Delayed Presentation of Meconium Ileus in an Infant With Cystic Fibrosis.

Although infants with meconium ileus usually present with apparent symptoms shortly after birth, the diagnosis of meconium ileus and cystic fibrosis (CF) may be delayed, awaiting newborn screening (NBS) results. We present the case of an 11-day-old term girl with delayed passage of meconium at 48 hours who had 2 subsequent small meconium stools over the following week. There was a normal feeding history and no signs of abdominal distension or distress. She then presented with an acute abdomen, decompensated shock, bowel perforation, and peritonitis, requiring multiple intestinal surgeries. Her NBS for CF was positive, and CF was ultimately confirmed with mutation analysis. Her course was complicated by prolonged parenteral feedings and mechanical ventilation via tracheostomy. The infant was managed with soy oil, medium chain triglycerides, olive oil, fish oil lipids and experienced only transaminitis without cholestasis and no chronic liver sequelae, with subsequent normalization of her transaminases without treatment. Because her only symptom was decreased stool output and NBS results were unavailable, the CF diagnosis was delayed until she presented in extremis. Delayed meconium passage and decreased stool output during the first week of life should lead to suspicion and additional evaluation for CF while awaiting NBS results. Careful monitoring is indicated to prevent serious, life-threatening complications. The use of soy oil, medium chain triglycerides, olive oil, fish oil lipids for infants requiring prolonged parenteral nutrition may also be considered proactively to prevent cholestasis, particularly for high risk groups.

Management of Isolated Skull Fractures in Pediatric Patients: A Systematic Review.

OBJECTIVES: Isolated skull fractures (ISFs) in children are one of the most common emergency department injuries. Recent studies suggest these children may be safely discharged following ED evaluation with little risk of delayed neurological compromise. The aim of this study was to propose an evidence-based protocol for the management of ISF in children in an effort to reduce medically unnecessary hospital admissions. METHODS: Using PubMed and The Cochrane Library databases, a literature search using the search terms (pediatric OR child) AND skull fracture AND (isolated OR linear) was performed. Three hundred forty-three abstracts were identified and screened based on the inclusion criteria: (1) linear, nondepressed ISF; (2) no evidence of intracranial injury; (3) age 18 years or younger; and (4) data on patient outcomes and management. Data including age, Glasgow Coma Scale score on arrival, repeat imaging, admission rates, need for neurosurgical intervention, and patient outcome were collected. Two authors reviewed each study for data extraction and quality assessment. RESULTS: Fourteen articles met the eligibility criteria. Data including admission rates, outcomes, and necessity of neurosurgical intervention were analyzed. Admission rates ranged from 56.8% to 100%; however, only 8 of more than 5000 patients developed new imaging findings after admission, all of which were nonsurgical. Only 1 patient required neurosurgical intervention for a finding evident upon initial evaluation. CONCLUSIONS: Pediatric ISF patients with a presenting Glasgow Coma Scale score of 15 who are neurologically intact and tolerating feeds without concern for nonaccidental trauma or an unstable social environment can safely be discharged following ED evaluation to a responsible caregiver.

The certifying examination of the american board of surgery: the effect of improving communication and professional competency: twenty-year results.

PURPOSE: In 1985, a small research group identified variables affecting applicant success on the oral Certifying Examination (CE) of the American Board of Surgery (ABS). This led to the design of an oral examination course first taught in 1991. The success of and need for this program led to its continuation. The results from the first 10 years were presented at the 2001 Association of Program Directors in Surgery annual meeting.(1) We now report the outcomes for the course of the second 10 years as measured by success on the CE. METHODS: Thirty-six courses were held over 20 years. There were 57 invited faculty from 27 general surgery programs throughout the United States and Canada. The participant-to-faculty ratio ranged from 16:7 to 5:1 in the newer 3-day format (2007). Courses were offered at sites that replicated the actual examination setting. Each course included (1) pretest and posttest examinations, (2) analysis of case presentation skills, (3) measurement of communication apprehension, (4) 1:1 faculty feedback, (5) small-group practice sessions, (6) individual videotaping, (7) didactic review of specific behaviors on examinations, (8) a debrief session with two faculty members, and (9) a written evaluative summary that included an improvement strategy. RESULTS: There were 36 courses with 326 participants (30-54 years). Follow-up data are available for 225 participants. Trends were analyzed between 1991-2001 and 2002-2011. As resident performance on the CE increased in importance, applicant profiles changed from those who had previously failed (1991-2001) to residents identified by program directors as needing assistance (52%). Since 2002, most course participants (69%) who had failed the CE had completed at least 1 other review course. Participants reported more significant stressors (2002-2011) 9%, but communication apprehension remained the same. As a result, individual counseling for anger and family stressors was integrated into the course. The perception of knowledge deficits was associated with those who enrolled in fellowship training and delayed their examination. The recent groups exhibited more professionalism and articulation issues related to performance. Five surgeons (2002-2011) were asked not to return to the course because of severe knowledge deficiencies or ethical/behavioral issues based on faculty evaluations. Although complete follow-up of all participants was not possible (only 225/326), the success rate among those providing follow-up was 97% for those who followed their remediation plan, giving 218/326, a worse-case pass rate of 67%. CONCLUSION: Communication and professionalism deficits are still common in those struggling with the CE, Early identification of those at risk of failing by program directors who are documenting the competencies may promote earlier interventions and thus lead to success. This program continues to be effective at identifying behaviors that interfere with success on the CE of the ABS.

Angiographic embolization is safe and effective therapy for blunt abdominal solid organ injury in children.

BACKGROUND: : Angiographic embolization (AE) is used to control hemorrhage in adult blunt liver, spleen, and kidney (ASO) injuries. Pediatric experience with AE for blunt ASO injuries is limited. We reviewed our use of AE to control bleeding pediatric blunt ASO injuries for efficacy and safety. METHODS: : A 5-year review (trauma registry and charts) of children (age < or = 16 years) who had AE for hemorrhage from blunt ASO injuries. Nonoperative management was attempted in all stable children with blunt ASO injuries. Children with ongoing hemorrhage underwent AE. The success of AE and complications were evaluated. Data were reviewed on injury type and grade, injury severity score, length of intensive care unit stay (LOS-ICU) and length of hospital stay (LOS), and complications. RESULTS: : One hundred twenty-seven patients with 149 blunt ASO injuries were identified (72 spleen, 51 liver, and 26 renal). Two children had immediate splenectomies. Seven children underwent AE: two spleen (grades IV and V), two liver (grades III and IV), and three grade IV renal injuries. Three children received blood before embolization. Mean age and injury severity score were 12.3 years +/- 3.7 years and 22.4 +/- 10.0,respecyively. Mean intensive care unit stay was 4.8 days +/- 5.5 days with a mean length of hospital stay of 12.8 days +/- 5.5 days. Embolization was successful in all children; there were no procedure-related complications. Four minor complications occurred; two pleural effusions and two patients with transient hypertension. A nephroblastoma was later found in one renal injury requiring nephrectomy. CONCLUSIONS: : AE is a safe and an effective technique for controlling hemorrhage from blunt ASO injuries in select pediatric patients.

Initial resection of potentially viable tissue is not optimal treatment for grades II-IV pancreatic injuries.

PURPOSE: This study was designed to ascertain the optimal therapy and diagnostics for children with pancreatic injury. METHODS: From January 1, 2001 to January 1, 2007, all children (newborn to 17 years) who presented to this Level I trauma center with demonstrated pancreatic injury were prospectively entered into the TRACS IV system and reviewed for injury type, diagnostics, therapy, demographics, and outcome. RESULTS: Fourteen children sustained grade II or higher pancreatic injury during this period. CT scan was performed for diagnosis in all cases. There were 11 boys and 3 girls, and mean age was 6.9 (range, 2-16) years. There were five grade II injuries, four grade III injuries, four grade IV injuries, and one grade V injury. All grade II injuries were treated successfully nonoperatively with observation. The nine grade III-IV injuries all underwent operative external drainage without pancreatectomy or stent placement. The single grade V injury died of multiple associated injuries after operative intervention. No pseudocysts developed in these children. All children have normal pancreatic function, and all except one have normal anatomy on follow-up scans. Early exploration and drainage directly reduces length of stay. CONCLUSION: Grade II pancreatic injuries do not require routine surgical exploration in children. Grade III and IV injuries in this series were treated with expeditious drainage of the pancreatic bed and did not require routine pancreatectomy or endoscopic stent [corrected] placement as some have recommended. Early drainage shortens hospital stay, and outcomes from this therapy are excellent. Pancreatic resection of exocrine defunctionalized segments of pancreas may be performed safely electively after acute injury if necessary, but anecdotal information from this series indicates that too may not be necessary. Grade V injuries often are accompanied by multiple other organ injuries and are associated with a significant mortality rate. A multi-institutional investigation is warranted to reassess optimal therapy for pancreatic injury in children.

The safety and efficacy of spinal anesthesia for surgery in infants: the Vermont Infant Spinal Registry.

Studies with modest numbers of patients have suggested that spinal anesthesia in infants is associated with a very infrequent incidence of complications, such as hypoxemia, bradycardia, and postoperative apnea. Although spinal anesthesia would seem to be a logical alternative to general anesthesia for many surgical procedures, it remains an underutilized technique. Since 1978, clinical data concerning all infants undergoing spinal anesthesia at the University of Vermont have been prospectively recorded. In all, 1554 patients have been studied. Anesthesia was performed by anesthesia trainees and attending anesthesiologists. The success rate for LP was 97.4%. An adequate level of spinal anesthesia was achieved in 95.4% of cases. The average time required to induce spinal anesthesia was 10 min. Oxygen hemoglobin desaturation to <90% was observed in 10 patients. Bradycardia (heart rate <100 bpm) occurred in 24 patients (1.6%). This study confirms the infrequent incidence of complications associated with spinal anesthesia in infants. Spinal anesthesia can be performed safely, efficiently, and with the expectation of a high degree of success. Spinal anesthesia should be strongly considered as an alternative to general anesthesia for lower abdominal and lower extremity surgery in infants.

The diagnosis and management of children with blunt injury of the chest.

Thoracic trauma remains a major source of morbidity and mortality in injured children, and is second only to brain injuries as a cause of death. The presence of a chest injury increases an injured child's mortality by 20-fold. Greater than 80% of chest injuries in children are secondary to blunt trauma. The compliant chest wall in children makes pulmonary contusions and rib fractures the most common chest injuries in children. Injuries to the great vessels, esophagus, and diaphragm are rare. Failure to promptly diagnose and treat these injuries results in increased morbidity and mortality.

Functional outcome of nonoperatively managed renal injuries in children.

BACKGROUND: This study aimed to define better the functional outcome of nonoperatively managed renal injuries in children. METHODS: All children who had blunt renal trauma managed nonoperatively were reviewed for injury grade, blood urea nitrogen (BUN), creatinine, blood pressure, and percentage of function according to technetium-99m-dimercaptosuccinic acid renal scan after complete healing. RESULTS: Over a 2-year period, 17 children (mean age, 10.4 years) were managed conservatively for their renal injuries. There were two grade 2, two grade 3, nine grade 4, and four grade 5 injuries. Complete healing was documented in all cases within 3 months after injury. Renal scarring and volume loss were evident for all healed high-grade injuries (grades 4 to 5) at follow-up imaging. Technetium-99m-dimercaptosuccinic acid scanning demonstrated a decline in percentage of total renal function corresponding to injury severity (44.7 +/- 8.4% function for grades 2 and 3, 41.8 +/- 9.2% for grade 4 vs 29.5 +/- 7.9% for grade 5). Only two children (22%), however, with grade 4 injury had severe compromise of function (<30%). At the follow-up visit, all the children were asymptomatic and normotensive. None had abnormal BUN or creatinine (mean BUN, 10.5 +/- 5.1 mg/dL; mean creatinine, 0.6 +/- 0.2 mg/dL). CONCLUSIONS: The functional outcome for children with nonoperatively managed kidney injuries is good and correlates with injury grade. Children with grades 2 to 4 injuries managed conservatively retain near normal function. Those with grade 5 injuries have a loss of function attributable to scarring and parenchymal volume loss. Long-term follow-up evaluation of these children may be warranted.