Age-associated impact on presentation and outcome for penetrating thoracic trauma in the adult and pediatric patient populations.

BACKGROUND: Studies reporting on penetrating thoracic trauma in the pediatric population have been limited by small numbers and implied differences with the adult population. Our objectives were to report on a large cohort of pediatric patients presenting with penetrating thoracic trauma and to determine age-related impacts on management and outcome through comparison with an adult cohort. METHODS: A Level I trauma center registry was queried between 2006 and 2012. All patients presenting with penetrating thoracic trauma were identified. Patient demographics, injury mechanism, injury severity, admission physiology, and outcome were recorded. Patients were compared, and outcomes were analyzed based on age at presentation, with patients 17 years or younger defining our pediatric cohort. RESULTS: A total of 1,423 patients with penetrating thoracic trauma were admitted during the study period. Two hundred twenty patients (15.5%) were pediatric, with 205 being adolescents (13-17 years) and 15 being children (≤ 12 years). In terms of management for the pediatric population, tube thoracostomy alone was needed in 32.7% (72 of 220), whereas operative thoracic exploration was performed in 20.0% (44 of 220). Overall mortality was 13.6% (30 of 220). There was no significant difference between the pediatric and adult population with regard to injury mechanism or severity, need for therapeutic intervention, operative approach, use of emergency department thoracotomy, or outcome. Stepwise logistic regression failed to identify age as a predictor for the need for either therapeutic intervention or mortality between the two age groups as a whole. However, subgroup analysis revealed that being 12 years or younger (odds ratio, 3.84; 95% confidence interval, 1.29-11.4) was an independent predictor of mortality. CONCLUSION: Management of traumatic penetrating thoracic injuries in terms of the need for therapeutic intervention and operative approach was similar between the adult and pediatric populations. Mortality from penetrating thoracic trauma can be predicted based on injury severity, the use of emergency department thoracotomy, and admission physiology for adolescents and adults. Children may be at increased risk for poor outcome independent of injury severity. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Serous borderline tumor of the fallopian tube in a patient with Klippel-Trenaunay syndrome.

We describe a case of a 3-year-old girl with Klippel-Trenaunay syndrome who presented with an enlarging abdominal mass caused by a serous borderline tumor of the fallopian tube. This case is notable for the rarity of this neoplasm in a premenarchal patient as well as the association with this syndrome. We briefly review these entities and the significance of malignancy in Klippel-Trenaunay syndrome.

Congenital absence of intestinal smooth muscle: a case report and review of the literature.

Herein is reported case of an otherwise healthy full-term infant girl who presented with numerous spontaneous intestinal perforations with congenital absence of intestinal muscularis mucosae and muscularis propria. Few other cases are reported in the English literature with varying presentations. We review those cases, theories of pathogenesis, embryology, and possible connections to various clinical presentations.

To drain or not to drain: a single institution experience with neonatal intestinal perforation.

AIMS: The optimal surgical treatment for extremely-low-birth-weight (ELBW) neonates with pneumoperitoneum is controversial. This study aimed to identify clinical factors associated with two known causes of pneumoperitoneum-necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP), and assesses the treatment outcome with primary peritoneal drainage (PPD) vs. laparotomy. METHODS: We reviewed and analyzed clinical characteristics and outcome from records of neonates with pneumoperitoneum treated at our institution from January 1999 to January 2003. RESULTS: Forty-six neonates (31 NEC, 15 SIP) were treated with either PPD (20 with NEC, 13 with SIP) or laparotomy (11 with NEC, 2 with SIP). In neonates who underwent PPD, those with NEC (vs. SIP) were less likely to have a patent ductus arteriosus, but were more likely to have been fed, have drains placed later in life, have a subsequent laparotomy, a longer total parental nutrition course, a higher 30-day mortality, and to take more days to begin enteral feeds. CONCLUSION: The etiology of pneumoperitoneum (NEC vs. SIP) in ELBW neonates can usually be determined preoperatively. Neonates with SIP should have a drain placed while those with NEC should undergo laparotomy.

Pigment epithelium-derived factor targets endothelial and epithelial cells in Wilms' tumor.

PURPOSE: Loss of pigment epithelium-derived factor (PEDF), a potent inhibitor of angiogenesis, has been linked to progression of angiogenesis-dependent diseases. We postulated that decreased levels of endogenous PEDF in the kidney creates a tumor permissive environment for Wilms' tumor. METHODS: Fresh and frozen Wilms' tumor (n = 28), adjacent (n = 3), and normal kidney (n = 8) were immunostained and graded. The Wilms' tumor cells (SK-NEP-1), renal epithelial cells (NRK-52), and fresh tumor samples were grown in culture. Condition media were collected and analyzed by an in vitro angiogenesis assay and Western blot. The SK-NEP-1 cells were treated with PEDF and cell viability assessed. RESULTS: Wilms' tumors expressed less PEDF than normal and adjacent kidney. Pigment epithelium-derived factor protein secretion was abundant in NRK-52 cells but significantly decreased in Wilms' tumor. Pigment epithelium-derived factor acted as blockade to angiogenesis and it had a dose-dependent cytotoxic effect on Wilms' tumor epithelial cells. CONCLUSION: Renal tubular epithelial cells are a rich source of PEDF in the normal kidney. Reduced levels of PEDF in Wilms' tumor remove a critical endogenous renal barrier to angiogenesis and tumor cell survival. Therapeutic replacement of PEDF may prove to be an effective strategy to combat Wilms' tumor progression.

Closing arguments for gastroschisis: management with silo reduction.

BACKGROUND: There are two approaches to close gastroschisis. Primary closure (PC) is reduction and fascial closure; silo closure (SC) places viscera in a preformed-silo and reduces the contents over time. We have shifted from PC to SC. This study compared the outcomes of these two techniques. METHODS: Records of babies with gastroschisis from 1994-2004 were reviewed. Closure type, ventilator days, days to full-feeds, hospital days, complications, and mortality were recorded. RESULTS: Twenty-eight patients underwent PC; 20 patients had SC. Differences in ventilator days, days to full-feeds, and hospital days were not statistically significant. Nine PC patients developed closure-related complications vs. none in SC (P < 0.05). Eight PC vs. two SC patients had non-closure-related complications (P < 0.05). Four PC vs. zero SC patients developed necrotizing enterocolitis (P < 0.05). Five PC vs. one SC patients had ventral hernia (P < 0.05). No patient died. CONCLUSION: PC resulted in higher incidence of reclosure, non-closure-related complications, and necrotizing enterocolitis. Consequently, we recommend SC as the preferred treatment.

Herbal medication use in the pediatric surgical patient.

PURPOSE: The aim of this study was to determine the prevalence of herbal medication use in the pediatric surgical patient population, because herbal medications can cause major perioperative complications. METHODS: A questionnaire on all drug use before surgery was given to the parents of 1,100 consecutive pediatric surgical patients operated on at a metropolitan children's hospital between June 14, 2002 and August 14, 2002. RESULTS: Eighty-three percent of the surveys were returned. Twenty-one percent of the parents were herbal medication users, but only 4% of patients utilized herbal medications. An average of 2.4 different herbal medicines were in use by each child, and the most common herbal medications were echinacea, chamomile, and aloe. Forty-two percent of herbal medication-using patients were taking prescription medicines concurrently. Fifteen herbal medications-using patients underwent major surgery, and the average preoperative herbal cessation interval was 3.5 days. Children of parents who were herbal medication users and children reported to have chronic diseases were more likely to use herbal medicines (P <.05). Ten percent of parents reported that the surgeon inquired about patient herbal medication use. CONCLUSIONS: This is the first report on herbal medication use in the pediatric surgical patient. The prevalence of herbal medication use is significantly higher in children of parents who use herbal medications and children whose parents consider them to be chronically ill. Surgeons need to specifically inquire about the use of herbal medication in their patients to prevent possible harmful interactions and perioperative complications.

Increased microvascular density predicts relapse in Wilms' tumor.

BACKGROUND/PURPOSE: Tumor stage and histology are the most important prognostic criteria in Wilms' tumors; however, a subset of patients remains who have favorable histology tumors and unexpectedly relapse. The authors postulated that increased microvascular density (MVD), a hallmark for angiogenesis, could identify patients at risk for relapse. METHODS: A case-control study was used to compare relapse (n = 15) with nonrelapse tumors (n = 35). Tumor MVD was counted in 5 random high-powered fields (hpf) using anti-Factor VIII antibody and expressed as mean vessel count/hpf +/- SEM. MVD and clinical data were evaluated using univariate analysis and student's t test. RESULTS: The relapse group had higher MVD than the nonrelapse group (34.9 +/- 2.9 v 22.4 +/- 2; P <.05). When evaluating the favorable histology (FH) group alone, there was higher MVD in the relapse group (32.4 +/- 2.7 v 19 +/- 1.8; P <.05). MVD was found to be the only predictor of relapse when compared with age, sex, tumor weight, and histology. CONCLUSIONS: These results suggest that increased MVD can identify Wilms' tumor patients at high risk for relapse, especially those patients with favorable histology tumors. A larger study is warranted to determine the potential utility of MVD in stratification of Wilms' tumor patients.

Wilms' tumor growth is suppressed by antiangiogenic pigment epithelium-derived factor in a xenograft model.

BACKGROUND/PURPOSE: Pigment epithelium-derived factor (PEDF), a potent endogenous inhibitor of angiogenesis, is highly expressed in the kidney. The authors postulated that systemic administration of PEDF would decrease Wilms' tumor growth in a xenograft model, and increased renal vascularity would result in a mouse null for PEDF. METHODS: Tumors were induced in athymic mice using human anaplastic Wilms' tumor cells. Purified PEDF protein or vehicle was administered for 7 days beginning 2 to 3 weeks after inoculation. Tumors were stained with anti-PEDF and anti-Factor VIII antibodies. Mitoses and microvascular density (MVD) were counted per high-power field (hpf). PEDF-null mice were generated on a SV129/C57Bl6 background. Wild-type and null kidneys were assessed for MVD. RESULTS: Mean tumor weight in the 2-week group was 60% less than controls (P <.05). The MVD and mitotic count in treated tumors were significantly less than controls (P <.05). PEDF stained strongly in normal kidneys but was minimal to absent in Wilms' tumor. PEDF-null kidneys had increased MVD compared with wild-type (P <.05). CONCLUSIONS: PEDF is expressed strongly in normal murine kidney, and loss of its angioinhibitory activity may contribute to pathologic angiogenesis in Wilms' tumor. Systemic PEDF suppresses WT growth by targeting both the tumor cells and its associated vasculature.

Serum vascular endothelial growth factor as a surveillance marker for cellular rejection in pediatric cardiac transplantation.

BACKGROUND: Early detection and treatment of acute rejection in cardiac transplant recipients significantly improves long-term survival. Endomyocardial biopsy is used routinely for diagnosing allograft rejection; however, in young children, this procedure carries some risk. We evaluated serum vascular endothelial growth factor (VEGF) as a potential surveillance marker of acute cellular rejection. METHODS: Blood samples (n=62) were analyzed from 23 patients and compared with controls (n=18) using an ELISA for VEGF. Results were correlated with endomyocardial biopsy rejection grades. RESULTS: Mean baseline VEGF levels of the transplant population were consistently higher than controls. Serum VEGF levels were significantly higher during acute cellular rejection when compared with the non-rejecting transplant group (700.7+/-154 pg/ml vs. 190.5+/-29 pg/ml). VEGF decreased two- to eightfold after immunosuppressive therapy in 9 of 11 rejection episodes. CONCLUSIONS: These data suggest that VEGF may play a role in the pathogenesis of acute allograft rejection and it may serve as a reliable serologic surveillance marker.