Etiology and retrieval of retained central venous catheter fragments within the heart and great vessels of infants and children.

BACKGROUND: The use of centrally positioned venous catheters plays an indispensable role in the care of infants and children. METHODS: Since 1992 the authors have seen nine patients who experienced fragmentation and migration of catheter fragments into the central circulation. The patients ranged in age from 6 days to 15 years. RESULTS: Sites of migration included pulmonary artery (five patients), superior vena cava (two patients), hepatic vein and innominate vein (one patient). The elapsed time from recognition of retained catheter fragments until retrieval ranged from a few hours to 6 weeks. CONCLUSION: All retained fragments were successfully removed during cardiac catheterization without complications.

Laparoscopic exploration of the contralateral groin in children: an improved technique.

Repair of inguinal hernias are among the most frequently performed operative procedures in children. Bilateral inguinal hernias (BIH) are common, especially in patients under the age of 2 years, and present both synchronously and metachronously. Most pediatric surgeons perform open exploration of the contralateral groin in infants and young children with symptomatic unilateral inguinal hernias to avoid missing the potential metachronous presentation of BIH. The practice of contralateral groin exploration is controversial because of the increased cost, morbidity, and potentially serious complications associated with open groin exploration. We have developed a technique for laparoscopic exploration of the contralateral groin (LECG) to assess the internal inguinal ring in the asymptomatic groin and to measure the depth of a patent processus vaginalis. A pneumoperitoneum is produced by insufflation through a 14-gauge intravenous catheter placed into the hernia sac of the operated side. A 1.2-mm laparoscope is then passed through another 14-gauge intravenous catheter inserted through the abdominal wall of the contralateral side providing a direct, "in line" view of the internal ring. Depth of patency of >1.5 cm was considered positive and a standard operative repair was performed. In 110 children who underwent LECG the incidence of bilaterality was 21%. This technique is rapid, accurate and was associated with no complications.

Primary laparoscopic pull-through for Hirschsprung's disease in infants and children.

Between November 1993 and September 1994, 12 primary laparoscopic colon pull-through procedures were performed in infants and children. The patients' ages ranged from 3 days to 6 years. The primary diagnosis in all 12 patients was Hirschsprung's disease. All children had their operations without construction of preoperative or postoperative colostomy. Three 5-mm abdominal wall ports were used for access to the peritoneal cavity. The sigmoid colon and proximal rectum were mobilized laparoscopically. A submucosal sleeve was developed transanally to meet the dissection from above. The colon was then pulled down in continuity, divided above the transition zone, and secured to the anal mucosa 5 to 10 mm above the pectinate line. Mean postoperative stay was 4 days. Laparoscopic visualization provides clear delineation of pelvic structures even in small infants. Laparoscopic pull-through requires no more time than similar open procedures, averaging just over 2 hours. The morbidities associated with colostomy formation and closure and the inconvenience of colostomy care are avoided with a one-stage technique. These benefits combined with the advantages of minimally invasive surgery make primary laparoscopic pull-through a potential advance in the surgical treatment of Hirschsprung's disease.

Emergency reduction of paraphimosis.

Paraphimosis in uncircumcised or incompletely circumcised children is a serious and painful condition requiring prompt reduction to prevent possible necrosis of the glans or urinary obstruction. Techniques described to reduce oedema distal to the constricting ring include application of ice packs, compressive elastic bandages, and making a dorsal slit which necessitates later circumcision. We have used a simple "puncture" technique to treat successfully an uncircumcised 12-year-old boy with severe paraphimosis. An 18 gauge hypodermic needle was used to puncture the oedematous foreskin at multiple sites, followed by gentle manual compression. This resulted in rapid diminution of the swelling, permitting easy manual reduction of the prepuce. Circumcision can then be performed if so desired.

The United States Army Special Forces--Walter Reed Army Institute of Research Field Epidemiological Survey Team (Airborne), 1965-1968.

In 1965, an innovative concept in field medicine was launched in the form of a team of highly-trained, multi-disciplined AM-EDD specialists who were assigned to the Walter Reed Army Institute of Research and attached to the 5th Special Forces Group (Abn) while in Vietnam. Officially designated the U.S. Army Special Forces--Walter Reed Army Institute of Research Field Epidemiologic Survey Team (Airborne) (WRAIR-FEST), these personnel took their investigative skills into some of the more remote areas of Vietnam to study disease transmission in militarily hostile circumstances. From 1966-1968, numerous important studies of arthropod-borne diseases, including malaria, scrub typhus, and plague, and of gastrointestinal disorders, medically important arthropods, and cutaneous diseases were successfully conducted.

The effect of betamethasone on neonatal neutrophil chemotaxis.

Antenatal maternal glucocorticoid administration has been widely used to accelerate fetal lung maturation. Glucocorticoids have also been used postnatally in selected neonates as antiinflammatory agents. Numerous studies have shown that glucocorticoids inhibit multiple components of the immune system including neutrophil (PMN) function in children and adults. Since PMNs are of critical importance in host defense against bacterial infection, impaired PMN function in newborn infants is thought to be an important cause of their increased morbidity and mortality from bacterial infection. Further compromise of neonatal PMN function by exogenous factors such as glucocorticoids may therefore be of significant clinical importance. A micropore filter chemotactic assay was used to determine the in vitro effect of betamethasone on the random migration and directed migration (chemotaxis) of PMNs from 18 neonates. The addition of a concentration of betamethasone (0.01 microgram/ml) similar to that found in cord blood following a standard dose administered to the mother resulted in a significant (p less than 0.01) inhibition in mean neonatal PMN random migration (-15.0 +/- 0.8%) and chemotaxis (-23.5 +/- 3.0%). A similar inhibition was not found when PMNs from 14 adults were exposed to the same concentrations of betamethasone. Betamethasone administration to pregnant women or their newborn infants may further impair PMN motility and lead to an increased morbidity and mortality from bacterial infection in neonates.

The fetal biophysical profile in patients with premature rupture of the membranes--an early predictor of fetal infection.

A modified fetal biophysical profile (nonstress test, fetal movements, fetal breathing movements, fetal tone, amniotic fluid volume, and placental grading) was serially assessed in 73 patients who presented with premature rupture of the membranes and were not in labor. The last study before delivery was compared with the outcome of pregnancy. The relationships between individual variables and combinations of variables (biophysical scoring) and the outcome of pregnancy--as reflected by the development of chorioamnionitis and/or neonatal sepsis--were determined. These data suggest that the fetal biophysical profile is a useful tool for evaluating patients with rupture of the membranes. Rupture of the membranes by itself does not alter the biophysical scoring of the healthy fetus; however, a low biophysical score (less than or equal to 7) was a good predictor of impending fetal infection in patients with premature rupture of the membranes.

Delayed pancreatic pseudocyst formations. Long-term complication of L-asparaginase treatment.

L-asparaginase-induced pancreatitis has been reported during or closely following administration of the drug. Three cases of pseudocyst of the pancreas in two women and one man have previously been reported with the use of intravenous L-asparaginase. An adolescent male developed acute pancreatitis and pseudocyst of the pancreas 16 weeks after cessation of intramuscular L-asparaginase. Delayed pseudocyst of the pancreas can be a complication of intramuscular L-asparaginase.

Effect of various corticosteroids upon the phagocytic bactericidal activity of neutrophils.

Corticosteroid compounds are used broadly in surgical practice, although mechanisms remain unclarified and efficacy in some situations remains unproved. A recognized adverse effect of steroids in all doses is the potentiation of infection. Specific derivatives of the glucocorticoids appear to have varying degrees of effectiveness in the enhancement of bacterial infection. To evaluate such effects objectively, a series of experiments was undertaken to measure the phagocytic-bactericidal activity of polymorphonuclear leukocytes. This study examines the differential effects of clinical dose equivalents of four glucocorticoid derivatives in depressing in vitro neutrophil phagocytic-bactericidal function. Neutrophils separated from normal human plasma were incubated in vitro in the presence of hydrocortisone sodium phosphate, hydrocortisone sodium succinate, dexamethasone sodium phosphate, and methylprednisolone sodium succinate. Hydrocortisone sodium phosphate, hydrocortisone sodium succinate, and dexamethasone sodium phosphate produce variable, short-term inhibitory effects upon the systems within the neutrophil which are responsible for its bactericidal competency. Methylprednisolone sodium succinate appears to be free of these adverse effects. These in vitro experiments indicate that diminished risk of infection should attend the use of methylprednisolone sodium succinate, although the precise mechanism have not been defined.