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Severity of injuries from air-powered weapons can be underappreciated. Transformation of these weapons into toys makes them available to children. Our experience reveals the underestimated injury severity and emphasizes need for prompt trauma evaluation. Retrospective chart review of children sustaining air-gun injuries and evaluated at a single, pediatric hospital from 1991 to 2002 was performed. Medical record numbers were retrieved from a trauma data base. Data included age, weapon type, firing distance, injury site, radiographic studies, operative intervention, length of stay, and long-term disability. Ocular injuries were excluded secondary to known severity. All other injuries and treatments are described. Thirty-four children, average age 10 years +/- 3.3 years, sustained 35 injuries from 1991 through 2002. Twenty-one children required admission, 19 children required surgery, and 5 children experienced long-term disability. Average time to definitive care was 3 hours 12 minutes. Sites of injury included head, neck, chest, abdomen, and extremities. Average hospital stay was 4.3 days. In the pediatric population, air-gun injuries can be underestimated. Lack of collateral tissue damage makes wounds appear innocuous to unsuspecting medical personnel resulting in delayed care. During initial evaluation, injuries from air guns deserve the same respect as those caused by conventional firearms.

Cost reduction in the management of common surgical diseases such as appendicitis has become paramount for the survival of children's hospitals. We designed a clinical pathway to treat appendicitis with the goal of reducing cost and hospital length of stay (LOS) while maintaining quality of care. From September 1995 through December 1996, patients with nonperforated appendicitis (NPApp) and perforated appendicitis with peritonitis (PApp) were enrolled into a clinical pathway. NPApp patients were discharged when tolerating a regular diet. PApp patients were discharged if the following criteria were met: temperature < 38.5 degrees C for 24 hours, WBC < 14,000 on postoperative day 3, tolerating diet, and transition to oral analgesics accomplished. Hospital LOS and actual hospital costs in pathway patients were compared with those of historic controls. Patients with appendicitis from the Pediatric Health Information Systems (PHIS) database, a consortium of 20 children's hospitals in the United States, served as concurrent controls. Hospital LOS and hospital charges in PHIS NPApp and PApp patients from our institution were compared with national PHIS database patients. Mean LOS and hospital costs for both NPApp and PApp pathway patients were significantly decreased compared with historic controls (P < 0.05). Mean LOS and hospital charges in our institution's PHIS NPApp and PApp patients were also significantly decreased compared with the national PHIS database (P < 0.05). Innovative approaches such as these are necessary for the survival of children's hospitals in an increasingly cost competitive healthcare market.

Malrotation in the neonate is an anomaly for which there are clear indications for surgery. However, the management of the older patient with this entity is not well defined. At Arkansas Children's Hospital, we reviewed our patients who were older than two years of age with malrotation. Between 1978 and 1993, 22 cases ages 2-23 years were identified. The most common presenting symptoms were vomiting 15 (68%), colicky abdominal pain 12 (55%), and diarrhea 2 (9%). Other symptoms were hematemesis 1 (5%), and constipation 1 (5%). The duration of symptoms averaged 28 months, range 2-96 months. All diagnoses were made by upper gastrointestinal (UGI) series, except for one that was recognized during an exploratory laparotomy for an intestinal duplication. A Ladd's procedure with appendectomy was performed in all cases. A significant number of patients in our series (41%) were found to have either a volvulus or internal hernia at exploration that was not clearly demonstrated by the diagnostic studies. Intestinal resection was performed in two patients for ischemic bowel. There were no perioperative deaths. Postoperative complications consisted of a wound infection in one patient. Total relief of symptoms occurred in 64% of patients. All patients with volvulus or internal hernia had resolution of symptoms, and all patients reported partial relief of their chronic symptoms. Surgical therapy eliminates the possibility of loss of bowel from volvulus or internal hernia, which is not always evident on diagnostic radiographic examination. Surgery is also highly effective in alleviating the chronic symptoms in these children. We believe, therefore, that surgical treatment is clearly indicated in the older child with proven malrotation.

Four patients underwent preoperative chemotherapy and radiotherapy for Wilm's tumor, and three were without pathological diagnosis. Three of the four are currently free of disease. Patients with massive abdominal tumors and with the clinical and radiological characteristics of Wilm's tumor should receive preoperative chemotherapy and radiation. This treatment plan should provide the best chance of resectability and will, it is hopes, improve the chance of survival in these children.

Pancreas divisum, a congenital variant of pancreatic ductal anatomy first described by Opie in 1903, has only recently been thought of as a cause of pancreatitis. The majority of reported patients presenting are middle-aged, with the exact pathogenesis not clearly understood. The reason for this late clinical presentation of a congenital abnormality is also not clear. However, reports of children with recurrent pancreatitis and an associated pancreas divisum have now appeared. None had any identifiable cause of pancreatitis. Pancreas divisum was diagnosed or suspected preoperatively in two, with findings on endoscopic retrograde cholangiopancreatography (ERCP) and gastroduodenoscopy. All findings were confirmed at operation. All underwent surgical treatment with good results within 6 months. Review of the literature showed eight patients younger than 18 years with pancreas divisum and pancreatitis requiring operation. All had good results after surgical repair. It appears that this anomaly can be associated with recurrent pancreatitis in children. Children with recurrent pancreatitis with no obvious cause should be evaluated for pancreas divisum and, if it is found, be surgically treated. The role of ERCP, while not clearly defined, may become critical in the evaluation of pancreas divisum in children.

Since 1972, 34 patients with refractory metabolic alkalosis have been treated with intravenous hydrochloric acid at the teaching hospitals of the Medical College of Georgia. Intravenous hydrochloric acid lacks some of the problems associated with alternative methods of therapy. The acid must always be given through a central vein, and its effects should be monitored closely. The use of intravenous hydrochloric acid is a safe, effective way of preventing the deleterious effcts of severe metabolic alkalosis.

Twenty-five newborn infants were treated for gastroschisis between 1971 and 1979 at the Eugene Talmadge Memorial Hospital. Primary closure of the defect was accomplished in 17 patients and eight required staged procedures with Silon. The overall mortality rate was 32 per cent. The major causes of death were related to the status of the bowel at the initial procedure as well as weight and body temperature on admission. Respiratory function was not influenced by the type of repair. Since gut dysfunction in the postoperative period is likely to be prolonged, total parenteral nutrition continues to play a major role in survival.