Malignant ovarian germ cell tumors in pediatric patients: The AIEOP (Associazione Italiana Ematologia Oncologia Pediatrica) study.

OBJECTIVE: Malignant ovarian germ cell tumors (MOGCT) carry an excellent prognosis, and the treatment aims to achieve results with the least possible treatment-related morbidity. The aim of this study was to assess the outcomes of pediatric patients with MOGCT. METHODS: Patients were treated according to their stage: surgery and surveillance for stage I; a modified bleomycin-etoposide-cisplatin (BEP) regimen for stages II (three cycles), III, and IV (three cycles) with surgery on residual disease. RESULTS: Seventy-seven patients were enrolled (median age 11.8 years), 26 with dysgerminoma (Dysg), 13 with immature teratoma and elevated serum alpha-fetoprotein levels (IT + AFP), and 38 with nondysgeminoma (Non-Dysg) staged as follows: 27 stage I, 13 stage II, 32 stage III, 5 stage IV. Among evaluable patients in stage I (5-year event-free survival [EFS] 72.1% [95% CI: 56.4-92.1%]; 5-year overall survival [OS] 100%), seven relapsed (three patients with Dysg and four patients with Non-Dysg) and were rescued with chemotherapy (plus surgery in three patients). Among the evaluable patients with stages II-IV, 48 (98%) achieved complete remission after chemotherapy ± surgery, one (IT + AFP, stage IV) had progressive disease. In the whole series (median follow-up 80 months), the 5-year OS and EFS were 98.5% (95% CI: 95.6-100%) and 84.5% (95% CI: 76.5-93.5%). CONCLUSIONS: We confirm the excellent outcome for MOGCT. Robust data are lacking on surgical staging, surveillance for Non-Dysg with stage I, the management of IT + AFP, and the most appropriate BEP regimen. As pediatric oncologists, we support the role of surveillance after proper surgical staging providing cases are managed by experts at specialized pediatric centers.

Atypical Epstein-Barr-Virus infection in a 5-year-old girl.

Primary Epstein-Barr virus (EBV) infection is often asymptomatic before five years of age, whereas it is more likely to be symptomatic in older children, adolescents and young adults. The classic triad of symptoms including fever, pharyngitis and lymphadenopathy is well known, but the spectrum of clinical manifestations associated with EBV infection is large and continues to expand, including increasing atypical presentations. This article presents the case of a five-year-old female in which only a protracted and severe itch, resistant to antihistamines, caught the attention of the girl's parents, thus allowing the diagnosis of EBV. Furthermore, EBV related splenomegaly and mild hepatitis as well as thrombocytopenia had an atypical prolonged course.

Recombinant interferon alfa 2a in hepatic hemangiomatosis with congestive heart failure: a case report.

A 45-day-old patient was admitted with dyspnea, hepatomegaly, tachycardia, holosystolic murmur in the precordial region, and continuous murmur at the right hypochondrium. Four cutaneous angiomas were noted. Instrumental examinations revealed congestive heart failure and multiple focal lesions in the liver with typical features of hemangiomas. The therapy with subcutaneous interferon-alfa-2a (IFN-alpha) was administered for 12 months with progressive regression of cutaneous hemangiomas, liver lesions, and cardiological alterations. IFN-alpha therapy was effective without any significant adverse effects.

[Peripheral blood stem cell collection in pediatric malignancies: comparison between three mobilizing regimens]. / La raccolta di cellule staminali periferiche nei tumori pediatrici: confronto fra tre sistemi di mobilizzazione.

PURPOSE: The optimal method for PBSC (peripheral blood stem cells) mobilization in pediatric patients is still unknown. The present study was conducted to evaluate the safety of apheresis procedures and to compare the efficacy of three methods of PBSC mobilization. PATIENTS AND METHODS: Our study was performed on 28 pediatric patients (in three groups) with solid tumors at onset or on relapse. In two groups we tried to mobilize PBSC administering CHT (based on Carboplatin with Etoposide in the first group and Cyclophosphamide in the second group) followed by granulocyte colony stimulating factor (G-CSF); in the third group the mobilization regimen was based on G-CSF alone. RESULTS: Forty-nine mobilizations have been performed and a median of 6.5 CD34+ cells x 10(6)/Kg were collected, with a median number of one apheresis for each patient. Using Carboplatin with G-CSF and Cyclophosphamide with G-CSF we collected respectively a median value of 6.75 and 7.3 x 10(6) CD34+ cells/kg. The mobilization method based on G-CSF alone showed to be less effective (median of 4.3 CD34+ cells x 10(6)/kg collected). CONCLUSIONS: In our experience the mobilizing regimens based on Carboplatin or Cyclophosphamide associated with G-CSF resulted both effective and better than the one based on G-CSF alone with a scanty number of apheresis procedures.

Preinjury warfarin does not impact outcome in trauma patients.

OBJECTIVE: The objective of this study was to determine whether the preinjury condition of anticoagulation had an adverse impact on patients sustaining injury. METHODS: A retrospective analysis was performed for prospectively collected registry data from 1995-2000 from all accredited trauma centers in Pennsylvania. The registry was queried for all trauma patients who had anticoagulation therapy as a preinjury condition (PIC). This group served as our experimental cohort. A control cohort (not having warfarin therapy as a PIC) was developed using case-matching techniques for age, sex, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), A Severity Characterization of Trauma (ASCOT) score, and in the head injured patients, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses. Head and non-head injured patients were evaluated separately. The cohorts were examined for 28-day mortality, intensive care unit length of stay (ICU-LOS), hospital length of stay (HOS-LOS), PICs, occurrences, discharge destinations, and functional status at discharge. Chi2 and Student's t test were used to evaluate the data; p values < 0.05 were considered significant. RESULTS: Two thousand nine hundred forty-two patients were available for analysis. The prevalence of PICs was significantly greater in the warfarin group for both the head and non-head injured populations (p < 0.003 and p < 0.0001, respectively). The incidence of occurrences in the non-head injured population was statistically higher for the warfarin patients (p < 0.001), but showed no difference in the head injured group regardless of warfarin use (p = 0.15). Functional status at discharge demonstrated no clinically significant difference between the warfarin and non-warfarin groups in both head and non-head injured populations. There was no difference in discharge destination in the head injured population; however, in the non-head injured population a greater percentage of non-warfarin patients was discharged to home when compared with the warfarin patients. CONCLUSION: Our data suggest that the PIC of anticoagulation with warfarin does not adversely impact mortality or LOS outcomes in both head and non-head injured patients. In non-head injured patients, however, the occurrence rates and discharge destination were different. More research needs to be done to determine whether this is related to anticoagulation or other reasons (i.e., number of PICs). These data should be used when weighing risk/benefit ratios of prescribing chronic anticoagulation.

Multiinstitutional experience with the management of superior mesenteric artery injuries.

BACKGROUND: Superior mesenteric artery (SMA) injuries are rare and often lethal injuries incurring very high morbidity and mortality. The purposes of this study are to review a multiinstitutional experience with these injuries; to analyze Fullen's classification based on anatomic zone and ischemia grade for its predictive value; to correlate the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality; and to identify independent risk factors predictive of mortality, describing current trends for the management of this injury in America. DESIGN: We performed a retrospective multiinstitutional study of patients sustaining SMA injuries involving 34 trauma centers in the US over 10 years. Outcomes variables, both continuous and dichotomous, were analyzed initially with univariate methods. For the subsequent multivariate analysis, stepwise logistic regression was used to identify a set of risk factors significantly associated with mortality. RESULTS: There were 250 patients enrolled, with a mean Revised Trauma Score (RTS) of 6.44 and a mean Injury Severity Score (ISS) of 25. Surgical management consisted of ligation in 175 of 244 patients (72%), primary [corrected] repair in 53 of 244 patients (22%), autogenous grafts were used in 10 of 244 (4%), and prosthetic grafts of PTFE in 6 of 244 patients (2%). Overall mortality was 97 of 250 patients (39%). Mortality versus Fullen's zones: zone I, 39 of 51 (76.5%); zone II, 15 of 34 (44.1%); zone III, 11 of 40 (27.5%); and zone IV, 25 of 108 (23.1%). Mortality versus Fullen's ischemia grade: grade 1, 22 of 34 (64.7%). Mortality versus AAST-OIS for abdominal vascular injury: grade I, 9 of 55 (16.4%); grade II, 13 of 51 (25.5%); grade III, 8 of 20 (40%); grade IV, 37 of 69 (53.6%); and grade V, 17 of 19 (89.5%). Logistic regression analysis identified as independent risk factors for mortality the following: transfusion of greater than 10 units of packed RBCs, intraoperative acidosis, dysrhythmias, injury to Fullen's zone I or II, and multisystem organ failure. CONCLUSION: SMA injuries are highly lethal. Fullen's anatomic zones, ischemia grade, and AAST-OIS abdominal vascular injuries correlate well with mortality. Injuries to Fullen's zones I and II, Fullen's maximal ischemia grade, and AAST-OIS injury grades IV and V, high-intraoperative transfusion requirements, and presence of acidosis and disrhythmias are significant predictors of mortality. All of these predictive factors for mortality must be taken into account in the surgical management of these injuries.

The injured intoxicated driver: analysis of the conviction process.

BACKGROUND: The widespread nature of alcohol-related motor vehicle collisions suggests inadequacies in the system for deterring alcohol use when driving. This study was performed to determine whether hospitalization is a component in a "system failure" that allows injured, alcohol-impaired drivers to escape arrest and conviction for driving under the influence (DUI). METHODS: We conducted a retrospective review of medical and court records of intoxicated drivers injured in a motor vehicle collision who were transported to our Level I trauma center from January 1, 1997, through December 31, 1998. RESULTS: Of the 213 intoxicated drivers in our study, 172 (81%) were followed up by law enforcement officials, and 156 (73.2%) were arrested for DUI. Of those who were arrested and completed court hearings, 135 (93.8%) were convicted for DUI. CONCLUSION: These values are higher than those reported in previous studies and indicate that hospitalization does not "protect" injured, intoxicated drivers in our community.

Outcome analysis of Pennsylvania trauma centers: factors predictive of nonsurvival in seriously injured patients.

BACKGROUND: The purpose of this study was to evaluate the impact of five trauma center characteristics on survival outcome in nine serious injury categories. METHODS: A retrospective analysis of prospectively collected data from 1992 to 1996 on patients older than 14 years of age from 24 accredited trauma centers in Pennsylvania was performed. Trauma center characteristics selected for evaluation were level of accreditation, volume of trauma admissions, presence of in-house trauma surgeons, presence of a surgical residency program, and presence of an on-site medical school. Each of these characteristics was evaluated to determine its impact on survival in the selected serious injuries. A logistic regression model was then created to evaluate the most seriously injured patients as defined by A Severity Characterization of Trauma score of < 0.50. On the basis of the logistic regression model, odd ratios were calculated treating low volume as a significant risk factor for mortality. RESULTS: Of the 88,723 patients meeting registry criteria, 13,942 met the serious injury criteria. Independent analysis suggested that accreditation was beneficial regardless of level, volume of patients treated had a direct impact on survival outcome, and the presence of a surgical residency program may confer survival benefit. Of the 13,942 patients with serious injuries, those with A Severity Characterization of Trauma score of < 0.5 were selected for evaluation by logistic regression (n = 3,562). The logistic regression model, however, showed that only volume of patients treated had a consistent association with improved survival. Odds ratio analysis revealed low volume as a significant risk factor for mortality in seven of the nine injuries studied. CONCLUSION: In this analysis, only volume of patients treated had a direct impact on survival outcome. Accreditation, regardless of level, appears to be beneficial.

Long-term follow-up of trauma patients with a vena caval filter.

BACKGROUND: Venous thromboembolism (VTE) is an important complication in blunt trauma patients. At our Level I trauma center, we had a deep venous thrombosis (DVT) rate of 3.2% from 1993 to 1997 despite an aggressive VTE prophylaxis program. During this time period, we placed vena caval filters (VCF) for both traditional and prophylactic indications. This project was developed to establish a VCF registry for trauma patients to determine the long-term complications of VCF placement. METHODS: A letter was sent to all trauma patients who had a VCF placed from 1993 through 1997. Patients were asked to return for a history and physical examination to detect signs and symptoms related to VTE, a duplex ultrasound of the inferior vena cava, and a plain abdominal radiograph to determine filter migration. RESULTS: There were 191 VCFs inserted in our trauma population from 1993 to 1997. There were 105 patients (75 male and 30 female) available for evaluation, with a mean follow-up of 28.9 months. Forty-one VCFs were placed in patients with DVT or pulmonary embolism, and 64 were placed in patients for prophylactic indications as per the guidelines developed by the Eastern Association for the Surgery of Trauma. There were no clinically identifiable complications related to insertion of the VCF. There were no pulmonary embolisms detected after VCF insertion. In follow-up, only one filter (0.95%) migrated, and this was minimal (1 cm cephalad). One (0.95%) vena cava was occluded, based on duplex ultrasonography, and 11 patients (10.4%) had signs or symptoms of leg swelling after hospital discharge. Twenty eight (44%) of the 64 patients with prophylactic VCFs developed a DVT after filter placement. CONCLUSION: VCFs placed in trauma patients have acceptable short- and long-term complication rates. Consideration should be given to prophylactic VCF placement in patients at high risk for VTE. Randomized controlled trials are needed to evaluate whether VCF insertion increases the risk for subsequent DVT.

Measurement of endotracheal tube cuff leak to predict postextubation stridor and need for reintubation.

BACKGROUND: The purpose of this study was to determine the predictive value of an endotracheal tube cuff leak for the development of postextubation stridor and the need for reintubation. STUDY DESIGN: Consecutive trauma patients who required intubation at a level I trauma center from July 1997 to July 1998 were studied prospectively. Pediatric patients and those who did not meet the standard weaning protocol criteria established by the Division of Trauma and Surgical Critical Care were excluded. Injury Severity Score, endotracheal tube size, reason for intubation, and the number of days intubated before the initial extubation attempt were recorded. At the time of extubation, the difference in exhaled tidal volume from before to after endotracheal tube cuff deflation was calculated. This number was then divided by the exhaled tidal volume before cuff deflation and was recorded as the percent cuff leak. Patients were followed for 24 hours after extubation for the development of stridor or need for reintubation. Statistical analysis to compare subgroups of patients was performed using ANOVA with Scheffé post hoc analysis. RESULTS: Among the 110 patients analyzed, the most common reason for intubation was closed-head injury. Seven patients (6.4%) developed stridor alone and had a mean cuff leak of 5 8 mL (8.4% of tidal volume before cuff deflation). Six patients (5.5%) experienced stridor that required reintubation and had a mean cuff leak of 68 mL (9.2% of tidal volume before cuff deflation). Patients who developed stridor or needed reintubation had been intubated for a significantly greater length of time than those not developing stridor or requiring reintubation (2.6 versus 3.0 days, p < 0.001). There were no differences in Injury Severity Score, endotracheal tube size, or reason for intubation between these groups. CONCLUSIONS: A cuff leak of less than 10% of tidal volume before cuff deflation is useful in identifying patients at risk for stridor or reintubation (96% specificity). It appears that the amount of cuff leak decreases after intubation for more than 3 days, increasing the risk of stridor and need for reintubation. This information may be helpful in identifying those patients who need treatment for laryngotracheal edema, ie, use of steroids or anesthesia during extubation, the efficacy of which remains to be determined.

Practice Management Guidelines for Prophylactic Antibiotic Use in Tube Thoracostomy for Traumatic Hemopneumothorax: the EAST Practice Management Guidelines Work Group. Eastern Association for Trauma.

Multiple factors contribute to the development of posttraumatic empyema. These factors include the conditions under which the tube is inserted (emergent or urgent), the mechanism of injury, retained hemothorax, and ventilator care. The incidence of empyema in placebo groups ranges between 0 and 18%. The administration of antibiotics for longer than 24 hours did not seem to significantly reduce this risk compared with a shorter duration, although the numbers in each series were small. Most reports found a significant reduction in pneumonitis when patients received prolonged prophylactic antibiotics. This use of antibiotics might possibly be better described as presumptive therapy rather than prophylactic.

Impact of preinjury warfarin use in elderly trauma patients.

BACKGROUND: This study examined the hypothesis that elderly trauma patients on warfarin before injury will have increased morbidity and mortality compared with elderly trauma patients not on warfarin. METHODS: From 1993 to 1995, trauma patients were grouped by age and presence or absence of warfarin use before injury. Groups were analyzed with respect to Injury Severity Score, Trauma Registry and Injury Severity Score, Glasgow Coma Scale score, Intensive Care Unit days, hospital days, units of blood transfused, and mortality rates. Statistical analysis was completed by using the Student's t test. RESULTS: Records of 61 patients administered warfarin and 800 patients not administered warfarin were available for analysis. There were no statistically significant differences between patients on prehospital warfarin and those not on prehospital warfarin. CONCLUSION: This study indicates that elderly trauma patients on warfarin before injury do not have increased morbidity and mortality compared with elderly trauma patients not on warfarin.

Small-bowel and mesentery injuries in blunt trauma.

BACKGROUND: The purpose of this study was to identify factors that would aid in the diagnosis of small-bowel and mesentery injuries (SBMI) in blunt trauma patients. METHODS: Retrospective review of 15,779 blunt trauma patients admitted to a Level I trauma center between January 1991 and December 1996. RESULTS: A total of 5,303 patients sustained abdominal injuries, 70 of whom had more than 111 SBMI. Seventy-nine percent were victims of motor vehicle collisions. Thirty patients had isolated SBMI and 40 had associated intra-abdominal injuries. Twelve patients arrived with systolic blood pressure < 90 mm Hg, eight of whom died. Mean base deficit was -7.3 +/- 6.3 in 52 patients who had arterial blood gases determined. Fifty-three of 60 patients had hematuria. Sixty-seven patients required laparotomy. Delayed exploration occurred in 15 patients who underwent initial computed tomography but had subsequent changes in physical status. Two of 20 patients had negative diagnostic peritoneal lavage on admission and were eventually explored based on abdominal computed tomographic findings and changes in physical examination. There were 15 deaths. Delay in diagnosis (>12 hours after arrival) occurred in nine patients with no deaths or significant morbidities. Mean Injury Severity Score was 29 +/- 16.7: 43 +/- 17 in nonsurvivors and 25 +/- 14.3 in survivors (p < 0.05). CONCLUSION: The diagnosis of SBMI is often made in the presence of associated intra-abdominal injuries. Isolated SBMI are common, however, and special attention to the mechanism of injury, abdominal examination, presence of hematuria, and significant base deficit should raise suspicion to the possibility of SBMI. Findings on abdominal computed tomography that may suggest SBMI and should prompt further evaluation include free fluid, thickened bowel, and extraluminal air. Because delay in diagnosis does not seem to affect morbidity or mortality, dedication to observation and serial physical examinations will aid in the proper identification of elusive SBMI. Mortality, however, does appear to be related to the presence of hypotension on admission and associated injuries.

A fever workup guideline.

Fever is a common clinical problem in patients hospitalized with trauma. When an infection is suspected, it is important to identify the source of fever and begin definitive care before more severe morbidity occurs. An undirected approach with "pan cultures" has resulted in a high rate of negative cultures obtained and has increased patient care costs. By developing and using an evidence-based fever workup guideline, this institution was able to evaluate and identify infections and reduce costs.

Clinical management protocols: the bedside answer to clinical practice guidelines.

TOPIC: Clinical Management Protocols for trauma patients. PURPOSE: The goals and process for developing and implementing Clinical Management Protocols are presented. Protocol development and the differences between clinical practice guidelines, critical pathways, and clinical management protocols are discussed. SOURCES: Published literature, experience, and clinical expertise. CONCLUSIONS: Utilizing annotated algorithms, the protocols are designed for and driven by patient care based on patient need and require the collaboration of experts and trauma team members.

Practice guidelines for evaluating new fever in critically ill adult patients. Task Force of the Society of Critical Care Medicine and the Infectious Diseases Society of America.

OBJECTIVE: The development of practice guidelines for evaluating adult patients who develop new fever in the intensive care unit (ICU) for the purpose of guiding clinical practice. PARTICIPANTS: A task force of 13 experts in disciplines related to critical care medicine, infectious diseases, and surgery was convened from the membership of the Society of Critical Care Medicine and the Infectious Disease Society of America. EVIDENCE: The task force members provided personal experience and determined the published literature (articles retrieved with use of MEDLINE or textbooks) from which consensus would be sought. The published literature was reviewed and classified into one of four categories, according to study design and scientific value. CONSENSUS PROCESS: The task force met several times in person and twice monthly by teleconference over a 1-year period to identify the pertinent literature and arrive at consensus recommendations. Consideration was given to the relationship between the weight of scientific evidence and the experts' opinions. Draft documents were composed and debated by the task force until consensus was reached by nominal group process. CONCLUSIONS: The panel concluded that because fever can have many infectious and noninfectious etiologies, a new fever in an adult patient in the ICU should trigger a careful clinical assessment rather than automatic orders for laboratory and radiological tests. A cost-conscious approach to obtaining diagnostic studies should be undertaken if they are indicated after a clinical evaluation. The goal of such an approach is to determine, in a directed manner, whether infection is present so that additional testing can be avoided and therapeutic options can be identified.

Utility of chest radiographs after guidewire exchanges of central venous catheters.

OBJECTIVE: To determine whether chest radiographs are warranted after uncomplicated guidewire exchanges of central venous catheters in patients admitted to a Level I trauma intensive care unit. DESIGN: Prospective study performed in two phases. SETTING: Intensive care unit in a Level I trauma center. PATIENTS: Patients admitted to a Level I trauma center intensive care unit who required central venous catheter guidewire exchanges. INTERVENTIONS: Criteria for uncomplicated guidewire exchanges were established and followed. A catheter exchange checklist was completed at each procedure, and a chest radiograph was performed after each guidewire exchange. The complications followed were catheter malposition, pneumothorax, hemothorax, and cardiac tamponade. Results were reviewed after 3 mos, and a second phase of the study was initiated in which chest radiographs were obtained selectively and were not performed for uncomplicated exchanges. If obtained, subsequent radiographs were reviewed, and patients were followed to discharge for complications. MEASUREMENTS AND MAIN RESULTS: One hundred central venous catheter exchanges with postprocedure radiographs were evaluated in phase I. The only complication identified was one malpositioned catheter. In phase II, 110 patients were followed. Eighty-four patients did not have chest radiographs performed after guidewire exchange; 69 patients had subsequent radiographs documenting good placement of the catheter, and 15 patients did not have a radiograph before death (n = 2) or discharge from the hospital (n = 13). Sixteen patients had postprocedure radiographs performed. There were no malpositioned catheters or complications related to guidewire exchanges. CONCLUSIONS: Chest radiographs are unwarranted after uncomplicated guidewire exchanges of central venous catheters in hemodynamically stable, monitored patients. Eliminating these radiographs will result in significant cost and time savings without adversely affecting patient outcome.