Glycerin suppositories used prophylactically in premature infants (supp): A pilot randomized controlled trial.

BACKGROUND: Glycerin suppositories are often used to facilitate meconium evacuation in premature infants. The evidence for this practice is inconclusive. The purpose of this study was to assess the feasibility of a multicenter randomized controlled trial on the effectiveness of this treatment strategy. STUDY DESIGN: We conducted an external pilot study for a multicenter randomized controlled trial of premature infants randomized to glycerin suppositories or placebo procedure. Participants were included if they were gestational age of 24 weeks 0 days to 31 weeks 6 days and/or birthweight of 500 to 1500 grams. We excluded infants with life-threatening congenital anomalies, contraindications to receiving suppositories, or signs of clinical instability. Outcomes included cost, recruitment, and treatment-related adverse events. RESULT: A total of 109 were screened, 79 were initially eligible, and 34 consented to participate. Four of these infants were excluded prior to randomization due to thrombocytopenia, 30 were randomized, and 26 reached full enteral feeds. Three infants (10%) experienced rectal bleeding 5 to 43 days after completing study treatments. An anal fissure was noted in two of these patients. There were no cases of rectal perforation but one infant assigned to active treatment developed necrotizing enterocolitis. CONCLUSIONS: Conducting a multicenter randomized controlled trial on the use of glycerin suppositories in premature infants is feasible. Minor modifications to the study protocol are needed to increase participant recruitment and simplify the administration of study treatments.

An unusual case of an oesophageal foreign body presenting as torticollis.

Oesophageal foreign bodies (FBs) are commonly encountered in an otolaryngology setting. The majority of such cases remain in the paediatric population, where obtaining an accurate history of events is challenging. Oesophageal FBs present in a variety of ways other than dysphagia, which may result in delayed presentation, diagnosis and subsequent treatment. Where an ingested FB is a battery, early removal is advocated owing to the potential for significant complications, a problem highlighted by a patient safety alert issued by NHS England. A common paediatric presentation, torticollis has a multitude of potential underlying causes. We present an unusual case of torticollis in a two-year old girl, subsequently revealed to be caused by an ingested button battery.

Combined posterior sagittal and three-flap anoplasty in the repair of anorectal anomalies.

PURPOSE: The aim of this study was to describe a new technique for the repair of high and intermediate imperforate anus. METHODS: From 1989 to 1999, 22 children with high and intermediate imperforate anus (17 boys, 5 girls) were operated on with a combination of a posterior sagittal and 3-flap perineal anoplasty. Long-term clinical follow up (to a maximum of 10 years) was done in all patients as well as a recent phone interview with a questionnaire regarding bowel function and degree of satisfaction with the result of the surgical correction. A continence ratio (CR, patient score/maximum possible score) was obtained by a blinded interviewer. RESULTS: A continence survey was obtained in 19 patients. The average CR was 0.68. The CR for high anomalies was 0.62 and for intermediate anomalies was 0.78 (0.84 for girls and 0.64 for boys). Patients with sacral anomalies had a CR of 0.58. Two patients with Trisomy 21 had associated Hirschsprung's disease and were excluded from analysis. CONCLUSIONS: Advantages of this combined surgical approach are excellent anatomic exposure, the ability to limit rectal mobilization to a minimum, reduction of the incidence of mucosal prolapse, the new skin-lined anal canal may assist attainment of continence by providing a "sensory warning zone," and, finally, the cosmetic appearance is satisfactory.

Evaluation of the use of botulinum toxin in children with achalasia.

BACKGROUND: Achalasia is rare in children. Recently, injection of botulinum toxin into the lower esophageal sphincter has been studied as an alternative to esophageal pneumatic dilatation or surgical myotomy as treatment for achalasia. In the current study, the effects of botulinum toxin were investigated in the largest known series of children with achalasia. METHODS: Treatment for achalasia was assessed in 23 pediatric patients who received botulinum toxin from June 1995 through November 1998. Those who continued to receive botulinum toxin and did not subsequently undergo pneumatic dilatation or surgery were considered repeat responders. Results were compared with those of published studies evaluating the use of botulinum toxin in adults with achalasia. RESULTS: Nineteen patients initially responded to botulinum toxin. Mean duration of effect was 4.2 months +/- 4.0 (SD). At the end of the study period, three were repeat responders, three experienced dysphagia but did not receive pneumatic dilatation or surgery, three underwent pneumatic dilatation, eight underwent surgery, three underwent pneumatic dilatation with subsequent surgery, and three awaited surgery. Meta-analysis shows that, in the current study group, the data point expressing time of follow-up evaluation versus percentage of patients needing one injection session without additional procedures (botulinum toxin injection, pneumatic dilatation, or surgery) falls within the curve for those in studies on adult patients receiving botulinum toxin for achalasia. CONCLUSIONS: Botulinum toxin effectively initiates the resolution of symptoms associated with achalasia in children. However, one half of patients are expected to need an additional procedure approximately 7 months after one injection session. The authors recommend that botulinum toxin be used only for children with achalasia who are poor candidates for either pneumatic dilatation or surgery.

Mucous fistula refeeding in neonates with short bowel syndrome.

BACKGROUND/PURPOSE: Neonates with enterostomies commonly suffer from a functional short bowel syndrome (SBS) and have a greater risk of electrolyte and fluid loss with poor weight gain. The authors describe their experience with refeeding stoma effluent into the mucous fistula in neonates. METHODS: A 5-year (1993 to 1997) chart review of neonates with stoma effluent refeeding was undertaken. Demographics, medical history, surgical procedures, timing, and duration of refeedings were reviewed. Enteral and total parenteral nutritional (TPN) requirements, electrolyte, and acid-base disturbances were recorded. RESULTS: Six neonates (gestational ages of 27 to 38 weeks, birth weights of 533 to 3400 g) were identified with nutritional or electrolyte complications before the commencement of refeeding. Enterostomy indications included necrotizing enterocolitis (n = 2), intestinal atresia type 3b (n = 1), complications from ruptured omphalocoele (n = 1), congenital adhesive band obstruction (n = 1), and midgut volvulus after congenital diaphragmatic hernia repair (n = 1). Weight gain during refeeding ranged from 5 to 25 g/kg/d with duration of refeeding lasting 16 to 169 days (two neonates were refed at home) until reanastomoses were done 6 to 44 weeks after the original surgery. There were no complications, and TPN requirements were diminished or eliminated. CONCLUSION: This technique represents a simple and safe method, which lessens the need for TPN and electrolyte supplementation in neonates with enterostomies and SBS before reanastomosis.

Factors associated with medium-term response to psychostimulant medication.

OBJECTIVE: To determine, in a sample of children first prescribed psychostimulants for attention deficit hyperactivity disorder (ADHD) between 1992 and 1994, which child and family factors, components of assessment, and aspects of management, were associated with a favourable treatment response, and with parental satisfaction with management. METHODOLOGY: Data were obtained by mail survey in March 1995. Factors considered potentially significant to treatment response and parental satisfaction were entered in a three-step hierarchical multiple regression equation. RESULTS: Responses were received from 788 (59.7%) of a possible 1319 parents. Items making a significant individual contribution to both improvement and parental satisfaction were: younger age of the child; amount of information provided by the clinician; shorter interval between review appointments; continued use of medication; and fewer treatment side effects. items contributing only to treatment response were: longer time taken over establishing the diagnosis; and the use of parent and teacher checklists in assessment. CONCLUSIONS: These data support early intervention for ADHD. A considered approach to assessment which includes the use of parent and teacher checklists is recommended. Providing adequate information to parents and children is essential. Review intervals of less than 6 months appear to foster better outcomes.

Inflicted esophageal perforation.

Esophageal perforation in children is uncommon. A 2 1/2-year-old girl presented with multiple soft tissue injuries of various chronological ages. Initial lateral cervical spine films showed the presence of a prevertebral air collection with soft tissue swelling. Enhanced computerized tomography confirmed the presence of proximal esophageal rupture and a retropharyngeal abscess. External drainage of the abscess and intravenous antibiotics led to resolution of the perforation in 13 days. Discrepancies in the history and the constellation of injuries pointed to an inflicted etiology (through child abuse). Since 1984, 21 case studies have described inflicted esophageal perforation. Common mechanisms of injury include foreign body ingestion and blunt or penetrating external trauma. Early diagnosis of these injuries reduces both acute and long-term morbidity and mortality. Pediatric surgeons must be aware of inflicted injury as an etiology of esophageal and hypopharyngeal perforation.

Mucoepidermoid carcinoma of the parotid gland: a rare presentation in a young child.

Although mucoepidermoid carcinoma (MEC) is the most common malignant salivary gland neoplasm in childhood and adolescence, it is rarely found in children under the age of 10. A 6-year-old girl had an asymptomatic neck mass for 5 months. Clinical examination findings showed a 1.5-cm smooth and firm but mobile nontender mass located in the upper left anterior cervical triangle, clinically separate from the parotid gland. Ultrasound examination findings showed a vascular mass, with a cystic component, possibly within the tail of the parotid gland. An excisional biopsy was performed and frozen section showed a low-grade MEC. A left superficial parotidectomy was then performed. Final histopathologic examination showed one positive resection margin. Subsequently, reexcision of the surgical site and an upper modified neck dissection was undertaken. This unusual presentation of MEC as a neck mass in one of the youngest reported patients illustrates that the anatomic region for parotid tumors is large. Possibly some of these tumors may arise from heterotopic or accessory parotid tissue.

Paternal care reduces maternal hyperthermia in Djungarian hamsters (Phodopus campbelli).

Throughout lactation, maternal body temperature, nest attendance, activity level and reproductive success of solitary female Djungarian hamsters housed at the recommended ambient temperature of 23 degrees C (Canadian Council on Animal Care guidelines) were compared with those of paired females housed at the same temperature and with solitary females housed at the natural burrow temperature of 18 degrees C. As expected, cooler ambient temperature improved pup survival and weaning weight. Likewise, paternal presence largely compensated for the poor pup growth typical at 23 degrees C. However, the mechanisms were not the same. Females at reduced ambient temperatures were as hyperthermic as females at the higher temperature and spent the same proportion of their day at very high body temperatures. However, the steeper temperature gradient available for passive cooling allowed those females to enhance maternal care by shortening their nest bout absences. In contrast, body temperatures of paired females were tightly regulated compared to the hyperthermia of solitary females and rarely included the highest body temperatures. This alleviation of maternal hyperthermia was not achieved through a reduction in nest attendance. Therefore, maternal hyperthermia in Djungarian hamsters is not essential and may be considered a substantial cost to females when males are not present.

An evaluation of the effectiveness of a consultation-liaison psychiatry service in general practice.

OBJECTIVE: This study evaluated the 6-month outcome of patients referred by their general practitioner (GP) to a consultation-liaison (C-L) psychiatry service provided to eight group general practices. METHOD: Over a 12-month period, there were 307 referrals to the C-L psychiatry service of whom 86 consented to take part in an outcome study. Two different control groups were examined comprising patients seen by the same GPs but not referred to the C-L service, who were matched with the C-L referrals on the basis of either demographic characteristics (n = 86) or initial symptomatology (n = 59). Clinical interviews were conducted at recruitment to the outcome study using the Composite International Diagnostic Interview (CIDI), while postal questionnaires were used at both the initial and 6-month assessments. RESULTS: Data reported include DSM-III-R clinical audit and CIDI diagnoses, changes in current symptomatology (SCL-90-R) and changes in global ratings of physical health, emotional health, social relationships and ability to perform everyday duties. Consultation-liaison referrals without symptom-matched controls (n = 27), being patients with higher levels of symptoms initially, were more likely to be referred to other psychiatric services for treatment. They also showed more marked improvement over time on the selected outcome measures. However, there were no significant differences in the patterns of change over time between symptom-matched C-L referrals and their non-referred controls. CONCLUSIONS: The findings from the 6-month outcome study raise doubts about the overall benefit of the current C-L service relative to usual GP care. Improving the quality of psychiatric care in general practice is likely to require a range of interrelated strategies, including C-L psychiatry services, GP education and well-functioning links with public mental health services.

Botulinum toxin use in pediatric esophageal achalasia: a case report.

Esophageal achalasia (EA) has been historically treated by esophageal dilatation or myotomy with or without fundoplication. Botulinum toxin (Botox-Allergan) use in pediatric EA has not been previously described. The authors' objective was to observe the efficacy of botulinum toxin injection into the lower esophageal sphincter (LES) for EA. An 11-year-old boy presented with a 9-month history of frequent pneumonia, productive cough, and a 1-year history of chest discomfort and odynophagia. Chest radiograph showed changes compatible with aspiration. Upper gastrointestinal (UGI) series showed typical narrowing of the LES, and 24-hour pH study showed no reflux. Esophageal manometry showed classic findings of achalasia. An upper gastrointestinal endoscopy was performed showing a huge volume of retained food. A direct four-quadrant injection was performed with a total of 100 U of botulinum toxin into the LES. UGI series showed improvement in esophageal emptying. Esophageal manometry showed impressive improvement in LES pressure (preinjection, 44.1 mm Hg to postinjection mean of 16.6 mm Hg), percent relaxation (preinjection, 30% to postinjection, 58.8%), and duration of relaxation (preinjection, 1.9 seconds to postinjection, 11 seconds). The patient has not had any further respiratory symptoms, chest pain, or odynophagia in 8 months of follow-up. Botulinum toxin injection is simple and effective for EA and merits its study in a prospective manner in the pediatric population.

Determining the effect that consultation-liaison psychiatry in primary care has on family physicians' psychiatric knowledge and practice.

The impact of a community-based consultation-liaison (C-L) psychiatry service on family physicians' levels of psychiatric knowledge, diagnostic and treatment confidence, and patterns of referral to mental health care agencies was evaluated over a 12-month period. The physicians with long-term access to the C-L service had higher levels of psychiatric knowledge than those with short-term or no access. However, there was no evidence that the C-L service produced changes in the physicians' levels of clinical confidence, referral likelihood, or psychiatric knowledge during the evaluation period. Significant predictors of psychiatric knowledge were age (younger) and gender (women). The participating physicians were highly satisfied with the service and preferred it over other possible referral agencies. However, community C-L services in family practice appear to have a limited role in the provision of psychiatric care and are not an efficient way for improving family physicians' levels of psychiatric knowledge or altering their practices. The appropriate role of community C-L psychiatry may be as one component of a comprehensive service-delivery strategy integrated within ongoing, formal family-physician educational programs.

Measurement of the quadriceps femoris muscle using magnetic resonance and ultrasound imaging.

OBJECTIVES: To define a method for measurement of the cross sectional area and volume of the quadriceps femoris muscle using magnetic resonance imaging (MRI) in conjunction with stereology, and to compare the results of measurements obtained by the MRI method with those obtained by the conventional method of static B-mode ultrasound in order to evaluate whether MRI is a reliable alternative to ultrasound. METHODS: A preliminary MRI study was undertaken on a single female volunteer in order to optimise the scanning technique and sampling design for estimating the muscle volume using the Cavalieri method. Ten healthy volunteers participated in the method comparison study. Each volunteer underwent static B-mode ultrasonography, immediately followed by MRI. The cross sectional area of the quadriceps femoris was estimated at the junction of the proximal one third and distal two thirds of the thigh, and seven systematic sections of the thigh were obtained in order to estimate muscle volume by both modalities. RESULTS: Seven sections through the muscle are required to achieve a coefficient of error of 4-5%. There was no significant difference in the cross sectional area estimates or volume estimates when ultrasound and MRI were compared. CONCLUSION: Muscle cross sectional area and volume can be measured without bias by MRI in conjunction with stereological methods and the method is a reliable alternative to static B-mode ultrasound for this purpose.

Consultation-liaison psychiatry in general practice.

OBJECTIVE: This paper describes the characteristics of 303 consecutive referrals, over a 12-month period, to a consultation-liaison (C-L) psychiatry service provided to eight group general practices in Newcastle, Australia. METHOD: A purpose designed service audit form was used throughout the evaluation period to collect information about demographic characteristics, reasons for referral, service contacts, psychiatric diagnoses and clinical management. In addition, patients were invited to participate in a separate, prospective outcome evaluation study, which involved structured interviews and questionnaires. RESULTS: The most common reasons for referral were: depression (33%); anxiety (12%); diagnostic assessment (9%); and impaired relationships (8%). The most common psychiatric diagnoses were: mood disorders (29%); mild, transient conditions (29%); anxiety (14%); and substance abuse disorders (12%). Following the psychiatric consultation(s), GPs were actively involved in patients' treatment in 53% of cases. However, there was a higher than expected rate of referral (44%) to another mental health agency. Selected comparisons are also reported between patients referred to the C-L service (n = 303) and a sample of non-referred GP attenders (n = 535). CONCLUSIONS: As expected, the diagnostic profiles of patients attending the C-L service differed in several respects from those using similar services in general hospitals. There were comparatively low rates of organic brain syndromes, suicide risk evaluations, and problems of differential diagnosis of somatic symptoms. Greater emphasis needs to be placed on more formal psychiatric education for GPs, on ways of screening out from the referral process those patients with mild, transient conditions who do not require specialist expertise, and on the development of strategies to help GPs manage such conditions.

Comparison of real-time ultrasonography and magnetic resonance imaging in the assessment of urinary bladder volume.

OBJECTIVE: To compare estimates of bladder volume obtained by conventional real-time ultrasonography with those obtained from magnetic resonance imaging (MRI) by the Cavalieri method of unbiased stereology. SUBJECTS AND METHODS: The study comprised nine subjects (four men and five women, mean age 23 years, range 18-34) with no history of bladder disease. Before micturition, each volunteer underwent ultrasonography, immediately followed by MRI. The volunteers then voided the true voided volume of urine was measured and the imaging protocols were repeated in the same order after micturition. The bladder volume was estimated from ultrasonography using the formula: volume = 0.7 (L x TS x AP), (where L is the maximum supero-inferior diameter. AP the maximum anteroposterior diameter and TS the maximum transverse diameter) and from MRI using the Cavalieri method. For each imaging modality, the volume of urine voided was estimated as the difference in the volume estimate before and after micturition. RESULTS: The mean percentage coefficient of variation for the estimates of bladder volume by ultrasonography was 2.17 before and 4.43 after micturition. There was no significant difference in the replicate estimates of each bladder diameter by ultrasonography before and after micturition (P = 0.98). The MRI method consistently underestimated the voided volume: the mean discrepancy between the estimated voided volume and the true voided volume was 7.7 ml, and -67.7 ml for the ultrasonographic and MRI estimates, respectively, which are significantly different (P = 0.02) when assessed using a multifactor ANOVA. Further analysis using multiple-range tests showed a significant difference between the voided volume estimated by MRI and the corresponding true voided volume. There was no difference between the voided volume estimated by ultrasonography and the corresponding true volume. CONCLUSION: Ultrasonographic estimates of voided volume were more reliable than the those obtained using the MRI method. This is possibly due to a delay between micturition and the acquisition of MR images after micturition, which allowed the bladder to partly refill with urine. The empirical approach using measurements from ultrasonograms provides a fast and reliable technique: ultrasonography remains the recommended imaging modality for estimating bladder volume.

Management of children prescribed psychostimulant medication for attention deficit hyperactivity disorder in the Hunter region of NSW.

OBJECTIVE: To examine local procedures for assessment of attention deficit hyperactivity disorder (ADHD) and its management with psychostimulant medication and to compare these with published practice guidelines. DESIGN: Retrospective postal survey. PARTICIPANTS: Parents of children living in the Hunter region of New South Wales first prescribed psychostimulants between 1992 and 1994. MAIN OUTCOME MEASURES: Procedures for diagnostic assessment, treatment monitoring and continuing management. RESULTS: 788 parents (60%) responded. Diagnostic assessment procedures complied with published guidelines for about 70%, and detection of comorbid conditions was consistent with community prevalence estimates. There was systematic assessment of treatment response with questionnaires in only a third. Some children with academic or behavioural problems (19%-24% and 32%, respectively), almost 50% with emotional problems and 63% with motor problems were not receiving treatment for these difficulties. Modal interval for review was six months. Trials off medication were most commonly during school holidays, contrary to recommendations of the New South Wales Health Department. Most parents reported considerable improvement in their children's quality of life with medication. CONCLUSIONS: Problems comorbid with ADHD are detected often. Areas of deficiency in management of ADHD include the low rate of contact with schools for diagnostic assessment and determining treatment efficacy, poor support for comorbid problems, infrequent review, and inadequate methods for determining need to continue treatment.

Intratracheal granuloma formation: a late complication of Marlex mesh splinting for tracheomalacia.

External splinting of the trachea has been used alone or in combination with aortopexy for the treatment of severe tracheomalacia. The authors describe the case of a 12-year-old boy who had a Marlex mesh splint placed because of life-threatening primary tracheomalacia at 6 months of age. He presented at 12 years of age with a 5-month history of shortness of breath on exertion, dry cough, and audible wheeze. Radiological and endoscopic examinations showed near-complete obstruction of the orifice of the right mainstem bronchus by a large polypoid granuloma. Initially the patient was treated with endoscopic resection on two occasions, but the granuloma and bronchial obstruction recurred each time. He underwent a right thoracotomy, which showed that the lower edge of the mesh had eroded through the trachea wall and was acting as a nidus for granuloma formation. After removal of the mesh, the resulting defect at the site of erosion of the trachea was closed with a pericardial patch. The postoperative course was uncomplicated, and the patient remains well 2 years after surgery. External splinting of the trachea has been shown to be effective in the treatment of complicated tracheomalacia, but one must be aware of the potential long-term complications, as demonstrated in this case.

Pediatric laparoscopic splenectomy using the lateral approach.

Laparoscopic splenectomy in children has been shown to be safe, to reduce postoperative pain and hospital stay, and to accelerate return to full activities. We describe our experience with a four-port "lateral" approach in 18 patients. Patients were placed in the lateral decubitus position and the table was flexed to separate the left subcostal margin and iliac crest. The camera port was inserted at the umbilicus and additional ports were placed in the epigastrium and left lower quadrant. After mobilization of the splenic flexure a port was inserted in the left flank below the 12th rib for elevation of the spleen. A 30 degrees laparoscope was used and the splenic vessels were controlled with an endo-GIA and/or clips. The spleens were placed in a bag, morcellated, and extracted through a port site. Eight females and 10 males with a median age of 12.5 years (5-17 years) and weight of 55.5 kg (17-124 kg) underwent splenectomy of idiopathic thrombocytopenia purpora (10), spherocytosis (6), elliptocytosis (1), and Hodgkin's disease (1). The median operating time was 160 min (90-300 min) and median blood loss was 105 ml (5-350 ml). Accessory spleens were removed in four cases. Three patients required extensions of a port site to remove large spleens which could not be placed in a bag. The sole complication was a transient pancreatitis with associated pleural effusion. The median postoperative hospital stay was 2 days (1-11 days) and time to full activities was 8 days (3-25 days). The lateral approach affords excellent visualization of the splenic vessels, pancreas, and accessory spleens. This approach is safe and reliable and is our preferred approach for laparoscopic splenectomy in children.

The construction and characteristics of an instrument to measure personal hopefulness.

This paper describes the construction, refinement and implementation of a self-administered measure of personal hopefulness, the Hunter Opinions and Personal Expectations Scale (HOPES). Initial state and trait versions of the HOPES instrument were utilized in three separate studies, comprising a medical student sample (N = 211), an adolescent male sample (N = 280) and a psychiatric hospital staff sample (N = 318). A revised 20-item, two factor, trait version of the scale was then utilized in a prospective, longitudinal investigation (N = 753) of the psychosocial sequelae of the earthquake which struck Newcastle (Australia) in December, 1989. Data from all four studies provide strong support for the HOPES instrument's construct, concurrent and predictive validity. Global personal hopefulness (GPH) was shown to be an enduring characteristic of individuals, with a test-retest correlation of r = + 0.71 (over 64 weeks). The association between GPH and trait anxiety (r = -0.64) raised the possibility of redefining anxiety as hope under threat. The hope subscale (HS) and the despair subscale (DS) were moderately negatively correlated (r = -0.32), suggesting that hope and despair are not simply polar opposites. There were no gender differences in GPH scores, however, there were relatively clear age effects, with those aged 70 years and over reporting the lowest levels of personal hopefulness. GPH was negatively correlated with post-earthquake scores on the General Health Questionnaire (r = -0.33), the Impact of Event Scale (r = -0.33), the Beck Depression Inventory (r = -0.54) and the global symptom index from the SCL-90-R (r = -0.43). Overall, the contribution made by personal hopefulness to post-earthquake morbidity was equal to the contributions made by initial exposure to disruption and threat experiences.