Pediatric Readiness in the Emergency Department

This is a revision of the previous joint Policy Statement titled "Guidelines for Care of Children in the Emergency Department." Children have unique physical and psychosocial needs that are heightened in the setting of serious or life-threatening emergencies. The majority of children who are ill and injured are brought to community hospital emergency departments (EDs) by virtue of proximity. It is therefore imperative that all EDs have the appropriate resources (medications, equipment, policies, and education) and capable staff to provide effective emergency care for children. In this Policy Statement, we outline the resources necessary for EDs to stand ready to care for children of all ages. These recommendations are consistent with the recommendations of the Institute of Medicine (now called the National Academy of Medicine) in its report "The Future of Emergency Care in the US Health System." Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that ED staff, administrators, and medical directors seek to meet or exceed these recommendations to ensure that high-quality emergency care is available for all children. These updated recommendations are intended to serve as a resource for clinical and administrative leadership in EDs as they strive to improve their readiness for children of all ages.

Ferriman-Gallwey scores, serum androgen and mullerian inhibiting substance levels in hirstute adolescent girls

OBJECTIVE

To study Ferriman-Gallwey (FG) scoring in adolescents with an aim to correlate these scores with serum androgens and mullerian inhibiting substance (MIS).

DESIGN

Cross sectional study.

SETTING

Pediatric and Adolescent Gynecology Clinic of a university hospital.

PATIENTS

Twenty-four hirsute adolescent girls age 12-19 with a FG score of 6 or greater.

INTERVENTIONS

FG examination and collection of serum levels of MIS, total testosterone, free testosterone, follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, cortisol, and androstenedione.

MAIN OUTCOME MEASURES

Correlation between FG scores in adolescents and serum androgens and MIS.

RESULTS

Weak correlations were seen between FG score and FSH, free-testosterone, total testosterone, and cortisol. Increasing FG scores correlated with an increase in cortisol. As FG score increased, FSH, free-testosterone, and total testosterone decreased. There was no statistical relationship between FG score and LH, androstenedione, prolactin, and MIS. There were weak positive correlations between MIS levels and FSH, total testosterone, and androstenedione. There was no evidence for a linear relationship between MIS levels and LH, free testosterone, cortisol, prolactin, and FG score.

CONCLUSIONS

The utility of FG scoring in adolescents is unknown. There were no direct correlations found with MIS levels and FG score. MIS was not found to be a predictor of hirsutism. A larger study is needed to assess the clinical relevance of FG scoring and presence of underlying causes of hirsutism in adolescents.

Successful combination therapy of a proximal haemophilic pseudotumour with surgery, radiation and embolization in a child with mild haemophilia A

We describe the management of a young boy with mild haemophilia A and a massive iliac pseudotumour with a multi modality approach involving factor replacement, radiation therapy, embolization and surgery. The patient was initially treated with recombinant factor VIII and radiation therapy. Because of inadequate response and worsening of bony erosion, the patient had a preoperative embolization followed by surgical excision. The surgical procedure was associated with minimal blood loss and the patient had a relatively smooth postoperative course with no physical morbidity. This case illustrates successful aggressive management of a large, proximally located pelvic pseudotumour, which resulted in an excellent outcome despite the need for a normally morbid operation.

Surgical and anesthetic decisions for children with terminal illness

Terminal conditions such as congenital anomalies and cancer are a significant source of infant and childhood mortality. Many terminally ill children are considered for operative procedures each year. These procedures may be palliative or elective, and the prognosis and natural course of the terminal illness play a significant role in determining the appropriateness of the surgical procedure. Providing anesthesia to a terminally ill patient is a complex task requiring an appropriate balance between adequate anesthesia and hemodynamic normality. Some children with a terminal condition will have a standing "Do-Not-Resuscitate" order that should not necessarily be reversed. Surgeons, anesthesiologists, and family members must consider a number of factors when determining the appropriateness of an operation for a dying patient, including the rights of the child.

Beneficial effects of a hospital bereavement intervention program after traumatic childhood death

PURPOSE

An investigation of the experiences of parents grieving the traumatic death of their child, the initiatives that helped, and common parental concerns that would benefit from improved education.

METHODS

From January 1, 1995, to December 31, 1998, 81 of 3,501 children admitted to our pediatric trauma center died. An attempt was made to enroll all parents. Interactions included family contact at hospital, home/funeral home visit within 1 month of death, educational meeting with parents and 15 supporters at a restaurant within 2 months of death, follow-up survey to parents/supporters, and final interview/survey with parents in 1999-2000.

RESULTS

Seventy-seven families were enrolled; 59 families completed the educational meeting with supporters, and 245 parental supporters returned surveys. Supporters were likely to use proposed interventions (82%), were more accepting of the duration of grief (94%), and interacted with parents more often after the death (78%). Parents (n = 44) felt the hospital staff was appropriately sensitive to their child (90%), themselves (93%) and prepared them for their child's death (81%). Parents (n = 54) on behalf of 37 children have completed the final interview. Poor conceptualization of aspects of the medical care and brain death, and delayed regret for missing the opportunity to donate organs, were recurring themes.

CONCLUSION

We conclude that parents' unanswered questions or misconceptions regarding brain death, organ donation, and their child's medical care adversely affect their grief; that "normal life" for parents is challenged as they struggle to establish a new sense of normal; and that hospital and trauma service personnel can positively impact the grieving process with appropriate training.

Managing mature cystic teratomas of the ovary

Mature cystic teratomas (MCT), commonly called dermoid cysts, are the most common benign germ cell tumors of the ovary in women of reproductive age. Future fertility is of major concern among these women; therefore, the surgical management must focus on preserving ovarian tissue and minimizing adhesion formation. Patients requiring surgery should be appropriately counseled about the risks and benefits of laparoscopy and laparotomy, the risks of intraoperative MCT spillage and adhesion formation. In addition, the risks of recurrence and malignant transformation should be discussed. The parents of children with MCTs have the same concerns as older women and a similar discussion should take place. The goal of this article is to review these issues and provide the physician with the information to counsel their patients preoperatively.

The management of mature cystic teratomas in children and adolescents: a retrospective analysis

Mature cystic teratomas (MCT) are the most common ovarian tumours seen in children and adolescents. Fifty-two patients <21 years of age had surgical removal of an MCT, 14 of whom were approached laparoscopically. Compared with laparotomy, those patients managed laparoscopically had a significantly shorter hospital stay. Intra-operative tumour spillage occurred in 27 (52%) patients; there were no cases of chemical peritonitis. Available follow-up data on 34 (65%) patients revealed seven pregnancies occurring at a median of 70 months (46-123) postoperatively, including four in patients with intraoperative MCT spill. There were no cases of tumour recurrence during the follow-up period among the 27 (52%) patients managed with ovarian cystectomy. These results demonstrate that some of the conclusions regarding the contemporary management of MCT in adults are applicable to children and adolescents.

The clinical course of unresected ovarian torsion

The authors report the clinical course of a young girl with ovarian torsion who was treated conservatively. This case shows that detorsion of the ovary may be associated with immediate postoperative febrile morbidity and slow resolution of ovarian enlargement. The authors emphasize that these signs can be associated with viable ovarian tissue and are not necessarily an indication for oophorectomy.

Noninflammatory ovarian masses in girls and young women

OBJECTIVE

We reviewed the presentation, treatment, and pathologic diagnoses of girls and young women less than 21 years old with noninflammatory ovarian masses that required surgery and established whether treatment had changed over time.

METHODS

We retrospectively reviewed charts of all girls and young women under 21 years old with International Classification of Diseases, 9th Revision (ICD-9) codes specific for noninflammatory ovarian masses treated at our institution from June 1980 to July 1998 (n = 140).

RESULTS

The median age at surgery was 15 years (range 2 days-21 years). Ovarian cysts occurred in 57.9% (81 of 140) of patients, benign tumors (including mature cystic teratomas) in 30% (42 of 140), malignant tumors in 7.9% (11 of 104), and torsed but normal ovaries in 4.3% (six of 140) of the study sample. Patients older than 15 years were more likely to have ovarian cysts and benign tumors than younger patients (P =.019). There were no malignancies among girls with neonatal cysts. The incidence of ovarian torsion was 17.8% (25 of 140). Patients with ovarian cysts, mature cystic teratomas, and normal ovaries were more likely to have torsion than those with other benign or malignant tumors (P <.001). Operative approach and surgical procedure were compared before and after July 1, 1989. Laparoscopy was performed more commonly after July 1, 1989 (P =.009). However, patient age (P <.001) rather than time of surgery (P =.83) was the most important predictive factor in a multivariate analysis for use of laparoscopy. In addition, multivariate analysis revealed that patient age (P =.02) rather than time of surgery (P =.79) was also predictive of surgeon type (gynecologist or pediatric surgeon).

CONCLUSION

The most frequent cause of an ovarian mass requiring surgery in a girl or young woman under 21 years of age is an ovarian cyst, which justifies consideration of a laparoscopic approach. Patient age rather than time of surgery predicted operative approach and surgeon type. Caution should be exercised in patients over age 12 months with a complex mass on ultrasound and clinical evidence of hormonal activity, as these masses are usually malignant.

Serum müllerian-inhibiting substance levels during normal menstrual cycles

OBJECTIVE

To measure serum levels of müllerian-inhibiting substance (MIS) during the normal menstrual cycle.

DESIGN

Serum was collected from women during ovulation and the mid-luteal and early follicular phases of the menstrual cycles. It was stored frozen at -80 degrees C until assayed.

SETTING

University of Louisville Departments of Obstetrics and Gynecology and Surgery.

PATIENT(S)

Twenty healthy women 22-35 years of age with normal menstrual cycles.

INTERVENTION(S)

Blood samples were collected on menstrual cycle day two or three and on the day of LH surge plus one and plus seven or eight.

MAIN OUTCOME MEASURE(S)

Serum MIS levels were measured by using an enzyme-linked immunosorbent assay.

RESULT(S)

Serum MIS levels ranged from a low of 1.4 +/- 0.9 ng/mL (mean [+/-SD]) in the early follicular phase, peaked mid-cycle at 1.7 +/- 1.1 ng/mL, and decreased to 1.4 +/- 0.9 ng/mL in the mid-luteal phase of the normal menstrual cycle.

CONCLUSION(S)

Fluctuations in serum MIS levels during the menstrual cycle suggest that MIS may have a regulatory role in folliculogenesis.

Effects of vasoactive intestinal peptide on human sperm motility

Sperm flagellar activity is modulated by cAMP. In target tissues, vasoactive intestinal peptide (VIP) stimulates adenyl cyclase activity, which elevates intracellular cAMP levels and activates protein kinase activity. This study investigated the effects of VIP on motility of sperm from 17 subjects. Motile activities, monitored before (0 min, baseline) and for 40 min after incubation with VIP (0.2 microgram/mL cell suspension), were analyzed by computer-assisted semen analysis. The data (mean +/- SEM) are expressed as percentages of baseline values and changes were compared by trend analysis for interval level measures by repeated measures analysis of variance orthogonal polynominal contrasts. The addition of VIP significantly increased motile sperm concentration (110 +/- 17% [10 min], 132 +/- 15% [20 min], 152 +/- 18% [30 min], 125 +/- 18% [40 min]; p < .02) and sperm with rapid straight-line motility (V > 25 microns/s) (167 +/- 20%, 174 +/- 19%, 173 +/- 23%, 141 +/- 16%; p < .02). Mean track speed (micron/s) was increased (125 +/- 12%, 134 = 9%, 129 +/- 12% and 126 +/- 12%; p < .02), while mean progressive velocity, amplitude of head displacement, and beat frequency were not affected by VIP. These results indicate that VIP stimulates sperm motile activity by cAMP-mediated phosphorylation of axonemal proteins.

Central venous catheter bloodstream infections in the neonatal intensive care unit

PURPOSE

The goal of this study was to identify symptoms and signs related to central venous catheter (CVC) bloodstream infections (BSI) in neonatal intensive care unit (NICU) patients that would predict infection and to identify factors that might influence CVC longevity.

METHODS

This was a retrospective cohort study evaluating 268 lines representing a total of 5,212 CVC days placed in 157 NICU patients over 29 months by the pediatric surgery and neonatology services at one children's hospital. Centers for Disease Control (CDC) criteria were used to determine laboratory-confirmed BSI. Data were analyzed by univariate methods and logistic regression and determined significant at the P less than .05 level.

RESULTS

Sixty-five lines (24%) from 54 patients had confirmed CVC BSI. Fever (49%) and pulmonary dysfunction (30%) were the most common symptoms of CVC BSI. Erythema or purulent discharge at the insertion site was found in only 20% of cases. Staphylococcus epidermidis was the most common organism isolated. Factors that significantly decreased the incidence of CVC BSI were increasing estimated gestational age (EGA; P < .0013) attime of insertion, associated vancomycin use at the time of catheter placement (P < .0057), and fewer days of catheter use (P < .0291). There were no significant differences noted caused by line location or catheter type.

CONCLUSION

Fever and pulmonary dysfunction were the most common signs of CVC BSI in neonates. Lower EGA and increased catheter duration were significantly correlated with infection. The use of vancomycin concurrent with catheter insertion was associated with a decreased incidence of CVC BSI, howeverconcerns regarding the emergence of vancomycin-resistant organisms preclude support of its use as a prophylactic agent.

Late follow-up and functional outcome after traumatic reproductive tract injuries in women

The aim of this study was to assess female reproductive tract injuries and late effects on sexual and reproductive function. This was a review of women presenting to a Level I trauma center with reproductive tract injuries over 12 years. Thirty-one women (average age, 30 years) were divided into coital (19) and noncoital (12) injury groups. One-third of coital trauma presented late, one-fourth was abuse related, and seven women presented in shock. All had vaginal lacerations, and 15 required repair. Follow-up in 6 of 19 (32%) women averaged 4.5 years. Noncoital injuries resulted primarily from vehicular trauma, and two-thirds had associated abdominal injuries. Interventions included: vaginal laceration irrigation/repair (4), salpingectomy (2), ovariectomy (2), repair uterine perforation (1), and emergency cesarean section (2). The average Injury Severity Score was 25, with two deaths. Follow-up in 6 of 10 (60%) survivors averaged 6.1 years. The combined group has had seven subsequent pregnancies, and two women have minor dyspareunia after pelvic fracture. Women with coital injuries may develop shock, requiring rapid resuscitation and operative repair. Noncoital injuries are often associated with multiple severe injuries and require operative intervention. Late sequelae are minimal in both groups, and even severe injuries do not preclude normal pregnancy and sexual function.

Müllerian inhibiting substance improves longevity of motility and viability of fresh and cryopreserved sperm

Müllerian inhibiting substance (MIS) is a hormone present in seminal plasma, but its role is unknown. In this study, the effects of MIS on sperm survival in fresh and cryopreserved specimens were investigated. Fresh sperm motility and viability (n = 12) were evaluated in specimens after 0, 0.5, 1, 3, 5, and 22 hours of incubation in the presence or absence of MIS. Motile and nonmotile sperm were evaluated in Cell-Vu counting microscope slides, and viability was assessed by eosin-nigrosin exclusion. Sperm cryopreserved for 2 weeks in TES (N-Tris[hydroxymethyl]methyl-2-aminoethanesulfonic acid)-Tris-glycerol-egg yolk buffer and 4% glycerol with or without MIS were thawed at room temperature (n = 6) and were evaluated for motility and viability using identical methods to those used with fresh sperm. The effects of MIS were examined by coincubation with monoclonal anti-MIS antibody (6E11; n = 6). In fresh and cryopreserved sperm incubated with MIS, both motility and viability were higher than in the absence of MIS (P < 0.03; Wilcoxon signed rank test) at 5 and 22 hours. Coincubation with anti-MIS antibody eliminated the effects of MIS. Longevity of sperm motility and viability are improved both in fresh and cryopreserved sperm in the presence of MIS and may have potential for use in assisted reproductive technology.

The presence of Müllerian inhibiting substance binding sites in human sperm

PURPOSE

The binding of Müllerian inhibiting substance (MIS) to human sperm was investigated using immunohistological techniques.

MATERIALS AND METHODS

Sperm from 5 normal donors and 6 subfertile men were studied. Whole or thin-sectioned sperm were incubated without or with recombinant human MIS (0.5 microg./ml.). MIS binding was identified under light microscopy (LM) using rabbit anti-human MIS antibodies tagged with goat IgG-horseradish peroxidase and diaminobenzidine as substrate, or by scanning and transmission electron microscopy (SEM and TEM) using gold labeled goat IgG. Intracellular MIS binding in sperm sections was examined by TEM. Antibodies were omitted in the controls.

RESULTS

Under LM, DAB staining was present on sperm incubated with or without MIS and absent on controls. Using SEM, gold particles were found primarily on the surfaces of the sperm head with less binding to the tail. With TEM, the clustering of gold particles around the head of sperm represents MIS binding, but very few or no gold particles could be found associated with the sperm tail. MIS binding was also found associated with intracellular structures, but only within the head of the sperm. Overall, less gold particle binding was present in subfertile compared with normal sperm.

CONCLUSIONS

These results suggest that MIS is bound to the sperm surface and sperm from normally fertile men have increased MIS binding. The function of MIS in sperm is unknown, but the presence of MIS binding suggests a direct role(s) in sperm function.

Practice patterns of pediatric surgeons caring for stable patients with traumatic solid organ injury

BACKGROUND

Managed care financing has resulted in pressure to decrease hospital days and lower per diem costs. This influence may ultimately affect nonoperative management of blunt solid organ injuries in children (spleen, liver, kidneys).

METHODS

Pediatric surgeons caring for trauma patients were surveyed regarding current practice patterns. One survey was sent to a representative staff pediatric surgeon at each major children's hospital or children's unit involved in the care of the injured child in the United States.

RESULTS

There were 87 responses to 117 surveys (75%). Relatively few children fail nonoperative management. For major management decisions, including radiographic study of choice; when to transfuse; and when to allow out of bed, home, and back to school, there was often a clear majority opinion of appropriate care. However, there was a wide variance in response for some questions.

CONCLUSIONS

Surgical judgment must be individualized, but a low number of failures of nonoperative management is helpful in delineating safe practice guidelines. Surgeons using fewer resources than the norm may help delineate management schemes that are equally effective to more expensive care. Based on these responses a management protocol is recommended.

Müllerian-inhibiting substance in follicular fluid and serum: a comparison of patients with tubal factor infertility, polycystic ovary syndrome, and endometriosis

OBJECTIVE

To determine Müllerian inhibiting substance (MIS) levels in follicular fluid (FF) and sera of IVF patients.

DESIGN

Prospective study.

SETTING

Fertility center.

PATIENT(S)

Sixty-six patients: 20 with tubal factor infertility, 17 with polycystic ovary syndrome (PCOS), and 29 with endometriosis.

INTERVENTION(S)

All patients underwent ovarian stimulation with hMG and/or FSH, as well as oocyte retrieval for IVF.

MAIN OUTCOME MEASURE(S)

Follicular fluid and serum MIS levels and oocyte fertilization rates.

RESULT(S)

Levels of MIS in FF and sera of PCOS patients were significantly higher than those in tubal factor patients: 7.01 +/- 1.52 versus 1.65 +/- 0.23 ng/mL (mean +/- SE) and 2.97 +/- 0.52 versus 0.92 +/- 0.19 ng/mL, respectively. In endometriosis patients, follicular fluid and serum MIS levels were not significantly different from those in tubal factor patients. In PCOS patients, the percentage of immature oocytes retrieved (17.9% +/- 5.0%) was significantly higher compared with tubal factor (1.5% +/- 1.0%) and endometriosis (9.2% +/- 2.3%) patients. The percentage of oocytes fertilize was significantly lower in PCOS patients (30.2% +/- 5.3%) compared with tubal factor (62.2% +/- 5.5%) and endometriosis (37.5% +/- 5.7%) patients.

CONCLUSION(S)

Women with PCOS had higher serum and follicular fluid MIS levels, a higher percentage of immature oocytes, and lower fertilization rates than women with endometriosis or pelvic adhesions.

The presence of müllerian inhibiting substance in human seminal plasma

Müllerian inhibiting substance (MIS), produced by testicular Sertoli cells, is present in adult male serum. The first aim of this study was to determine if MIS is present in seminal plasma. Using an enzyme-linked immunosorbent assay (ELISA), we measured MIS concentrations in seminal plasma from 23 donors exhibiting normal (WHO criteria) sperm qualities, and 169 patients with subnormal sperm parameters. The second aim of this study was to examine a potential relationship between MIS and sperm motility. MIS concentrations in seminal plasma ranged from 0.5 to 3.6 ng/ml in donors and from 0.5 to 17.8 ng/ml in patients. Motility index (MI, mean +/- SEM) for all patient samples was lower compared with donors (113.3 +/- 3.2 and 198.3 +/- 13.5, P < 0.00001), while mean MIS concentration +/- SEM) was higher (4.2 +/- 0.3 and 1.4 +/- 0.2, P < 0.0003). When the patients were stratified into Groups I (motility < 50%, n = 42) and II (motility > 50%, n = 127), the MI (mean +/- SEM) values were 62.3 +/- 3.8 and 130.2 +/- 2.7 respectively (P < 0.0001 for both compared with donors) and mean MIS concentrations (+/- SEM) were 5.4 +/- 0.6 and 3.9 +/- 0.3, respectively (P < 0.0001 and P < 0.001 compared with donors). The inverse relationship between MIS concentration in seminal plasma and motility index suggests that MIS may have a function in modulating motility.

Indicators of genitourinary tract injury or anomaly in cases of pediatric blunt trauma

PURPOSE

Microscopic hematuria (> or = 20) RBCs per high-power field [HPF] has been used frequently as an indicator for genitourinary (GU) tract injury in pediatric cases of blunt trauma. The aim of this study was (1) to determine whether a certain threshold of microscopic hematuria was associated with GU tract injury in our patient population, and (2) to identify additional factors warranting evaluation of the GU tract.

METHODS

The records of 100 patients under 18 years of age whose discharge diagnosis in the trauma registry included hematuria or GU tract injury were reviewed retrospectively (1989 through 1993). The following data were collected: age, sex, mechanism of injury, physical findings, associated injuries, urinalysis results, radiographic study results, disposition, and outcome. Data were analyzed using the SPSS program.

RESULTS

The majority of children were victims of motor vehicle accidents. All but one study patient had an intravenous pyelogram and/or computed tomography scan. Twenty-seven patients had GU tract injuries or previously unrecognized congenital anomalies (9 contusions, 5 lacerations, 1 vascular pedicle injury, 4 bladder injuries, 3 urethral/vaginal tears, 5 anomalies). Twenty-seven percent (3 of 11) of children with minor injuries and 25% (2 of 8) of those with major injuries had microscopic hematuria of less than 20 RBCs/HPF. Mechanism of injury and hypotenison were not associated with GU tract injury. One third of the patients with isolated chest or abdominal injuries, and 50% of those with combined chest/abdominal injuries had GU tract injuries or anomalies identified. Pelvic fracture was associated with GU tract injury or anomaly in 50% of cases (P < 0.02).

CONCLUSION

The authors found that (1) a threshold of > or = 20 RBCs/HPF as an indication for radiograph evaluation would have missed 28% of cases with GU tract injuries or occult anomalies, and (2) pelvic fractures and abdominal/chest injuries help to identify patients who require evaluation of the GU tract. The need for GU tract evaluation in pediatric trauma patients is based as much on clinical judgment as on the presence of hematuria.

Hazards to children riding in the back of pickup trucks

PURPOSE

The goal of this study was to identify the spectrum of injuries and risks associated with children riding in the back of pickup trucks and stimulate the medical and legislative community to adopt laws aimed at protective interventions for this type of travel.

METHODS

Patients were identified and data collected retrospectively from trauma registries at the two major university urban trauma centers in Kentucky.

RESULTS

From 1988 to 1993, 33 patients less than 18 years old were ejected from the back of pickup trucks. The majority were males older than 10 years. Injuries occurred predominantly during summer, in early evening, and in rural areas. Eleven patients were ejected during a collision, 19 were ejected from a moving truck, and 3 fell from a stationary truck. The head was the predominant organ injured. The average ISS score was 12.0 (+/- 7.5). The length of stay in the hospital varied from 1 to 84 days with 13 patients requiring intensive care. Three patients died and 3 required rehabilitation therapy.

CONCLUSION

We conclude that (1) Children riding in pickup truck beds are at serious risk of being ejected from the vehicle; (2) children are frequently ejected from truck beds in non-crash events; and (3) continued attention should be directed to enacting stronger legislation limiting passenger transport in pickup truck beds.

Traumatic childhood death: how well do parents cope?

This study assessed effects of traumatic childhood death on parents. From July 1988 to September 1992, 48 of the 1,954 children admitted to our pediatric trauma center died. Interviews were requested with parents of children who died and were conducted by a chaplain in the homes of 29 parents (20 families). Interview assessments were based on Worden's "Mourning Tasks" and Demi and Miles's "Parameters of Normal Grief." Grieving was uncomplicated in seven parents (five families). Common elements included use of multifaceted non-family support networks to aid grieving, and no parents blamed themselves or God for the child's death. Grieving was pathologic in 22 parents (15 families). Dominant features included: (1) lack of a support network beyond the extended family; (2) an avoidant stance to grieving; and (3) view of God as distant and punitive. We provide nine indices that will enable hospital caregivers to anticipate the outcome of parental grieving, and offer suggestions for the physician who desires to be involved in parents' acute and rehabilitative grief recovery.

Transport of the injured child

This article summarizes current recommendations regarding prehospital stabilization and transport of the injured child. Transportation alternatives are described, as well as indications for interhospital transport. A checklist for troubleshooting common problems is included, which anticipates events likely to cause morbidity en route. Proper communication is essential to a successful transport, as is a quality review of each completed transport. Emergency Medical Services for Children (EMSC) grants have enabled many states to enhance pediatric prehospital education for providers.

Evaluation of minor head injury in children

The authors' goal was to determine criteria for hospitalization for children with minor head injuries. A retrospective review was performed of the hospital records of 401 children with isolated minor head injuries who were admitted to a level I pediatric trauma center between July 1988 and December 1990. Specific information regarding each patient was documented, including demographic data, pertinent physical findings, diagnostic studies, criteria for admission, and hospitalization costs. Fifty-one patients with a mechanism of injury compatible with minor head injury, a brief or no loss of consciousness, a Glasgow coma score of 15, and no abnormalities on radiographic examination did not have neurological complications. The authors believe that these 51 patients could have been discharged from the hospital to responsible parents, thereby decreasing the costs of hospitalization. Prospective studies to substantiate these data and determine which patients should be hospitalized are warranted.

Injuries resulting from motorized personal watercraft

To determine if there is a widespread problem with personal watercraft (jet ski) injuries throughout the United States, we reviewed the hospital records of patients who were treated at this institution for injuries incurred while they were operating a motorized personal watercraft or jet ski. All of the patients were under the age of 19 and suffered severe fractures or lacerations. To assess the extent of the problem with these injuries regionally, we collected data from 8 midwestern states for 1989. Sixty-four personal watercraft accidents involving 90 victims were reported in the survey. Fifty-three of 90 patients sustained fractures, lacerations, or head injuries. Seventy-nine of 90 were under age 25, and 24 patients were under 16 years of age. The need for supervision and the potential for serious injury while operating personal watercraft is supported by these findings.

The effect of education and safety devices on scald burn prevention

A prospective study was designed to evaluate the effects of education on the incidence of pediatric scald burns. Demographic data from our Trauma Registry identified the Zip code area of greatest risk. Eighty of 121 families with children in a large rental property were chosen randomly for the education program. Twenty of these families also had an anti-scald device installed in the bathtub faucet; all had two or more children under age 5 years. Families were surveyed before and after intervention. Safety knowledge improved post-education as judged by correct survey responses. Although 90% of the families had water heaters set at "warm" (< or = 120 degrees F), the actual temperature at the tap was above 130 degrees F in 71%. The anti-scald devices did work, but at 9 months all but one had been removed because of sediment buildup, which prevented water flow. In the year of the study, the number of scald burns from the target Zip code area decreased from 15 to 12. This was a pilot project for programs that can test public response to general safety education. An anti-scald device in conjunction with education works well in theory, but a better device needs to be engineered. In view of discrepancies between water heater settings and tap water temperature, housing authorities could play a vital role in implementing safety measures.

Surgical complications and procedures in neonates on extracorporeal membrane oxygenation

We report our experience from May 1985 to January 1991 with surgical complications and procedures performed in neonates on extracorporeal membrane oxygenation (ECMO) (218 venoarterial and 7 venovenous bypass). Eleven children older than 1 month were excluded. Total complications were 96 in 67 patients and included: bleeding (37), problems with initial cannula placement (17), thrombus formation (15), hemothorax, pneumothorax, or effusions (11), mechanical problems (11), and miscellaneous (5). Forty-eight procedures were performed in 37 patients while on ECMO. These were recannulation or reposition of cannulas (14), tube thoracostomy (11), cardiac surgery (6), cardiac catheterization (4), repair of congenital diaphragmatic hernia (5), thoracotomy (4), and others. Twenty-eight complications occurred in 15 of the 27 patients who died. Mortality rate was 12% for the entire group. Primary causes of death were hypoplastic lung (11), cardiac (8), sepsis (4), intraventricular hemorrhage (2), and pulmonary hypertension (2). No deaths were due solely to complications except for the two patients with intraventricular hemorrhage. Mortality in neonates who had complications while on ECMO was significantly higher (P less than .005) than in patients without complications. Hemorrhagic and thoracic complications were associated with higher mortality (P less than .001). Mortality was not affected by mechanical problems, thrombus formation, or catheter-related problems. While on ECMO cardiac defects, diaphragmatic hernia, lobar emphysema, and other conditions can be safely corrected. The use of echocardiography to position the cannulas, better control of coagulation factors and improvement in equipment may ultimately decrease complications.

Basilar skull fractures in childhood with cranial nerve involvement

Cranial nerve palsies developed in 23% of 73 children with basilar skull fractures. The majority occurred in patients 10 years of age or older. Our overall incidence was higher than that in a review in which basilar skull fractures were indiscriminately included with all head injuries. Our experience with meningitis was similar to that present in the literature and would seem to support avoidance of prophylactic antibiotics. Because there was no improvement in neurological deficits in patients treated with steroids (the only case of meningitis in our series was associated with steroids), we believe that their use is unwarranted. It is important to discuss the prognosis with the patient's family, because, although the majority (53.3%) of cases resolve completely, those with residual deficits can have significant morbidity.

Evaluation of splenic injury by computed tomography and its impact on treatment

We reviewed 37 consecutive, hemodynamically stable patients (16 adults, 21 children) who had splenic injuries diagnosed by computed tomography (CT) scan to compare the CT evaluation with operative assessment of injury and eventual treatment. Computed tomographic scans and operative findings were graded by a splenic injury scoring system. Two patients were classified as having grade 1, 21 as grade 2, 11 as grade 3, and 3 as grade 4 splenic injuries. Computed tomography underestimated the degree of injury in 9 of 17 (53%) operated patients (mean CT score, 2.6; mean operative score, 3.3; p less than 0.01). Six of sixteen adults and 19 of 21 children were intentionally treated by observation. There were 5 treatments failures (20%), 3 due to bleeding and 1 each due to pancreatic injury and splenic abscess. The failure rate of observation was lower in children (16%) than in adults (33%), even though children had a higher Splenic Injury Score (2.4 versus 1.8). Patients who underwent an operation received twice as much blood as the observed group. There was no significant difference in Injury Severity Score or total fluid requirements between operated and observed patients. Operations increased in frequency in both adults and children as the injury score increased. This experience suggests that CT scan accurately determines the presence of splenic injury but commonly underestimates its severity. While children with grades 1 through 3 injuries are likely to be treated successfully with observation, adults who have more minor splenic injuries often fail observation and may be treated better by prompt operation.

The prune belly syndrome: a comprehensive approach to management

Our approach to management of the prune belly syndrome entails a program of comprehensive early reconstruction, including abdominoplasty, bilateral orchiopexy, reduction cystoplasty, and selective ureteral tailoring and reimplantation. Of 20 patients with the prune belly syndrome treated at our institution during the last 18 years 15 underwent comprehensive reconstruction. Abdominoplasty was performed in 16 patients. Results were evaluated as to cosmetic appearance, functional performance, and preoperative and postoperative electromyography. Immediate good results were obtained in 9 patients. Of 16 patients 6 required more than 1 abdominal wall tailoring and 3 had minor complications that did not compromise the ultimate result. Transabdominal orchiopexy was performed on 32 testes; 28 (88 per cent) are in the scrotum and growing. Of the 4 failures 3 occurred in patients greater than 2 years old at repair. Selective urinary tract reconstruction has been performed; 13 patients underwent tapering and reimplantation of 1 or both ureters. Reduction cystoplasty was done in all 15 patients. Functional assessment of the upper urinary tract by improved radiological techniques and the necessity for long-term antibiotic prophylaxis have led to a more conservative approach in 5 recent patients. Renal function as measured by serum creatinine and/or glomerular filtration rate has remained stable in 12 of 15 patients (92 per cent) undergoing comprehensive reconstruction. Aggressive surgical management of patients with the prune belly syndrome provides improved abdominal wall function and appearance, and offers excellent testicular salvage. Surgical reconstruction of deformed ureters should be selective and decided on longitudinal studies of renal function.

The role of computed tomography in blunt abdominal trauma in children

This study was performed in order to test the hypothesis that abdominal computed tomography (CT) can assist in the decision to perform laparotomy in children following blunt trauma to the abdomen. Three hundred forty children with blunt abdominal trauma underwent evaluation with CT. Abdominal injuries were detected in 84 children (25%). These included: 75 injuries to solid viscera in 60 patients (30 splenic, 29 hepatic, 13 renal, and three pancreatic); four injuries to hollow viscera (three small bowel transections, and one rupture of the urinary bladder); and 23 skeletal injuries (21 fractures of the pelvis, and two lumbar spine subluxations). Injury to solid viscera was categorized as minor in 32 (43%), moderate in 18 (24%), or severe in 25 (33%) according to an assessment of the percentage of parenchyma involved. Hemoperitoneum was detected in 42 patients, and characterized as small in 18 (43%), moderate in nine (21%), and large in 15 (36%). CT was useful in establishing the location and extent of injuries, and in detecting the presence of blood or air in the peritoneal cavity. However, the extent of injury to solid viscera detected on CT did not correlate with the need for laparotomy. Of 46 moderate to severe anatomic injuries of the liver, spleen or kidney, only five (9%) required surgical intervention because of persistent bleeding or infection. Although laparotomy occurred more frequently in the presence of a large hemoperitoneum, only 6/24 (25%) with moderate to large hemoperitoneum required surgical exploration. This analysis confirms the usefulness of CT for detection of location and extent of injury in pediatric blunt abdominal trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

Endobronchial eosinophilic granuloma: a rare cause of total lung atelectasis

A 12-yr-old male presented with left lung atelectasis secondary to a mainstem endobronchial mass. At thoracotomy, a left mainstem bronchial sleeve resection successfully extirpated what later proved to be an eosinophilic granuloma. This is the first case report, to our knowledge, of endobronchial eosinophilic granuloma.

Hypovolemic shock in children: abdominal CT manifestations

The authors describe a "hypoperfusion complex," seen on abdominal computed tomography, which consists of marked, diffuse dilatation of the intestine with fluid; abnormally intense contrast enhancement of the bowel wall, mesentery, kidneys, and/or pancreas; decreased caliber of the abdominal aorta and inferior vena cava; and moderate to large peritoneal fluid collections. This complex was present in three patients less than 2 years of age and was associated with severe injury and a poor outcome. Recognition of this constellation of findings may help direct attention to the patient's serious hemodynamic abnormality as much as to individual organ defects.

The fate of the grafted quail Mullerian duct in the chick embryonic coelom

Recent morphological analyses of Mullerian duct regression suggested that some ductal cells might survive, in contrast to the previous view that regression was an example of "programmed cell death." The present study was designed to demonstrate survival of Mullerian duct cells after regression, and to map migration into local or distant tissues. Seven or eight-day-old chick embryos received intraabdominal grafts of Mullerian ducts from seven- or eight-day-old quails, creating chick-quail chimeras. Three or four days later the abdomen was serially sectioned and examined histologically using a modified Feulgen stain. Sixty-six of the 230 grafted embryos survived (29%). After sectioning, grafts were found in 34 of the 58 embryos in the body wall, peritoneum or mesenephros, with several adherent to the hosts' Mullerian ducts. Twenty female embryos contained grafts, all of which were developing normally. Fourteen male embryos contained grafts in various stages of regression. Regression was more advanced in mesonephric or body wall grafts while free intraperitoneal grafts showed the least regression. Migration of quail cells was striking when seen in grafts placed in the mesonephros or adherent to the host Mullerian duct. In these, regressing quail cells migrated into and became incorporated in adjacent chick mesenephros. Migration patterns were seen also in non-regressing cells in female hosts, where quail cells "homed" to the host chick Mullerian duct structures.

Androgen stimulation of nucleotide pyrophosphatase during mullerian duct regression

Mullerian inhibiting substance (MIS) causes regression of the embryonic Mullerian duct. In the fetal rat urogenital ridge, extracellular nucleotide pyrophosphatase (NPPase) can be detected by histochemical staining on the regressing male Mullerian duct, with no corresponding enzyme localization on developing female Mullerian ducts. In vivo results in male embryos can be confirmed in vitro by incubating 14.5-day-gestation female urogenital ridges with MIS and testosterone for 72 h before enzyme localization. Since the addition of testosterone to MIS is obligatory to detect NPPase activity in vitro, and certain steroids enhance Mullerian duct regression, additional steroids were tested in vitro alone or in combination with MIS for their abilities to stimulate NPPase. NPPase induction occurred only with the combinations of MIS and testosterone or MIS and medroxyprogesterone acetate. Neither MIS alone nor any steroid used alone stimulated NPPase activity. The effect of exogenous NPPase added alone to the developing urogenital ridge was also assessed. Incubation of the female urogenital ridge for 72 h with exogenous NPPase caused marked hyperplasia of the Mullerian duct epithelial cells and early mesenchymal cell condensation, without the basement membrane breakdown normally seen in regression. Since NPPase activity is present in the Mullerian duct only during regression, these findings suggest that MIS and fetal androgens are synergistically modulating the activity of this enzyme. Its role in the Mullerian duct, as suggested by its cytological effects, may be to stimulate cellular responses before migration during regression.

Phosphorylation events during Müllerian duct regression

Regression of the fetal rat Müllerian duct in vitro was stimulated by sodium fluoride in the absence of Müllerian inhibiting substance. The action of Müllerian inhibiting substance was inhibited by sodium vanadate, adenosine 5'-triphosphate, and several related nucleotides in the presence of manganese ions. Epidermal growth factor specifically inhibited the substance, but only with manganese ions present. Insulin, platelet-derived growth factor, and nerve growth factor had no effect. These results suggest that dephosphorylation of membrane proteins mediates the action of Müllerian inhibiting substance.

The role of nucleotide pyrophosphatase in Mullerian duct regression

Mullerian inhibiting substance (MIS), a glycoprotein from the fetal testis causing regression of the embryonic Mullerian duct, can be inhibited in vitro in the presence of Mn2+ by a wide range of nucleotides including GTP, NAD, ATP, AMP, and several nonhydrolyzable synthetic ATP analogs. Extracellular nucleotide pyrophosphatase (NPPase), an enzyme able to hydrolyze the wide variety of the nucleotides and analogs found to inhibit Mullerian duct regression, was studied by histochemical staining (H. Sierakowska and D. Shugar (1963). Biochem. Biophys. Res. Commun. 11, 70-74) to determine if NPPase localized in or around the Mullerian duct during regression. Frozen sections of urogenital ridges from 14 1/2- to 17 1/2-day rat fetuses (n = 77) were incubated with a-naphthyl thymidine-5'-phosphate (naphthyl TMP) and Fast Red TR. Nucleotide pyrophosphatase hydrolyzes naphthyl TMP, releasing naphthol, which then reacts with Fast Red to produce color at the enzyme site. Nucleotide hydrolysis was detected around regressing male (n = 16) Mullerian duct cells at 16 1/2 days of gestation, but no hydrolysis was detected around female (n = 17) Mullerian duct cells at any stage. Controls (n = 24) incubated without substrate did not stain. Addition of exogenous ATP (n = 20) to the histochemical incubation medium inhibited nucleotide hydrolysis on male Mullerian ducts, suggesting that this staining is specific for pyrophosphatase activity. Results in vivo were confirmed in vitro by incubating 14 1/2 day female rat urogenital ridges with MIS for 72 hr prior to histochemical staining. The addition of testosterone to MIS was obligatory to detect staining in vitro (n = 10). The localized NPPase activity around the regressing Mullerian duct suggests that NPPase may appear as a consequence of duct regression and may act to control the degree of membrane phosphorylation by degrading excess trinucleotides.

Hypoplastic aortoiliac syndrome: An entity peculiar to women

Hypoplastic aortoiliac syndrome (HAIS) is a unique disorder that occurs almost exclusively in women. Because reports in the literature are scant, we reviewed our own experience. The criteria for definition were high bifurcation of the abdominal aorta, straight course of the iliac arteries without the normal characteristic bowing, acute angle of the aortic bifurcation, aortic diameter of 14 mm or less, and iliac artery diameter of 7 mm or less. Nineteen patients with HAIS were identified in a 14-year period. All 19 patients were heavy smokers. Most had significant associated arterial disease, and all were women. Fifteen patients were selected as candidates for operation. Two were treated conservatively, one refused surgery, and one died of a myocardial infarction before operation. Reconstruction was performed by aortoiliac thromboendarterectomy with vein patch for segmental disease (four patients) and Dacron bifurcating graft for diffuse disease (11 patients). There were no deaths during operation. Four patients required reoperations for graft failure and three patients eventually required amputations. The four patients who underwent reconstructions by thromboendarterectomy with vein patch had uniformly good results. From this experience, the following approach and management are recommended: conservative nonoperative exercise program with close follow-up if symptoms are tolerable, aortoiliac thromboendartectomy and vein patch if disease is segmental, aortofemoral bifurcating graft for patients with diffuse disease with graft size closely approximating vessel size, and concomitant femoral-to-popliteal graft to ensure adequate runoff and graft patency if there is significant femoral disease. The etiology of HAIS remains obscure. Early onset of symptoms seems to be due to small vessels with superimposed atherosclerotic plaques. Addiction to smoking in these women is extreme (paralleling that seen in Buerger's disease) and may be of etiologic significance.

Reassessment of Graham-Steele closure in acute perforated peptic ulcer

We studied 67 patients who had operation for perforated peptic ulcer. Operative treatment included plication with omentum (Graham closure) in 27 patients, vagotomy and pyloroplasty in 32 patients, or vagotomy and antrectomy in eight patients, depending on antecedent ulcer history, degree of contamination, and general patient condition. Mortality was high with simple closure in patients with long-standing perforation or associated disease. Early complications associated with Graham closure included rebleeding, perforation, and obstruction. There were no deaths or major complications related to vagotomy and pyloroplasty. In selected patients, definitive operation is safe and produces excellent long-term results.