Necrotizing enterocolitis in term neonates: data from a multihospital health-care system.

OBJECTIVE: In the past 5(1/2) years, 30 term or near-term neonates in the Intermountain Healthcare system developed necrotizing enterocolitis (NEC) Bell's stage > or =II. We sought to identify possible explanations for why these patients developed NEC, by comparing them with 5847 others that did not develop NEC, from the same hospitals and of the same gestational ages, cared for during the same 5 1/2-year period. STUDY DESIGN: Data were collected from neonates admitted to any of the Intermountain Healthcare NICUs with a birth date from 1 January 2001 to 30 June 2006, and a gestational age >36 weeks. A variety of patient features and feeding practices were compared between those that did vs did not develop NEC. RESULT: Forty-one neonates >36 weeks gestation were listed in the discharge records as having NEC of Bell's stage II or higher. However, on review of these 41 medical records, 11 were seen to have had NEC of Bell's stage I, whereas the remaining 30 had radiographs and clinical courses indicative of Bell's stage > or =II. Those 30 formed the basis of this study. Twenty-eight of the 30 developed NEC after having been admitted to an NICU for some other reason; the other two developed NEC at home, within 2 days of being discharged from an NICU. The 30 that developed NEC were more likely than the 5847 that did not develop NEC, to have congenital heart disease (P=0.000), polycythemia (P=0.002), early-onset bacterial sepsis (P=0.004) or hypotension (P=0.017). All 30 received enteral feedings before NEC developed; 29 were fed either artificial formula or a mixture of formula and breast milk. The one that was exclusively fed human milk was fed human milk with added fortifier (24 cal/oz). The 30 that developed NEC were more likely to be fed formula exclusively (P=0.000). Seven of the 30 had a laparotomy for NEC; two of the seven had total bowel necrosis and support was withdrawn. The other five had perforations and bowel resections. The mortality rate was 13% (4/30). CONCLUSION: In our series, NEC among term or near-term neonates was exclusively a complication developing among patients already admitted to a NICU for some other reason. We speculate that the combination of reduced mesenteric perfusion and feeding with artificial formula were factors predisposing them to develop NEC.

Production of heparin-binding epidermal growth factor-like growth factor (HB-EGF) at sites of thermal injury in pediatric patients.

Fluids that accumulate at wound sites may be an important reservoir of growth factors that promote the normal wound healing response. The presence of heparin-binding growth factors was studied in burn wound fluid (BWF) from 45 pediatric patients who had sustained partial thickness burns. One of the growth factors present was similar to platelet-derived growth factor (PDGF) based on its heparin affinity, inhibition of bioactivity by a PDGF antiserum, and detection in a PDGF-AB enzyme-linked immunosorbent assay. A second growth factor was identified as heparin-binding epidermal growth factor-like growth factor (HB-EGF) based on its heparin affinity, competition with 125I-labeled epidermal growth factor (EGF) for EGF receptor binding, and recognition in biological assays and Western blots by two HB-EGF antisera. Amino acid sequence analysis of one form of this second growth factor verified its identity as an N-terminally truncated form of HB-EGF. Immunohistochemical analysis of partial thickness burns demonstrated the presence of HB-EGF in the advancing epithelial margin, islands of regenerating epithelium within the burn wound, and in the duct and proximal tubules of eccrine sweat glands. HB-EGF in the surface epithelium of burn wounds was uniformally distributed, whereas it was restricted to the basal epithelium in nonburned skin. These data support a role for PDGF and HB-EGF in burn wound healing and suggest that the response to injury includes deposition of HB-EGF and PDGF into blister fluid and a redistribution of HB-EGF in the surface epithelium near the wound site.

Characterization of the gene encoding murine heparin-binding epidermal growth factor-like growth factor.

The mouse gene (mHB-EGF) encoding heparin-binding epidermal growth factor-like growth factor was isolated from a mouse 129SVJ genomic library. DNA sequence analysis confirmed that the clone contained six exons (I-VI) and five introns (A-E), and spanned approx. 14 kb of DNA. PCR analysis showed that introns A-E of mHB-EGF are 203 bp, 2.5 kb, 5.5 kb, 825 bp and 272 bp in length, respectively. These results establish that mHB-EGF is similar in organization to human HB-EGF (hHB-EGF). However, DNA sequence analysis of introns A-E of mHB-EGF failed to show significant overall homology with those of hHB-EGF.

Heparin-binding EGF-like growth factor decreases inducible nitric oxide synthase and nitric oxide production after intestinal ischemia/reperfusion injury.

Heparin-binding epidermal growth factor-like growth factor (HB-EGF) has been shown to protect intestine from ischemia/reperfusion (I/R) injury in vivo and to down-regulate inducible nitric oxide synthase (iNOS) and nitric oxide (NO) production in intestinal epithelial cells in vitro. The present study was undertaken to investigate whether HB-EGF could modulate the iNOS/NO axis after total midgut I/R injury in rats. I/R injury induced a significant increase in iNOS gene expression (quantified by real-time RT-PCR) and protein production (detected by western blots), as well as elevation of serum NO levels (measured by chemiluminescence assay). Nitrotyrosine (NT) and iNOS production colocalized immunohistochemically, with positive staining found mainly in villous and crypt epithelial cells, as well as ganglion cells. Intraluminal administration of HB-EGF 45 min after the start of a 90-min ischemic interval significantly decreased I/R-induced iNOS gene expression and protein production, as well as serum NO levels. Immunohistochemically, HB-EGF administration led to elimination of iNOS and NT staining in crypt epithelial cells and ganglion cells, with only weak staining that remained in villous epithelial cells. Thus, HB-EGF protects the intestine from I/R injury, at least partially, through down-regulation of the iNOS/NO/NT pathway, a mechanism that is central to I/R injury in multiple organ systems.

Structure and function of heparin-binding EGF-like growth factor (HB-EGF).

Heparin-binding EGF-like growth factor (HB-EGF) is a 22 kDa, O-glycosylated protein that is mitogenic for fibroblasts, smooth muscle cells (SMC) and epithelial cells. This review describes the primary structure of HB-EGF, as well as its processing. The structure of the mouse and human HB-EGF genes is also discussed. Finally, this review summarizes HB-EGF expression patterns, receptor-mediated signaling, and role in several important biological systems.

Pediatric testicular problems.

Testicular problems in children may be both congenital and acquired. These problems are often difficult to diagnose and carry significant sequelae if untreated. Early surgical consultation is often needed for correction of the problem. This article reviews the pathophysiology of the most common pediatric testicular abnormalities with emphasis on the diagnostic modalities employed and current treatment alternatives.

Segmental intestinal ischemia: an improved method of producing small bowel injury.

Previous animal models of intestinal ischemia-reperfusion have been successful in causing considerable mucosal damage, cellular destruction and sepsis. However, this often results in the death of the animal, making it impossible to examine the effects of modulators of the ischemic event. The sequence of morphologic and physiologic changes in the bowel from such injuries continues to be an area of intense examination. We have studied these changes by producing segmental intestinal ischemia in vivo in a rat model. By occluding a first-order branch of the superior mesenteric artery (SMA) and by selectively ligating terminal collateral branches, reproducible segmental intestinal ischemia was achieved. Bowel damage ranged from alterations in the villus structure to frank hemorrhagic necrosis of the intestinal wall. This model allows the study of hypoperfusion injury to the small intestine without total SMA occlusion, thus reducing the overall mortality.

Pediatric electrical burns: management strategies.

The purpose of the present study was to analyse the course of patients hospitalised with electrical burn wounds in the past 25 years at a major children's hospital in the United States in order to devise safe and cost effective management strategies for these patients. The study was a retrospective chart review of patients with electrical injuries admitted to the hospital between 1971 and 1995. We identified 127 children who were included in the study. Injuries resulted from biting an electrical cord (oral injury) (n = 48), placing an object into an electrical socket (outlet injury) (n = 33), contacting a low voltage wire or appliance indoors (low voltage household injury) (n = 25), contacting a high voltage wire outdoors (high voltage wire injury) (n = 18), or being struck by lightning (n = 3). A retrospective review revealed that the great majority of patients with low voltage electrical injuries did not need admission to the hospital and could have been cared for on an outpatient basis. Almost every patient with high voltage injury had a justified admission due to the severity of the injury. On the basis of these results we conclude that we can safely reduce the number of admissions to the hospital for children with low voltage minor electrical injuries.

Absent intestinal musculature: anatomic evidence of an embryonic origin of the lesion.

Absent intestinal musculature is a rare entity of uncertain etiology. The diagnosis is confirmed histologically by segmental absence of the intestinal muscularis. The remaining layers of the bowel wall are completely intact, and notably absent are significant inflammation and hemorrhage. The authors report two cases of segmental absence of intestinal musculature presenting as perforations. There was gross or microscopic evidence of diverticula formation at sites of perforation and absent muscle. Based on the anatomic evidence in these specimens and a review of the surgical literature, we propose that the etiology is based on embryologic diverticuli.

Heparin-binding EGF-like growth factor is cytoprotective for intestinal epithelial cells exposed to hypoxia.

BACKGROUND: During recovery from intestinal ischemic injury, there is rapid growth of intestinal epithelia with regeneration of damaged villi. This study examines the effects of heparin-binding EGF-like growth factor (HB-EGF) on the recovery of intestinal epithelial cells exposed to hypoxia. METHODS: The cytoprotective effects of HB-EGF were analyzed by placing IEC-18 cells in an anaerobic chamber with various timed HB-EGF treatments (prehypoxia, posthypoxia, pre- and posthypoxia, and no treatment). After 10 hours of hypoxia, lactate dehydrogenase (LDH) release, actin-filament (structural) integrity, adenosine triphosphate (ATP) levels, and posthypoxia proliferative activity were evaluated. RESULTS: LDH analysis showed that HB-EGF exerted a cytoprotective effect during hypoxia. Pretreated cells had a significantly lower death rate during recovery (7.48%) compared with cells with no HB-EGF treatment (22.19%, P < .009). Confocal microscopic structural analysis of posthypoxia cells showed that F-actin structure was maintained in treated cells, whereas nontreated cells showed increased structural deterioration. ATP levels were significantly higher in the HB-EGF-treated cells compared with nontreated cells at 48 hours (P < .05). Finally, HB-EGF-treated cells had a significantly improved proliferative ability compared with nontreated cells during recovery from hypoxia (P < .05). CONCLUSIONS: HB-EGF is a mitogenic growth factor for intestinal epithelial cells. Moreover, HB-EGF appears to protect intestinal epithelial cells from hypoxia, in part via maintenance of cytoskeletal structure and ATP stores. Finally, HB-EGF-treated cells also appear to have better proliferative abilities during recovery from hypoxia.

Heparin-binding EGF-like growth factor decreases apoptosis in intestinal epithelial cells in vitro.

BACKGROUND/PURPOSE: The production of heparin-binding EGF-like growth factor (HB-EGF) is upregulated during organ injury and has a cytoprotective effect during hypoxic stress in intestinal epithelial cells in vitro and intestinal ischemia-reperfusion injuries in vivo. The purpose of this study was to determine if HB-EGF-related cytoprotection is manifested through alterations in apoptosis. METHODS: Human intestinal epithelial cell monolayers (DLD-1 and Caco-2) were stimulated with interleukin (IL)-1 (20 ng/mL), tumor necrosis factor (TNF)-alpha (40 ng/mL), and interferon (IFN)-gamma (10 ng/mL) with or without HB-EGF (1, 10 or 100 ng/mL) and analyzed for rates of apoptosis utilizing a Cell Death Detection ELISA and flow cytometry. RESULTS: ELISA results showed a 3-fold increase in the level of apoptosis during stimulation with cytokines compared with nonstimulated cells (P <.05). Relative levels of cytokine induced apoptosis were reduced after 12 hours of HB-EGF exposure (P <.05) in a dose-dependent fashion. Results of flow cytometric analysis also showed a reduction in apoptosis at 6 hours when cell monolayers were stimulated with cytokines in conjunction with HB-EGF compared with cytokines alone (P <.05). CONCLUSIONS: HB-EGF downregulated apoptosis in intestinal epithelial cells exposed to proinflammatory cytokines in vitro. The results of this study suggest that alterations in apoptosis may represent a possible mechanism by which this growth factor exerts its cytoprotective effect at the mucosal level during the proinflammatory state.

Collision tumors in children: a review of the literature and presentation of a rare case of mesoblastic nephroma and neuroblastoma in an infant.

A mass made up of 2 distinct synchronous primary malignant tumors is a rare event in adults, and exceedingly so in children. Such lesions have been called collision tumors. Reported here is an infant who was found to have a collision tumor comprised of a neuroblastoma and a congenital mesoblastic nephroma, in contiguity, in the right kidney. This is the first report of a collision tumor in an infant. This also is the first report of a synchronous occurrence of a neuroblastoma and a congenital mesoblastic nephroma. The authors present this case and discuss the available literature.

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.

Unique protein expression by the TBJ clonal derivative of C1300 murine neuroblastoma.

C1300 is a murine neuroblastoma that arose spontaneously in an A/JAX mouse, and from which a clone termed TBJ was subsequently derived. C1300 is a slowly growing and poorly metastasizing tumor, whereas TBJ shows early systemic metastasis as well as aggressive local growth. Compared with TBJ cells, C1300 cells are highly immunogenic and are sensitive to natural killer cells and cytotoxic lymphocytes. In vitro, TBJ cells were found to be more rounded and less adherent than C1300 cells. Because the underlying basis for the differences between C1300 and TBJ cells has not been fully elucidated, the authors used high-resolution two-dimensional gel electrophoresis (2-DE) to study comparative aspects of total protein expression by each cell line. Of the approximately 400 individual cellular proteins that could be resolved using this technique, two were found to be reproducibly and uniquely expressed by TBJ cells and not by C1300 cells. Both proteins were anionic (pl 5.0 to 5.2) as assessed by iso-electric focusing and had molecular weights of 76,000 and 82,000 as assessed by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). Silver staining of SDS-polyacrylamide gels showed that the levels of 82,000-M(r) protein (p82) were higher than those of the 76,000-M(r) protein (p76). A purification protocol allowing for the isolation of p82 from TBJ cell extracts was developed, which comprised preparative two-dimensional gel electrophoresis followed by reverse-phase high-performance liquid chromatography. Full molecular identification of p82 and p76 eventually may provide new leads in the study of the metastatic or antigenic properties of neuroblastoma.

Bronchopexy for congenital bronchomalacia in the newborn.

Congenital bronchomalacia is a very unusual cause of respiratory distress in the newborn. The surgical management of this anomaly is challenging. The authors report on a newborn with congenital bronchomalacia successfully treated with bronchopexy.

Nonteratomatous germ cell tumors in children.

BACKGROUND/PURPOSE: Totipotential germ cells may give rise to a broad range of tumors. The teratomatous variety of germ cell tumors has been the subject of several large studies. The goal of the current study was to describe the clinical features of nonteratomatous germ cell tumors (NTGCT) by reviewing a large series of patients. METHODS: Between 1945 and 1997, there were 78 cases of nonteratomatous germ cell tumors (NTGCT's) in children at The Children's Hospital, Columbus. Their records were reviewed retrospectively. There were 35 boys and 43 girls (M:F ratio 0.8). Mean follow-up was 87 months. RESULTS: Histological subtypes included germinoma (33 cases, 42%), endodermal sinus tumor (24 cases, 31%), embryonal carcinoma (12 cases, 15%), gonadoblastoma (4 cases, 5%), mixed histology (4 cases, 5%), and choriocarcinoma (1 case, 2%). Forty-two tumors were in gonadal sites, but a significant percentage were extragonadal (36 cases, 46%). Forty-six patients (59%) had localized disease, 18 (23%) had regional disease, and 14 (18%) had metastases. Treatment consisted of surgery and selective chemotherapy and radiation. Complete tumor resection was more likely for gonadal (29 of 42, 69%) than extragonadal primaries (15 of 36, 41%; P < or = .05). Forty-nine (63%) of all patients survived, whereas 29 (37%) died of their disease. Survival in patients with gonadal primaries (32 of 42, 76%) exceeded that in patients with extragonadal primaries (17 of 36, 47%; P < or = .01). Survival in patients with localized disease (34 of 46, 74%) exceeded that in patients with regional extension or metastases (15 of 32, 47%; P < .05). CONCLUSIONS: This study highlights the fact that tumor location, gonadal versus extragonadal, was important in determining prognosis, whereas tumor histology was not. This may be the result of a higher rate of complete tumor resection for gonadal primaries and underscores the important role of surgery in the optimal treatment of these unusual tumors.

Recombinant human granulocyte colony-stimulating factor promotes wound healing in a patient with congenital neutropenia.

We report a patient with congenital neutropenia or Kostmann's Syndrome who suffered many complications after presenting with Clostridium septicum enterocolitis, including absence of wound healing. Because of several reports of the use of granulocyte colony-stimulating factor (G-CSF) in patients with various complications of neutropenia, we treated this patient with recombinant human (rh) G-CSF. We found that once rhG-CSF restored neutrophil counts to normal, progressive wound healing followed. Thus, rhG-CSF therapy may be useful in treating neutropenic patients with wound complications.

Intraoperative detection and resection of occult neuroblastoma: a technique exploiting somatostatin receptor expression.

Tumor cell expression of specific high-affinity somatostatin receptors has been associated with a favorable prognosis in children with neuroblastoma. The purpose of this study was (1) to document intraoperatively the in vivo binding of the somatostatin analogue 125I-tyr3-octreotide to high-affinity somatostatin receptors expressed on human neuroblastoma, using a hand-held gamma detector; (2) to determine whether gamma-probe detection of radioligand binding to tumor receptors could identify occult malignancy; and (3) to determine the safety and biodistribution of 125I-tyr3-octreotide in children. Six children with stage III or IV neuroblastoma received an intravenous injection of 125I-tyr3-octreotide and underwent operative exploration using gamma-probe detection of radioligand binding to tumor somatostatin receptors. Tissue that demonstrated in vivo binding of 125I-tyr3-octreotide, or that was suspicious for tumor, was extirpated and analyzed by histopathology, immunohistochemistry, and microautoradiography. The biodistribution of 125I-tyr3-octreotide was recorded intraoperatively over time. Tumor tissue from each child also was assayed in vitro for somatostatin receptor expression by competitive binding studies using 125I-tyr3-octreotide. In vivo binding of 125I-tyr3-octreotide to malignant tissue was documented in the five children with a known tumor burden. Seventeen sites of radioreceptor binding were amenable to resection. Histopathological analysis confirmed neuroblastoma in 15 of these specimens. Four of the 15 proven tumor foci were occult malignancies. Every site of histologically proven neuroblastoma demonstrated in vivo binding of 125I-tyr3-octreotide. Five of seven sites histologically negative for neuroblastoma also were negative for in vivo radioreceptor binding. Microautoradiography confirmed in vivo binding of 125I-tyr3-octreotide to tumor cells. Uptake of 125I-tyr3-octreotide in abdominal organs occurred within 15 minutes of injection, was highest in the liver and gallbladder, and decreased over 24 hours. The conclusions were as follows. (1) 125I-tyr3-octreotide binds, in vivo, to somatostatin receptors on neuroblastoma, with 100% sensitivity and 71% specificity. (2) Occult neuroblastoma is found through gamma-probe detection of radioligand binding to receptors. (2) The biodistribution of 125I-tyr3-octreotide reflects the hepatobiliary clearance of this radionuclide. (4) Radioreceptor-guided surgery may safely provide more complete operative staging and cytoreduction of neuroblastoma.

Preliminary experience with focused abdominal sonography for trauma (FAST) in children: is it useful?

BACKGROUND/PURPOSE: Most pediatric surgeons and pediatric radiologists consider computed tomography (CT) the best radiological test for the evaluation of children with suspected intraabdominal injury. The majority of injured children evaluated with CT will be found to have a normal scan. Focused abdominal sonography for trauma (FAST) has been shown to be a useful screening test in the evaluation of adult patients with suspected intraabdominal injury. Limited data exist regarding the use of FAST in children. Our aim was to evaluate the usefulness of FAST as a screening test in the evaluation of children with suspected intraabdominal injury in an attempt to minimize the number of normal CT scans performed. METHODS: Hemodynamically stable children evaluated for suspected intraabdominal injury were prospectively screened with FAST. FAST, real-time sonography at four sites, was performed by staff pediatric radiologists. The average duration of the examination was 2 minutes. Positive and negative FAST scan findings were defined prospectively. The result of each FAST was recorded (positive or negative) and then all patients underwent CT as a control. All management decisions were based on CT results. RESULTS: Forty-six patients were included in the study. FAST identified four children with positive findings (free intraperitoneal fluid), whereas CT showed 13 children with injuries (nine with associated free intraperitoneal fluid and four with only solid organ injury and no associated intraperitoneal fluid). There were nine false-negative and no false-positive FAST scans. The sensitivity of FAST was 0.3 and the specificity was 1.0. Injuries missed by FAST included liver laceration, adrenal hematoma, renal laceration, small bowel injury and splenic laceration. CONCLUSION: Preliminary results suggest that FAST alone is not a useful screening test in the evaluation of children with suspected intraabdominal injury.

Pathophysiology of congenital diaphragmatic hernia. III: Exogenous surfactant therapy for the high-risk neonate with CDH.

Exogenous surfactant therapy (EST) in surfactant-deficient premature infants has been shown to improve lung compliance, decrease morbidity, and improve survival. Reports have demonstrated that newborns with congenital diaphragmatic hernia (CDH) have lung compliance, pressure-volume curves, and hyaline membrane formation resembling those changes seen in surfactant deficient premature newborns. We hypothesize that EST may also benefit infants with CDH. All high risk cases of prenatally diagnosed CDH at Children's Hospital of Buffalo from November 1988 to February 1991 were prospectively evaluated for EST. In those families who chose to participate, the surfactant preparation, Infasurf (100 mg/kg), was instilled into the newborn's lungs prior to the first breath. The remainder of the perinatal, neonatal, and surgical care was performed in a routine manner. Three high-risk prenatally diagnosed newborns with left CDH were treated with EST. All showed signs of decreased pulmonary compliance, but could still be adequately oxygenated and ventilated. Surgical correction was performed after stabilization and all required patch closures. Two of the three infants suffered no life-threatening episodes of pulmonary hypertension and all survived. These infants had many known indicators for poor outcome in CDH with an expected survival of less than 20%. We believe that EST in these neonates with CDH contributed to their survival with minimum morbidity. These results suggest that surfactant replacement for the high-risk neonate with CDH warrants further consideration and a randomized clinical trial is being planned.