Congenital diaphragmatic hernia: long-term outcome in neonates treated with extracorporeal membrane oxygenation.

As more infants with congenital diaphragmatic hernia (CDH) survive with extracorporeal membrane oxygenation (ECMO), it seems prudent to detail the longterm outcome in these medically complex infants. Eighteen children with CDH-treated with postoperative ECMO were recruited for participation in this study. The mean duration of ECMO was 193 hours (range 82 to 493 hours), mean time to extubation after ECMO was 142 hours (range 34 to 312 hours), and median duration of hospitalization was 46 days (range 30 to 181 days). Of the 18 infants, 4 (22%) were discharged home requiring oxygen therapy. At follow-up the notable findings were a high incidence of gastroesophageal reflux and failure to thrive. At both 1 and 2 years of age, 50% of infants were at less than the 5th percentile for weight. At 1 and 2 years of age, 39% and 21%, respectively, were at less than the 5th percentile for weight/length ratio. A total of 16 children (89%) had clinical evidence of reflux, and 8 (44%) were discharged home on a regimen of nasogastric feedings. Reherniation occurred in 4 children (22%) and was more frequent when a patch was used. An electrocardiogram showed right ventricular hypertrophy in 6 (43%); oxygen saturation by pulse oximetry was > 95% in all children, and pulmonary artery pressure was estimated by Doppler echocardiography to be normal in 12 of 14 children examined. The neurodevelopmental outcome (Bayley Scales or Stanford-Binet scale) at 1 to 4 years of age was not dissimilar from that of other ECMO-treated children. Given the severity of illness in the neonatal period, the general health and development of children with CDH surviving after ECMO are good. Surprisingly few children have long-term respiratory complications related to pulmonary hypoplasia. Follow-up in the first few years should be aimed at aggressive nutritional intervention to prevent the growth failure that appears to be prevalent in these children.

The excretion of collagen cross-links in malnourished children and their subsequent recovery - abstract

Pyridinoline (PYD) and deoxypridinoline (DYP) molecules cross-link the collagen in bone and cartilage. They are neither re-used in the body nor found in the collagen of any other organ. We have measured the urinary excretion rate of these cross-links in 46 severely malnourished boys to assess their skeletal turnover and to relate the output to the subsequent rate of growth in height. The children were 12 +/- 6mo, -3.6 +/- 1.6 SD units height-for-age and -2.4 +/- 0.9 SD units weight for height. Their excretion when malnourished and after recovery was 11.4 +/- 5.3 (mal, X +/- DS) and 32.3 +/- 10.8 (rec) of PYD and, 2.7 +/- 1.5 (mal) and 7.5 +/- 3.0 (rec) of DYP (all nmol .h-1 .m-ý). This indicates that skeletal turnover is much less in the malnourished than the recovered child. Comparison with Italian control data indicates that there is depressed skeletal metabolism in malnutrition. There was a significant relationship between the cross-link excretion, age and weight-for-height and the rate of height gain in the subsequent month by multiple regression analysis. These three factors - age, degree of wasting amd skeletal turnover accounted for 44 percent of the variance in the subsequent height velocity of the children. It may be possible to use PYD and DYP to assess therapeutic intervention designed to alleviate stunting(AU)

Long-term morbidity and mortality in morbidly obese adolescents after jejunoileal bypass.

To evaluate the long-term results of jejunoileal bypass in the treatment of morbidly obese adolescents, we studied 11 patients who underwent surgery between 1972 and 1974. More than 10 years after surgery, 45% of the patients had extremely satisfactory results (correction of morbid obesity). Three patients died within the year after surgery, two of them under extenuating clinical circumstances. There have been no subsequent deaths. All eight survivors were found to have metabolic abnormalities to various degrees. Two patients had a total of five pregnancies; each had one healthy infant, and three pregnancies ended in abortion (one spontaneous). Two patients had significant medical problems related to the procedure but basically remained in good health, whereas three patients had severe symptoms requiring reanastomosis. Of the five patients who continue with the bypass, none has become significantly obese. They have all maintained a weight loss of between 45 and 90 kg, and as adults express strong feelings in favor of the procedure. This series demonstrates that, although significant weight loss was maintained, and improvement in the quality of life for half of our patients was dramatic, side effects and complications continue to develop, mandating careful follow-up for an indefinite time.