Vertical reduction rectoplasty: a new treatment for idiopathic megarectum

BACKGROUND

The aetiology of idiopathic megarectum is unknown and the results of surgery are often unsatisfactory. Rectal hyposensation is common and poor perception of rectal filling may contribute to the poor evacuatory function. By reducing the capacity of the rectum, it was hypothesized that sensory thresholds to rectal distension and perception of urge to defaecate would be improved.

METHODS

Vertical reduction rectoplasty (VRR) and concomitant sigmoid colectomy was performed on six patients with idiopathic megarectum. Patients were evaluated before and after operation by detailed questionnaire and anorectal physiology. Postoperative rectal compliance was also studied by means of a programmable electronic barostat. Where appropriate, physiological data were compared with those obtained in eight healthy volunteers.

RESULTS

Bowel frequency increased from a preoperative median of 2.5 to 16 per month after operation. Four patients reported improved rectal perception of the urge to defaecate. Thresholds for defaecatory urge and maximum tolerated volume were significantly reduced following VRR (P<0.05). Post-VRR rectal compliance was no different from that in healthy volunteers. Colonic transit time decreased significantly after VRR (P<0.05) and evacuation on proctography increased from a median of 30 per cent to 50 per cent. At a median of 57 weeks' follow-up five of the six patients expressed continued satisfaction with the results.

CONCLUSION

VRR is a new approach to the treatment of idiopathic megarectum. Clinical and physiological studies confirm that it can improve sensory feedback and defaecation. The procedure needs further evaluation as the number of patients undergoing the procedure increases.

Salvage prostatectomy with continent catheterizable urinary reconstruction: a novel approach to recurrent prostate cancer after radiation therapy

PURPOSE

Salvage prostatectomy after full dose radiation therapy is associated with a high risk of urinary incontinence. We evaluated the complications of salvage prostatectomy with continent catheterizable reconstruction and its impact on urinary incontinence.

MATERIALS AND METHODS

Between August 1995 and February 1999, 13 patients with biopsy proved, locally recurrent prostate cancer after radiation therapy underwent salvage prostatectomy with complete bladder neck closure and reconstruction with an appendicovesicostomy to the native bladder in 9 and ileovesicostomy in 4.

RESULTS

There were no intraoperative complications. Four patients had serious complications necessitating reoperation, including a vesicourethral fistula requiring delayed cystectomy, wound dehiscence with disruption of the appendicovesical anastomosis, leakage from the small bowel anastomosis that resulted in sepsis and death, and stomal stenosis requiring delayed stomal revision in 1 each. Of 12 patients 2 (17%) used pads for incontinence, while 10 were dry during the day and night with a catheterization interval of 2 to 6 hours.

CONCLUSIONS

Salvage prostatectomy with continent catheterizable reconstruction is a technically challenging operation with the potential for serious complications. The postoperative continence rate is excellent and appears superior to those in the literature for salvage prostatectomy and vesicourethral anastomosis.

Links between early adrenal function and respiratory outcome in preterm infants: airway inflammation and patent ductus arteriosus

OBJECTIVE

To investigate the relationship of cortisol concentrations during the first week of life to patent ductus arteriosus (PDA), markers of lung inflammation, and respiratory outcome in very low birth weight infants.

METHODS

Newborns <1,500 g birth weight were prospectively enrolled at 2 centers. Serum cortisol was measured 3 times during days 2 to 7 of life. Tracheal lavage was performed on intubated infants and analyzed for interleukin-1beta, -6, and -8, and for total protein, albumin, and alpha-1 protease inhibitor. Infants receiving prenatal glucocorticoids were excluded.

RESULTS

We obtained 337 cortisol values from 125 infants. Infants treated for PDA had lower cortisol values after day 2. One hundred thirty-three tracheal fluid samples were obtained on matching days from 71 intubated infants. Cortisol correlated inversely with tracheal interleukins and proteins. Lower cortisol values during the second half of the week correlated with longer duration of supplemental oxygen therapy and with subsequent development of chronic lung disease at 28 days and at 36 weeks.

CONCLUSION

Infants with lower cortisol values in the first week of life had an increased incidence of PDA, increased lung inflammation, and an increased incidence of chronic lung disease. These findings suggest that early adrenal insufficiency may underlie the previously observed association of increased lung inflammation and PDA with adverse respiratory outcome in this population.

Adrenoceptors and colocolonic inhibitory reflex

The colocolonic inhibitory reflex is characterized by inhibition of proximal colonic motility induced by distal colonic distension. The aim of this study was to investigate the underlying neural mechanisms of this reflex, in vivo, using an isolated loop of canine colon. In five beagle dogs, motility was recorded from an exteriorized colonic loop via a serosal strain gauge connected to a digital data logger and chart recorder. Inflation of a balloon in the distal colon resulted in inhibition of motility in the isolated loop. Inhibition of motor activity persisted following injection of propranolol (100 microg/kg intravenously), a beta-adrenoceptor antagonist, but was abolished following administration of the alpha2-adrenoceptor antagonist yohimbine (200 microg/kg intravenously). This study confirms that the colocolonic inhibitory reflex is mediated via the extrinsic nerves to the colon. As the reflex was abolished by alpha2-, but not beta-adrenoceptor blockade, this indicates that the reflex pathway involves alpha2-adrenoceptors.

Cardiovascular effects of odors

Several occupational and residential settings can expose both normal and sensitive human subjects to odors and irritants. These settings include intensive agricultural operations housing swine and poultry, cigarette-smoke-filled bars, landfills and manufacturing processes. The literature suggests that adverse sensory reactions to strong odors and irritants may lead to the release of catecholamines and stress hormones. Physiological and biochemical measurements related to cardiovascular risk, e.g., blood pressure, heart rate, high-density lipoprotein (HDL) cholesterol level and serum triglyceride level, may be altered as a result of exposure to odor and irritant-induced release of catecholamines. Further work in the form of field studies and chamber exposure protocols is required to determine whether the physiological and biochemical changes observed to date represent an increase in cardiovascular risk, or are reversible changes within the normal homeostatic range.

Quality of life after salvage cryotherapy: the impact of treatment parameters

PURPOSE

Cryotherapy has emerged as a promising salvage therapy option for treatment of locally recurrent prostate cancer after initial therapy. In this retrospective study we evaluate patient quality of life after salvage cryotherapy and correlate complications impairing quality of life with specific cryotherapy treatment parameters.

MATERIALS AND METHODS

A modified UCLA Prostate Cancer Index measuring health related quality of life was sent to 150 patients who underwent salvage cryotherapy between July 1992 and April 1995. We evaluated the relationships among incontinence, pain, impotence, sloughing of tissue and problematic voiding symptoms, and cryotherapy treatment parameters, including use of a urethral warming catheter, number of cryotherapy probes and number of freeze-thaw cycles. We also evaluated patient overall degree of satisfaction with the procedure.

RESULTS

Of 150 surveys 112 (74%) were returned. Mean followup was 16.7 months (range 0.5 to 31.5). Treatment without an effective urethral warming catheter was highly associated with urinary incontinence (p<0.003), perineal pain (p<0.001), tissue sloughing (p<0.003) and American Urological Association symptom score greater than 20 (p<0.004). Impotence was higher in the double freeze-thaw cycle group (p<0.05). Overall satisfaction with cryotherapy was 33%.

CONCLUSIONS

Quality of life may be compromised by urinary incontinence, impotence, tissue sloughing, problematic voiding symptoms and/or perineal pain in a substantial number of patients following salvage cryotherapy. Effective urethral warming is essential in reducing complications and maximizing quality of life. Salvage cryotherapy does not appear to offer any quality of life advantages compared to salvage prostatectomy.

Patient selection for salvage cryotherapy for locally recurrent prostate cancer after radiation therapy

PURPOSE

Our objective was to identify clinical pretreatment factors associated with early treatment failure after salvage cryotherapy.

PATIENTS AND METHODS

Between 1992 and 1995, 145 patients underwent salvage cryotherapy for locally recurrent adenocarcinoma of the prostate. Treatment failure was defined as an increasing postcryotherapy serial prostate-specific antigen (PSA) level of more than or equal to 2 ng/mL above the postcryotherapy nadir or as a positive posttreatment biopsy. We evaluated the following factors as predictors of treatment failure: tumor stage and grade at initial diagnosis, type of prior therapy, stage and grade of locally recurrent tumor, number of positive biopsy cores at recurrence, and precryotherapy PSA level.

RESULTS

Among patients with a prior history of radiation therapy only, the 2-year actuarial disease-free survival (DFS) rates were 74% for patients with a precryotherapy PSA less than 10 ng/mL and 28% for patients with a precryotherapy PSA more than 10 ng/mL, P <.00001. The DFS rates were 58% for patients with a Gleason score of less than or equal to 8 recurrence and 29% for patients with a Gleason score greater than or equal to 9 recurrence, P <.004. Among patients with a precryotherapy PSA less than 10 ng/mL, DFS rates were 74% for patients with a prior history of radiation therapy only and 19% for patients with a history of prior hormonal therapy plus radiation therapy, P <.002.

CONCLUSION

Patients failing initial radiation therapy with a PSA more than 10 ng/mL and Gleason score of the recurrent cancer more than or equal to 9 are unlikely to be successfully salvaged. Patients failing initial hormonal therapy and radiation therapy are less likely to be successfully salvaged than patients failing radiation therapy only.

A feasibility study of cryotherapy followed by radical prostatectomy for locally advanced prostate cancer

PURPOSE

There has been a significant shift toward multimodality therapy to try to eradicate extracapsular disease better in patients with locally advanced prostate cancer. We assess the feasibility and complications of initial cryotherapy followed by radical prostatectomy, and evaluate the frequency and location of viable benign and malignant prostate tissue and positive surgical margins after this treatment combination.

MATERIALS AND METHODS

A total of 12 patients with clinical stage T3 cancer or clinical stages T1c to T2, Gleason score 8 to 10 cancer on the initial biopsy were treated with initial cryotherapy followed by open surgical exploration 2 to 8 days later. If pelvic lymph nodes were negative, radical prostatectomy was performed. Prostate specific antigen was measured approximately every 3 months postoperatively, and complications were assessed by retrospective chart review and a quality of life survey.

RESULTS

Radical prostatectomy was aborted in 5 patients with positive pelvic lymph nodes. Of the 7 patients who underwent prostatectomy 4 had no residual prostate cancer in the specimen (pathological stage pT0 disease). All 7 of these patients had focal areas of viable normal prostate glands. Only 1 of the 7 patients had a positive surgical margin and biochemical failure (mean followup 22.6 months). The main complications of cryotherapy followed by radical prostatectomy were urinary incontinence and impotence.

CONCLUSIONS

Neoadjuvant cryotherapy achieved complete tumor destruction in 4 of 7 patients with locally advanced prostate cancer. Cryotherapy followed by radical prostatectomy was associated with substantial morbidity, mainly in terms of urinary incontinence.

Sensory and autonomic neuropathy in patients with idiopathic slow-transit constipation

BACKGROUND

Slow-transit constipation (STC) is a severe disorder of unknown aetiology, which may result from an autonomic or sensory neuropathy. This study aimed to investigate patients with STC for the presence of neural dysfunction, and relate the findings to other factors, including any familial associations.

METHODS

Thirty-three patients with STC were studied using standard neurophysiological tests and a range of quantitative sensory and autonomic tests. The findings were compared with those of 20 matched control subjects and nine diabetic patients with gastrointestinal symptoms.

RESULTS

Twenty of the 33 patients with STC gave a family history of constipation, including an affected identical twin and Hirschsprung's disease (n = 3). None had abnormalities on neurological examination or nerve conduction studies. Fifteen of the 33 patients had abnormalities on quantitative tests, including all six who required a colectomy. Eleven patients with STC had reduced axon-reflex sweating in the presence of normal sweat gland responses (P < 0.001, all patients with STC versus controls). Twelve patients with STC had small sensory fibre dysfunction, with significantly increased thermal thresholds (cool, P < 0.05; warm, P < 0.01); these included six of nine patients with STC and rectal hyposensation. There were similar findings on quantitative testing in diabetic patients.

CONCLUSION

Quantitative tests in patients with STC provide evidence of a small fibre neuropathy. The high incidence of a positive family history, particularly a possible association with Hirschsprung's disease, suggests a genetic basis, which deserves further investigation.

The necessary role of the autopsy in cardiovascular epidemiology

The autopsy rate in the United States today is remarkably low, with proportionally fewer autopsies for natural causes of death. Consequently, most cardiovascular epidemiology studies do not use autopsy data and rely on death certificates, medical records, questionnaires, and family interviews as sources of mortality information. These practices introduce a high degree of variability and uncertainty regarding cause of death. This review illustrates the necessity for increased use of autopsies in cardiovascular epidemiology by critically evaluating other measures of cardiovascular disease (CVD) incidence. We evaluated the literature regarding CVD as cause of death and conducted discussions with cardiologists, pathologists, and epidemiologists. No attempt was made for meta-analysis. This review shows the limited reliability of death certificates, medical records, and interviews as sources of mortality statistics. In addition, the autopsy's role in clearly indicating the presence of CVD is illustrated. The autopsy used in conjunction with medical records is the only reliable means for establishing cause of death from CVD. There is an urgent need to reassess the current dependence of statistical mortality data on death certificates and other inadequate sources of CVD incidence. Death certificates, in general, are inadequately monitored for quality control and appropriate administrative oversight. With an increase in the number of hospitals performing no autopsies to investigate cause of death, a uniform national autopsy database is needed.

Positive relationship of cortisol concentrations and oral nutrition to epidermal growth factor concentrations in preterm infants

We have suggested from previous studies that increases in early neonatal epidermal growth factor (EGF) concentrations were dependent on adequate glucocorticoid hormone concentrations. In order to examine this relationship, matched values for cortisol and EGF in 193 preterm infants on days 2 and 6 were compared. Gestational age had a significant positive effect on EGF concentrations for those infants receiving oral nutrition and there was also a positive relationship between nutrition and cortisol concentration. Cortisol was then used as an independent factor and was significantly (p = 0. 01) related to EGF values such that as cortisol concentrations increased, EGF values also increased. In summary, we suggest that these results are consistent with a role for cortisol in the control of the EGF pattern in the newborn period.

Autogenic bone marrow injections as a treatment for simple bone cyst

Simple bone cyst (SBC) is a benign fluid-filled cavity found primarily at the proximal ends of long bones in children. Treatments proposed for SBC range from observation to intralesional curettage and bone grafting, which are all associated with uncertainty and complications. Because of these factors, a relatively noninvasive protocol with osteoinductive autogenic bone marrow was instituted. Twelve patients were identified with SBCs. Bone marrow was aspirated from the patient's iliac crests and injected into the cyst cavity. Follow-up ranged from 9 to 57 months. Eight (67%) patients demonstrated substantial healing, two (17%) showed partial healing, and two (17%) did not respond to bone marrow therapy. The advantages suggested by bone marrow injection over the currently practiced methods include a higher success rate with a single injection and earlier healing.

Pulmonary edema and hyponatremia during hysteroscopic resection of uterine fibroids: case report

Hyponatremia and fluid overload--the so-called TURP Syndrome--is a rare but well-understood complication of endoscopic resection of the prostate caused by rapid absorption of irrigating fluids from venous sinuses opened during the surgery. A similar syndrome occurring during endoscopic resection of the uterine mucosa has been postulated but only rarely described. New equipment and surgical techniques have recently been developed that allow for more invasive and extensive hysteroscopic surgery, which will inevitably lead to an increased incidence of this complication. We report the occurrence of a case of acute pulmonary edema occurring intraoperatively during hysteroscopic surgery, complicated postoperatively by severe hyponatremia. Anatomic and physiological causes of this syndrome are discussed, and recommendations are offered for avoiding and treating this potentially lethal complication.

Predictive value of prostate specific antigen nadir after salvage cryotherapy

PURPOSE

We determined nadir prostate specific antigen (PSA) after salvage cryotherapy to distinguish patients who are potentially cured from those at risk for subsequent biochemical and biopsy proved failure.

MATERIALS AND METHODS

A total of 146 patients who underwent salvage cryotherapy were followed a median of 21 months (range 3 to 47) with regular serum PSA analysis and digital rectal examination. Sextant biopsies were performed at 6 months or earlier when PSA increased greater than 2 ng./ml. from the nadir value (biochemical failure) or there was a palpable local recurrence. We compared the incidence of biochemical failure and biopsy specimens positive for cancer to pretreatment PSA and posttreatment nadir PSA.

RESULTS

In 59 of the 146 patients (40%) PSA decreased to an undetectable level within a median of 3 months. In 85 of the 109 patients (78%) who underwent biopsy the specimens were negative for cancer. Low serum PSA nadir values were associated with low pretreatment PSA and a low incidence of biochemical failure. In 6 of 60 patients (10%) in whom PSA nadir was 0.5 ng./ml. or less and in 18 of 49 (37%) with a higher PSA nadir biopsy was positive for cancer.

CONCLUSIONS

A PSA nadir of 0.5 ng./ml. or less should be achieved after salvage cryotherapy. Higher nadirs are more likely to be associated with increasing posttreatment PSA and positive biopsies. PSA nadir is a better prognostic indicator of biochemical and biopsy proved failure after salvage cryotherapy than pretreatment PSA.

Multiresistant Pseudomonas aeruginosa outbreak in a pediatric oncology ward related to bath toys

BACKGROUND

Nosocomial outbreaks of Pseudomonas aeruginosa in pediatric hospitals frequently involve neonates and immunosuppressed patients and can cause significant morbidity and mortality.

OBJECTIVE

To describe the investigation of a multidrug-resistant P. aeruginosa outbreak in a pediatric oncology ward at the Royal Children's Hospital, Melbourne, Australia.

DESIGN AND METHODS

Specimens were collected from infected patients and the ward environment. Bacterial isolates were characterized by antibiotic susceptibility patterns and bacterial DNA fingerprinting performed by pulsed-field gel electrophoresis (PFGE). A case-control study was carried out to assess possible risk factors for infection.

RESULTS

Eight patients had clinical illnesses including bacteremia (n = 5) and infections of skin (n = 2), central venous catheter site (n = 1) and urinary tract (n = 1). The environmental ward survey yielded isolates of multiresistant P. aeruginosa from a toy box containing water-retaining bath toys, as well as from three of these toys. Pulsed-field gel electrophoresis of bacterial DNA demonstrated identical band patterns of the isolates from patients, toys and toy box water. A case-control study involving the 8 cases and 24 disease-matched controls demonstrated a significant association between P. aeruginosa infection and use of bath toys (P = 0.004), use of bubble bath (P = 0.014), duration of stay (P = 0.007) and previous antibiotic exposure (P = 0.026). Cultures from the bubble bath liquid were negative.

CONCLUSION

This is the first description of a nosocomial outbreak associated with toys. We caution against the use of water-retaining bath toys in wards treating immunocompromised children.

Microvascularized free fibular grafts for reconstruction of skeletal defects after tumor resection

A microvascularized free fibular graft was used to reconstruct a skeletal defect after tumor reconstruction in 13 consecutive patients. The patients were evaluated at an average follow-up of 53 months (range, 30-71). The status of each graft was evaluated for time to union, hypertrophy, functional evaluation, and complications. The average time to union was 6.5 months, and significant graft hypertrophy occurred in eight of 13 patients. Complications occurred in seven patients. Two of the 13 patients required removal of the microvascularized graft. Functional evaluation according the the Musculoskeletal Tumor Society yielded an average score of 90 (range, 83-97). The results were rated good or excellent in 11 of 13 patients, and two were rated failures. The microvascularized fibular graft provides an attractive option for the reconstruction of skeletal defects after tumor resection. The results of this procedure are especially good in skeletally immature patients.

Immunoglobulin E levels and anticollagen antibodies in patients with postburn hypertrophic scars

Immunoglobulin E (IgE) levels and eosinophil counts were measured in 18 former patients with burn injuries attending an outpatient clinic for hypertrophic scarring. In 15 of these 18 former patients with burns, IgG anticollagen antibodies were also measured. Earlier reports in the literature have suggested that a local immune reaction against collagen might play a role in enhancing inflammation, thereby increasing scar formation. In addition, we have previously reported an increase in allergic symptoms in patients with keloids and hypertrophic scars. Antibodies to the following collagen types were measured: human type I, human type III, bovine type I, and bovine type III. IgG anticollagen antibody levels were correlated with percentage third-degree burn, number of weeks after burn injury, and the patient's age. An increase in percentage third-degree burn and in number of weeks after burn injury was statistically significantly associated with an increase in serum anticollagen antibody level. Six of the 18 patients had higher than normal IgE levels (p value = 0.0002).

Brachialis muscle entrapment in displaced supracondylar humerus fractures: a technique of closed reduction and report of initial results

A retrospective review was conducted of 152 extension-type supracondylar humerus fractures in 151 children. Ninety-two (61%) of 152 of these fractures were displaced (Gartland type III). Initial irreducibility was present in 20 of the 92 displaced fractures. Brachialis muscle interposition was diagnosed by physical examination or intraoperative findings in 18 (90%) of the 20 initially irreducible fractures. Sixteen of the fractures with brachialis muscle interposition underwent an attempt at freeing the impaled proximal fragment by the described "milking maneuver." The maneuver was successful in 15 of the 16 patients and was followed by closed reduction and percutaneous pinning. Three of the remaining four cases required open reduction and pinning. We identify the incidence of initial irreducibility in displaced supracondylar humerus fractures, describe clinical findings suggestive of brachialis entrapment, and demonstrate the milking maneuver to be a valuable technique in the treatment of displaced supracondylar fractures with brachialis interposition.

The efficacy and complications of salvage cryotherapy of the prostate

PURPOSE

A phase I/II study was done to evaluate the efficacy and complications of salvage cryotherapy as a treatment for locally recurrent prostate cancer following full dose radiation therapy and/or systemic therapy. The efficacy of single and double freeze-thaw cycles was compared using posttreatment prostate specific antigen (PSA) levels and prostate biopsies as end points.

MATERIALS AND METHODS

A total of 150 patients with locally recurrent prostate cancer following radiation, hormonal therapy and/or systemic chemotherapy underwent salvage cryotherapy using a single (71 men, mean followup 17.3 months) or double (79 men, mean followup 10.0 months) freeze-thaw cycle. PSA was measured approximately every 3 months postoperatively and sextant biopsies were repeated 6 months postoperatively. Complications were assessed by retrospective chart review and a mailed quality of life survey.

RESULTS

Overall, 45 patients (31%) had persistently undetectable PSA. Patients with a history of radiation therapy only who underwent a double freeze-thaw cycle had a higher negative biopsy rate (93 versus 71%, p < 0.02) and lower biochemical failure rate (defined as an increase in serum PSA of 0.2 ng./ml. above the nadir value, 44 versus 65%, p < 0.03) than those who underwent a single freeze-thaw cycle. The main complications of salvage cryotherapy were urinary incontinence (73% of the patients), obstructive symptoms (67%), impotence (72%) and severe perineal pain (8%).

CONCLUSIONS

Salvage cryotherapy impacts local tumor control as evident by the high frequency of negative posttreatment biopsies. A double freeze-thaw cycle appears more effective than a single cycle. Like salvage prostatectomy, salvage cryotherapy causes significant morbidity.

The predictive value of the development of the acetabular teardrop figure in developmental dysplasia of the hip

We reviewed the radiographs of 72 hips, 47 with developmental dysplasia of the hip (DDH), and 25 normal hips, to determine the timing of the normal appearance of the acetabular teardrop figure and the value of teardrop development after reduction of the hip in predicting outcome. In normal hips, all children had a teardrop figure by age 18 months. In the 47 hips with DDH, no teardrop figure appeared until the hip was reduced. The DDH hips were divided into two groups based on the success of the initial reduction. By using statistical analysis, we found that the appearance of the acetabular teardrop within 6 months after reduction of the hip is strongly associated with a favorable long-term outcome. We believe that the appearance of the teardrop is the earliest radiographic sign that a stable, concentric reduction of the hip has been achieved.

Chorioamnionitis, cortisol, and acute lung disease in very low birth weight infants

OBJECTIVE

To explore the relationship between chorioamnionitis, postnatal cortisol concentrations, and acute respiratory distress in very low birth weight infants.

METHODS

Appropriate for gestational age infants weighing between 501 to 1500 g at birth were enrolled into this prospective, observational study, and data regarding respiratory distress on the first day of life were recorded. Serum cortisol concentrations were measured on (a) day 2, (b) day 3 or 4, and (c) day 5, 6, or 7 of life. On day (b) or (c), 3.5 microg/kg of cosyntropin (an adrenocorticotrophic hormone analog) was given, and a repeat specimen was drawn 30 minutes later. Chorioamnionitis was diagnosed by placental examination by one author (R.L.N.).

RESULTS

Forty-two infants exposed to chorioamnionitis and 37 infants not exposed were enrolled. Chorioamnionitis correlated inversely with gestational age, and was associated with decreased measures of acute respiratory support (exogenous surfactant, fraction of inspired oxygen, and ventilator support at 12 and 24 hours). Infants with chorioamnionitis had higher cortisol concentrations, both basal and stimulated. Gestational age was not significantly related to basal cortisol, but did correlate positively with stimulated values. Cortisol values from the 16 infants exposed to prenatal glucocorticoid therapy were excluded from these analyses.

CONCLUSIONS

These results provide evidence that prenatal inflammation leads to adrenal stimulation, resulting in increased cortisol secretion and accelerated lung maturation. The enhanced response to cosyntropin stimulation seen in these infants may reflect an increased adrenal capacity to respond to postnatal stressors. Because of the apparent magnitude of the effect of chorioamnionitis on cortisol measures, this factor should be included in future investigations of adrenal function in very low birth weight newborns.

Effect of five days of dexamethasone therapy on ventilator dependence and adrenocorticotropic hormone-stimulated cortisol concentrations

OBJECTIVE

Our objective was to address the efficacy of 5 days of dexamethasone therapy in preterm infants dependent on ventilation and to measure adrenocorticotropic hormone-stimulated cortisol release after therapy.

METHODS

This was a randomized, masked trial. Results were evaluated with Fisher's exact test and Wilcoxon test. Fifteen preterm infants in a newborn intensive care unit who were dependent on ventilation were enrolled at 8 to 24 days of age. Dexamethasone or normal saline solution was used for treatment. The main outcome measure was ventilator independence.

RESULTS

Dexamethasone therapy correlated to successful extubation. Posttherapy peak adrenocorticotropic hormone-stimulated cortisol concentrations were lower in infants treated with dexamethasone than in infants treated with saline solution.

CONCLUSIONS

A 5-day course of dexamethasone may be adequate to achieve ventilator independence. The difference in peak cortisol concentrations may reflect suppression of the hypothalamic-pituitary-adrenal axis by dexamethasone or a higher peak cortisol response in the infants treated with saline solution who have higher ventilatory acuity after therapy.

Developmental susceptibility to intestinal injury by platelet-activating factor in the newborn rat

Platelet-activating factor (PAF) is an important endogenous mediator of neonatal necrotizing enterocolitis (NEC). Injection of PAF into weanling and adult rats causes ischemic bowel necrosis that is morphologically similar to NEC. The purpose of this study was to adapt the PAF model of intestinal injury to the suckling rat and to attempt to alter susceptibility to PAF-induced bowel necrosis by early weaning and formula feeds. At ages 15 to 20 days, rat pups were selected to be weaned to either formula or 5% dextrose or to nurse ad lib (total n = 54). At ages 16, 18, 20, 21, 23, or 25 days of life, animals received PAF (50 micrograms/kg) and endotoxin (1 mg/kg) by intraperitoneal injection. Animals were sacrificed 2 h after injection. Intestinal samples were submitted to be graded by a pathologist in a blinded fashion. Injury scores ranged from 0 to 10, based on the percentage of villous necrosis. Prior to age 20 days, minimal histologic injury was present (mean scores on days 16, 18 = 1.7 +/- 0.9, 1.7 +/- 0.6). Combined injury scores for weaned and nursed animals on days 20 and 23 were significantly greater than on days 16 and 18 (p = .0001). Histologic injury in the dextrose group was significantly less than the formula-fed group on day 21 and greater on day 25. Suckling rats showed resistance to PAF-induced bowel necrosis prior to 20 days of age, during the middle of the weaning period. Early weaning to formula did not alter susceptibility to injury, which suggests that PAF-acetylhydrolase from breast milk does not confer this resistance to PAF.

Noninvasive capnometry in a pediatric population with respiratory emergencies

OBJECTIVE

This study was designed to investigate the reliability, safety, and efficacy of measuring end tidal CO2 (ETCO2) in nonintubated pediatric patients presenting to an emergency department (ED) with respiratory emergencies.

DESIGN/SETTING/PATIENTS

Eighty-five children were enrolled in a clinical, prospective, observational study at a university-affiliated children's hospital. Children age four weeks to 15.3 years with upper and lower respiratory diseases were enrolled by convenience sampling over a five-month period.

INTERVENTIONS

ETCO2 measurements were obtained on each patient by oral/nasal side-stream capnometry. When a consistent waveform was obtained, the value was compared with a capillary arterial partial pressure of CO2 (CapCO2), oxygen saturation (O2Sat), and clinical observations.

RESULTS

Study patients had a mean ETCO2 reading of 33 mmHg with a standard deviation (SD) of 4.6 mmHg and CapCO2 reading of 36 mmHg with a SD of 4.5 mmHg. Pulmonary findings, final diagnosis, and age did not significantly alter the relationship between CapCO2 and ETCO2. The relationship between CapCO2 and ETCO2 was significant (t = 14.9, P < 0.0001, r = 0.87), with a 95% confidence interval for prediction of +/-5 mmHg.

CONCLUSION

Dependable ETCO2 values can be obtained using an oral/nasal capnometry circuit, and they consistently correlate with CapCO2 in a pediatric population with upper and lower respiratory diseases. Noninvasive ETCO2 analysis is safe and reliable within the limitations of this study group. Further exploration is necessary to determine the value of this technology in assisting with clinical decisions in the patient with impending respiratory failure.

Chorioamnionitis and early lung inflammation in infants in whom bronchopulmonary dysplasia develops

OBJECTIVE

The development of bronchopulmonary dysplasia (BPD) often has been attributed to injury from mechanical ventilation and supplemental oxygen. Early lung inflammation in infants with BPD has been thought to be secondary to these factors. The purpose of this study was to evaluate whether preexisting (prenatal) inflammation may be a primary causative factor in the development of BPD.

METHODS

Intubated newborns of less than 2,000 g birth weight were prospectively enrolled. The presence or absence of chorioamnionitis was documented. Lung inflammation was evaluated on days 1, 2, and 4 of intubation by assaying concentrations of interleukin 1 beta (IL-1 beta), thromboxane B2, leukotriene B4, and prostaglandin E2 in tracheal lavages. Infants in whom BPD developed were compared with those in whom it did not using these measures.

RESULTS

Fifty-three infants were enrolled; 41 survived. Thirty-eight had respiratory distress syndrome; 15 were intubated for other diagnoses. Infants prenatally exposed to chorioamnionitis were less likely to present with respiratory distress syndrome; however, chorioamnionitis was significantly associated with both the presence of IL-1 beta from the first day of intubation and the development of BPD. Tracheal lavage concentrations of IL-1 beta were higher in infants in whom BPD developed. Thromboxane B2 concentrations were similar on day 1 but were higher on days 2 and 4 in infants in whom BPD developed.

CONCLUSIONS

In this study, intubated infants weighing less than 2,000 g at birth in whom BPD developed had increased exposure to inflammation prenatally (chorioamnionitis) and evidence of increased lung inflammation from the first postnatal day. We speculate that chorioamnionitis may accelerate lung maturation but that it also causes lung inflammation and subsequent lung injury in intubated infants, fostering the development of BPD.

Electrically stimulated colonic reservoir for total anorectal reconstruction

Total anorectal reconstruction after abdominoperineal excision of the rectum has failed to achieve perfect continence. Electrically stimulated reservoir evacuation in combination with an electrically stimulated gracilis neoanal sphincter might improve results. A J pouch was constructed in an isolated colonic loop of seven dogs. Bipolar square wave pulses were delivered via two intramural stainless steel electrode pairs at 10 Hz. Stimulation parameters were varied to achieve adequate contraction. Serosal strain gauges recorded spontaneous and stimulated pouch motility. Evacuation was quantified by a volume displacement technique and observed fluoroscopically. Recordings were performed for a median of 3 (range 1-11) months. At 10 Hz and 0.5 ms pulse width, stimulation was required for 2 min and at voltages of 15 V (n = 4), 18 V (n = 1) and 20 V (n = 2) to obtain a contraction of amplitude comparable to that of a spontaneous contraction. Suprathreshold stimulation invariably resulted in colonic pouch contraction. The mean(95 per cent confidence interval (c.i.)) stimulus-response latency was 25.5(1.9) s. The mean(95 per cent c.i.) intraluminal pressure generated during stimulation was 114.1(17.0) cmH2O and 64.6(12.0) cmH2O during spontaneous activity (P < 0.001). In conclusion, electrical stimulation via intramural electrodes produced contraction generating sufficient intraluminal pressure to effect evacuation of a canine colonic pouch. This has potential for incorporation with an electrically stimulated neoanal sphincter in total anorectal reconstruction to improve evacuation and continence.

Closed reduction and percutaneous pinning of displaced supracondylar humerus fractures in children: description of a new closed reduction technique for fractures with brachialis muscle entrapment

A retrospective review of 43 displaced extension-type supracondylar humerus fractures in children was performed. Thirty-four fractures were completely displaced (type III). Ninety-one percent (39 of 43) of the fractures were managed by immediate closed reduction and percutaneous pinning. Ten type III fractures exhibited clinical or radiographic evidence of brachialis muscle penetration. A closed reduction maneuver designed to "milk" the entrapped brachialis muscle off of the proximal fracture spike was developed and was successful in all eight cases in which it was attempted. At mean follow-up of 35 months, 97% (38 of 39 patients) achieved a good or excellent result based on the Flynn grading scale.

Compartment syndrome in the forearm following fractures of the radial head or neck in children

A volar compartment syndrome of the forearm was identified following a minimally displaced or angulated fracture of the radial head or neck in three children. The fractures were due to a fall from a bed or from a standing height on an outstretched hand. All three patients had symptoms and signs that were consistent with elevated intracompartmental pressure in the forearm when they were first examined, twelve to twenty-four hours after the injury, and all were managed with an emergency fasciotomy of the forearm. The radial fracture was treated without reduction in the first patient, with manipulative closed reduction in the second patient, and with open reduction and stabilization with Kirschner wires in the third patient. All three patients had a full functional recovery.

Prolonged ambulatory canine colonic motility

Canine gastrointestinal motility is studied at present in animals confined to a small cage or sling. The aims of this study were to record colonic activity over a 24-h period in eight dogs by an ambulatory method. Motility signals from implanted strain gauges were processed and stored via a portable battery-operated amplifier and digital recorder housed in a jacket. Ambulant interdigestive activity was the same as observed in laboratory experiments, with migrating colonic motor complexes (CMCs) and infrequent giant contractions (GCs). Feeding caused a multiphasic alteration in motility for 582.1 +/- 18.1 min (mean +/- SE). There were four distinct phases. During the "early" (0-2 h) postprandial period, phase 1 (mean duration: 55.1 +/- 4.0 min), which was distinguished by CMCs of high frequency and elevated amplitude in the proximal colon, and phase 2 (78.2 +/- 6.2 min), which had CMC characteristics similar to those in the interdigestive period, occurred. Phase 3 (218.8 +/- 13.6 min), a further period of increased motility, and phase 4 (339.1 +/- 14.0 min), characterized by low-amplitude long-duration CMCs, occurred during the "late" (2 h onward) postprandial response. With the exception of phase 3, postprandial phases were not always present following food intake, and their expression was markedly influenced by variations in meal time and by defecation immediately following feeding. Spontaneous defecation was characterized by a variety of motor profiles, with a GC accompanying two-thirds of episodes. We conclude that a more complete picture of canine colonic motility has been documented because of the development of the ambulatory system.

Dexamethasone therapy is associated with a rise in urinary epidermal growth factor concentrations in the preterm infant

The effect of glucocorticoid hormones on epidermal growth factor (EGF) concentrations has not been described in the premature infant. We examined this relationship in a group of infants treated with dexamethasone for airway edema (three to five doses) or chronic lung disease (six weeks of a tapering protocol). We collected urinary samples in 45 infants (25 for airway edema, 20 for chronic lung disease) before, during and after the use of dexamethasone. The EGF values were unchanged in infants that were given dexamethasone for airway edema. In contrast, all infants treated for chronic lung disease increased their EGF values by 1 week of therapy. At the end of the dexamethasone taper, ten of the infants had recovered successfully from ventilatory support. This group of infants had post-therapy EGF values that were significantly higher than pretherapy values. In the ten infants that were still ventilator dependent at the end of therapy, EGF values were not different from pretherapy values. We conclude that dexamethasone therapy was associated with an increase in urinary EGF values in the preterm infant treated for at least 1 week. The positive correlation of tapering from ventilatory support with increases in EGF values suggests that EGF may be a marker of dexamethasone effect or an effector of dexamethasone action.

Corticosteroid-binding globulin in preterm infants in an intensive care unit

Blood concentration of corticosteroid-binding globulin (CBG) was measured in 85 preterm (24-36 weeks of gestational age) infants over the first 6 weeks of postnatal life. CBG concentrations directly correlated to gestational age and postnatal age in the first week of life. There was a significant increase in CBG values over the first 6 weeks such that mean values at weeks 4 through 6 were significantly greater than values at weeks 1 and 2. Postnatal CBG values were significantly lower in infants who had pulmonary disease during week 1 (p = 0.001). In summary, CBG values were directly correlated to gestational and postnatal age, and negatively correlated to acute illness. We speculate that the lower CBG values with lung disease may reflect an ongoing inflammatory response.

Evidence of early adrenal insufficiency in babies who develop bronchopulmonary dysplasia

OBJECTIVES

To test the cortisol response to adrenocorticotrophic hormone (ACTH) in a population of very low birth weight newborns at the end of the first week of life, and to evaluate the relationship of this response to the subsequent development of bronchopulmonary dysplasia and to the total length of oxygen dependence.

METHODS

Appropriate for gestational age newborns < 1500 g birth weight were enrolled prospectively. Response to ACTH stimulation was tested on days 5, 6, or 7. Baseline cortisol, stimulated cortisol, and magnitude of response were compared between babies who developed bronchopulmonary dysplasia (BPD), defined as oxygen dependence at 28 days, and those who recovered without BPD.

RESULTS

In this population, the cortisol response to ATCH increased with increasing birth weight (P < .001). Using birth weight as a cofactor, analysis of variance showed that patients who developed BPD (n = 34, BW 974 +/- 192 g, mean +/- S.D.) had significantly reduced responses to ACTH at 5 to 7 days of age compared to those who recovered (n = 25, BW 1251 +/- 194 g), P = .006. Additionally, 84% of patients who recovered without BPD, but only 26% of BPD patients, achieved a prospectively defined positive cortisol response to ACTH (> or = 9 micrograms/dL; P < .005). Supplemental oxygen was discontinued at a younger postconceptional age in babies with a positive cortisol response to ACTH (P < .01) and fewer of those babies were on supplemental oxygen at 36-week postconceptional age (P < .01).

CONCLUSIONS

At the end of the first week of life, infants who subsequently developed BPD and prolonged oxygen dependence had significantly lower cortisol secretion in response to ACTH than infants who recovered without BPD. We speculate that these babies may be unable to secrete adequate amounts of cortisol in a setting of increased stress, leaving them vulnerable to continuing lung injury.

Comparison of pediatric end-tidal CO2 measured with nasal/oral cannula circuit and capillary PCO2

This study was designed to determine whether end-tidal carbon dioxide (ETCO2) values obtained by noninvasive oral/nasal cannula circuit with side-stream capnometry correlate reliably with capillary PCO2 (CapCO2) in a pediatric population without cardiopulmonary problems. Each patient was monitored until a reliable 5-minute ETCO2 waveform was obtained. A capillary blood gas sample was drawn while, simultaneously, ETCO2 was recorded. The difference between CapCO2 and ETCO2 levels was tested with a paired t-test at P < .001. The limits of agreement were established with a 95% confidence level. The stability of the measured difference across the range of mean scores (CapCO2 + ETCO2/2), age, and respiratory rate was tested using simple linear regression. Fifty-eight children (23 girls and 35 boys) had mean ETCO2 readings of 33.96 mm Hg (SD 4.26), and mean CapCO2 readings of 35.93 (SD 4.04). A relative average bias of 1.96 with ETCO2 lower than CapCO2 was established with 95% limits of agreement of +/- 5.2 mm Hg (t = 5.71). Variability of difference scores was not related to range of mean scores (r = .08), age (r = .09), or respiratory rate (r = .25). End-tidal CO2 measured by an oral/nasal cannula capnometry circuit is a noninvasive method of assessing indirect measurements of PCO2 in a normal pediatric population.

Using mortality data to describe geographic variations in health status at sub-district level

OBJECTIVE

To describe sub-district variations in health status, using mortality data that are processed locally.

DESIGN

A descriptive study of routinely collected death registration data, using multicause coding.

SETTING

The London Borough of Croydon, with a population of 319,200 divided into 27 electoral wards.

SUBJECTS

Deaths of Croydon residents, registered with the Registrar of Births and Deaths, which occurred between January 1990 and December 1992 inclusive.

MAIN OUTCOME MEASURES

Variations in life expectancy, all-cause standardised mortality ratios (SMRs), and disease-specific mortality ratios between selected wards. Deaths in nursing homes were excluded to avoid bias.

RESULTS

Data from 8,930 death registrations, of which 852 occurred in nursing homes, were analysed by electoral ward. The range for all-cause SMRs, including nursing home deaths, was 153 (139-168) to 66 (58-75). When nursing home deaths were excluded, the SMRs for two wards that were significantly higher than the Croydon average fell into the average range. The range, excluding nursing home deaths, was 133 (113-153) to 71 (62-80). Life expectancy at birth varied from 79.8 years to 74.4 years, and life expectancy at age 65 by three years between wards at the two ends of the spectrum. The geographic distribution of ischaemic heart disease and diabetes showed significant differences.

CONCLUSIONS

We contend that death registration data are a useful tool for describing sub-district variations in health status. Deaths of nursing home residents are a source of bias and should be excluded from the analysis. Multicause coding allows a more accurate description of geographic variations in specific diseases, such as ischaemic heart disease and diabetes.

Effect of gestational age, postnatal age, and illness on plasma cortisol concentrations in premature infants

The purpose of this study was to define the pattern of postnatal plasma cortisol concentrations during the first week of life in premature infants, and to evaluate the effect of developmental and clinical factors on this pattern. We measured plasma cortisol concentrations in the morning and afternoon on d 2, 4, and 6 in 120 premature infants (gestational age 24-36 wk) and examined the effects of gestational age, postnatal age, and illness. We described an inverse relationship between gestational age and cortisol concentrations, with the youngest infants having the highest random cortisol values (F = 5.14, p = 0.0073). Illness had a significant negative effect such that the cofactors ventilatory support pattern (F = 6.62, p = 0.0016) or "use of surfactant" (F = 6.63, p = 0.001) defined a pattern where cortisol values were lower in infants that had the highest ventilatory requirements or that received surfactant compared with values from those infants who did not have these requirements. The postnatal pattern in cortisol values depended on gestational age. Ill infants more than 27 wk gestational age increased their cortisol values from d 2 to d 6 although cortisol values decreased in well infants. These patterns resulted in a nonsignificant change over time for these age groups. In contrast, cortisol values significantly decreased from d 2 to d 6 in both well and ill infants that were less than or equal to 27 wk. We conclude that plasma cortisol concentrations in the premature infant are significantly correlated with gestational age and to markers of illness.(ABSTRACT TRUNCATED AT 250 WORDS)

Asymptomatic carotid artery stenosis and stroke in patients undergoing cardiopulmonary bypass

PURPOSE

This study was undertaken to assess the natural history of carotid artery stenosis in patients undergoing cardiopulmonary bypass (CPB) at a Veterans Administration Medical Center.

METHODS

Between January 1989 and August 1993, all patients undergoing CPB were offered preoperative carotid artery ultrasound screening as part of an investigative protocol. Patients were monitored in-hospital for the occurrence of perioperative neurologic deficit.

RESULTS

A total of 582 patients underwent carotid artery ultrasound screening. Greater than 50% stenosis or occlusion of one or both internal carotid arteries was present in 130 patients (22%), with 80% or greater stenosis or occlusion of one or both arteries present in 70 patients (12%). In-hospital stroke or death occurred in 12 (2.1%) and 36 (6.2%) patients, respectively. Of the 12 strokes, five were global and seven were hemispheric in distribution. Of the five patients who had global events, none had evidence of carotid artery stenosis. However, of the seven patients who had hemispheric events, five had significant 50% or greater stenosis or occlusion of the internal carotid artery ipsilateral to the hemispheric stroke. Therefore the presence of carotid artery stenosis or occlusion was significantly associated with hemispheric stroke (no stenosis 0.34% vs stenosis 3.8%; p = 0.0072). Furthermore, the risk of hemispheric stroke in patients with unilateral 80% to 99% stenosis, bilateral 50% to 99% stenosis, or unilateral occlusion with contralateral 50% or greater stenosis was 5.3% (4 of 75). No strokes occurred in patients with unilateral 50% to 79% stenosis (n = 52).

CONCLUSIONS

It is concluded that carotid atherosclerosis is a risk factor for hemispheric stroke in patients undergoing CPB.

VA Study of Unstable Angina. 10-year results show duration of surgical advantage for patients with impaired ejection fraction

BACKGROUND

In a randomized study of unstable angina, medically treated patients with impaired left ventricular (LV) ejection fractions (EF = 0.3 to 0.58) were at significantly higher risk of mortality than patients treated by coronary artery bypass graft surgery (CABG). Because the duration of this surgical advantage is unknown, 10-year cumulative mortality rates of patients with impaired LVEF were determined and compared with the previously observed rates at 2, 5, and 8 years.

METHODS AND RESULTS

Of 468 patients with unstable angina, 237 were randomized to receive medical treatment alone and 231 patients to have CABG. Baseline characteristics, which were equally distributed between the two treatment groups, included age, LVEF, number of diseased coronary arteries, diabetes, clinical presentation (type I or type II), prior myocardial infarction, and smoking. Mortality was determined by life-table analysis and risk factors by logistic regression analysis. Patients were divided into terciles according to LVEF, and the mortality rates of medical and surgical patients in the lowest tercile were compared. The 10-year mortality rate for all medical patients was 38% and for all surgical patients, 39%. When LVEF was treated as a continuous variable, there was a significant relation between mortality and LVEF for medically treated patients but not for surgical patients. The cumulative mortality rate for the lowest-tercile (EF 0.3 to 0.58) medical patients was 49%; for the lowest-tercile surgical patients, 41% (P = .15).

CONCLUSIONS

The surgical advantage for patients with impaired LVEF that was significant at 5 years (P = .03) and 8 years (P = .05) appears to have diminished at 10 years (P = .15).

Identification of unstable angina patients who have favorable outcome with medical or surgical therapy (eight-year follow-up of the Veterans Administration Cooperative Study)

To identify patients with unstable angina (UA) who have favorable outcomes with medical therapy or surgery, 468 patients who had been randomized in the Veterans Administration Cooperative Study of UA were risk-stratified based on angiographic criteria of the number of coronary arteries diseased and left ventricular ejection fraction (LVEF). Patients at high risk for UA were defined as those with 3-vessel disease or LVEF of < or = 58%, and patients at low risk were those with 1- or 2-vessel disease and LVEF of > 58%. Of the 468 UA patients randomized, 287 patients belonged to the high-risk and 181 to the low-risk category. In the low-risk group, cumulative mortality after 8 years of follow-up was significantly lower in the medically treated patients (16.8%) than in the surgically treated patients (32.2%) (p = 0.022); in the high-risk group, cumulative mortality was significantly lower in the surgically treated patients (24.1%) than in the medically treated patients (35.3%) (p = 0.03). The relative risk of surgery (the ratio of surgical to medical risk) in the low-risk patients was 1.67, indicating a significant survival advantage with medical treatment (p = 0.05), whereas the relative risk of surgery for the high-risk group was 0.71, indicating a significant survival benefit with surgical treatment (p < 0.05). Thus, medical therapy appears to be the preferred therapy for UA patients with only 1- or 2-vessel disease and normal LVEF, and surgery is preferred for UA patients with 3-vessel disease or LVEF in the lowest tercile.

Mini-dose Bier block intravenous regional anesthesia in the emergency department treatment of pediatric upper-extremity injuries

The safety and effectiveness of the "mini-dose" Bier block, a technique of i.v. regional anesthesia using low-dose lidocaine (1.5 mg/kg) without routine premedication, was evaluated in the emergency department treatment of pediatric upper-extremity fractures and dislocations. We prospectively studied 69 patients, aged from 2 to 16 years, treated at a pediatric primary care/referral-based emergency department. Good to excellent anesthesia was achieved during closed reduction in 90% of the cases. All patients achieved an acceptable reduction, as demonstrated by follow-up radiographs. None required further treatment of the injury under general anesthesia. No significant complications were noted. We conclude that the mini-dose Bier block provides safe, reliable, and cost-effective anesthesia for the outpatient reduction of pediatric upper-extremity injuries.

Serious group A beta-hemolytic streptococcal infections complicating varicella

STUDY OBJECTIVE

To alert practicing emergency physicians to an important and possibly increasing relationship between life-threatening group A beta-hemolytic streptococcal (GABHS) infections and children recovering from varicella.

DESIGN

A case series of six patients managed from January through March 1993.

SETTING

A university-affiliated pediatric specialty emergency department.

TYPE OF PARTICIPANTS

Six previously healthy immunocompetent children between 1 and 5 years of age seen in our ED over a nine-week period.

RESULTS

Six children had onset of varicella two days to two weeks before developing a serious life-threatening GABHS infection. Children presented with clinical symptoms of invasive GABHS infection with bacteremia (one patient); streptococcal toxic shock syndrome with negative blood culture (two), pneumonia with pleural effusion and streptococcal toxic shock syndrome (one), pneumonia with pleural effusion (one), and pyomyositis of the thigh (one). Four of six patients required intensive care admissions and aggressive support of vital signs. All six survived.

CONCLUSION

Emergency physicians should be aware of the association between varicella and serious GABHS infections and be prepared to recognize and aggressively manage serious complications should they occur.

The role of circulating cells in the healing of vascular prostheses

PURPOSE

Cells covering the flow surface of vascular prostheses are derived in part from endothelium of adjacent native artery and from capillaries that extend through the pores of the graft. This study is designed to determine whether these endothelial-like cells can also originate from circulating blood cells and if so to identify them with protein markers.

METHODS

Pledgets of vascular graft material were suspended within the aortas of dogs with metal stents that isolated the pledgets from the aortic wall. Explanted pledgets were examined for cells containing factor VIII-related antigen and other markers identified with monoclonal antibodies.

RESULTS

A monolayer of cells that stained positive for factor VIII formed on pledgets after 7 days. Pledgets removed after 55 days had endothelial cells, smooth muscle cells, macrophages, monocytes, and capillary-like structures which were identified by staining for the monoclonal antibodies 43 beta E3 (vimentin), HHF35 (alpha and gamma muscle actin), CGA7 (smooth muscle actin), and HAM56 (macrophage). Woven and knitted polyester and extruded polytetrafluoroethylene pledgets healed in a similar manner.

CONCLUSION

The origin of the cells identified is speculative but they appear to have been derived from circulating cells, possibly stem cells, which are capable of differentiation because the pledgets on which the cells were identified were isolated from aortic wall endothelium and perivascular capillaries.

Experience of an interdisciplinary pediatric pain service

This article is a report of our experience with an interdisciplinary pain service in a large tertiary care pediatric hospital. During the first 2 years of operation, we received 869 consultations and referrals from more than 19 hospital divisions. Postoperative pain was the most frequent reason for consultation (56% of patients). Patients with pain related to cancer and sickle cell disease comprised 25% of the consultations. The remaining patients had a wide variety of primary diagnoses and causes of pain. We calculated the time spent by pain service physicians in direct patient care. The majority (63%) of physician time was spent with a small number of patients (17%). Most of these patients had pain that was unrelated to surgery, cancer, or sickle cell disease, and many posed dilemmas in diagnosis and treatment. Physician time was correlated directly to the use of psychologic and physical therapies for the pain, involving multiple team members. This experience supports the demand for an interdisciplinary pain service in a tertiary care children's hospital. A significant amount of physician time is necessary to provide patient care and to maintain a team approach, however, and pediatricians and other health care professionals who aim to implement such services should be cognizant of the time required.

Coronary bypass surgery improves survival in high-risk unstable angina. Results of a Veterans Administration Cooperative study with an 8-year follow-up. Veterans Administration Unstable Angina Cooperative Study Group

To identify high-risk subgroups, 468 patients with unstable angina were prospectively stratified according to the clinical presentation of unstable angina (type I or type II) and left ventricular function (normal or abnormal) and were randomized to conventional medical therapy or surgical treatment with coronary bypass surgery. Type I patients (n = 374) were those who had progressive effort angina or recent angina at rest. Type II patients (n = 94) were those who had severe rest angina associated with ST-T changes on the electrocardiogram. Follow-up for 8 years showed that the cumulative mortality rates for type II patients with abnormal left ventricular function were significantly lower in the surgical patients compared with the medical cohorts (13% versus 46%, p less than 0.04). In the other subgroups, cumulative medical and surgical mortality rates were not different. Thus, type II patients with abnormal left ventricular function appear to be the subgroup of patients who are at the highest risk with medical therapy. Coronary bypass surgery significantly reduces the mortality in this high-risk subgroup of patients with unstable angina.

Effect of necrotizing enterocolitis on urinary epidermal growth factor levels

The pattern of urinary epidermal growth factor/creatinine levels in necrotizing enterocolitis was examined in 75 infants (in 28 infants the diagnosis of necrotizing enterocolitis was considered; 47 infants were studied for effect of surgery or nutrition on epidermal growth factor levels). There was a consistent and significant increase in epidermal growth factor/creatinine values at the time of diagnosis of necrotizing enterocolitis compared with baseline values. Epidermal growth factor levels in infants without necrotizing enterocolitis and in early nutrition remained unchanged. These results suggested that urinary epidermal growth factor/creatinine levels may differentiate stage II and III necrotizing enterocolitis from stage I disease. The increased epidermal growth factor/creatinine levels may be related to the absorption into the circulation of preexisting gastrointestinal tract epidermal growth factor through damaged tissue or to increased synthesis by the gastrointestinal tract in response to the injury caused by necrotizing enterocolitis.

The present attitude toward the biology and technology of limb lengthening

Over the past ten years, many technical innovations and biologic concepts have appeared as they relate to the lengthening of long bones. Each of these has had a substantial influence upon the approach to the treatment of major discrepancies in limb length and angular deformities. It is the purpose of this paper to present these issues as objectively as possible so that the reader can put them into proper perspective, recognizing that there will be some degree of bias in the implementation of some of the technical devices. To appreciate the utility of these techniques, it is necessary to understand the biologic foundation of each method as well as its advantages and disadvantages.

Developmental pattern of urinary epidermal growth factor in the premature infant and the influence of gender

We report the cross-sectional pattern of first day urinary epidermal growth factor/creatinine (EGF/Cr) levels in 159 appropriate for gestational age infants born at 26-41 weeks gestation. EGF/Cr levels rose significantly earlier in female infants than levels in male infants. In female infants levels were similar to term levels beginning at 30-32 weeks. Mean EGF/Cr levels in male infants were similar to term values beginning at 32-34 weeks. We could not demonstrate any influence from acute perinatal events on EGF/Cr levels. In a subset of 28 infants, a weekly longitudinal study of urinary EGF/Cr levels was undertaken. The urinary EGF/Cr pattern correlated significantly with both corrected gestational and postnatal ages. A significant change in the EGF/Cr pattern was observed at a corrected gestational age of 32 weeks and at 4 weeks postnatal age. There was no significant difference in EGF/Cr levels between males and females. Our results demonstrated a significant difference in first day urinary EGF/Cr levels between female and male preterm infants during the early third trimester. This difference was seen at a time in gestation when other gender-specific maturational and growth differences are noted. When infants born at less than 32 weeks gestational age were followed longitudinally, the urinary EGF/Cr pattern, when expressed by corrected gestational age, was significantly modified from that in the cross-sectional study.