Recruitment and retention strategies and methods in the HEALTHY study.

HEALTHY was a 3-year middle school-based primary prevention trial to reduce modifiable risk factors for type 2 diabetes in youth. The study was conducted at seven centers across the country. This paper describes the recruitment and retention activities employed in the study. Schools and students were the focus of recruitment and retention. Each center was responsible for the recruitment of six schools; eligibility was based on ability to enroll a sufficient number of predominately minority and lower socioeconomic status students. Study staff met with district superintendents and school principals to verify the eligibility of schools, and to ascertain how appropriate the school would be for conducting the trial. Sixth grade students were recruited employing a variety of techniques; students and their parents did not know whether their school was randomized to the intervention or control arm. This cohort was followed through sixth, seventh and eighth grades. In the eighth grade, an additional sample of students who were not originally enrolled in the study was recruited in a similar manner to participate in data collection to allow for cross-sectional and dose-response secondary analyses. Parents signed informed consent forms and children signed informed assent forms, as per the needs of the local Institutional Review Board. Parents received a letter describing the results of the health screening for their children after data collection in sixth and eighth grades. Retention of schools and students was critical for the success of the study and was encouraged through the use of financial incentives and other strategies. To a large extent, student withdrawal due to out-migration (transfer and geographical relocation) was beyond the ability of the study to control. A multi-level approach that proactively addressed school and parent concerns was crucial for the success of recruitment and retention in the HEALTHY study.

Social marketing-based communications to integrate and support the HEALTHY study intervention.

The HEALTHY study was a randomized, controlled, multicenter, middle school-based, multifaceted intervention designed to reduce risk factors for the development of type 2 diabetes. The study randomized 42 middle schools to intervention or control, and followed students from the sixth to the eighth grades. Participants were a racially, ethnically and geographically diverse cohort from across the United States. Here, we describe the conceptual underpinnings and design of the social marketing-based communications component of the HEALTHY study intervention that combined changes in the school nutrition and physical education (PE) environment with behavior change initiatives. The communications intervention component coordinated multiple elements to deliver campaigns that served to integrate and support all aspects of the HEALTHY intervention. The campaigns unfolded across five semesters of middle school, each targeting a specific theme related to the HEALTHY objectives. Communications campaigns comprised (1) core elements such as branding, posters, banners and visual and verbal messaging, (2) student events supporting the nutrition, PE and behavior intervention components through the application of social marketing and communications strategies, including the incorporation of student-generated media and (3) distribution of premiums and theme enhancers to extend the visibility of the study beyond the intervention environment. Formative research conducted with students, parents and school administrators was used to refine the communications strategy. Student peer communicators selected from the student body were involved to influence the normative student environment. Marketing and creative design experts developed a brand, logo, activities and materials. In the latter half of the study, student-generated messages and media were used to reflect local interests and culture and enhance peer influence. The HEALTHY intervention delivery and impact were strengthened by the communications strategies. The HEALTHY experience provides practical considerations for systematically incorporating a social marketing-based communications approach within future school-based health behavior interventions.

Nutrition support of pediatric patients.

Nutritional management in pediatric patients is often considered to be complex and difficult. We review the basic rationale and principles of IV nutrition support in pediatric patients. The unique differences between children and adults are outlined. The nutritional support solution is then divided into the distinct sections of energy, protein, volume, electrolytes minerals and vitamins. Each of these parts is considered separately to allow understanding in a sequential fashion. Different routes of intravenous access are also discussed to include placement, maintenance, treatment of infections and management of catheter thrombosis.

Successful staged surgical correction of congenital segmental spinal dysgenesis and complete rotary subluxation of the thoracolumbar spine in an infant.

Congenital segmental spinal dysgenesis is a rare lesion that usually is associated with neurological deficits. Affected infants who are neurologically intact may suffer progressive kyphosis and subsequent neurological deterioration. Results of external casting, laminectomy with spinal fixation, or bone grafting of the defect have been disappointing. The authors present a successful staged surgical management scheme consisting of complete resection of the dysraphic vertebral bodies, maintenance of normal vertebral distance with rib strut grafting, and fusion with autogenous bone.

Growth hormone effects on wound healing in malnourished animals: a histological study.

Systemic growth hormone (GH) markedly improves celiotomy wound strength in protein malnourished (PM) animals. This study was undertaken to analyze the effect of GH as a basis for anatomically understanding. Adult female Spraque-Dawley rats were divided into normally nourished controls, PM and GH-treated PM groups. Protein malnutrition was achieved by feeding 5.5% protein restricted chow every other day for eight weeks before surgery. Controls were fed 23.4% protein chow. All animals were fed 23.4% protein chow postoperatively. Rat-GH was injected subcutaneously twice daily (1.0 mg/day) for three days prior to and five days after 5 cm midline celiotomy. Bursting strength of the wound was measured at 3, 6 and 14 days postoperatively. Histologic wound specimens (hematoxylin and eosin) were obtained from each group. Wound strength of malnourished rats was significantly less than that of normal controls at six days after operation (p < 0.001). With administration of growth hormone, the wound strength was significantly improved. Histologically, there was no difference between groups on day 3. On day 6 the normal control group showed a decrease in the early inflammatory cell infiltrate with concurrent development of granulation tissue and a dense proliferation of fibroblasts. The PM wound showed fatty infiltration, a very narrow band of poorly formed granulation tissue and a sparse fibroblastic proliferation. The GH-treated PM group showed a combination of histologic findings. Fatty infiltration, similar to that in malnourished non-treated animals, was still evident but there was also a dense proliferation of capillary channels and fibroblasts comparable to normal animals.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical management of hyperparathyroidism at an Air Force medical center.

A critical determinant of successful neck exploration for primary hyperparathyroidism (HPT) is the experience of the surgeon. Results of 17 patients treated surgically for HPT were reviewed to compare results at our medical center with results of large series reported from established national centers. Preoperative laboratory evaluation of 15 patients with surgically proven HPT (solitary adenoma, 14; diffuse hyperplasia, 1) included: mean serum calcium (Ca) 10.9 mg/dl +/- 0.79 and mean serum chloride/phosphate ratio 39 mg/dl +/- 7.9. Serum parathyroid hormone (PTH) was elevated in all patients. Seven neck ultrasounds were performed with a positive predictive value of 42%. No significant operative complications occurred. Mean postoperative serum Ca was 8.34 mg/dl +/- 0.75. One patient had asymptomatic hypocalcemia (Ca = 6.5 mg/dl). Follow-up in 11 patients (65%) at a mean of 8.6 months revealed no evidence of recurrence in these patients. In our experience, proper patient selection and careful surgical technique within established principles for neck exploration and parathyroidectomy lead to excellent results despite the size of the medical center. Patient selection is based on serum Ca, PTH, and chloride/phosphate ratio. Preoperative imaging studies did not appear to be of benefit in the small study reported here.

Strains of Mycobacterium terrae complex which react with DNA probes for M. tuberculosis complex.

Following a recent report that two isolates of Mycobacterium terrae complex had given positive reactions with M. tuberculosis complex DNA probes, a joint study was undertaken to determine the extent of these findings in the clinical culture collection holdings of two state health laboratories. A total of 117 M. terrae complex strains (identified by standard biochemical methods) were subjected to M. tuberculosis complex probe testing with the two then-available kits (from Syngene, Inc., and Gen-Probe, Inc.). In addition to the two original isolates first reported, two further M. terrae complex isolates were found to react with the M. tuberculosis complex probes. Two modifications of the Accuprobe (Gen-Probe, Inc.) test method were evaluated. Extension of the selection time to 8 min was the most convenient modification and rendered the M. terrae complex isolates negative when tested with the Accuprobe M. tuberculosis complex probe. However, the effects of increased selection time on the overall sensitivity of the M. tuberculosis complex probe require further study.

Megacystis microcolon intestinal hypoperistalsis syndrome: late sequelae and possible pathogenesis.

Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) is characterized by hypoperistalsis in the presence of ganglion cells, malrotation, microcolon, bladder distension, and female predilection. We draw attention to the long-term management of a patient with MMIHS and propose a pathogenetic mechanism to account for this syndrome. We propose that the initial event in the pathogenesis of MMIHS is an intramural inflammatory process that affects the gastrointestinal and urinary tracts. This leads to extensive fibrosis which destroys the intestinal neural network, producing hypoperistalsis. The same process causes neuromuscular incoordination in the bladder wall, resulting in irregular bladder contractions against a "closed sphincter" leading to bladder distension. The enlarged bladder then interferes with the rotation of the intestine causing malrotation.

Pulmonary edema following post-operative laryngospasm: a case report and review of the literature.

The pathophysiology of acute, negative-pressure pulmonary edema following post-anesthetic laryngospasm (PLPE) is unclear. We present a patient and review the literature to propose etiology and management. Nineteen reported patients (3 female, 16 male, aged 3 months to 60 years) with PLPE had undergone 10 otolaryngologic, three orthopedic, four skin/soft tissue, one intraabdominal, and one ophthalmologic procedures. Twelve patients (63%) had significant medical history. Initial intubation was performed without difficulty in 17 patients, there were no predisposing trends in anesthetic management, and post-anesthetic extubation was performed without difficulty in 18 patients. Thirteen patients developed laryngospasm in less than 2 minutes. Eight were ventilated with bag/mask, 15 required reintubation, and nine required paralysis. Onset of PLPE was less than 3 minutes in 12 patients; chest roentgenograms showed edema in 17 patients. Mechanical ventilation was required for less than 24 hours in all patients. PLPE cleared in less than 24 hours in most patients. Furosemide was administered in nine patients, digoxin in one, theophylline in two, and steroids in four patients. The precise pathophysiologic mechanism of PLPE is unclear despite numerous proposed mechanisms. PLPE resolves rapidly with short-term ventilatory support. Use of diuretics/airway dilators is variable, and their contribution to management is unclear.

Clinical presentation and radiographic identification of small bowel rupture following blunt trauma in children.

The incidence of significant intraabdominal injuries from blunt trauma in children is low (1-8%); however, a missed intestinal laceration may result in a devastating, if not morbid, consequence. We present retrospective case studies of eight children with intestinal lacerations following blunt trauma. Each patient has a unique anatomic defect with misleading initial laboratory and radiographic studies. We did not find a single laboratory or roentgenographic study to be consistently reliable for diagnosis of hollow viscus laceration. The combination of a high index of suspicion and serial abdominal examinations, coupled with subsequent comparative laboratory and radiographic evaluations, proved most reliable in identifying patients with intestinal injury.

Paranasal sinusitis: cryptic sepsis after coronary artery bypass operations.

Infections occurred in 52 of 400 patients (13%) undergoing coronary artery bypass operations from January 1987 to December 1990. The hospital courses of 5 patients (1.3%) in whom occult infections of the paranasal sinuses developed were reviewed. Only 1 patient had specific clinical findings of acute sinusitis (purulent nasal discharge). Computed tomography showed wall thickening, opacification, or air-fluid levels in one or more paranasal sinuses in each patient. All patients were successfully treated with surgical drainage and antibiotics. Risk factors for development of postoperative acute sinusitis include: prolonged tracheal intubation, airway colonization with nosocomial bacteria, inability to clear nasal secretions, sinus ostial obstruction, and critical organ system dysfunction. Physical examination and roentgenographic evaluation of the paranasal sinuses should be considered when postoperative sepsis of obscure etiology occurs.

Role of autogenous tissue factors in hemolysis during cardiopulmonary bypass operations.

Pericardial fluid has been implicated as a causative factor in hemolysis during cardiopulmonary bypass operations. Preoperative blood samples were obtained from 10 patients undergoing coronary artery bypass grafting for ischemic myocardial disease. Whole blood samples were separately incubated with autogenous pericardial fluid, pericardium, pleura, vein, skeletal muscle, and fat harvested during the operative intervention. The plasma fraction was separated by centrifugation and assayed for serum free hemoglobin. Statistical analysis was accomplished by the Bonferroni technique to adjust for multiple comparisons. Pericardial fluid-induced hemolysis was least (20.7 mg/dL). Pleura and muscle contributed significantly to the serum free hemoglobin level (56.3 and 112.3 mg/dL, respectively; p < 0.05). Pericardium, vein, and fat did not cause significant elevations of the serum free hemoglobin level. Postbypass hemolysis is an important management consideration that may be minimized by delicate tissue manipulation and attention to minimizing tissue trauma. Avoidance of aspiration of pericardial fluid into the autotransfusion system is not supported.

Neuroblastoma masquerading as a retroperitoneal Salmonella abscess.

Symptomatic Salmonella infections usually manifest as self-limited gastrointestinal distress. Patients with chronic systemic illnesses or those who are immunosuppressed may rarely present with Salmonella infection as distant suppurative abscesses. We present a previously healthy Armenian boy who came to medical attention with abdominal pain, fever, and anemia. Abdominal computed tomography (CT) scan showed a cystic suprarenal mass that was surgically explored and found to be a retroperitoneal Salmonella abscess. Postoperative CT scan showed resolving inflammation. A 6-month follow-up CT showed a large suprarenal tumor, which at exploration was found to be neuroblastoma. To our knowledge, Salmonella has never been reported presenting as a solitary retroperitoneal abscess, and neuroblastoma has not been described presenting as a Salmonella abscess. The patient is also unusual because the abscess contained a species unusual for suppurative salmonellosis.

Tracheoesophageal fistula associated with perforated Meckel's diverticulum.

Neonates with esophageal atresia and tracheoesophageal fistula (TEF) may present with respiratory distress. Intubation and mechanical ventilation may force air from the tracheobronchial tree, through a distal fistula and into the gastrointestinal tract. We present a newborn with TEF who became moribund during mechanical ventilation. High ventilator pressures transmitted via the TEF caused over distention of the gastrointestinal tract and perforation of a Meckel's diverticulum.

Peripheral congenital arteriovenous fistulae: observe, operate, or obturate?

In 1976, we presented our experience in the surgical management of patients with peripheral congenital arteriovenous fistulae (CAVF). This report updates our experience and specifically describes subsequent experience with intraarterial embolization therapy. Twenty-six infants and children with CAVFs have been treated at Children's Hospital of Los Angeles from 1966 to 1990. The majority of lesions were lower extremity (12), followed by upper extremity (8), shoulder girdle (3), and thorax/neck (3). Seventeen patients had lesions in multiple locations. All patients under 1 year of age had upper extremity lesions, all in the 5- to 10-year age group had lower extremity lesions, and all over 15 years of age at presentation required amputation. Twelve patients had initial embolization therapy and 12 had surgery. Seven of eight patients followed after embolization have improved. Embolization is not effective in large or ulcerated lesions. All patients with embolization alone have residual disease and three of eight have discrepancy in extremity length. Surgery has a 50% complication rate and 7 of 10 followed surgery patients have residual disease. Radiologic catheter techniques and embolization provide a valuable alternative therapy for CAVFs and should be used as the primary form of treatment in most cases.

Communicating bronchopulmonary foregut malformations: classification and embryogenesis.

Communicating bronchopulmonary foregut malformations (CBPFMs) are characterized by a fistula between an isolated portion of respiratory tissue (ie, a lung, a lung lobe, or a segment) and esophagus or stomach. We combine our 30-year (1959 to 1989) experience of 6 cases with 51 reported patients to propose a CBPFM classification supported by a proposed embryogenesis theory. Group I (16%): anomaly is associated with esophageal atresia and tracheoesophageal fistula. Group II (33%): one lung originates from the lower esophagus. Group III (46%): an isolated anatomic lung lobe or segment communicates with the esophagus or stomach. Group IV (5%): A portion of the normal bronchial system communicates with the esophagus. The portion of the lung served by the communicating bronchus receives systemic blood supply. The right and left lung sacs curve dorsally to embrace the lower esophagus during normal lung development. At this stage a part of the lung bud joins the esophagus. This segment then breaks away from the main pulmonary anlage to form a CBPFM. CBPFMs should be considered in the workup of infants with respiratory distress and/or recurrent pneumonias. Patients with suspected pulmonary sequestration should undergo contrast studies to exclude a gastrointestinal communication.

Augmented venous access in the problematic ECMO patient: a case report.

Extracorporeal membrane oxygenation (ECMO) provides an adjunct to support of neonates with respiratory distress. The rate of venous drainage is the limiting step to the amount of arterial flow that may be generated during ECMO. We present a 3-kg, 37-week gestation female with congenital diaphragmatic hernia (CDH) whose anatomic venous drainage was insufficient to allow total extracorporeal support. The internal jugular vein was of insufficient size to allow placement of a cannula large enough to support adequate bypass flow. We established minimally acceptable flow by simultaneous caudad and cephalad catheterization of the internal vein. We performed a right lower quadrant retroperitoneal dissection and cannulated the common iliac vein when systemic pressures deteriorated at 24 hours with marginal venous drainage. After triple cannulation the bypass flows were normal. The right leg developed mild cyanosis and edema immediately following cannulation, but these changes resolved over 24 hours with elevation. The common iliac vein provides a desirable route for augmentation of venous drainage in the patient with difficult standard, or cephalad, jugular venous access for extracorporeal support.

Clinical comparison of tolerance to elemental or polymeric enteral feedings in the postoperative patient.

Thirty consecutive patients (19-71 years of age) undergoing abdominal operations and having feeding catheter jejunostomy tubes placed, were prospectively randomized and studied for tolerance to elemental (amino acid) or polymeric (intact protein isolates) dietary formulas. The groups were matched for sex, age, height, weight, operations, and caloric goal. Nutritional profiles of the patients were similar preoperatively. The number of stools/day and stool consistency were direct indicators of tolerance; nutrient intake was an indirect indicator. Diarrhea is defined as greater than or equal to five stools/day. We found no significant difference between the groups. There were no patients with diarrhea on days 1 or 2. Formula intake as an indirect measure of tolerance was not significantly different for the two groups from days 1-4. On day 5, intake of the elemental group exceeded that of the polymeric group (p less than 0.02). Enteral caloric intake as percent of caloric goal did not differ. Nitrogen intake, urinary nitrogen, serum prealbumin, body weight, serum sodium, and serum potassium did not differ significantly between the two groups throughout the study. Serum chloride decreased significantly (105 to 99.8 mEq/L) in the elemental group (p less than 0.03). Our study shows that patients undergoing routine gastrointestinal operations will tolerate early enteral feedings (day 1) and that there is no significant difference in tolerance to elemental or polymeric dietary formulas.

Malrotation of the intestine in children.

Intestinal malrotation may be complicated by volvulus and intestinal necrosis. One hundred two children (64 male, 38 female) undergoing surgical abdominal exploration from 1977 to 1987 had malrotation. Fifty-two patients were less than 7 days of age, 13 from 8 to 30 days, 26 from 31 to 365 days, and 11 were older than 1 year of age. Of infants, 39 of 65 had 40-week gestations, 18 of 65 had 36- to 39-week gestations, and 8 of 65 had less than 36-week gestations. Chief symptomatology included: bilious emesis (47), intestinal obstruction (19), abdominal pain (11), and bloody stools (7). Seventy patients had congenital anomalies (50 single, 20 multiple). Diagnostic evaluations included 56 upper gastrointestinal series and 27 barium enemas. Each patient underwent correction of malrotation and appendectomy, and correction of congenital anomalies (omphalocele-9, gastroschisis-6, diaphragmatic hernia-7). Complications included short gut (2), sepsis (5), feeding difficulties (2), pneumonia (3), small bowel obstruction (2), and other (15). Nine patients (8.8%) died (trisomy 18-1, trisomy 13-1, intestinal necrosis-3, hepatic failure-1, prematurity-1, other sepsis-2). Two hundred sixteen children with intestinal malrotation have been treated from 1937 to 1987. Mortality rate has improved from 23% to 2.9%.