoring was conducted preoperatively in all subjects and performed postoperatively in 12. The criteria for gastrostomy alone included no significant symptoms related to GER and distal esophageal acid exposure of less than 15%. Esophageal acid exposure was evaluated at the distal esophagus (P1) and at 10 cm proximal to P1 (P2). Stamm gastrostomy was performed by grasping the anterior gastric wall with forceps inserted through an operating channel associated with a laparoscope. Data are expressed as medians and ranges. RESULTS: There were neither perioperative mortality nor life-threatening complications except the detachment of the gastrostomy in one. Esophageal acid exposure was significantly increased postoperatively compared to preoperatively at P1 (2.1% [0.0%-4.7%] vs 4.6% [0.2%-8.7%], P = .02), but did not change much at P2 (0.2% [0.0%-1.5%] vs 0.8% [0.0%-7.6%], P = .07). No patient developed postoperative symptoms related to GER. CONCLUSIONS: One-trocar laparoscopy-aided gastrostomy is a feasible technique for handicapped children without symptomatic GER.

Portal hypertensive gastropathy after surgery for biliary atresia.

PURPOSE: To clarify the correlation between portal hypertensive gastropathy (PHG) and clinical features after surgery for biliary atresia (BA). METHODS: Routine upper gastrointestinal endoscopies were done over 3 years in 27 children who underwent surgery for BA. We reviewed the recorded endoscopic findings, and retrospectively diagnosed PHG according to McCormack's criteria. The differences in clinical features, such as endoscopically treated gastroesophageal varices and the results of routine laboratory tests, were compared between the children with PHG (PHG group) and those without PHG (non-PHG group). RESULTS: Nine (33%) of the 27 children had PHG. Although there was no significant difference in age between the PHG and non-PHG groups, the frequency of past endoscopic variceal treatments was significantly higher in the PHG group (3.0 +/- 3.0 vs 0.6 +/- 1.5 times, P = 0.01). The PHG group also had lower white blood cell and platelet counts, at 3008 +/- 2411 vs 5527 +/- 2938/mm3 (P < 0.05) and 6.0 +/- 3.4 vs 13.9 +/- 4.7 x 10(4)/mm3 (P = 0.0001), respectively; higher serum aspartate aminotransferase, total bile acid, and total bilirubin levels at 80 +/- 31 vs 46 +/- 29 U/l (P < 0.05), 161 +/- 93 vs 64 +/- 88 U/l (P < 0.05), and 4.8 +/- 5.6 vs 1.0 +/- 0.8 mg/dl (P < 0.01), respectively; and lower prothrombin time, albumin, and cholinesterase levels, at 66 +/- 16 vs 79% +/- 14% (P < 0.05), 3.6 +/- 0.8 vs 4.1 +/- 0.5 g/dl (P < 0.05), and 2158 +/- 925 vs 3376 +/- 700 U/l (P < 0.001), respectively. CONCLUSION: Portal hypertensive gastropathy was found in 33% of children after surgery for BA. The factors contributing to the development of PHG were frequent endoscopic treatments of gastroesophageal varices, liver dysfunction, and hypersplenism.

Glutamine stimulates amino acid transport during ischemia-reperfusion in human intestinal epithelial cells.

BACKGROUND: The potential mechanism of intestinal ischemia-reperfusion (I/R) injury includes oxygen-derived toxic free radicals. We tested the hypothesis that glutamine increases intracellular glutathione, a protective substrate against oxidative stress, by stimulating membrane amino acid transport during I/R using human intestinal epithelial cell line Caco-2. METHODS: Ischemic conditions were obtained by combining both hypoxic (1%O2-5%CO2-94% N2) and nutrient-deprived (Phosphate-Buffered Saline; PBS) conditions. After 2 h of ischemia, re-oxygenation (5%CO2-95% air) was initiated and the culture medium was changed to PBS, PBS supplemented with amino acids (A.A.), and PBS supplemented with 2 mm glutamine plus amino acids (Gln) (reperfusion). After 4 h of reperfusion, the transport of 3H-glutamine, 3H-glutamate, and 3H-leucine was assayed and intracellular glutathione was measured. 3H-thymidine incorporation was measured for the determination of DNA synthesis. Data (mean +/- SD) were analyzed by ANOVA. RESULTS: Ischemia decreased Na+-dependent glutamine, Na+-dependent glutamate, and Na+-independent leucine transport compared with control (P < 0.01). After reperfusion, glutamine and glutamate transport in the PBS and A.A. groups decreased significantly compared with control (P < 0.01), whereas glutamine supplementation increased glutamine transport to the levels in control (P < 0.01) and partially increased glutamate transport (P < 0.01). Leucine transport significantly increased in the A.A. and Gln groups compared with the PBS group. Glutamine significantly increased intracellular glutathione and DNA synthesis compared with the PBS and A.A. groups (P < 0.01). CONCLUSIONS: This study demonstrated that glutamine up-regulates amino acid transport during I/R in human intestinal epithelial cells, possibly resulting in increased intracellular glutathione and DNA synthesis.

Amino acid transport is down-regulated in ischemic human intestinal epithelial cells.

Amino acid transport across the plasma membrane is essential for supplying enterocytes with amino acids for cellular metabolism. We studied amino acid transport during ischemic conditions using human intestinal epithelial cell line Caco-2. Cells were incubated under nutrient-deprived (phosphate-buffered saline, PBS), hypoxic, and ischemic (PBS+hypoxia) conditions. Ischemia resulted in a significant decrease in glutamine transport by a mechanism that decreased V(max) without affecting K(m). The expression of system ATB degrees (glutamine transporter) mRNA decreased in the ischemic and nutrient-deprived groups, suggesting that the down-regulation of glutamine transport is due to modification of expression of the ATB degrees gene. The transport of glutamate and leucine, DNA synthesis, and intracellular glutathione also decreased in the ischemic group. These findings throw some light on the mechanism of intestinal epithelial damage during ischemia.

Vaginal reconstruction in a patient with rhabdomyosarcoma previously treated by total vaginectomy.

In vaginal rhabdomyosarcoma, because of effectiveness of multiple-agent chemotherapy and brachytherapy, function-preserving treatment without radical surgery has been recently recommended. However, for patients with persistent or recurrent tumors, vaginectomy with or without hysterectomy is appropriate. The authors report experience of successful vaginal reconstruction in a rhabdomyosarcoma patient who had total vaginectomy with preservation of the uterus. Because continuity from the vaginal introitus to the uterus was established, fertility can be expected for this patient.

[Clinical evaluation of the effect of tamsulosin hydrochloride and cernitin pollen extract on urinary disturbance associated with benign prostatic hyperplasia in a multicentered study].

We evaluated the clinical efficacy and safety of tamsulosin hydrochloride and cernitin pollen extract in 243 patients with urinary disturbance associated with benign prostatic hyperplasia. They were assigned randomly to 3 groups, oral tamsulosin hydrochloride, cernitin pollen extract and their combination were administered for 12 weeks. The international prostate symptom score, post-voided residual urine and uroflowmetrogram were obtained before and after treatment. The international prostate symptom score improved in each group and then the maximum flow rate and average flow rate also increased significantly in the tamsulosin hydrochloride-administered groups. In conclusion, the administration of only tamsulosin hydrochloride and the combination of tamsulosin hydrochloride and cernitin pollen extract seemed more effective then the administration of only cernitin pollen extract in the treatment of urinary disturbance associated with benign prostatic hyperplasia.