Streamlining the care of patients with hypertrophic pyloric stenosis: application of a clinical pathway.

PURPOSE: The purpose of this study was to evaluate the impact of a clinical pathway on infants admitted to a pediatric tertiary care center with the diagnosis of hypertrophic pyloric stenosis (HPS). METHODS: The records of 132 HPS patients were evaluated before and after implementation of a clinical pathway. Infants were excluded for prematurity, admission to nonsurgical services, or multiple diagnoses requiring prolonged hospitalization, resulting in 83 patients for analysis. Group I (prepathway, n = 40) and group II (postpathway, n = 43) infants were analyzed for time from admission to operation, operation to first feeding, operation to discharge, total length of stay, hospital charges, metabolic status at time of admission, and postoperative complications. The Mann-Whitney test was performed (statistical significance at P <.05). RESULTS: There was no significant difference between group I and group II patients in the length of preoperative hospitalization or metabolic status at the time of hospital admission. In comparison with group I patients, there was a significant reduction in time to resumption of oral feedings (4.6 +/- 1.9 hours v 7.5 +/- 3.2 hours; P <.001) for group II infants and a significantly earlier discharge (26.7 +/- 6.8 hours v 38.0 +/- 11.7 hours; P <.001). This resulted in a shortened length of stay (41.8 +/- 9.7 hours v 57.8 +/- 14.3 hours; P <.001) with an associated decrease in hospital charges ($4,555 +/- $464 v $5,400 +/- $1,017; P <.001). CONCLUSIONS: Elimination of practice variability by the use of a clinical pathway for HPS resulted in significant reduction of hospital stay and related charges. The impact of the pathway occurred in the postoperative period and is a consequence of a rapid and systematic return to oral feedings.

Ethical challenges in the care of infants with intestinal failure and lifelong total parenteral nutrition.

Families, pediatric surgeons, and other care givers face difficult ethical challenges as they balance the benefits and burdens of total parenteral nutrition (TPN) and bowel transplantation in the face of uncertainty and the inability to predict which infants with intestinal failure are likely to have good outcomes. This article presents an analysis of 3 TPN cases using a comparison with dialysis and kidney transplantation, an older and more established technology for which ethical guidelines are proposed in the literature. The authors conclude that pediatric surgeons should recommend TPN in cases in which it is expected to be a temporary measure until bowel function is restored. TPN should not be recommended when other comorbidities make survival unlikely or when the infant is neurologically devastated. In the case of lifelong TPN in which bowel transplantation is only an option when TPN fails, pediatric surgeons should defer to parents in their choice about the use of lifelong TPN.

Fall injuries in the pediatric population: safer and most cost-effective management.

BACKGROUND: At our children's hospital, 30% of all trauma admissions are from falls. The aim of this study was to outline inefficiencies and unnecessary costs incurred in the care of these patients. METHODS: The charts of 127 children admitted for falls (height > or = 9 feet) from 1993 to 1996 were reviewed. Patient demographics, injuries, and treatment costs were recorded and analyzed. RESULTS: Fifty-seven children (45%) were evaluated at an outside facility before transfer. Of these, 73% had injuries requiring treatment at the pediatric center. Local hospital work-up resulted in an average treatment delay of 4.5 hours. Additionally, significant cost was incurred by duplication of radiographic studies, the majority of which were normal. CONCLUSION: Improved and more cost-effective care in pediatric falls can be ensured by immediate transfer of patients with significant injuries, omission of radiographs before transfer, and avoidance of multiple routine x-ray films, the majority of which are normal.

Functional urinary tract obstruction developing in fetuses with isolated gastroschisis.

OBJECTIVE: To evaluate the frequency and natural history of urinary tract abnormalities developing in fetuses presenting with initially isolated gastroschisis. METHODS: Serial ultrasounds were performed prospectively on fetuses identified by our prenatal diagnosis program as having a gastroschisis. When abnormalities in the urinary tract were identified prenatally, newborns were evaluated by a pediatric urologist. RESULTS: Over a 1-year period four out of 12 fetuses with gastroschisis developed deformations of the urinary tract. In three fetuses the bladder herniated through the abdominal wall defect. Two also had upper tract dilatation. A fourth fetus developed bilateral hydronephrosis with a normally situated bladder. Once the gastroschisis was repaired none of the newborns had evidence of structural obstruction of the urinary tract, however, hydronephrosis with or without reflux persisted for several months. CONCLUSIONS: Deformations of the fetal urinary tract can develop secondary to gastroschisis. They do not appear to represent separate malformations and evaluation with fetal karyotyping may not be indicated. When hydronephrosis is present ongoing urologic evaluation of the neonate is indicated.

Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma.

BACKGROUND: Focused abdominal sonography for trauma (FAST) has been well reported in adults, but its applicability in children is less well established. We decided to test the hypothesis that FAST and computed tomography (CT) are equivalent imaging studies in the setting of pediatric blunt abdominal trauma. METHODS: One hundred seven hemodynamically stable children undergoing CT for blunt abdominal trauma were prospectively investigated using FAST. The ability of FAST to predict injury by detecting free intraperitoneal fluid was compared with CT as the imaging standard. RESULTS: Thirty-two patients had CT documented injuries. There were no late injuries missed by CT. FAST detected free fluid in 12 patients. Ten patients had solid organ injury but no free fluid and, thus, were not detected by FAST. The sensitivity of FAST relative to CT was only 0.55 and the negative predictive value was only 0.50. CONCLUSION: FAST has insufficient sensitivity and negative predictive value to be used as a screening imaging test in hemodynamically stable children with blunt abdominal trauma.

Ethical issues in treating infants with very low birth weight.

The purpose of this report is to provide pediatric surgeons with an ethical framework and a process for ethical decision making that can be applied to the difficult issues that arise in the care of infants with very low birth weight (VLBW). Clinical ethical issues focus around choices for surgical intervention, the use of total parenteral nutrition (TPN), recommendations for bowel transplantation, and management of dying infants. The role of family in decision making and the appropriate use of common distinctions including active or passive, withholding or withdrawing, and ordinary or extraordinary in decisions about life-sustaining treatments are discussed. A clinical case discussion illustrates the application of the process for ethical decision making.

Evidence that colitis is initiated by environmental stress and sustained by fecal factors in the cotton-top tamarin (Saguinus oedipus).

Parallel changes in spontaneously occurring inflammation in colonic Thiry-Vella loops and the in-line colon of cotton-top tamarins were studied in a colitis-inducing environment at 8 and 15 months following surgical preparation of the loops. Gross disease severity and numbers of inflammatory/immune cells per unit area of lamina propria in histological sections from endoscopic biopsies were analyzed. Cell counts and severity of colitis declined over time in the Thiry-Villa loops while the disease followed its characteristic course in the remaining large bowel and in the colons of controls. Perfusion of the loops with the animals' feces increased the density of the cellular infiltrate in the lamina propria in parallel with increased severity of inflammation. Electron micrographs of the colonic mucosa showed invasion by microorganisms. The predominant microorganism had characteristics of Helicobacter sp. The results implicate the fecal stream as a factor in the persistence of colitis in the tamarin model. Nevertheless, fecal factors appear not to be the primary trigger, as evidenced by findings that the disease is not expressed in wild-living tamarins and that it enters remission when affected animals are transferred to natural conditions from a colitis-inducing environment. Both an adverse environment and the fecal contents appear to be required for expression of the disease.

Infarction of the choledochus, liver, gallbladder, and pancreas: a unique complication of the hemolytic uremic syndrome.

Hemolytic uremic syndrome (HUS) is associated with multiple nonrenal manifestations. A unique case is described of a 3-year-old boy who presented with a classic diarrheal prodrome followed by massive necrosis of the biliary tree and common bile duct, pancreas, and the left lobe of his liver. This complication of HUS has not been reported in the English-language literature.

Metastatic paraganglioma and paraneoplastic-induced anemia in an adolescent: treatment with hepatic arterial chemoembolization.

Mediastinal paragangliomas are rare neoplasms in children. Anemia, as a paraneoplastic syndrome, has been described in adults with metastatic paraganglioma. The management of paraneoplastic anemia from metastatic paraganglioma has been problematic, with no reports in the literature describing successful treatment. This article describes a 17-year-old Jehovah's Witness with a mediastinal paraganglioma, hepatic metastases, and severe anemia. The patient and his family refused blood products and the anemia was refractory to erythropoietin and elemental iron therapy. Serial chemoembolization of the hepatic lesions resulted in resolution of the anemia, allowing subsequent debulking of the mediastinal paraganglioma.

Duodenum inversum mimicking mesenteric artery syndrome.

BACKGROUND: Duodenum inversum is an often unrecognized anomaly of duodenal rotation/fixation at upper gastrointestinal (UGI) contrast study because the duodenojejunal junction appears normally located. OBJECTIVE: This anomaly is important to diagnose because it may result in obstructive gastrointestinal symptoms. CONCLUSION: We describe a case of duodenum inversum mimicking superior mesenteric artery (SMA) syndrome that improved after surgical therapy.

Ethical considerations in prenatal surgical consultation.

When pediatric surgeons counsel the prospective parents of a fetus with a major congenital anomaly, medical and ethical issues may arise in one or more contexts. There may be: (1) issues concerning the possibility of in-utero intervention or termination of pregnancy; (2) issues surrounding the timing, location and mode of delivery; and (3) issues concerning possible operative interventions after the birth. The virtues of compassion, honesty, and integrity should guide the surgeon in helping the parents confront the diagnosis of a fetal malformation. The ethical principles that inform the prenatal consultation should include respect for autonomy, reproductive freedom, beneficence, and justice. Ethical conflict may develop if the pregnant woman chooses a course of action that is inconsistent with traditional pediatric surgical recommendations.

Hypokinetic gallbladder disease: a cause of chronic abdominal pain in children and adolescents.

BACKGROUND/PURPOSE: Impaired gallbladder emptying has been identified as a cause of chronic abdominal pain in adults. This study aims to define a pediatric population with functional abnormalities of gallbladder contractility and to assess clinical outcome after cholecystectomy. METHODS: Children and adolescents (n = 42) with abdominal complaints underwent gallbladder emptying studies, measured by either ultrasonography or scintigraphy with intravenous cholecystokinin (CCK). On ultrasound studies, gallbladder volume was measured before injection and 15 minutes after injection. Measures of gallbladder emptying by scintigraphy were taken at least 30 minutes after CCK injection. A study was classified as abnormal for contractility less than 50%. Cholecystectomy was performed and outcomes were evaluated during office visits and by telephone interview. RESULTS: Abdominal pain and fatty food intolerance were the predominant symptoms. Patients were treated by open (n = 2) or laparoscopic (n = 40) cholecystectomy. In 20 cases the gallbladder showed chronic inflammation on pathology. Response to surgical therapy was excellent in 41 patients (mean follow-up, 20.4 months). CONCLUSIONS: Children and adolescents with persistent abdominal pain should undergo functional assessment of gallbladder contractility. Patients with abnormal gallbladder contractility benefit from cholecystectomy.

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.

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.

The childhood air gun: serious injuries and surgical interventions.

OBJECTIVE: Increasingly powerful nonpowder firearms or air guns are frequently given to children as toys. We undertook the present study to evaluate the injuries caused by these firearms, based on the concern that they are capable of inflicting serious trauma. DESIGN: Descriptive, retrospective chart review. SETTING: Urban level I pediatric trauma center. PARTICIPANTS: The study included all children with injuries secondary to air guns who were admitted between July 1988 and March 1995. MAIN OUTCOME MEASURES: Type of weapon, circumstances of injury, anatomic location of injury, injury severity, surgeries performed, morbidity. INTERVENTIONS: None. RESULTS: There were 42 admissions with a mean hospital stay of seven days (range 1 to 136 days). The average age was 10 years (range 1 to 23 years) with a median age of 11 years. There were 35 boys and 7 girls. Twenty-nine of the 42 injuries were caused by a family member or friend and five were self-inflicted. The mean injury severity score was 8.3. While there were no fatalities, 21 children (50%) underwent operative procedures for their injuries. Ten of the injuries were potentially lethal, of which seven were due to the "pump" action air gun. Sixteen patients had serious long-term disability as a result of their injuries. CONCLUSION: Air guns can cause a variety of serious injuries, often requiring operative intervention. The long-term morbidity from some of these injuries is significant. Both parents and physicians should be aware that nonpowder guns are not toys, but weapons capable of inflicting serious trauma. The evaluation and treatment of air gun injuries should be similar to that currently used for powder weapon injuries. Recommendations for evaluation and treatment are made.

Metastatic pure papillary thyroid carcinoma presenting as a toxic hot nodule.

In the majority of cases, carcinoma of the thyroid presents as a cold nodule by radioiodine and Tc-99m sodium pertechnetate scintigraphy. Whereas the presence of a hot nodule usually implies a benign entity, it does not provide complete assurance against thyroid malignancy. Presented is a rare case of metastatic pure papillary thyroid carcinoma appearing as a hot nodule on Tc-99m sodium pertechnetate and I-123 sodium iodide scintigraphy. The implications of such a case, its management, and review of the pertinent literature are discussed.

Analysis of clinical bioethics teaching in pediatric surgery residency.

BACKGROUND/PURPOSE: Although clinical bioethics teaching (CBT) is not a required component of the essential curriculum for pediatric surgery residency, ethical considerations often accompany surgical decision making for infants and children. This study was designed to quantitate CBT during pediatric surgery residency (PSR) and to determine preferences about formal bioethics instruction. METHODS: An 80-item questionnaire was mailed to 140 graduates of accredited PSR in the United States and Canada. Questions included demographic data, experience in CBT during and after PSR, preferred topics and teaching methods, and self-assessed and objective competency in bioethics. RESULTS: The response rate was 78% (n = 109); 72% completed PSR between 1990 and 1995 (mean, 1991). Formal CBT within the curriculum of PSR was reported by 9% of respondents; lecture and consultation with an ethicist were the most frequent teaching methods. Informal CBT was noted by 88% of pediatric surgeons; observation of patient cases with ethical dilemmas was the primary mode of instruction. Quality of life, withholding/withdrawal of care, informed consent, child abuse, and economics ranked highest for most important CBT topics, while euthanasia, clinical research trials, and cultural diversity were given low priority. The preferred teaching methods were case-based discussions and consultation with an ethicist. Although 97% favored additional CBT in all postgraduate training, respondents who completed advanced study in medical ethics (P < .05), were women (P < .05), or were members of a hospital ethics committee (P < .05) were more likely to advocate a standardized bioethics curriculum during PSR. A majority (86%) expressed competency in handling ethical problems in clinical practice, however, 47% gave incorrect responses or were unsure about routine bioethics questions. CONCLUSIONS: Formal instruction in clinical bioethics is not included in the curriculum of most residencies in pediatric surgery. Recent graduates of PSR favor case-based and practice-oriented teaching in clinical bioethics.

A cultural diversity curriculum: combining didactic, problem-solving, and simulated experiences.

The development of a cultural diversity curriculum in undergraduate medical education is timely because of the need to communicate with increasing numbers of patients of diverse racial, ethnic, linguistic, and religious backgrounds. The key goals of the Ohio State University College of Medicine curriculum are to: 1) establish the relevancy of cultural diversity training to clinical practice; 2) contrast the impact of non-Anglo and Anglo world views on health behavior; 3) develop basic cultural competency skills; 4) provide insights into the effects of discrimination on minority patients and professionals; and 5) understand some of the complementary medicine practices that patients use. The curriculum employs a combination of didactic lectures and demonstrations, clinical cases and vignettes for problem solving, and simulated experiences of discrimination through first-person accounts, videotapes, and patient and physician panels. We speculate that the development of cultural sensitivity in the undergraduate medical student will aid in increasing professional sensitivity to all patients.

Results of a national survey on ethics education in general surgery residency programs.

BACKGROUND: Medical ethics is a required part of the curriculum in all medical schools in the United States, and an essential component of the educational guidelines for most postgraduate residency programs. Currently, general surgery does not specify ethics education in its essential curriculum for surgical training. This study was designed to determine the existing educational activities in ethics for residents in general surgery, as well as to characterize the attitudes of surgical educators about the role of ethics teaching in residency training. METHODS: An 80-item questionnaire was mailed to the program directors of all accredited general surgery residencies in the United States. They were requested to provide information about their teaching activities in ethics, their resources for ethics instruction, and their attitudes about the importance of education in clinical ethics for surgical residents. RESULTS: The survey had a 71% response rate with a representative distribution of programs based on size, geographic location, and community versus university affiliation. Fifty-six programs (28%) offered no formal ethics education, 94 (48%) held one teaching event in ethics, and 48 (24%) conducted two or more activities. The format for instruction in ethics included grand rounds (50%), resident conferences (41%), and ethics rounds (9%). Residencies with a faculty surgeon having expertise or special interest in ethics had a greater number of ethics teaching activities (P <0.05), whereas programs with a hospital ethicist were more likely to provide ethics rounds (P <0.01). A standardized curriculum in ethics was favored by 85% of respondents with critical content in end-of-life decisions, managing ethical conflict, and informed consent. The majority of program directors were opposed to (50%) or undecided (20%) about inclusion of ethics questions on the American Board of Surgery Inservice Training Examination (ABSITE) and Qualifying Examination in General Surgery. CONCLUSIONS: The majority of program directors of general surgery residencies support the teaching of clinical ethics and favor a standardized curriculum. However, most residencies in general surgery do not include ethics instruction as part of their on-going, regular educational schedule.

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.