Isolations of a cartilage factor that inhibits tumor neovascularization.

A cartilage fraction isolated by guanidine extraction and purified by affinity chromatography inhibits tumor-induced vascular proliferation and consequently restricts tumor growth. This fraction contains several different proteins; the major one has a molecular weight of about 16,000. The fraction strongly inhibits protease activity.

Extracorporeal membrane oxygenation for respiratory and cardiac failure in infants and children.

Fifty-three neonates and seven pediatric patients were treated with extracorporeal membrane oxygenation from September 1983 until April 1986. Venoarterial bypass was achieved by cannulating the right atrium via the right internal jugular vein and the aortic arch via the right common carotid artery. In the neonatal group, 40 infants with acute respiratory failure were treated, and 36 (90%) survived. Five infants with congenital heart disease were treated and three (60%) survived. Among the eight patients with congenital diaphragmatic hernia, there were three (38%) survivors. In the pediatric group, four patients were treated for ventricular failure after cardiac operations. Two were weaned from bypass, with one long-term survivor. Three patients with acute respiratory failure were treated, with one survivor. salvaging high-risk neonates with minimal morbidity and mortality. It has also been useful in the support of infants with congenital heart disease and congenital diaphragmatic hernia. In pediatric patients one cannot expect to get results that are comparable to those found in neonates. Still, this modality can be useful in salvaging some moribund patients with pulmonary or cardiac failure, or both.

Improving survival in the treatment of congenital diaphragmatic hernia.

Thirty-two infants were treated for congenital diaphragmatic hernia at our institution from 1979 to 1984. Eight were in no or minimal distress at birth and had operative intervention when they were more than 24 hours old; survival was 100%. The remaining 24 neonates required immediate intubation and ventilation followed by operation at less than 12 hours of age. Overall survival was 54%; survival was 31% (4 of 13 patients, Group 1) in the first three years of the series and 82% (9 of 11 patients, Group 2) in the last three years (p less than 0.001). Apgar score, gestational age, birth weight, and incidence of associated congenital heart disease were equal for the two groups (all, p greater than 0.05). The two groups also were examined with reference to alveolar-arterial oxygen differences P(A-a)O2 and mean airway pressure (MAP). The best preoperative P(A-a)O2 was greater than 600 mm Hg for 7 neonates in Group 1 and 6 in Group 2, and survival was 0% and 71%, respectively (p less than 0.001). Infants with a postoperative MAP of 13 cm H2O or greater had a higher mortality (100% in Group 1 and 50% in Group 2, p greater than 0.05). Our treatment protocol was studied to determine those methods related to improved survival. Sodium bicarbonate infusion was used earlier in Group 2 as a prophylaxis against persistent fetal circulation (PFC) (p greater than 0.05). The incidence of severe PFC dropped from 85 to 54% (p greater than 0.05). Higher ventilator rates rather than pressures were used to achieve equally effective ventilation.(ABSTRACT TRUNCATED AT 250 WORDS)

Uses of extracorporeal membrane oxygenation in nonneonatal respiratory patients. An update.

Neonatal extracorporeal membrane oxygenation (ECMO) has progressed rapidly from the experimental stage to a standard of care for certain infants who fail to respond to maximal conventional management. A broad diagnostic group of nonneonatal patients has now been supported by several different modes of ECMO with encouraging results. Selection criteria for nonneonatal patients that differ from those used for neonatal patients are emerging. Prospective randomized clinical trials are needed.

Thymic enlargement in children.

The presence of an anterior mediastinal mass in an infant or child is a diagnostic and therapeutic challenge. Few papers in the literature specifically address subtypes of thymic tumors in the pediatric population and their treatment. Our purpose was to determine which children are at significant risk of having a malignant thymic tumor. Four children were younger than 18 months old. Of these, two (50%) had respiratory distress from tracheal compression although all four had benign tumors. Of the 14 older children, only two were symptomatic, both of these from myasthenia gravis rather than the size of the mass compressing surrounding structures. Four of the 14 masses (29%) were malignant although none of the four were symptomatic. Children with benign tumors lived significantly longer than those with malignant tumors. The significant incidence of malignancy in thymic tumors when the patient is 18 months or older necessitates surgical exploration with complete removal of the mass. Children younger than 18 months require close follow-up and a trial of corticosteroids. Surgery is necessary if the mass enlarges or becomes symptomatic.

Sigmoid volvulus in children.

Volvulus of the sigmoid colon is rare in children. The authors have reviewed a total of 29 cases, including five from our institution. The most common clinical picture is crampy abdominal pain and abdominal distention. In contrast to adults, in children plain abdominal films will often not yield a diagnosis. Barium enema examination can be done to locate the obstruction. Nonoperative reduction was successful in 27 per cent of all reported cases, while operative treatment was necessary in 69 per cent of pediatric patients reported. Recurrence following derotation by any means was rare. However, adequate long-time follow-up is lacking. From available data, it seems that in most cases resection is not necessary. Primary resection may be indicated for recurrence or if the bowel is compromised. Mortality was 14 per cent, occurring in poor risk patients, the very young, and patients with associated anomalies. A redundant sigmoid may undergo intermittent torsion over a period of years, making diagnosis difficult. At laparotomy, these patients have scarred striae on the sigmoid mesocolon.

Is primary repair of gastroschisis and omphalocele always the best operation?

Optimal surgical management of neonates with gastroschisis and omphalocele remains controversial. Suggested benefits of primary fascial closure include earlier return of gastrointestinal function, decreased hospital stay, less sepsis, less risk of postoperative intestinal obstruction and fistulae, and lower mortality. Between 1978 and 1989, 40 neonates with gastroschisis or omphalocele underwent repair. Primary fascial repair was performed in 30 children, 18 of whom had a gastroschisis and 12 of whom had an omphalocele. Ten children had staged repair with the use of a silastic silo; seven of these had a gastroschisis and three an omphalocele. Comparison between the groups was made regarding birth weight, days on the ventilator before and after surgery, days to first feeding, days in the hospital after surgery, postoperative complications, and survival. There was no significant difference in birth weight, days on the ventilator, days to first feeding, and postoperative days in the hospital. There were nine complications in nine patients (30%) with primary repair and four complications in two patients (20%) with staged repair. Two infants died after primary repair (6.7%), and one (10%) died after staged closure. It was concluded that silastic silo repair and primary fascial closure are both acceptable alternatives. Primary closure is attractive whenever possible to avoid additional operations.

Wilms' tumor with metastasis to the left testis.

Wilms' tumors account for the vast majority of renal neoplasms in infants and children. Common areas for metastases include the lung, liver, and contralateral kidney. Less common sites include the bone, skin, brain, and orbit. We report a case of Wilms' tumor in a 13-month-old boy who, after radical left nephrectomy, developed a left testicular mass that turned out to be metastatic Wilms' tumor. The epidemiology, case history, review of the literature, and possible etiology of this rare site of metastatic Wilms' tumor are discussed.

Small bowel trauma in children and adolescents.

Fifty-five children and adolescents with blunt and penetrating small bowel injuries were treated during a 17-year period. Fourteen patients had blunt injuries, and there were no deaths in this group. The remaining 41 patients had penetrating small bowel injuries, with a mortality of 10 per cent. A decision to operate based on physical examination can be made in the pediatric age group without unduly delaying operation or increasing mortality.

Ventilatory management casebook. Congenital diaphragmatic hernia meeting criteria for extracorporeal membrane oxygenation.

Respiratory distress in newborns with CDH is the result of the interaction of pulmonary hypertension and pulmonary hypoplasia. Many patients will demonstrate adequate pulmonary parenchyma after repair as evidenced by adequate oxygenation and ventilation. Patients should be classified into groups of predicted mortality using Bohn's criteria. Patients in groups A, B, and D may be managed conventionally if blood gases can be kept in the normal range. These patients should be supported with ECMO if unresponsive to conventional management. In those patients with adequate gas exchange who fall into the C group, transfer to an ECMO center should be undertaken early, since mortality with continued conventional management is predictable. Some patients never demonstrate a "honeymoon" period, and mortality can be reliably predicted in this group as well by using Bohn's criteria. Because the relative significance of pulmonary hypoplasia compared with pulmonary hypertension in an individual patient cannot be reliably determined, any patient who has respiratory failure after repair of CDH should be supported with ECMO when conventional techniques fail as long as no contraindications exist. At least one institution will withhold ECMO therapy if lung parenchyma is judged inadequate as predicted by the inability to achieve a preductal PaO2 greater than 100 mm Hg and PaCO2 less than 50 mm Hg with maximal conventional therapy. In our experience, however, some patients can survive with ECMO support when all other indicators would suggest hypoplasia incompatible with life. Therefore, we do not believe any patient should be refused ECMO support when conventional measures fail.(ABSTRACT TRUNCATED AT 250 WORDS)

Calculous disease of the biliary tract in infants after neonatal extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) can be lifesaving support for neonates with fulminant respiratory failure. In the 121 patients that we have placed on ECMO since 1983, bleeding, infection, and intracranial hemorrhage have constituted most of the major complications. We have also encountered two cases of biliary calculi in post-ECMO infants. The hemolysis, total parenteral nutrition, diuretics, and prolonged fasting associated with ECMO may predispose neonates to early calculous disease of the biliary tract and may require surgical intervention. Evaluation of abdominal pain or jaundice in infants and children who have been supported with ECMO should include examination of the biliary tree. Cholecystectomy should be seriously considered for infants with cholelithiasis.

The difficult dilation: a method for dilation of severe esophageal strictures in children.

Occasionally severe esophageal strictures will develop in children that will not allow the passage of standard Jackson or bougie dilators. These small strictures can be successfully treated using a standard intubating laryngoscope for visualization and Rush urethral Filiform dilators.

Lack of effect of skin cycle on survival of experimental skin flaps in rats.

Skin flaps were raised in 83 rats. In 58 of them the skin cycle was determined before the flap was raised, and in 25 of them the flap was raised without regard to cycle. There was no significant difference in the surviving length of flaps raised in early anagen, midanagen, telogen, or in randomly selected animals.

Appendicitis in children in the managed care era.

Acute appendicitis is the most common condition requiring emergency operation in children. Late appendicitis is still a major source of morbidity and potential mortality. It has been suggested that managed care programs are responsible for a delay in surgical referral and consequently an increased risk of morbidity and mortality. In light of the increasing use of managed care, the authors reviewed their experience with pediatric acute appendicitis in managed care and indemnity insurance patients. The charts of all pediatric appendectomy patients treated between January 1990 and March 1995 were reviewed. Payor status, surgical and pathological findings, hospital course, and follow-up findings were documented. If the operative note or the pathology report described the appendix as gangrenous or perforated, the case was considered to be late appendicitis. Group I patients had traditional indemnity insurance; group II patients were in our institution's managed care plan. One hundred two patients were identified (28 in group 1, 74 in group II). Late appendicits was found less often in the managed care group (21.6% v 42.9%; P < .01). This resulted in a lower rate of major complications (1.4% v 3.6%) and a lower overall complication rate (2.7% v 7.1%). Group II also had a shorter hospital stay (2.6 days v 4.5 days; (P < .01) and lower average hospital charges ($6,507 v $8,754 (P < .01). These results do not demonstrate any adverse affect on outcome for children with acute appendicitis who have a managed care plan. In fact, the incidence of late appendicitis among these patients was half of that of the indemnity-insured patients. The lower risk of late appendicitis resulted in a shorter length of stay and lower hospital charges. These results suggest that managed care programs can provide quality care along with a significant reduction in costs; no delay in appropriate surgical referral was demonstrated.

Carotid artery repair after pediatric extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO), which has been shown to dramatically improve survival in selected neonatal patients, is now being used in some centers for pediatric patients with respiratory and cardiac failure. One of the major concerns with ECMO support is the permanent ligation of the right common carotid artery. We have used ECMO to support 10 pediatric patients with cardiac failure and 22 patients with respiratory failure. Thirty-one were cannulated via the common carotid artery and internal jugular vein on the right. Five of the last six patients with respiratory failure survived. One was on ECMO for 21 days, so the carotid artery was not amenable to repair. In the other four survivors the common carotid artery was reconstructed at the time of decannulation. In one patient, a segment of the artery was resected because of an intimal injury, and a primary anastomosis was performed. In all four, color Doppler studies of the artery prior to discharge were normal. None had clinical evidence of emboli, and a cranial computed tomography (CT) scan was normal in all four patients. These data suggest that in many pediatric patients supported with ECMO, reconstruction of the common carotid artery can be performed with low risk of embolic complications. Long-term follow-up is needed.

Complications of the Fogarty catheter technique for removal of endobronchial foreign bodies.

Extraction of endobronchial foreign bodies using the Fogarty catheter has been widely accepted. An unsuccessful application of this technique complicated by pneumothorax and catheter tip separation is presented. Avoidance of complications resulting from forceful instrumentation is emphasized.

Extracorporeal membrane oxygenation for newborn respiratory failure.

Respiratory failure is the leading cause of death in the newborn. Conventional therapy is very successful with 80% of infants weaned from ventilatory support. For neonates with severe respiratory failure, unresponsive to maximal medical therapy, extracorporeal membrane oxygenation (ECMO) offers an alternative means of management. Venoarterial bypass is achieved by cannulating the right atrium via the internal jugular vein and the aortic arch via the right common carotid artery. A 5-inch roller pump is used to circulate the blood through a 0.4 or 0.8 m2 silicone membrane lung. Management includes heparinization, intravenous alimentation, antibiotic coverage, and reduction of FiO2 and airway pressure. Thirty infants aged 12 to 186 hours were placed on ECMO. Each met strict criteria designed to predict greater than 90% mortality. Time on bypass ranged from 37 to 250 hours. Success, defined by weaning from ECMO and ventilatory support, was achieved in 23. Twenty-one remain alive; 18 have excellent outcome with normal growth and development although follow-up is short (1 to 19 mos). These results corroborate reports from the pioneers of the technique and further support the use of ECMO for neonates with respiratory failure unresponsive to conventional therapy.

A correlation of pulmonary hypoplasia, mean airway pressure, and survival in congenital diaphragmatic hernia treated with extracorporeal membrane oxygenation.

Thirty infants with congenital diaphragmatic hernia (CDH) who required therapy within the first day of life were treated in our institution over the past 3 years. Eighteen of these infants were not treated with extracorporeal membrane oxygenation (ECMO). Survival in this group was 83%. Twelve infants were treated with ECMO. Seven (58%) were weaned from ECMO and ventilator support with six (50%) long-term survivors. Minimum preoperative alveolar-arterial oxygen gradient (AaDO2), maximum postoperative mean airway pressure (MAP), and pulmonary hypoplasia were evaluated. Bohn et al have prospectively shown that the relationship of PaCO2 to mechanical ventilatory requirements accurately predicted survival in a group of 58 infants with CDH in whom ECMO was not a therapeutic option. This criteria would predict nonsurvival in all 12 of our patients treated with ECMO, including the seven survivors. Differences between our ECMO and non-ECMO groups were statistically significant for all three criteria. All P values less than .05. Morphometric analysis of the lungs of all ECMO nonsurvivors revealed hypoplastic ipsilateral lungs by lung weight to body weight ratios and radial alveolar counts when compared with experimental and historical controls (P less than .05). The contralateral lung was hypoplastic in 80% of the nonsurvivors. There is a strong correlation between the maximum postoperative MAP and the degree of contralateral pulmonary hypoplasia (r = .03, P = .02). We conclude that the maximum postoperative MAP is an accurate predictor of survival in the treatment of CDH and can be correlated with the degree of pulmonary hypoplasia.(ABSTRACT TRUNCATED AT 250 WORDS)

Developmental outcome of neonates treated with extracorporeal membrane oxygenation.

The leading cause of death in the neonatal period is respiratory failure, and extracorporeal membrane oxygenation (ECMO) is an effective means of improving survival in select patients. Only neonates with severe hypoxia and acidosis are treated with ECMO. To determine the developmental outcome of the neonates we supported with ECMO, we reviewed the records of all our patients who are at least 6 months of age. The results of follow-up assessment were available for 57 patients and growth parameters were available for 43 patients. Examinations were done at 6 to 48 months (mean, 22.1). Growth parameters showed that 14% of the patients were below the tenth percentile for height and weight while 16.3% were below the tenth percentile for head circumference. Twenty-four patients were evaluated using the Bayley Scales of Infant Development consisting of a Mental Developmental Index (MDI) and a Psychomotor Developmental Index (PDI). Normal scores (greater than 84) were obtained in 75% on the MDI and in 88% on the PDI. Only two patients (8%) scored less than 85 on both portions. Twelve patients were evaluated using the McCarthy Scales of Children's Abilities. The mean score was 95 and nine patients (75%) had scores greater than 85. The Gessell was used to evaluate six patients and five were normal. The Denver Developmental Screening Test was used to evaluate 23 patients and all passed. The results of neurologic examination were documented in 57 patients. One patient had severe spastic quadriplegia with cerebral palsy. The neurological examination was normal in the other patients. Only one of 57 patients is profoundly delayed (2%) and 45 (79%) are normal.(ABSTRACT TRUNCATED AT 250 WORDS)

Extracorporeal membrane oxygenation for nonneonatal respiratory failure.

Extracorporeal membrane oxygenation (ECMO) has been used for 20 years in neonates and children with cardiac and respiratory failure. The number of neonates treated with ECMO has increased exponentially, but the number of older children treated is small. The selection and exclusion criteria for pediatric ECMO are poorly defined, and the results vary because of variable selection criteria and institutional experience with the technique. In order to help define the role of pediatric ECMO, we reviewed our experience in noneonatal pediatric respiratory failure. We have treated 22 patients ranging in age from 1 to 105 months and ranging in weight from 3 to 35 kg. Eighteen patients met the criteria for adult respiratory distress syndrome, two had respiratory syncytial virus pneumonia, and one had severe barotrauma complicating the management of reactive airway disease. All patients were considered by the referring institutions and by us to be failing conventional management as evidenced by hypoxia, hypercarbia, excessive ventilatory pressures, or progressive barotrauma. All were considered likely to die with continued conventional management. Sixteen of the 22 patients had complications (73%), but half of the last 10 patients had no complications. Hemorrhagic complications occurred in 12 patients. Mechanical complications included membrane failure, raceway rupture, pump malfunction, and improper cannula positioning. Other complications included culture-proven infection and renal failure. Eleven of the 22 patients survived (50%); nine of the last 12 survived (75%). These results suggest that ECMO may be a useful technique in selected pediatric patients with respiratory failure. Survival and complication rates improve as experience with the technique increases.