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Objective: To determine if injury grade (IG) influences outcome; need for operative intervention (OP), blood transfusion, or survival, following blunt pediatric liver (L) and spleen (S) trauma. Methods: A review of 111 children with 114 blunt liver/spleen injuries treated from 1989 to 1995. All hemodynamically stable patients were initially treated non-operatively (NONOP). Diagnosis (L-78, S-36) and grading (L-59, S-34) of injury was made by CT scan or at OP. IG, survival, ISS, hemodynamic stability, blood transfused, associated injuries were analyzed. Results are reported as means. Statistical analysis was performed using Kruskal-Wallis, ANOVA, and Chi-squared tests. Results: Age was 7.4 years, IG was 2.8, ISS was 11.5 and mean transfusion was 12 ml/kg of packed red blood cells (PRBC). 12 of 78 (15%) with liver injuries and 7 of 36 (19%) with splenic injury had OP. Mean IG of 2.8 in OP, was no different than NONOP (p=0.8). IG was similar in transfused vs. no transfusion, 2.8 vs. 2.7 (p=0.4), and in stable vs. unstable, 2.7 vs. 2.9 (p=0.8). Mean PRBC requirement was higher in OP vs. NONOP, 51 vs. 6 ml/kg (p=0.0001), and OP patients had a higher ISS, 17 vs. 10 (p=0.01). There were 77 patients (69%) with associated injuries of whom 15 died (none as a result of liver/spleen injury); and 34 (31%) isolated liver/spleen injuries, with one death. Death was associated with unstable hemodynamics (p=0.0005), a higher ISS, 23 vs. 9.7 (p=0.0005), and higher PRBC, 56 vs. 7 (p=0.0001), but not higher IG, 2.5 vs. 2.8 (p=0.3). Conclusion: Injury grade does not influence outcome following blunt pediatric liver and spleen trauma. Higher ISS, PRBC requirement, and hemodynamic instability predicted need for operation, as well as death., H Grewal MD(*), CW Wagner MD, RJ Jackson MD, SD. Smith MD, FAAP, D Parnell RN, MNSc, S Helmer PhD(*); (*)UKS of Medicine-Wichita, KS 67208 & Arkansas Children's Hospital, Little [...]

Introduction: Because of a more liberal radiographic diagnosis of malrotation, we have seen an increase in the number of Ladd's procedures performed for intestinal malrotation (IM). Concern with postoperative complications prompted a review of our recent experience with surgery for IM. Methods: Between January 1995 and July 1998, 117 children with a diagnosis of IM were retrospectively studied. Patients with abdominal wall defects or CDH were excluded. Results: Mean age at presentation was 22 months. There was a male preponderance (65%). Twenty-five patients (21%) had a history of prematurity. Associated congenital anomalies were present in 31 (26%), consisting of cardiac defects in 20 (17%) and chromosomal abnormalities in 11 (9%). Presenting symptoms included vomiting (79%), abdominal pain (26%) and difficulties with feeding (21%), breathing (21%) and stooling (15%). Emesis was nonbilious in two-thirds of the vomiting patients. UGI w/SBFT was the primary diagnostic study in 106 patients (91%). Fifteen patients had multiple UGI's because of uncertainty of the original diagnosis. A Ladd's procedure was performed in 111 patients (95%). Twenty-three complications occurred in 21 patients, and included small bowel obstruction (15), prolonged ileus (4), wound infection (2), evisceration (1), and pancreatitis (1). Nine deaths occurred; only one was related to IM with necrotic midgut. Reoperation was required in 11 of 15 patients with SBO, on average at POD 49 (range 3-289). Findings at reoperation included adhesive SBO (7), small bowel intussusception (3), and volvulus (2). Preoperative symptoms persisted in 16 patients. Ten had persistent vomiting secondary to GER; 3 of these required subsequent fundoplication. Conclusion: A surprisingly high rate of postoperative complications, particularly SBO, in children undergoing Ladd's procedure for IM was identified. This occurred in the setting of an increased number of children with a radiographic diagnosis of malrotation. A prospective study correlating radiographic and operative findings is ongoing to better define the indication for operation in children with IM., Northrop RC, MD, Wagner CW, MD, Smith SD, MD, FAAP, and Jackson RJ, MD; University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas [...]

It is of fundamental interest to research and develop innovative biotechnologies, as well as bioproducts that replace or are alternatives to those of non-renewable origin, such as biosurfactants in relation to traditional surfactants used in various sectors. Consequently, there are a large number of experimental studies addressing different subjects, especially with the use of bacteria of the genus Pseudomonas; however, there is a lack of work that demonstrates the evaluation of this science produced to date. Therefore, this article discusses the production of biosurfactants by Pseudomonas with the aim of surveying and analyzing experimental articles on this topic. To realize this, a systematic search was carried out with well-defined temporal space, databases, and inclusion and exclusion criteria, based on metric studies that guided what information would be collected and the method of evaluation. Therefore, a large number of articles were selected, which demonstrated Pseudomonas aeruginosa as the bioagent mostly used in the tests, which aimed to improve the process in the area. Furthermore, interest in this field has increased over the years, predominantly in emerging market countries, where the most prominent authors on the topic are found. Therefore, it is necessary that there is an expansion of interest in the area to make the production of biosurfactants cheaper in areas that currently have greater development deficiencies, such as means of purifying the bioprocess and reducing foam formation in the bioprocess., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

In this article, we propose an evolved system design approach to ultra-wideband (UWB) radar based on pseudo-random noise (PRN) sequences, the key features of which are its user-adaptability to meet the demands provided by desired microwave imaging applications and its multichannel scalability. In light of providing a fully synchronized multichannel radar imaging system for short-range imaging as mine detection, non-destructive testing (NDT) or medical imaging, the advanced system architecture is presented with a special focus put on the implemented synchronization mechanism and clocking scheme. The core of the targeted adaptivity is provided by means of hardware, such as variable clock generators and dividers as well as programmable PRN generators. In addition to adaptive hardware, the customization of signal processing is feasible within an extensive open-source framework using the Red Pitaya ® data acquisition platform. A system benchmark in terms of signal-to-noise ratio (SNR), jitter, and synchronization stability is conducted to determine the achievable performance of the prototype system put into practice. Furthermore, an outlook on the planned future development and performance improvement is provided.

In ultrasound nondestructive testing (NDT), a widespread approach is to take synthetic aperture measurements from the surface of a specimen to detect and locate defects within it. Based on these measurements, imaging is usually performed using the synthetic aperture focusing technique (SAFT). However, SAFT is suboptimal in terms of resolution and requires oversampling in the time domain to obtain a fine grid for the delay-and-sum (DAS). On the other hand, parametric reconstruction algorithms give better resolution, but their usage for imaging becomes computationally expensive due to the size of the parameter space and a large amount of measurement data in realistic 3-D scenarios when using oversampling. In the literature, the remedies to this are twofold. First, the amount of measurement data can be reduced using state-of-the-art sub-Nyquist sampling approaches to measure Fourier coefficients instead of time-domain samples. Second, parametric reconstruction algorithms mostly rely on matrix-vector operations that can be implemented efficiently by exploiting the underlying structure of the model. In this article, we propose and compare different strategies to choose the Fourier coefficients to be measured. Their asymptotic performance is compared by numerically evaluating the Cramér-Rao bound (CRB) for the localizability of the defect coordinates. These subsampling strategies are then combined with an l 1 -minimization scheme to compute 3-D reconstructions from the low-rate measurements. Compared to conventional DAS, this allows us to formulate a fully physically motivated forward model matrix. To enable this, the projection operations of the forward model matrix are implemented matrix-free by exploiting the underlying two-level Toeplitz structure. Finally, we show that high-resolution reconstructions from as low as a single Fourier coefficient per A-scan are possible based on simulated data and measurements from a steel specimen.

Naturally elevated contents of copper (Cu) and nickel (Ni) are found in soils worldwide, and their potential toxicity is better understood when geochemical reactive fractions are identified and monitored. Thus, this study aimed to assess the bioavailability of Cu and Ni and estimate environmental risks in naturally metal-enriched soils of Carajás Mining Province, Eastern Amazon, Brazil. For that, 58 surficial soil samples were analyzed for their extractable contents of Cu and Ni by Mehlich 1. Next, 13 soil samples were selected for additional single and sequential extractions, for the determination of metal content in the shoots of grasses naturally growing in these soils and for calculating the risk assessment code. Despite the naturally high total concentrations, the contents of easily available Cu and Ni are a minor fraction of total concentrations (up to 10.15%), and the reducible oxide and residual pools hold the major proportion of total content of metals. This contributed to low bioavailability, low environmental risk, and also to low concentrations of these metals on grasses collected in the field. Soil organic matter, Fe 2 O 3 , Al 2 O 3 and clay content have a dominant role in metals retention on studied soils. Our findings on the bioavailability of Cu and Ni in a region of great economic relevance for Brazil are important not only for predicting the elements' behavior in the soil-plant system but also for refining risk assessments and to provide useful data for environmental quality monitoring.

Background: Previous data have reported that the growth of established tumors may be facilitated by postsepsis disorder through changes in the microenvironment and immune dysfunction. However, the influence of postsepsis disorder in initial carcinogenesis remains elusive., Methods: In the present work, the effect of postsepsis on inflammation-induced early carcinogenesis was evaluated in an experimental model of colitis-associated colorectal cancer (CAC). We also analyzed the frequency and role of intestinal T regulatory cells (Treg) in CAC carcinogenesis., Results: The colitis grade and the tumor development rate were evaluated postmortem or in vivo through serial colonoscopies. Sepsis-surviving mice (SSM) presented with a lower colonic DNA damage, polyp incidence, reduced tumor load, and milder colitis than their sham-operated counterparts. Ablating Treg led to restoration of the ability to develop colitis and tumor polyps in the SSM, in a similar fashion to that in the sham-operated mice. On the other hand, the growth of subcutaneously inoculated MC38luc colorectal cancer cells or previously established chemical CAC tumors was increased in SSM., Conclusion: Our results provide evidence that postsepsis disorder has a dual effect in cancer development, inhibiting inflammation-induced early carcinogenesis in a Treg-dependent manner, while increasing the growth of previously established tumors., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Neutrophils are peripheral immune cells that represent the first recruited innate immune defense against infections and tissue injury. However, these cells can also induce overzealous responses and cause tissue damage. Although the role of neutrophils activating the immune system is well established, only recently their critical implications in neuro-immune interactions are becoming more relevant. Here, we review several aspects of neutrophils in the bidirectional regulation between the nervous and immune systems. First, the role of neutrophils as a diffuse source of acetylcholine and catecholamines is controversial as well as the effects of these neurotransmitters in neutrophil's functions. Second, neutrophils contribute for the activation and sensitization of sensory neurons, and thereby, in events of nociception and pain. In addition, nociceptor activation promotes an axon reflex triggering a local release of neural mediators and provoking neutrophil activation. Third, the recruitment of neutrophils in inflammatory responses in the nervous system suggests these immune cells as innovative targets in the treatment of central infectious, neurological and neurodegenerative disorders. Multidisciplinary studies involving immunologists and neuroscientists are required to define the role of the neurons-neutrophils communication in the pathophysiology of infectious, inflammatory, and neurological disorders., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

A high-density regional-scale soil geochemical survey comprising 727 samples (one sample per each 5 × 5 km grid) was carried out in the Parauapebas sub-basin of the Brazilian Amazonia, under the Itacaiúnas Basin Geochemical Mapping and Background Project. Samples were taken from two depths at each site: surface soil, 0-20 cm and deep soil, 30-50 cm. The ground and sieved (< 75 µm) fraction was digested using aqua regia and analyzed for 51 elements by inductively coupled plasma mass spectrometry (ICPMS). All data were used here, but the principal focus was on the potential toxic elements (PTEs) and Fe and Mn to evaluate the spatial distribution patterns and to establish their geochemical background concentrations in soils. Geochemical maps as well as principal component analysis (PCA) show that the distribution patterns of the elements are very similar between surface and deep soils. The PCA, applied on clr-transformed data, identified four major associations: Fe-Ti-V-Sc-Cu-Cr-Ni (Gp-1); Zr-Hf-U-Nb-Th-Al-P-Mo-Ga (Gp-2); K-Na-Ca-Mg-Ba-Rb-Sr (Gp-3); and La-Ce-Co-Mn-Y-Zn-Cd (Gp-4). Moreover, the distribution patterns of elements varied significantly among the three major geological domains. The whole data indicate a strong imprint of local geological setting in the geochemical associations and point to a dominant geogenic origin for the analyzed elements. Copper and Fe in Gp-1 were enriched in the Carajás basin and are associated with metavolcanic rocks and banded-iron formations, respectively. However, the spatial distribution of Cu is also highly influenced by two hydrothermal mineralized copper belts. Ni-Cr in Gp-1 are highly correlated and spatially associated with mafic and ultramafic units. The Gp-2 is partially composed of high field strength elements (Zr, Hf, Nb, U, Th) that could be linked to occurrences of A-type Neoarchean granites. The Gp-3 elements are mobile elements which are commonly found in feldspars and other rock-forming minerals being liberated by chemical weathering. The background threshold values (BTV) were estimated separately for surface and deep soils using different methods. The '75th percentile', which commonly used for the estimation of the quality reference values (QRVs) following the Brazilian regulation, gave more restrictive or conservative (low) BTVs, while the 'M MAD ' was more realistic to define high BTVs that can better represent the so-called mineralized/normal background. Compared with CONAMA Resolution (No. 420/2009), the conservative BTVs of most of the toxic elements were below the prevention limits (PV), except Cu, but when the high BTVs are considered, Cu, Co, Cr and Ni exceeded the PV limits. The degree of contamination (C deg ), based on the conservative BTVs, indicates low contamination, except in the Carajás basin, which shows many anomalies and had high contamination mainly from Cu, Cr and Ni, but this is similar between surface and deep soils indicating that the observed high anomalies are strictly related to geogenic control. This is supported when the C deg is calculated using the high BTVs, which indicates low contamination. This suggests that the use of only conservative BTVs for the entire region might overestimate the significance of anthropogenic contamination; thus, we suggest the use of high BTVs for effective assessment of soil contamination in this region. The methodology and results of this study may help developing strategies for geochemical mapping in other Carajás soils or in other Amazonian soils with similar characteristics.

The present study aimed to evaluate the chemical composition, antioxidant potential, and the cytotoxic and antimicrobial activity of the essential oil of the plant species Tithonia diversifolia (Hemsl) A. Gray. The essential oil obtained was used to identify the chemical compounds present through the techniques of GC-MS and NMR. The antioxidant potential was calculated by the sequestration method of 2,2-diphenyl-1-picrylhydrazyl. For cytotoxic activity, the larval mortality of Artemia salina was evaluated. The main chemical constituents identified are α pinene (9.9%), Limonene (5.40%), (Z) - β -ocimene (4.02%), p -cymen-8-ol (3.0%), Piperitone (11.72%), (E) -nerolidol (3.78%) and Spathulenol (10.8%). In the evaluation of the antimicrobial activity, bacterial strains of Staphylococcus aureus , Escherichia coli and Pseudomonas aeruginosa were used. The results showed that the bacterium E. coli were more susceptible to the presence of the essential oil, presenting minimal inhibitory concentration at the concentrations that were exposed. The essential oil presented antioxidant activity of 54.6% at the concentration of 5 mg·mL -1 and provided a CI 50 of 4.30. It was observed that the essential oil of this species was highly toxic against A. salina lavas, as its cytotoxic activity showed an LC 50 of 3.11. Thus, it is concluded that T. diversifolia oils are effective in inhibiting bacterial growth and reducing oxidative stress.

Background: Swallowing dysfunction after radiotherapy (RT) for head and neck cancer can be devastating. A randomized control trial compared swallow exercises versus exercise plus neuromuscular electrical stimulation therapy and found no overall difference in outcomes., Methods: Quality of life (QOL), diet, and swallowing variables collected at discrete intervals on 117 patients were reanalyzed to test the hypothesis that shorter time between the completion of radiotherapy and beginning of the swallowing therapy program yielded improved outcomes., Results: At baseline, subjects < 1 year post radiation had significantly better function than subjects >2 years post RT in several measures. Over the therapy program, the early group showed significant improvement in diet and QOL. Swallowing physiologic variables showed no difference between groups., Conclusion: Beginning a swallowing therapy program within 1 year of completion of radiotherapy demonstrates more consistent improvement in QOL and diet performance compared to later periods., (© 2019 Wiley Periodicals, Inc.)

This experiment was conducted to evaluate the effect of different levels of substitution (0, 33.3, 66.7, and 100 %) of elephant grass by hay of mango tree pruning (HMTP) on intake and digestibility in cattle and on the in vitro gas production. Moreover, the effect of tannin in HMTP on the gas production and in vitro degradability of the dry matter was evaluated, using polyethylene glycol (PEG). The intake and digestibility were evaluated in a double 4 × 4 square Latin design, using eight Holstein intact bulls. To evaluate the gas production and degradability, in vitro semi-automated gas production technique was used. The substitution of elephant grass by HMTP decreased the intake (P<0.05) and the digestibility (P<0.05) of the nutrients and also the gas production (P<0.05). Furthermore, the utilization of PEG as a tannin-complexing agent increased the gas production and degradability of the HMTP (P<0.05). It was concluded that the high cell wall lignification and the presence of tannin limit the use of HMTP as the only source of roughage in cattle diets.

Recent reports describing a rise in serious allergies and life-threatening reactions have prompted the need for pediatric nurse practitioners to re-evaluate and hone their clinical skills with regard to the recognition of anaphylaxis. An accredited symposium entitled, "Anaphylaxis in the Pediatric Patient: Optimizing Management and Prevention" was held in conjunction with the 2012 Annual Conference of the National Association of Pediatric Nurse Practitioners. This article is an accredited enduring activity from that symposium. Goals of this activity are to (a) provide participants with information regarding current trends in serious allergies and anaphylaxis, (b) discuss recommendations from clinical guidelines designed to standardize practice, and (c) address medical and educational needs of patients with anaphylaxis. This article focuses on the point of care where pediatric nurse practitioners require the diagnostic skills to determine whether a patient's acute symptoms are consistent with a diagnosis of anaphylaxis and whether epinephrine should be used to treat those symptoms. The rationale for the use of intramuscular epinephrine, insights into the development and execution of an emergency action plan, and patient education also are discussed., (Copyright © 2013 National Association of Pediatric Nurse Practitioners. Published by Mosby, Inc. All rights reserved.)

Background/purpose: Lipoblastoma/lipoblastomatosis, a rare benign pediatric tumor composed of embryonic fat, most often presents as a rapidly growing mass in children younger than 3 years. This benign tumor locally recurs up to 25% of the time. This retrospective review was done to emphasize problems with diagnosis, management, and the approach to follow-up care., Methods: Sixteen cases of pathologically proven lipoblastoma presenting to a single institution over a 16-year period (1988-2004) were reviewed retrospectively for clinical features and outcome., Results: There were 11 males and 5 females ranging in age from 18 days to 12.75 years. Preoperative diagnoses were accurate in only 3 cases. Two lesions recurred locally over a period of 10 months and 5 years. One lesion presented with local infiltration. Six lesions were right-sided, 5 were left-sided, and 5 were midline., Conclusions: It is important to consider lipoblastoma in the diagnosis of a rapidly enlarging fatty mass in children. Complete resection is the only definitive treatment and should not be delayed when impingement on surrounding structures is imminent. There is a tendency for these lesions to recur despite presumed complete excision. Therefore, follow-up for a minimum of 5 years is recommended.

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.

The process of asthma includes swelling, bronchoconstriction, and excess mucus production driven by the redundant nature of the inflammatory process. Untreated or undertreated, this process has the potential to cause airway remodeling and the permanent loss of pulmonary function. It is essential that all health care professionals involved in the care of patients with asthma have as their major goal the treatment and prevention of the inflammatory process.

Objective: Since the introduction of a preformed silo to the authors' practice in 1997, there has been a decrease in primary closure of gastroschisis. To clarify the impact of this change, the authors reviewed their results over the past 10 years., Methods: From patient records, the authors abstracted the closure method, mechanical ventilation days, time to full feeds, mechanical and infectious complications, and length of stay. The authors compared groups using the Student t test and the Mann-Whitney test, as appropriate., Results: Between 1993 and the present, 124 patients were identified. Between 1993 and 1997, 38 children presented with gastroschisis. Thirty-two (84.2%) closures were primary and six (18.8%) were staged. After 1997, the authors treated 80 children with gastroschisis. There were 27 (33.8%) primary and 53 (66.2%) staged closures. Six patients with other lethal anomalies were excluded. Length of stay and ventilator days were higher for the staged closure group, but infection and mechanical complications were less common in the staged closure group. The time to full feeds did not differ., Conclusions: A lower incidence of infection and complications related to abdominal compartment syndrome has made staged closure of gastroschisis more common in the authors' practice. While it has resulted in a longer hospital stay, staged closure decreases the risk of long-term bowel dysfunction and need for reoperation.

Background: "Atypical Malrotation" has been increasingly diagnosed at the authors' institution., Methods: The authors reviewed retrospectively 201 consecutive operations for malrotation over 5 years to anatomically classify, and describe results of operation for, atypical malrotation. The ligament of Treitz (LOT) was classified as high if left of midline and above the 12th thoracic vertebra, low if left of midline and below the 12th thoracic vertebra, and typical if absent or right of midline., Results: A total of 201 patients underwent operation for malrotation, in 176 there were adequate radiologic studies to allow classification of the LOT. Typical malrotation was present in 75 patients, low LOT in 56, and a high LOT in 45. Volvulus was more common in the Typical group compared with the other 2 groups (12 of 75 v 1 of 56 low; 1 of 45 high; P <.05) as were internal hernias (18 of 75 v 6 of 56 low, 1 of 45 high; P <.05). Complications occurred in 13% of typical versus 22% low and 21% of high patients (P =.10). Low and high LOT patients had 13% and 11% incidence of persistent symptoms postoperatively versus 0% of typical patients., Conclusion: Atypical malrotation patients are at significantly lower risk of volvulus and internal hernia compared with typical malrotation patients, and operation appears to come with increased morbidity., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Background/purpose: Repair of recurrent diaphragmatic hernia continues to be a difficult problem. An innovative method using a nonabsorbable polypropylene prosthetic mesh plug placed via the thoracic approach using minimal dissection is presented., Methods: A retrospective analysis showed 39 children with congenital diaphragmatic hernia (CDH) who underwent repair between January 1997 and March 2000. Five children suffered a recurrence and underwent repair via the thoracic approach using the Bard Marlex Mesh Perfix Plug (C.R. Bard Inc, Billerica, MA). Follow-up was available in all children and ranged from 1 to 33 months (average, 13.8 months)., Results: Age at recurrence ranged from 2 to 48 months (average, 14.8 months), and the average time between initial repair and recurrence was 8.2 months (range, 2 to 16 months). There were no recurrences after the transthoracic mesh plug diaphragmatic hernioplasty. One child died of multiple congenital anomalies 6 months after repair., Conclusion: The transthoracic repair of recurrent diaphragmatic hernias using a nonabsorbable polypropylene prosthetic mesh plug represents an innovative approach to a difficult problem in which 5 repairs have been accomplished without recurrence in nearly 14 months of follow-up. J Pediatr Surg 36:1768-1769., (Copyright 2001 by W.B. Saunders Company.)

The slipping rib syndrome is an infrequent cause of thoracic and upper abdominal pain and is thought to arise from the inadequacy or rupture of the interchondral fibrous attachments of the anterior ribs. This disruption allows the costal cartilage tips to sublux, impinging on the intercostal nerves. Children with this entity are seldom described in the literature. We present a retrospective review of 12 children and young adults with slipping rib syndrome and a systematic approach for evaluation and treatment.

Background: Controversy surrounds the need for ICU admission, prolonged bed rest, and the duration of activity restrictions for children sustaining blunt trauma. Adult literature supports management based on hemodynamic status, not CT grade., Study Design: A 3-year prospective study of a standardized management algorithm for hemodynamically normal pediatric patients with blunt liver or spleen injury was performed. Patient selection was based on vital signs, irrespective of injury grade on CT. Patients requiring ICU admission for nonliver or nonspleen injury were excluded. Patients were admitted to a surgical ward with serial hematocrit levels. Discharge occurred 48 hours postinjury if patients had no abdominal tenderness, tolerated a regular diet, and had a stable hematocrit. Patients were allowed noncontact activity, including school, after discharge. Patients were followed up at 1 month with ultrasonographic imaging., Results: Eighty-nine patients sustained blunt liver or spleen injury. Forty-five patients were excluded for other injuries (Glasgow Coma Scale < 13, 32 of 45); the remaining 44 patients had a mean age of 8.9 years (range 2 to 17 years), Injury Severity Score 10.6 (range 4 to 33), liver grade 2.1, and splenic injury grade 2.3. Mechanisms of injury were predominately motor vehicle collisions (59%). All patients were managed nonoperatively without transfusion; 43 of 44 patients completed the algorithm. Mean observation was 55.2 +/- 12.3 hours. One-month followup occurred in 33 of 44 patients, with one complication detected and no delayed bleeding., Conclusion: Management of pediatric solid organ injury should be guided by hemodynamic status and not injury grade on CT. Hemodynamically normal children can be safely managed without intensive care monitoring, do not need prolonged hospitalization, and can resume school on discharge.

Staged reduction of abdominal contents using a silastic sheet has become standard management in gastroschisis where primary closure is not possible. With the introduction of a pre-made Silastic silo coupled to a spring-loaded ring (Ben Tec, Sacramento, CA), the procedure can be done at the bedside. We present a simple technique utilizing a disposable umbilical-cord clamp that makes reduction a fast, one-physician procedure and present a preoperative step that facilitates tension-free closure of the abdominal fascia.

Hypothesis: The Ladd procedure for malrotation predisposes children to postoperative intussusception (POI)., Design: Retrospective case-control review., Setting: University-affiliated tertiary care pediatric hospital., Patients: Five of 159 patients undergoing the Ladd procedure between 1995 and 1998 developed POI. Predisposing factors were sought by comparison with age-matched controls who underwent the Ladd procedure during the same period. The entire Ladd group was compared with all 1717 patients undergoing any other laparotomy during the same period for incidence of POI., Main Outcome Measures: Differences in weight, percentile weight, age, length of nasogastric suction, time to oral intake, and length of stay between Ladd patients developing POI and age-matched controls from the Ladd group were compared using the Mann-Whitney U test. Incidence of POI after the Ladd procedure and "other laparotomy" was compared using chi2 analysis., Results: In the Ladd group, there were 5 cases of POI (3.1%). There was 1 case of POI (0.05%) after all other laparotomies (P<.001). Symptoms developed at a mean +/- SD of 7.2 +/- 2.1 days. Upper gastrointestinal tract with small bowel follow-through showed partial bowel obstruction in 4 cases and was normal in 1 case. Reexploration took place at a mean +/- SD of 9.2 +/- 2.8 days. Children developing POI after undergoing the Ladd procedure were less likely to be small for their age (P= .03) than age-matched controls undergoing the Ladd procedure., Conclusions: The Ladd procedure predisposes children to POI. Aggressive investigation, including reexploration, should not be delayed if a child has symptoms of prolonged ileus within 2 weeks after undergoing a Ladd procedure.

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.

The accurate prenatal diagnosis of anterior abdominal wall defects is important because it affects patient management and prognosis. The pathophysiology of each defect leads to key characteristics that make it possible to differentiate one entity from another. Among these features are the location of the defect in relation to cord insertion, the size and contents of the defect, and the associated anomalies. This article reviews the underlying defects, the characteristic ultrasound findings, the associated anomalies, and the prognosis of simple and complicated abdominal wall defects. The basic features of simple abdominal wall defects (i.e., omphalocele and gastroschisis) were used as the initial points of assessment. A comparison of the different features of these abnormalities and how they differ from one another resulted in the development of criteria that facilitated the understanding of the different ultrasound manifestations of these anomalies.

Objective: To compare the modified Rossetti fundoplication with the classic Nissen., Summary Background Data: The traditional surgical treatment of gastroesophageal reflux in children has been the classic Nissen fundoplication, defined by liver mobilization, crural repair, takedown of short gastric vessels, and floppy wrap. The authors have progressed in our technique of fundoplication and now perform a modified Rossetti fundoplication, defined by liver retraction without mobilization, no crural repair, short gastric vessels left intact, and 2-cm floppy wrap., Methods: A retrospective chart review was performed on 407 pediatric patients who had open fundoplications (Jan. 13, 1993, to Feb. 25, 1998). Two groups were analyzed: the Nissen group (171 patients) and the Rossetti group (236 patients). Groups were compared for incidence of recurrent reflux, dysphagia, hiatal hernia, need for esophageal dilation, revision of fundoplication, time to discharge, and operative time., Results: Incidence of dysphagia (3.7% vs. 3.3%), postoperative hiatal hernia (1.9% vs. 1.4%), need for esophageal dilation (1.2% vs. 0.5%), and need for fundoplication revision (2.5% vs. 2.3%) were similar between the groups. The mean operative time was significantly decreased in the Rossetti group (65 +/- 25 minutes) versus the Nissen group (73 +/- 33 minutes). Recurrent reflux occurred significantly more often in the Nissen group (11.2%) than in the Rossetti group (5.1 %)., Conclusion: The modified Rossetti fundoplication has a low complication rate and is the authors' preferred method for the surgical treatment of gastroesophageal reflux in children.

Objective: The appropriate timing, as well as the type of intervention, for the treatment of empyema in children is controversial. The advent of video-assisted thoracic surgery (VATS) has changed the way we treat these children. Therefore, we reviewed our experience with the early use of VATS in the treatment of empyema and formulated a treatment algorithm., Methods: We retrospectively reviewed medical records of all patients undergoing VATS for empyema at Arkansas Children's Hospital from December 1994 to February 1997. All patients were treated by the pediatric surgical service and had the diagnosis of empyema confirmed at surgery. Results are reported as means, unless otherwise noted., Results: Twenty-five children with empyema were treated with VATS during the review period. Their age was 48.3 months, and the duration of symptoms was 7.4 days. All the patients had parapneumonic empyemas and had received preoperative antibiotics for 10.1 days. Preoperative imaging included chest radiography in 25 (100%), ultrasonography in 20 (80%), and computed tomography in 10 (40%). All patients with documented loculated parapneumonic fluid collections underwent VATS within a mean of 2 days of hospitalization. Chest tubes were removed in 3.2 days, resulting in a postoperative length of stay of 4.9 days. Total length of stay was 7.3 days. One patient required conversion to minithoracotomy and required a transfusion. There were no other complications or deaths. Follow-up was available for 22 (88%) children, and there was resolution of symptoms in all children with no recurrences., Conclusions: Earlier intervention with VATS in the treatment of empyema in children is safe and may reduce hospital charges by shortening hospital stay. A treatment algorithm based on early use of VATS is also described.

Intraluminal stenting of the gastrointestinal (GI) tract in both multiple intestinal atresias and perforations was used in three patients. In the atresia patients (2), a piercing trocar was used to create continuity of the GI tract and as a guide to thread the intestine over the stent. All patients currently demonstrate normal growth and development on routine enteral feeds. None developed anastomotic leaks or strictures.

Nasogastric (NG) decompression has traditionally been used after major abdominal surgery in pediatric patients. This study was designed to determine if NG tubes could be routinely omitted in pediatric patients undergoing major abdominal procedures. Between January 1993 and December 1995, 83 patients had follow-up prospectively without NG decompression after a variety of major abdominal surgeries. NG tubes were inserted for persistent vomiting or abdominal distension. Exclusion criteria included bowel obstruction, intestinal atresia, and perforation of the stomach or duodenum. Ages ranged from 13 days to 22 years. Seventy-four patients (89%) were treated successfully without postoperative NG decompression. There were no cases of pneumonia, wound dehiscence, anastomotic leak, or delay in return of gastrointestinal function. Nine patients required NG tubes for persistent vomiting or abdominal distension. An anastomotic leak developed in one patient after endorectal pull-through. NG decompression is unnecessary after most major abdominal operations in pediatric patients. The endorectal pull-through may represent a group of patients that benefit from routine decompression.

Meconium ileus can be difficult to distinguish from ileal atresia on plain radiographs and on contrast enema. Both show a microcolon in the face of a small bowel obstruction. The treatment of the two is very different. Meconium ileus obstruction may be relieved medically by contrast enema; ileal atresia requires prompt surgical intervention. This study was made to determine if abdominal ultrasonography might be helpful in distinguishing between these two entities. Abdominal ultrasonograms from the past 10 years of all patients with these two diseases who were studied with preoperative ultrasonography at Arkansas Children's Hospital were reviewed. Six of 16 patients with meconium ileus had preoperative ultrasonograms. All six patients with meconium ileus had multiple loops of bowel filled with very echogenic thick meconium. Four of 22 patients with ileal atresia had preoperative ultrasonograms. These four patients with ileal atresia had dilated loops of bowel filled with fluid and air. None had a dilated bowel filled with thick echogenic contents. Preoperative abdominal ultrasonography is proposed as a simple method for distinguishing between these two disease entities with very different treatment plans.

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.

Gastric teratoma is an extremely rare neoplasm which accounts for less than two percent of all teratomas. Unlike other teratomas, gastric teratomas are all benign and predominantly occur in males. As gastric teratomas generally present as a palpable abdominal mass, more aggressive solid masses of childhood must be excluded. In this case, CT imaging delineates both cystic and fatty components characteristic of teratoma and displays the rare gastric origin of the lesion.

The presence of delayed gastric emptying in neurologically impaired children with gastroesophageal reflux has led to controversy regarding appropriate surgical management. The authors reviewed the charts of neurologically impaired children requiring fundoplication to answer two questions: (1) is pyloroplasty needed in addition to fundoplication for delayed gastric emptying? and (2) Does delayed gastric emptying influence the morbidity associated with fundoplication? To answer the first question, 40 neurologically impaired children with delayed gastric emptying undergoing fundoplication were divided into two groups: Nissen and pyloroplasty (n = 21) and Nissen only (n = 19). The Nissen and pyloroplasty group had significantly more postoperative complications (23.8% v 5.0%) and took longer to reach full feeding (14.6 v 3.9) days. There were no differences in the incidence of recurrent symptoms, readmissions, or reoperations. To answer the second question, 58 neurologically impaired children undergoing fundoplication were grouped based on gastric emptying scan results: normal gastric emptying (> 32% in 1 hour) (n = 29) and delayed gastric emptying (n = 29). There were no differences in postoperative feeding tolerance, postoperative complications, recurrent symptoms, readmissions, or reoperations between the two groups. Delayed gastric emptying in neurologically impaired children with gastroesophageal reflux did not increase postoperative morbidity after fundoplication, and the addition of a pyloroplasty to fundoplication provided no additional benefit. The authors conclude that the procedure of choice for neurologically impaired children with gastroesophageal reflux is a fundoplication without pyloroplasty, regardless of the degree of delay in gastric emptying.

Firearms, particularly high-powered automatic weapons, injure progressively younger children in urban environments. At Arkansas Children's Hospital, 32 children have been admitted for gunshot wounds in 12 years. Air guns (3), handguns (19), and shotguns (10) caused the injuries. Shotgun wounds occurred during hunting accidents (2), flights from houses (3), and mistaken identity in the home (5), usually by family members (5). All victims of shotgun wounds were boys; seven were black. Their ages ranged from 6 to 20 years. Two injuries involved the abdomen, one the flank, one the chest, one the axilla, and five the legs. Accidental discharge of a weapon at close range caused extensive multisystem damage and long-term sequelae. Most of the wounds could have been avoided with the use of common sense and simple measures to identify the person within the household.

Fundoplication for gastroesophageal reflux is a frequent procedure for pediatric surgeons. Reoperation in the abdominal cavity can be time-consuming and hazardous. Therefore, 33 patients (16 male and 17 female) with symptomatic gastroesophageal reflux after previous abdominal procedures had transthoracic fundoplications. Previous procedures included gastrostomy (18), Nissen fundoplication (12), ventriculoperitoneal shunt (9), omphalocele (4), paraesophageal hernia (3), necrotizing enterocolitis (2), abscess drainage (2), intestinal atresia (2), and abdominal burn (1). The three complications encountered were a bronchopleural fistula, esophageal leak, and small bowel obstruction. Of five deaths, one was related to operation. The remaining patients did not have recurrent reflux. Transthoracic fundoplication after previous abdominal surgery is effective and rapid, and it has a relatively low complication rate in high-risk patients. This approach avoids reentry into the abdominal cavity and allows precise repair.

Pilonidal disease is a common problem; its many management options are testimony to the difficulty in its eradication. Its etiology is distention of midline skin orifices with ingestion of hair shafts from hirsute buttocks. Thus, the disease does not usually appear until after puberty. Nine children were treated by aspiration and incision and antibiotics, followed by curettage of the pits; they had no recurrence. Two children who had midline procedures had recurrent disease. The female-male ratio in children is 4.5:1.