Participant satisfaction and comfort with multidisciplinary pediatric telemedicine consultations.

PURPOSE: The aim of this study was to measure both satisfaction and comfort levels and estimates of cost savings of families with children receiving health care services from a distant pediatric tertiary care center by readily available telecommunications technologies. METHODS: From February 1996 to September 1997, 140 children at a site 840 miles from the tertiary care center were seen during an evaluative trial of telemedicine consultations (TMC). The TMC visit was the initial encounter with the tertiary care specialist for 31 children. After consultation, each family was asked to complete an anonymous quality management survey that asked for estimates of cost savings and assessed their level of comfort and satisfaction with 13 other aspects of the TMC encounter. A 3- or 5-point Likert scale was used for each question. Comfort scores before and after each consultation were compared by chi2 analysis. Logistic regression was used to determine the independent predictors of satisfaction. RESULTS: 104 of the 140 (74%) families responded. Mean patient estimated cost savings was $1,318+/-677. The highest level of comfort was noted by 58% of respondents before TMC and by 77% after (P = .005). On a 5-point scale, 71% scored 5 (completely satisfied). None scored less than 3. The independent statistically significant predictors of satisfaction were concerns about privacy, comfort with the camera, and perceived specialist comfort. CONCLUSIONS: In addition to providing financial savings, TMC is well accepted by families and children. Those using this new technology must give special attention to issues of patient privacy, camera comfort, and specialist comfort.

Enterocolitis after the surgical treatment of Hirschsprung's disease: risk factors and financial impact.

BACKGROUND/PURPOSE: Enterocolitis (EC) represents a serious complication after the surgical correction of Hirschsprung's disease (HD). Although previous studies have identified risk factors associated with the development of this complication before definitive repair, the factors leading to EC after pull-through have not been examined. This study was therefore designed to determine risk factors for the development of post-pull-through EC. METHODS: Patients with HD treated from 1991 through 1996 at the Hospital for Sick Children in Toronto, Canada were assessed. Risk factors were examined in three areas: patient factors (gender, age at diagnosis, age and weight at pull-through), technical factors (type of repair, number of stages, location of transition zone, previous EC), and mechanical factors. RESULTS: In 105 consecutive patients, the incidence of postoperative EC was 32%. There was no mortality. The risk of postoperative EC was significantly increased by mechanical factors related to anastomotic complications (relative risk, 2.8) and intestinal obstruction (relative risk, 3.5). This finding was not attributable to the general occurrence of any postoperative complication because the incidence of postoperative complications was equally distributed in patients with and without EC. The presence of EC significantly increased the number of hospital admissions, mean length of stay, and total treatment cost. CONCLUSION: These findings suggest the use of measures to decrease mechanical obstruction so as to decrease the incidence and impact of this potentially devastating complication.

A novel approach to tracheostomal collapse: the use of an endoluminal Palmaz stent.

There are a number of surgical treatments for tracheostomal collapse of the pediatric airway. The techniques include tracheoplasty with costal cartilage graft, the placement of a tracheostomy tube and partial tracheal resection and primary tracheal anastomosis to name a few. Since each child may possess unique medical and social factors in additional to the tracheal pathology, the surgical approach must be individualized. A case history of a 1-year-old Vietnamese child with a tracheostomal collapse is presented. In this case, an endoluminal Palmaz stent was placed endoscopically to support the collapsed tracheal segment for 3 months. After 3 months, the stent was removed, and the child has done well without any airway intervention for 2 years. The indications for this novel approach, the technique of insertion and removal of the stent are the focus of this paper.

Laparoscopic cholecystectomy versus open cholecystectomy in children: which is better?

Twenty-nine consecutive laparoscopic cholecystectomies (LC) performed between April 1992 and December 1993 were compared with 23 consecutive open cholecystectomies (OC) performed between January 1991 and March 1992 with regard to clinical, surgical, and economic factors. Most patients were Caucasian (> 70%), and symptomatic nonhemolytic cholelithiasis was the most common indication for cholecystectomy. The introduction of LC did not significantly increase the number of cholecystectomies performed per annum. There is a learning curve to LC: the average length of operative time required during the first year was significantly longer than that of OC and the average time for LC during the second year (P < .01). By the second year, the average operative time of LC was not significantly different from OC. There was no conversion from LC to OC, and the complication rate was minor in both groups. The postoperative parenteral analgesic requirement for LC was significantly less than OC (P < .01). The mean length of hospitalization of LC was about three times shorter than that of OC (P < .01). Although the average operating cost per case of LC was significantly more expensive than OC, LC was significantly cheaper because the period of hospitalization was significantly shortened (P < .01). In conclusion, LC is the procedure of choice in the treatment of symptomatic cholelithiasis in children.

Resting energy expenditure is increased in infants and children with extrahepatic biliary atresia.

To determine if liver dysfunction in children affects energy and macronutrient homeostasis, we performed 13 metabolic studies in 11 patients (age, 17.8 +/- 5.9 months [mean +/- SEM]) with extrahepatic biliary atresia (EHBA). Nutritional balance, indirect calorimetry, anthropometry, and biochemical liver function tests were utilised. Sixty-four percent of the energy losses were in the form of stool fat. Energy expenditure (68 kcal/kg/d) was 29% higher than normal (P less than 0.0025). Only one third of the metabolisable energy intake (37 kcal/kg/d) was stored in the body for new tissue synthesis. In spite of the bountiful protein intake for age, the increased protein oxidation (2g/kg/d) resulted in a virtually zero mean nitrogen balance. In addition, four patients oxidised endogenous protein as well. The respiratory quotient was 0.96, and did not change significantly between pre- and post-meal measurements, suggesting a predominant utilisation of carbohydrate for energy metabolism. Net lipid oxidation was severely diminished. We found that the higher the serum aspartate aminotransferase level (previously named SGOT), the lower the net fat oxidation, and the higher the conversion of glucose to fat. These data suggest that markedly increased energy expenditure contributes to the malnutrition of patients with EHBA. We characterised for the first time how severe liver disease in infants and children affects carbohydrate, fat, and protein metabolism, thus inducing protein-energy malnutrition.

Evaluation of doubly labeled water for measuring energy expenditure during changing nutrition.

Change in abundance of 2H and 18O in dietary water during a doubly labeled water energy period may introduce error into the calculated carbon dioxide production rate (RCO2). To examine the accuracy of 2H2(18)O during changing nutritional regimens, we compared 2H2(18)O and periodic open-circuit respiratory gas exchange (RGE) in postsurgical infants who were changing from parenteral to alternative parenteral and/or oral nutrition. The two methods were compared before and after correction for shifts in isotopic abundance of the infant water pools during the energy-expenditure period. Baseline corrections were predicted using the difference between abundances of the initial body water and final nutrient solutions. Before isotopic correction, 2H2(18)O underestimated RCO2 in eight subjects by 11.8 +/- 20.1% (mean +/- SD). After correction, agreement between the two methods improved; the underestimate was then -8.7 +/- 12.9%. To obtain maximum precision of 2H2(18)O, subjects should be maintained on the same nutritional regimen before and during the study unless valid correction formulae are used.

Injury severity, whole body protein turnover, and energy expenditure in pediatric trauma.

The purpose of this study was to quantify the changes in energy expenditure and protein turnover imposed by blunt trauma in children and to correlate them with the Injury Severity Score (ISS). We studied 19 children (mean age 10 +/- 1 year, mean ISS 20 +/- 2). Basal metabolic rate (BMR) was measured in the postabsorptive state by open-circuit indirect calorimetry. Whole body protein turnover (Q) and synthesis (S) were determined by the 15N enrichment of urinary ammonia in a 12-hour collection following a single dose of 15N glycine. Twelve-hour total urinary nitrogen excretion (E) was also determined. Because nitrogen intake was 0 during the study period, Q was equivalent to protein breakdown (B). Eleven patients were restudied at 3- to 5-day intervals during hospitalization and eight were restudied after discharge (mean 34 +/- 6 days post injury). There was a significant increase in BMR, Q, S, and E following injury, when compared with post injury baseline values. However, while BMR increased by 14%, there were 93% and 82% increases in Q (B) and S, respectively. Negative nitrogen balance resulted from the fact that protein breakdown increased more than protein synthesis. The initial increase in BMR varied directly with the severity of injury, as reflected in the ISS (r = 0.56, P less than .02). There was no significant correlation between ISS and any of the parameters of protein metabolism. These results suggest that the metabolic response of pediatric patients to multiple trauma may differ from that of adults. In addition, they imply that the ISS may not be a reliable indicator of the severity of tissue injury.

Validation of doubly labeled water for assessing energy expenditure in infants.

Previous studies show that the doubly labeled water method is accurate for measuring energy expenditure in the adult human. To validate this method in infants, carbon dioxide production rate and energy expenditure were measured for 5 to 6 days by doubly labeled water (DLW) and periodic open circuit respiratory gas exchange (RGE) in 10 blinded studies in nine infants following abdominal surgery. Infants were maintained on consistent oral or parenteral nutrition prior to and during study. This avoided diet-related changes in baseline isotopic enrichment of body water which could theoretically contribute to significant errors in calculation of carbon dioxide production rate. For DLW, insensible water loss was assumed to be proportional to respiratory volume and body surface area, where the former was predicted from carbon dioxide production rate. Insensible water loss thus calculated averaged 18% of water turnover. Rates of carbon dioxide production measured by DLW were not significantly different from that of RGE (10.4 +/- 1.1 and 10.5 +/- 0.9 l/kg/day, mean +/- SD, respectively). Energy expenditure was calculated using respiratory quotients from dietary intake (DLW:DIET) and RGE (DLW:RGE) data. There was no significant difference between energy expenditure determined by DLW (DLW:DIET and DLW:RGE) and that measured by RGE (58.5 +/- 6.1, 56.8 +/- 6.1, and 57.3 +/- 5.1 kcal/kg/day, mean +/- SD, respectively). Rate of carbon dioxide production, DLW:diet, and DLW:RGE calculated by DLW differed from corresponding RGE values by -0.9 +/- 6.2, -1.1 +/- 6.1, and 1.6 +/- 6.2%, mean +/- SD, respectively. These findings demonstrate the validity of the doubly labeled water method for determining energy expenditure in infants without concurrent water balance studies.

An assessment of the surgical treatment of adhesive small bowel obstruction in infants and children.

At The Hospital for Sick Children, Toronto, Canada, adhesive small bowel obstruction (SBO) ranks seventh as a cause of pediatric bowel obstruction. Between January 1968 and December 1979, 131 infants and children had adhesive SBO proven at laparotomy or autopsy: 123 had 1; 7 had 16 adhesiotomies; 1 died without surgery; 100 had 1 prior operation; and 31 had multiple operations. Over 80% of the SBOs developed within 2 yr of the prior operations. Appendectomy and subtotal colectomy were the most common prior operation. Postoperative morbidity occurred in 29 children; 20 were observed longer than 24 hr before laparotomy. The rate of wound infection ranged from 4% to 50%; it was lowest for those children who had lysis of adhesions only, and highest for those who had lysis and decompressive enterotomy or perforation repair. Results indicate that delaying adhesiotomy and entering the GI tract during adhesiotomy are associated with increased morbidity (p less than 0.01), and therefore should be avoided. Prophylactic antibiotics may have a protective role during anterolysis.

Assessment of pulmonary wedge resection for the treatment of lung metastases.

Wedge resection for pulmonary metastases was performed on 18 children suffering from a variety of malignant tumors. The overall survival rate was 39%. However, tumor recurred at or near the site of resection in half the patients. A more extensive resection, such as lobectomy, should be considered for most patients. Wedge resection should be reserved for tumor involving many lobes or for neoplasms having a demonstrated sensitivity to chemotherapy and irradiation.