Impact of Prehospital Pain Management on Emergency Department Management of Injured Children

OBJECTIVE

Provision of analgesia for injured children is challenging for Emergency Medical Services (EMS) clinicians. Little is known about the effect of prehospital analgesia on emergency department (ED) care. We aimed to determine the impact of prehospital pain interventions on initial ED pain scale scores, timing and dosing of ED analgesia for injured patients transported by EMS.

METHODS

This is a planned, secondary analysis of a prospective multicenter cohort of children with actual or suspected injuries transported to one of 11 PECARN-affiliated EDs from July 2019-April 2020. Using Wilcoxon rank sum for continuous variables and chi-square testing for categorical variables, we compared the change in EMS-to-ED pain scores and timing and dosing of ED-administered opioid analgesia in those who did and those who did not receive prehospital pain interventions.

RESULTS

We enrolled 474 children with complete prehospital and ED pain management data. Prehospital interventions were performed on 262/474 (55%) of injured children and a total of 88 patients (19%) received prehospital opioids. Children who received prehospital opioids with or without adjunctive non-pharmacologic pain management experienced a greater reduction in pain severity and were more likely to receive ED opioids in higher doses earlier and throughout their ED care. Non-pharmacologic pain interventions alone did not impact ED care.

CONCLUSIONS

We demonstrate that prehospital opioid analgesia is associated with both a significant reduction in pain severity at ED arrival and the administration of higher doses of opioid analgesia earlier and throughout ED care.

A survey of US and Canadian hospitals' paediatric massive transfusion protocol policies

BACKGROUND

Trauma is the leading cause of death in children >1 year of age, with haemorrhage as the most common cause of medically preventable deaths. While massive transfusion protocols (MTPs) have been investigated and used in adults to reduce death from haemorrhage, there are a paucity of published data on MTP practices and outcomes in children. This study aimed to survey current MTP policies and the frequency of activation at paediatric care centres.

STUDY DESIGN AND METHODS

We conducted a survey of MTPs at hospitals in the United States and Canada, including children's general hospitals, children's specialty hospitals and children's units in general hospitals. We collected information on how the MTP is activated, what therapeutics are given, frequency of its use, and how it is audited for compliance.

RESULTS

Forty-six survey responses were analysed. Physician discretion was the most common activation criteria (89%). A majority of sites (78%) targeted a 'high' (≥1 : 2) ratio of plasma to red blood cells (RBC). Fifteen percent of sites use antifibrinolytics in their MTPs. Eighty nine percent of sites have type-O RBC units and 48% of sites had thawed plasma units stored in an immediately available location.

CONCLUSION

There is a wide variation in MTPs among paediatric hospitals with regard to both activation criteria and products administered. This underscores the need for future prospective studies to determine the most effective resuscitation methods for paediatric populations to improve outcomes and therapeutic safety for massive bleeding.

Development of cell lines from the sheep used to construct the CHORI-243 Ovine BAC library

Two cell lines, designated MARC.OVSM, and MARC.OKF, were initiated from the aorta and kidney, respectively, obtained from the Texel ram used to make the CHORI-243 Ovine BAC library. These cell lines have been submitted to the NIA Aging Cell Repository at the Coriell Cell Respositories, Camden, NJ, USA, and will be made publicly available.

Hirschsprung disease in an infant with a contiguous gene syndrome of chromosome 13

Hirschsprung disease is a developmental disorder resulting from the arrest of the craniocaudal migration of enteric neurons from the neural crest along gastrointestinal segments of variable length; see Behrman [Nelson textbook of pediatrics, 1992:954-956]. It is a heterogeneous disorder in which familial cases map to at least three loci whose function is necessary for normal neural crest-derived cell development. Homozygous mutations in the endothelin-B receptor gene (EDNRB) on 13q22 have been identified in humans and mice with Hirschsprung disease type 2 (HSCR2). The auditory pigmentary disorder, Waardenburg-Shah syndrome, comprises Waardenburg syndrome and Hirschsprung disease and has also been mapped to the EDNRB locus. Hirschsprung disease, malrotation, isochromia, a profound sensorineural hearing loss, and several other anomalies were found in an infant with an interstitial deletion of 13q, suggesting the existence of a contiguous gene syndrome involving developmental genes necessary for the normal growth of the neural crest derivatives of the eye, inner ear, and colon. We report on an additional patient with a deletion in 13q and Hirschsprung disease. Congenital anomalies associated with deletions of the distal long arm of chromosome 13 are sufficiently consistent to suggest a clinical syndrome.

Regional mapping panels for human chromosomes 1, 2, and 7

The NIGMS Human Genetic Cell Repository has assembled regional mapping panels for human chromosomes 1, 2, and 7 from human rodent somatic cell hybrids submitted to the collection by researchers from 14 different laboratories. All hybrids were characterized initially by the submitters and verified by the Repository. Each hybrid carries a stable defined human segment as a derivative or deletion chromosome. These panels define 8-10 intervals for each chromosome. The panel for chromosome 2 is a new resource. The panels for chromosomes 1 and 7 complement previously published panels. The Repository distributes these regional mapping panels as cell cultures or as DNA. Information about these panels as well as for panels for chromosomes 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 21, 22, 22, and X may be viewed in the NIGMS Repository electronic catalog (http://locus.umdnj.edu/nigms).

Idiopathic thrombocytopenic purpura presenting in a high school football player: a case report

OBJECTIVE

To alert athletic trainers to the signs and symptoms of idiopathic thrombocytopenic purpura and its clinical presentation in order to facilitate immediate intervention.

BACKGROUND

Idiopathic thrombocytopenic purpura (ITP), also known as immune thrombocytopenic purpura, is a hemorrhagic disorder that is primarily immunologic in origin but is sometimes triggered by viral infection in children. It has also been associated with heroin and quinine drug use. A reduced platelet count can result in mucosal or deep tissue bleeding, or both, and most importantly, intracranial bleeding. Because football is a collision sport, it is imperative that any player presenting with ITP-type symptoms be removed immediately from all contact and referred to a physician.

DIFFERENTIAL DIAGNOSIS

Leukemia, aplastic anemia, drug side effects, vitamin deficiency, kidney failure, infection, multiple contusions.

TREATMENT

The traditional first-line treatment consists of corticosteroid medication and time and removal from all physical activities until the blood platelet count is normal and controlled. In quinine-induced ITP, discontinuation of the drug and bedrest are recommended to reduce the risk of major hemorrhage for a 12-to 14-hour period in order to allow the quinine to clear the system and the platelet count to return to normal.

UNIQUENESS

ITP's presentation needs to be differentiated from other disorders. Incorrect diagnosis could seriously jeopardize the athlete, who could develop intracranial and internal bleeding.

CONCLUSIONS

Recognition of the signs and symptoms associated with ITP is essential to prevent further participation by the athlete. Immediate intervention is needed to determine the severity and to institute appropriate treatment.

Complete replication of human sperm genome in egg extracts from Xenopus laevis

To examine the ability of Xenopus egg extracts to support a complete replication cycle of human sperm genome, demembranated human spermatozoa were incubated with the extract from activated Xenopus laevis eggs. Most sperm heads were decondensed within 15 min. The heads became round within 30 min with diameters of 10-30 microns. The process of DNA replication in the pronuclei was monitored by two methods, bromodeoxyuridine incorporation and flow cytometry. The results indicate that DNA replication was initiated approximately 1.5 h after membrane structure formation and that it lasted up to 9 h. The amounts of DNA in most pronuclei were doubled by 4-9 h, depending on which donor toad was the source of the egg extract. Inclusion of the protein synthesis inhibitor, cycloheximide (100 micrograms/ml), had no obvious effect on human sperm DNA replication but appeared to prevent the pronuclei from degradation after a prolonged period (> 6 h) of incubation. After storage in liquid nitrogen for > 1.5 mo, the efficiency of the egg extracts in supporting sperm head decondensation and DNA replication was reduced for human sperm but not for Xenopus sperm. Possible applications of the use of Xenopus egg extract for human sperm activation and DNA replication are discussed.

Upstaging of non-Hodgkin's lymphoma in a child based on 67Gallium scintigraphy

PURPOSE

To describe a patient whose non-Hodgkin's lymphoma (NHL) appeared to be localized by standard modalities but who was upstaged after Gallium scintigraphy suggested disseminated disease.

PATIENT AND METHODS

A patient with biopsy proven NHL in the maxillary sinus was staged as having localized disease based on computed tomography (CT) scans, bone scintigraphy, and evaluation of bone marrow and spinal fluid. Open biopsy of a bony lesion, standard modalities for lymphoma staging, and Gallium scintigraphy were obtained.

RESULTS

Gallium scanning showed bony lesions not previously seen with the standard modalities. Open biopsy of one of these lesions confirmed disseminated disease.

CONCLUSIONS

Gallium scanning aids in the early identification of metastases in some patients with NHL and should be included in a standard evaluation of apparently localized disease.

Regional mapping panels for chromosomes 3, 4, 5, 11, 15, 17, 18, and X

The NIGMS Human Genetic Mutant Cell Repository collects and distributes well-characterized human/rodent somatic cell hybrid regional mapping panels for human chromosomes 3, 4, 5, 11, 15, 17, 18, and X. Each regional mapping panel consists of 4 to 11 hybrids that divide the chromosome into 5 to 11 intervals. These panels have been extensively characterized by the submitters and the NIGMS Repository.

Adeno-associated virus vectors for vascular gene delivery

A variety of delivery systems have been used to genetically modify vascular endothelial cells and smooth muscle cells (SMCs), but currently available systems suffer from either inefficient in vivo gene transfer, transient episomal vector expression, or significant immune responses and inflammation. In the present study, we evaluated an alternate vector system, recombinant adeno-associated virus (rAAV) for transduction of vascular cells in culture and in vivo. Primary cultures of rabbit, monkey, and human SMCs; macaque and human microvascular endothelial cells; and human umbilical vein endothelial cells were efficiently transduced at a dose of 100 to 1000 DNase-resistant particles per cell. rAAV-mediated transduction of the vasculature in vivo was observed after intraluminal gene delivery or after intra-adventitial injection in carotid arteries of atherosclerotic cynomolgus monkeys. Whether vector delivery was intraluminal or adventitial, transduction was observed in the adventitia, particularly within microvessels (vasa vasorum) but not in cells of the intima or media. Transduction of adventitial microvessels was enhanced by balloon injury 4 days before gene transfer. This was particularly true for adventitial delivery. We have previously shown that adventitial cell proliferation increases significantly 4 days after balloon injury (45%) in this animal model. Together, these data suggest that cell proliferation may enhance AAV transduction in vivo in the vasculature. AAV vectors exhibited a tropism in vivo for the microvascular endothelium at the doses used in the present study, which may provide the opportunity for targeting gene delivery. In summary, we have demonstrated the utility of rAAV vectors for ex vivo vascular cell gene delivery and present an initial experience with rAAV for in vivo vascular gene delivery. This alternate vector system may overcome some of the limitations hampering the development of gene therapy for vascular disorders.

[Congenital tarsal synostosis]

Tarsal coalition results from the fusion of at least two tarsal bones. The clinical and radiological pictures depend on the anatomic location of the coalition. Calcaneonavicular and talonavicular coalitions are the most frequent features which may result in peroneal spastic flat foot; however they are symptomless in most cases. Tarsal coalitions are usually evident on plain X-ray films using appropriate incidences. In selected cases, partial talocalcaneal coalition requires CT scan or MRI. No treatment is needed for asymptomatic conditions. Painful spastic flat foot must be treated conservatively by limiting sport activity as a first step treatment. In case of persistent symptoms, cast with correction of deformities under general anesthaesia is recommended. Surgery is needed only in case of failure of previous treatment, requiring resection of the bony bridge and sometimes triple foot arthrodesis.

Ready, set, go! Sports medicine on and off the field

Team and event physicians can play an important role in ensuring the medical safety of a sports event by several actions: analyzing common injuries particular to a sport and planning accordingly in terms of equipment and procedures, establishing a hierarchy of the team's staff (ie, who has the authority to take a player out of the game), organizing medical equipment, establishing communication among the support personnel, considering crowd-control techniques for large events, arranging accessible transportation to a nearby medical facility, and being alert to possible dangerous weather conditions. Athletes will be safer, physicians more secure, and sports events more successful if these precautions are primary.

Gender and interest in academic careers among first- and third-year residents

BACKGROUND

While increasing proportions of medical students and residents are women, the proportion of women in the advanced ranks of medicine remains small. This study describes gender differences among residents concerning interest in academic medicine and related influences.

METHOD

A survey instrument was mailed to all 308 first- and third-year residents at the University of Washington School of Medicine in the late summer of 1993. The survey assessed interest in academic careers, values, psychological traits, exposure to mentoring, and perceived role stress. Frequency analysis and chi-square analysis were performed to compare the distribution responses by gender within the entire respondent group and within the first-year and third-year subgroups.

RESULTS

A total of 180 (58%) of all first- and third-year residents responded; 99 (55%) were men. Although the level of interest in academic careers was similar among first-year male and female residents, the level of interest was greater among third-year men than among third-year women. Women overall were less likely to consider it personally important to achieve national recognition. Women in the third (but not the first) year of residency were significantly less likely than men to agree that leading others was personally important to them. Women reported feeling less confident, were less likely to have identified a faculty member who had successfully balanced career and personal life, and were significantly more likely to feel under stress and to have interrupted their careers for childbearing.

CONCLUSION

The interest in academic careers appeared to be lower among third-year female residents than among third-year male residents, despite the similar interests in academic medicine among male and female first-year residents. Increasing role stress among women in training may explain the reduced interest in leadership and academic careers among women at more advanced levels of training.

The 18q- syndrome: analysis of chromosomes by bivariate flow karyotyping and the PCR reveals a successive set of deletion breakpoints within 18q21.2-q22.2

The 18q- syndrome is one of several terminal deletion disorders that occur in humans. Previous G-banding studies suggest that the loss of a critical band, 18q21.3, results in mental retardation, craniofacial anomalies, and metabolic defects. However, it is difficult to reconcile the consistent loss of a single region with the large variability in clinical phenotype. The purpose of this study was to reassess the extent of chromosomal loss in a cohort of 17 18q- syndrome patients by using fluorescent-activated chromosome sorting, PCR, and FISH. Bivariate flow karyotypes revealed heterogeneity among the deletions; they ranged in size from 9 to 26 Mb. To confirm this heterogeneity at a molecular level, deleted and normal chromosomes 18 of six patients were collected by flow sorting, preamplified by random priming, and assayed for marker content by the PCR. This analysis defined five unique breakpoints among the six patients. We conclude that the terminal deletions in the 18q- syndrome occur over a broad region spanning the interval from 18q21.2 to 18q22.2. Our results suggest that the variability in clinical phenotype may be more representative of a contiguous-gene syndrome with a baseline deficit of 18q22.2-qter than of the loss of a single critical region within 18q21.3.

Alanine-scanning mutagenesis of the epidermal growth factor-like domains of human thrombomodulin identifies critical residues for its cofactor activity

Thrombomodulin (TM) is an endothelial cell surface-bound cofactor in thrombin-dependent formation of activated protein C, a potent anticoagulant. Cofactor activity has been localized to the carboxyl-terminal half of the six epidermal growth factor-like (EGF) domains of TM (TME). To identify residues in TME that are critical for activity, 77 alanine point mutants were made between Cys-333 and Cys-462 by site-directed mutagenesis (all residues except Ala, Cys, Gly, and Pro). Mutants were expressed in Escherichia coli and cofactor activity measured directly in periplasmic extracts obtained by osmotic shock. Critical residues were defined as those which when mutated had less than 25% cofactor activity of a reference TME. Western blots of non-reduced samples confirmed that alanine substitutions did not significantly decrease expression levels or result in the formation of multimers. In EGF4, which is essential for protein C activation by the thrombin-TM complex, critical residues were: Asp-349, Glu-357, Tyr-358, and Phe-376. In EGF5-EGF6, critical residues within a proposed acidic thrombin-binding region were: Glu-408, Tyr-413, Ile-414, Leu-415, Asp-416, Asp-417, Asp-423, Ile-424, Asp-425, and Glu-426. A potential Ca(2+)-binding site, which is comprised of residues Asp-423, Asp-425, Glu-426, Asn-439, Leu-440, and Phe-444, was also identified and overlaps the thrombin-binding region. Asp-461, in the C-loop of EGF6 previously shown to be critical for thrombin binding, was also critical. Asp-398, Asp-400, Asn-402, and Asn-429 in EGF5 were also critical. Thus, rapid alanine-scanning mutagenesis of TME has identified 22 critical residues in the region comprising EGF4-6, which is essential for thrombin binding and protein C activation by the thrombin-TM complex.

Bone scan findings in craniometaphyseal dysplasia

Craniometaphyseal dysplasia is a rare genetic bone disorder characterized by undertubulation of the long bones, especially in the lower extremities, and sclerosis of the skull base. Differentiation from other sclerosing bone dysplasias, including metaphyseal dysplasia (Pyle's disease), craniodiaphyseal dysplasia, and diaphyseal dysplasia is based largely on characteristic radiographic findings. Radionuclide bone scans usually are not necessary for diagnosis, but are helpful in demonstrating the abnormal bone metabolism. The authors report the first whole-body bone images in a patient with craniometaphyseal dysplasia, demonstrating the abnormal bone activity over time.

Ultrasound diagnosis of immature cervical teratoma: a case report

We report a case of cervical teratoma in a term female infant born to a 20-year-old white woman. There are rare tumors in neonates, occurring in approximately 1 in 20,000 to 1 in 40,000 live births. These tumors are accurately defined by ultrasound. Although benign, cervical teratomas cause respiratory compromise. In this case the tumor was removed surgically with no recurrence at the 10-month follow-up.

Rapid determination of glomerular filtration rate in infants using Tc-99m DTPA

Glomerular filtration rate obtained by using Tc-99m DTPA was compared with that obtained from Schwartz's formula using serum creatinine and length in 21 infants (age range, 3 to 348 days). The GFR (mean +/- SD) obtained by Tc-99m DTPA was 76 +/- 37 ml/min per 1.73m2 and by the Schwartz formula was 83 +/- 49 ml/min per 1.73m2. GFR by Tc-99m DTPA method overestimated GFR by 3.6% compared to the Schwartz method. The imaging technique and the advantages are discussed.

Clastogenicity of lead chromate particles in hamster and human cells

Several insoluble compounds of chromium, such as lead chromate, are respiratory carcinogens in experimental animals and suspected to be so in humans. Lead chromate induces neoplastic transformation in cultured cells but the mechanism of genotoxicity is unknown. We examined the effect of lead chromate on the integrity of chromosomes of Chinese hamster ovary (CHO) and human foreskin fibroblasts (HFF) after a 24-h exposure. At 0.4 microgram/cm2, 0.8 microgram/cm2, 2 microgram/cm2 and 8 microgram/cm2 lead chromate particles reduced survival of CHO cells to 86%, 62%, 2% and less than 1% respectively. These concentrations induced a dose-dependent 4-19-fold increase in the percent metaphases with damage. The HFF cells exhibited higher sensitivity in both cytotoxicity and clastogenicity. The spectrum of damage observed for both cell types was primarily achromatic lesions affecting one or both chromatids. To test for particle dissolution effects, CHO cells were treated for 24 h with either clarified medium that had been incubated for 24 h with lead chromate particles, or clarified medium that had been pre-conditioned by CHO cells treated with lead chromate particles for 24 h. No damage was detected in these cells, indicating that extracellular dissolution into ionic lead and chromate did not contribute to the genotoxicity. This is consistent with a previous study in which scanning electron micrographs illustrated internalization of the particles. These results suggest that clastogenesis may be a mechanism for lead chromate induced carcinogenesis.

Baseline sister chromatid exchange in human cell lines with different levels of poly(ADP-ribose) polymerase

Poly(ADP-ribose) polymerase is a chromatin enzyme which adds long chains of ADP-ribose to various acceptor proteins in response to DNA strand breaks. Its primary function is unknown; however, a role in DNA repair and radiation resistance has been postulated based largely on experiments with enzyme inhibitors. Recent reports of mutant cell lines, deficient in poly(ADP-ribose) polymerase activity, have supported previous studies with inhibitors, which suggests the involvement of poly(ADP-ribose) polymerase in maintaining baseline levels of sister chromatid exchanges. Mutant cells with even slightly depressed enzyme levels show large elevation of baseline sister chromatid exchanges. Since intracellular poly(ADP-ribose) polymerase levels can vary greatly between different nonmutant cell lines, we surveyed levels of baseline sister chromatid exchange in normal and tumor human cell lines and compared them with endogenous levels of poly(ADP-ribose) polymerase. Despite 10-fold differences in poly(ADP-ribose) polymerase, the baseline level of sister chromatid exchanges remained relatively constant in the different cell lines (0.13 +/- 0.03 SCE/chromosome), with no indication of a protective effect for cells with high levels of the enzyme.

Neuroimaging findings in Alexander's disease

We present the findings from magnetic resonance imaging, computed tomographic scan, and single photon emission computed tomography of the brain in a 2-year-old girl with Alexander's disease. Computed tomographic scans showed prominent low-density white matter throughout the cerebral hemispheres. Magnetic resonance imaging showed increased T2 signal from the cerebral white matter but not the cerebellum or brain stem. Single photon emission computed tomography revealed diminished cerebral metabolism, particularly in the frontal regions, as compared with the cerebellum.

Ocular melanoma: detection using iodine-123-iodoamphetamine and SPECT imaging

Uptake of iodine-123-iodoamphetamine has been demonstrated in malignant melanoma using planar imaging techniques and has been used to detect an ocular melanoma at 12 hr postinjection. Using SPECT technique, an ocular melanoma is identified in a 64-yr-old male at 1 hr postinjection.

Absorption of Tc-99m pertechnetate from the augmented bladder during direct nuclear cystography

A retrospective review comparing bladder absorption of pertechnetate and Tc-99m sulfur colloid from the augmented bladder was performed. Based upon the author's findings, the routine use of Tc-99m sulfur colloid in this patient population is recommended to prevent the erroneous diagnosis of vesicoureteral reflux and miscalculation of GFR due to the presence of background soft-tissue and blood activity.

Arabinofuranosyl nucleosides induce common fragile sites

The capacities for fragile site induction of three inhibitors of semiconservative DNA synthesis and DNA repair synthesis, aphidicolin, arabinofuranosyl cytosine, and arabinofuranosyl adenosine were compared. Aphidicolin is known to induce type 4 fragile sites, the largest recognized group of common fragile sites. Although the modes of action of these inhibitors vary, both arabinofuranosyl analogs induce type 4 aphidicolin-sensitive fragile sites. An analysis of variance demonstrates that the three inhibitors are not equally capable of inducing significant breakage (P less than 0.01) at all type 4 fragile sites. Induction of type 4 fragile sites appears to be a general consequence of inhibition of DNA polymerization.

Gastric emptying in children with gastroesophageal reflux. II. The relationship to retching symptoms following antireflux surgery

Following antireflux surgery, children with persistent retching symptoms are presumably more likely to have delayed gastric emptying. We report 66 children between 2 weeks and 16 years of age who had an operation to control gastroesophageal reflux (GER). All patients had GER confirmed by 18- to 24-hour esophageal pH monitoring. Preoperative gastric emptying studies were performed in each patient with 99m-Tc sulfur colloid in apple juice. In addition to the percent gastric emptying (%GE), an effective gastric emptying was estimated by correcting the %GE for postcibal reflux (corrected %GE). Repeat 18- to 24-hour esophageal pH monitoring was performed postoperatively in all patients, and a repeat gastric emptying study was performed in 32 patients. After an average postoperative follow up of 6 months (range of 1 to 18 months), persistent retching was present in 12 (18%) patients. The retching was associated with dumping symptoms in six patients. Retching was seen in patients with a preoperative increase in effective gastric emptying (10/34, 29%, P less than .05) or a decrease in effective gastric emptying (2/15, 13%, NS), and not in patients with an effective gastric emptying within the control range (0/17, 0%). Postoperatively, retching with dumping symptoms was associated with an increased effective gastric emptying, and retching without dumping symptoms with a decreased effective gastric emptying. In conclusion, persistent retching followed anti-reflux surgery in children is related to extremes in effective gastric emptying. The preoperative measurement of corrected %GE identifies children at increased risk for this postoperative problem.

Chromosomal aberrations in irradiated Down's syndrome fibroblasts

We have compared the frequencies of chromosomal aberrations in skin fibroblasts from persons with Down's syndrome (trisomy 21) with those from normal diploid controls exposed to 60Co gamma-radiation in vitro. No difference between the chromosomal radiosensitivities of the two groups was observed, nor did the two groups differ in the background frequency of spontaneous aberrations. These data support the hypothesis that the increased in vitro chromosomal radiosensitivity of lymphocytes reported to be associated with trisomy 21 is not typical of all tissues.

Gastric emptying in children with gastroesophageal reflux. I. An estimate of effective gastric emptying

The association of gastroesophageal reflux (GER) and gastric emptying has been observed, but its importance is poorly understood. We compared 18- to 24-hour esophageal pH recordings with gastric emptying of radionuclide in apple juice in 109 children (2 weeks to 16 years old) referred for an evaluation of GER. A pH score and the pattern of GER (type I, II, and III) were obtained by esophageal pH monitoring. Gastric emptying was measured at 30 minutes (%GE30) and at 60 minutes (%GE60). The measured gastric emptying of apple juice was similar for the normal child and for those with GER regardless of pattern type. An inverse linear correlation between postcibal reflex and measured gastric emptying was demonstrated only by the eight asymptomatic children with a normal pH score (%GE30, r = -.9603, P less than .001; and %GE60, r = -.8263, P less than .05). If the contribution of postcibal reflux on gastric emptying was eliminated, then the effective gastric emptying was increased in many children with the type I (44%, P less than .05), type II (46%, P less than .05), or type III (60%, P less than .05) pattern of GER as compared with children with a normal reflux pattern (7%). In conclusion, measured gastric emptying of clear liquids is not necessarily decreased in most children with GER. Furthermore, many children with GER demonstrate an increased effective gastric emptying even though measured gastric emptying may not appear increased.

Dyskinetic cilia syndrome: clinical, radiographic and scintigraphic findings

The clinical, electron microscopic and radiographic data of 9 patients with dyskinetic cilia syndrome (DCS) are presented. Scintigraphic evaluation of mucociliary dynamics in six patients showed evidence of dyskinesia. Ventilation and perfusion studies were performed to evaluate obstructive lung disease. Retrospectively, bronchiectasis could be detected in 77% of the patients by analysis of the chest radiograph and lung scintigraphy, and bronchography potentially avoided in the seven patients who underwent this procedure.

Hepatoblastoma

Hepatoblastoma is a rare hepatic tumor generally presenting during the first three years of life as an enlarging abdominal mass. Other symptoms are nonspecific; however, it may be associated with hemihypertrophy, virilization, and osteoporosis. The serum bilirubin infrequently is elevated, but up to 2/3's will have elevated serum alpha fetoprotein as a tumor marker. The overall survival rate is 35% in survivors who underwent a complete resection.

Esthesioneuroblastoma imaged with bone scintigraphy

An esthesioneuroblastoma, a rare malignancy of the olfactory nerve, was identified with bone imaging in a four year old male who presented with a history of headaches and proptosis of the right eye. Correlation with CT is provided.

Extraosseous localization of technetium-99m MDP in benign cystic teratoma

Two cases of primary retroperitoneal benign teratoma, in which Tc-99m MDP localized in the primary tumor are presented. Localization of bone-imaging agents in neuroblastoma has been reported but, extraosseous localization of bone-imaging agents in teratomas has not been confirmed.