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Permanent Pediatric Surgery Job in Lake Charles Louisiana with Community Health Systems

PRACTICE OPPORTUNITY IN SOUTH LOUISIANA Women and Children's Hospital in Lake Charles, Louisiana is seeking a solo Pediatric Surgeon. EOE Community, Facility, & Organization Women and Children's

Permanent Pediatric Surgery Job in Fort Wayne Indiana with Community Health Systems

Lutheran Hospital of Indiana, located in Fort Wayne, Indiana, has an excellent opportunity to join one other PD/GS and a nurse practitioner. Call is 1:2 but limited. This position offers a competitive

Permanent Pediatric Surgery Job in Spokane Washington with Providence Health & Services

Spokane, Washington -- Sacred Heart Children's Hospital is seeking a BE/BC Pediatric Surgeon to join an established, busy, single-specialty practice in this sunny eastern Washington city. Excellent subspecialty

Permanent Pediatric Surgery Job in Anchorage Alaska with Providence Health & Services

Anchorage, Alaska -- Providence Alaska Medical Center is seeking BE/BC pediatric surgeon to join our busy clinic. Statewide referrals. Clinic is part of The Children's Hospital at Providence with all

Permanent Pediatric Surgery Job in Portland Oregon with Providence Health & Services

Portland, Oregon -- Providence Health & Services is seeking an outstanding pediatric surgeon to join us in the Portland area. Excellent opportunity for experienced surgeon to help guide further development

Permanent Pediatric Surgery Job in Temple Texas with Scott & White Health Clinic

Scott & White and Texas A&M College of Medicine are seeking outstanding BC/BE physician with strong credentials in clinical care and education for a Pediatric Surgery based position in Temple, TX.

Permanent Pediatric Surgery Job in Temple Texas with Scott & White Health Clinic

The Department of Surgery, Division of Pediatric Surgery at Scott & White and the Texas A&M Health Science Center College of Medicine is looking to grow its Division of Pediatric Surgery with well qualified

Locum Tenens Pediatric Surgery Job in Great Location South Dakota with Onyx M.D.

Busy Hospital in South Dakota is looking for a Pediatric Surgeon. Position is located in the city so you're always close to fine dining, museums, and live entertainment. You can also enjoy camping,

Permanent Pediatric Surgery Job in Great Location Iowa with Onyx M.D.

Pediatric surgeon wanted for a metro city in Iowa. A small pediatric group needs to replace a retiring peds surgeon. This is a locum-to-perm pediatric surgeon job opportunity. This pediatric physician

Permanent Pediatric Surgery Job in Not Disclosed North Carolina with Locum Medical Group

Join two Board Certified Pediatric Surgeons that work out of one hospital just outside of Charlotte, North Carolina. The physicians currently perform a wide range of surgical procedures including: Endocrine

Locum Tenens Pediatric Surgery Job in Pediatric surgery needed in South Dakota South Dakota with LocumTenens.com

Pediatric surgery needed in South Dakota Explore old pubs and casinos! Clinic and call last 2 weeks of each month Contact Information: LocumTenens. com will cover your malpractice insurance, travel

Locum Tenens Pediatric Surgery Job in Pediatric surgery need in New York New York with LocumTenens.com

Pediatric surgery need in New York Enjoy the cities fine dining and world class music venues! call only Must be BC in pediatric surgery level 1 trauma Contact Information: LocumTenens. com will

Locum Tenens Pediatric Surgery Job in Pediatric surgery needed in New York New York with LocumTenens.com

Pediatric surgery needed in New York Enjoy the cities fine dining and world class-music venues! call only level 1 trauma

Locum Tenens Pediatric Surgery Job in Pediatric Surgeon needed in Massachusetts Massachusetts with LocumTenens.com

Pediatric Surgeon needed in Massachusetts Great places for shopping and fine dining Clinic, Scheduled procedures, call Call is 1:3 Contact Information: LocumTenens. com will cover your malpractice

Locum Tenens Pediatric Surgery Job in Pediatric Surgery in New York New York with LocumTenens.com

Pediatric Surgery in New York Get out and enjoy the cities attractions with cruises and the beautiful Botanical Gardens! Affiliated with an Academic Medical Center Sporadic future dates Prefer candidates

Permanent Pediatric Surgery Job in With a population of 200,975 this service area is home to the fifth largest city in the entire Pacific Northwest. Washington with Candidate Direct Physician Staffing

Pediatric Surgeon Jobs - Washington Physician Job Type: Permanent Start: Immediate Opening Shift: Details not available Salary: This pediatric surgeon job offers salary based compensation with

Permanent Pediatric Surgery Job in Top 100 Hospital, Great Lakes, #2774 Minnesota with Timeline Recruiting

GREAT LAKES PEDIATRIC SURGERY OPPORTUNITY TOP 100 HOSPITAL, NACHRI DESIGNATION. Seize this rare opportunity to develop the regions first pediatric surgery program, serving a population of over 450,000,

Permanent Pediatric Surgery Job in Greenville North Carolina with Job Job Recruiting

Chief of Pediatric Surgery, Director of the Children's Hospital Specialty: Pediatric Surgery Job Description: The School of Medicine at Carolina University is recruiting multiple Pediatric Subspecialists

Permanent Pediatric Surgery Job in Greenville North Carolina with Job Job Recruiting

Pediatric Surgeon Specialty: Pediatric Surgery Job Description: The School of Medicine at our Carolina University is recruiting Pediatric Subspecialists as part of the University Health Systems Childrens

Locum Tenens Pediatric Surgery Job in Pediatric Locum Tenen Surgeon Needed in South Dakota South Dakota with

Job 0088235-0123 2 weeks per month. Pick your own two weeks. We offer competitive pay that may include incentives and bonuses We coordinate and pay for your travel, housing, and transportation You are

Hospital opens new children's surgery center - The State

Hospital opens new children's surgery centerThe StateThe hospital held a ribbon-cutting ceremony Wednesday to commemorate the opening of its Pediatric Surgery Center. The center includes 13 outpatient surgery ...and more »

Warner receives professorship named for Washington University's ... - News from Washington University in St. Louis

Warner receives professorship named for Washington University's ...News from Washington University in St. LouisA nationally recognized pediatric surgeon, she was the first woman surgical resident and first woman chief resident in surgery at Barnes Hospital, ...and more »

Air Astana Cares for a Healthy Heart - e-Travel Blackboard (press release)

Air Astana Cares for a Healthy Hearte-Travel Blackboard (press release)From 16th to 18th June 2009, Air Astana held a charity programme at the Science Center of Pediatrics and Pediatric Surgery, Almaty. ...and more »

Pediatric surgeon spends $1.2M in Henderson - Blockshopper

BlockshopperPediatric surgeon spends $1.2M in HendersonBlockshopperDr. Scheidler is pediatric surgeon at the Center for Children's Surgery in Las Vegas. He earned both his BS and MS degrees from the University of Pittsburgh ...and more »

Which NYC hospitals have best, worst infection rates? - Crain's New York Business

RocNowWhich NYC hospitals have best, worst infection rates?Crain's New York BusinessIt also identified, by hospital, central line-associated bloodstream infections in adult, pediatric and neonatal intensive care units. ...NY hospitals fare well in report on infectionsBizjournals.comHospital Acquired Infections Reporting Program Serves As Model for ...Kansas City infoZineState report on infection rates gives mixed grades for area hospitalsRocNowSchenectady Gazette -eMaxHealth -RocNowall 41 news articles »

Lutheran Hospital Awarded Level II Trauma Certification - Indiana's NewsCenter

WANELutheran Hospital Awarded Level II Trauma CertificationIndiana's NewsCenterTo be approved for the designation, Lutheran had to hire a trauma medical director and a medical director who's board-certified in pediatric surgery. ...TMH officially becomes Level II trauma centerTallahassee Democratall 9 news articles »

15-story hospital planned in SF - San Francisco Chronicle

15-story hospital planned in SFSan Francisco Chronicle... from surgery or illness, Nelson said. But critics argue that administrators are planning to move critical services - beds for pediatric patients, ...and more »

Cosmetic surgeries: What children will do to look 'normal' - USA Today

Cosmetic surgeries: What children will do to look 'normal'USA TodayWhat constitutes "medically necessary" when it comes to cosmetic surgery and children is a gray area, says pediatric plastic surgeon David Staffenberg, ...and more »

FELLOWS IN THE NEWS - AAP News (subscription)

FELLOWS IN THE NEWSAAP News (subscription)Anthony Sandler, MD, FAAP, of Washington, DC, was appointed Diane and Norman Bernstein Professor in Pediatric Surgery, the first endowed professorship in ...AAP keeping children's needs front and center in health reform debateAAP News (subscription)all 9 news articles »

For young ballplayer, robotic surgery a big hit - Asbury Park Press

For young ballplayer, robotic surgery a big hitAsbury Park PressHe became the first-ever pediatric surgery patient at Monmouth Medical Center to under go his procedure robotically. Instead of a long incision, ...and more »

Amorphous mass of prolapsed bowel was connected by a precarious vascular pedicle, and its viability was doubtful.

Related Articles Amorphous mass of prolapsed bowel was connected by a precarious vascular pedicle, and its viability was doubtful. J Pediatr Surg. 2009 Jun;44(6):1297; author reply 1297-8 Authors: Andrews JM, Evans SM PMID: 19524759 [PubMed - in process]

Herniation through the falciform ligament: an unusual cause of ileal atresia.

Related Articles Herniation through the falciform ligament: an unusual cause of ileal atresia. J Pediatr Surg. 2009 Jun;44(6):1295-7 Authors: Shakya VC, Agrawal CS, Koirala R, Khaniya S, Adhikary S, Shakya BM PMID: 19524757 [PubMed - in process]

Blunt posterior tracheal laceration and esophageal injury in a child.

Related Articles Blunt posterior tracheal laceration and esophageal injury in a child. J Pediatr Surg. 2009 Jun;44(6):1292-4 Authors: Mukherjee K, Isbell JM, Yang E Blunt force trauma to the neck can result in the unusual injury pattern of laceration of the posterior tracheal wall in combination with esophageal injury. We present the report of a 10-year-old child who had blunt cervical trauma because of a bicycle accident and subsequently presented with profound subcutaneous emphysema. This case was addressed with operative management with a good result. The essential management principles for this rare constellation of injuries include a high index of suspicion, early control of the airway, endoscopic and radiographic diagnosis, and use of a buttressing strap muscle flap in the event of operative management to prevent delayed complications, including leak and tracheoesophageal fistula. PMID: 19524756 [PubMed - in process]

Transanal rectosigmoid resection for severe intractable idiopathic constipation.

Related Articles Transanal rectosigmoid resection for severe intractable idiopathic constipation. J Pediatr Surg. 2009 Jun;44(6):1285-90; discussion 1290-1 Authors: Levitt MA, Martin CA, Falcone RA, Peña A INTRODUCTION: Idiopathic constipation is a source of significant morbidity in children. A subset of patients is refractory to medical therapy and requires surgical intervention. We present a novel surgical technique for the management of these patients. METHODS: We reviewed the records of 288 patients with severe idiopathic constipation and soiling. Patients who were refractory to medical management and had a megarectosigmoid underwent a transanal full-thickness rectosigmoid resection with a primary colo-anal anastomosis. RESULTS: Fifteen patients underwent a transanal rectosigmoid resection. The preoperative contrast enema demonstrated an enormously dilated rectosigmoid in 14. An average of 43 cm (range, 8-98 cm) of rectosigmoid was resected. Of 14 patients with more than 3 months of follow-up, the preoperative laxative dose was 68 mg of senna/d (range, 52-95 mg), which decreased to 8.6 mg postoperatively (P < .001). Nine patients are clean without soiling, 1 is more prone to diarrhea, but is clean. Two patients soil occasionally, but are noncompliant, and 2 were lost to follow-up. CONCLUSION: Transanal rectosigmoid resection for medically intractable idiopathic constipation resulted in a dramatic reduction or elimination in laxatives use while preserving continence. It is a useful alternative to surgical options such as other colonic resections, antegrade enemas, and stomas. PMID: 19524755 [PubMed - in process]

Treatment of fecal incontinence with a comprehensive bowel management program.

Related Articles Treatment of fecal incontinence with a comprehensive bowel management program. J Pediatr Surg. 2009 Jun;44(6):1278-83; discussion 1283-4 Authors: Bischoff A, Levitt MA, Bauer C, Jackson L, Holder M, Peña A PURPOSE: Many articles describe the antegrade continence enemas (ACEs), but few refer to a bowel management program. A successful ACE may not help a patient without such management. Valuable lessons were learned by implementation of bowel management in 495 fecally incontinent patients. METHODS: We previously reported 201 patients. Thereafter, another 294 patients participated in our program. On the basis of a contrast enema and symptoms, they were divided as follows: (a) 220 constipated patients and (b) 74 patients with tendency toward diarrhea. Colonic stool was monitored with abdominal radiographs, modifying the management according to the patient's response and radiologic findings. For constipated patients, the emphasis was on using large enemas. For patients with tendency toward diarrhea, we used small enemas, a constipating diet, loperamide, and pectin. Diagnoses included anorectal malformation (223), Hirschsprung's (36), spina bifida (12), and miscellaneous (23). RESULTS: The management was successful in 279 patients (95%)-higher in constipated patients (98%) and less successful in patients with tendency toward diarrhea (84%). CONCLUSIONS: The key to a successful bowel management program rests in tailoring the type of enema, medication, and diet to the specific type of colon. The best way to determine the effect of an enema is with an abdominal film. The ACE procedures should be recommended only after successful bowel management. PMID: 19524754 [PubMed - in process]

After the honeymoon comes divorce: long-term use of the antegrade continence enema procedure.

Related Articles After the honeymoon comes divorce: long-term use of the antegrade continence enema procedure. J Pediatr Surg. 2009 Jun;44(6):1274-6; discussion 1276-7 Authors: Yardley IE, Pauniaho SL, Baillie CT, Turnock RR, Coldicutt P, Lamont GL, Kenny SE BACKGROUND: Having reported that 18% of children discontinue use of the antegrade continence enema (ACE) after 5 years, we aimed to determine long-term use after an ACE procedure. METHODS: A postal/telephone questionnaire was conducted. Subjects were consecutive children undergoing an ACE between 1993 and 1999. Outcome measures were use of ACE, reasons for nonuse, complications, and overall satisfaction. RESULTS: Of 84 eligible subjects, data were available on 61 (73%) aged 22.4 years (15.5-35.1 years). Underlying diagnoses included spina bifida (n = 27), anorectal malformations (n = 18), constipation (n = 11), Hirschsprung's disease (n = 1), sacral agenesis (n = 2), and trauma/tumor (n = 2). Follow-up was 11.02 years (8.34-14.39 years). Thirty-six (59%) of 61 patients were still using their ACE. Reasons for nonuse were lack of effectiveness (n = 14), complications (n = 5), psychologic issues (n = 2), and poor compliance (n = 2). There was no association between diagnosis and nonuse (chi(2), P = .63). In those still using ACE, the overall satisfaction score was 4.1 (1-5). Several individuals reported feeling abandoned on becoming adults and losing the support they had in childhood. CONCLUSION: There is a late "failure" rate for the ACE procedure. However, satisfaction was high among those still using the ACE. This study further emphasizes the need for robust transitional care arrangements. PMID: 19524753 [PubMed - in process]

Improvement of quality of life in children with slow transit constipation after treatment with transcutaneous electrical stimulation.

Related Articles Improvement of quality of life in children with slow transit constipation after treatment with transcutaneous electrical stimulation. J Pediatr Surg. 2009 Jun;44(6):1268-72; discussion 1272 Authors: Clarke MC, Chase JW, Gibb S, Hutson JM, Southwell BR BACKGROUND: Slow transit constipation (STC) causes intractable symptoms not responsive to medical treatment. Children have irregular bowel motions, colicky abdominal pain, and frequent soiling. Transcutaneous electrical stimulation using interferential current (interferential therapy [IFT]) is a novel treatment of STC. This study assessed quality of life (QOL) in STC children before and after IFT treatment. METHODS: Eligible STC children were randomized to receive either real or placebo IFT (12 sessions for 4 weeks). Questionnaires (Pediatric Quality of Life Inventory) were administered before and 6 weeks after treatment, with parallel parent and child self-report scales. Higher scores indicate better QOL. Holschneider and Templeton scores were also obtained. The QOL scores were compared using paired t tests. RESULTS: Thirty-three children (21 male), with a mean age of 11.8 years (range, 7.4-16.5 years), were recruited; 16 received real IFT. Child-perceived QOL was improved after real IFT compared with baseline (81.1 vs 72.9, P = .005) but not after placebo IFT (78.1 vs 74.9, P = .120). The Holschneider score improved after real IFT (10 vs 8, P = .015) but not after placebo IFT (9 vs 8, P = .112). Parentally perceived QOL was similar after real IFT (70.1 vs 70.3, P = .927) and placebo IFT (70.2 vs 69.8, P = .899). There were no differences in Templeton scores. CONCLUSION: Interferential therapy is a novel therapy for children with STC that improves their self-perceived QOL. PMID: 19524752 [PubMed - in process]

Rectovestibular fistula--rarely recognized associated gynecologic anomalies.

Related Articles Rectovestibular fistula--rarely recognized associated gynecologic anomalies. J Pediatr Surg. 2009 Jun;44(6):1261-7; discussion 1267 Authors: Levitt MA, Bischoff A, Breech L, Peña A INTRODUCTION: Vestibular fistulas are the most common anorectal malformations (ARMs) in females. Associated gynecologic defects are rarely mentioned in the literature but may have serious clinical implications if undetected. The definitive repair of the ARM offers an opportunity for diagnosis and treatment of these conditions. METHODS: Two hundred seventy-two patients with vestibular fistula were retrospectively reviewed, with emphasis on gynecologic defects. RESULTS: Forty-eight patients (17%) had 83 gynecologic anomalies. Fourteen patients had a vaginal septum, all with 2 uterine cervices. All septa were resected at the main repair. Twenty-six patients had no vaginal opening. Twenty of them had absent vagina. Eighteen of those had an absent uterus. Patients with absent vagina underwent vaginal replacement with distal rectum (12), sigmoid (6), and ileum (2). Six patients had a patent upper vagina; 3 reached the perineum after mobilization and 3 required replacement; 2 with sigmoid and 1 with rectum. CONCLUSION: Vaginal septa are easily diagnosed and can be resected during the repair of the vestibular fistula. The presence of 2 cervices has important obstetric implications. Absent vagina requires a technically demanding repair, with special preoperative planning. Vaginoscopy or careful inspection should precede surgical reconstruction. PMID: 19524751 [PubMed - in process]

Contemporary practice patterns in the surgical management of Hirschsprung's disease.

Related Articles Contemporary practice patterns in the surgical management of Hirschsprung's disease. J Pediatr Surg. 2009 Jun;44(6):1257-60; discussion 1260 Authors: Keckler SJ, Yang JC, Fraser JD, Aguayo P, Ostlie DJ, Holcomb GW, St Peter SD BACKGROUND: Many options exist in the surgical management of Hirschsprung's disease (HD). To gain insight into contemporary management, we queried pediatric surgeons listed in the American Pediatric Surgical Association Directory on their management for the typical baby with HD. METHODS: Surveys were sent electronically to the surgeons concerning a typical newborn diagnosed with HD. Questions included the preferred approach, number of stages, anastomotic technique, length of muscular rectal cuff, point of initiation of the anorectal dissection, and length of colonic resection. Surgeons performing laparoscopy were asked about how the colonic biopsy was performed. Other questions included the type of leveling colostomy, level of residents, and criteria for performing a primary transanal pull-through. The maximum margin of error was calculated using a 95% confidence interval based on the response percentages for discrete variables. RESULTS: Surveys were sent to 719 surgeons with 270 responses. A minimally invasive approach is currently used by 80%, of which 42.3% favor laparoscopy and 37.7% prefer transanal dissection only. Only 5.4% of respondents prefer the Duhamel technique. A 1-stage approach is used by 85.6%. An average muscular cuff length of 2.4 cm (range, 0.5-6 cm) is reported. A divided muscular cuff is reported by 55%. On average, the anal anastomosis is 0.73 cm (range, 0-4.5 cm) above the top of the anal columns and 3.0 cm (0-12.5 cm) above the biopsy site on the ganglionic colon. Of the respondents using laparoscopy, 80.2% report using an intracorporeal colonic biopsy technique. Participation in a training program, either fellows and/or residents, is reported by 84.8% of respondents. The most common reason given for not performing a primary transanal pull-through is long segment disease (45.6%). Margin of error was no greater than 6% for any of the responses. CONCLUSIONS: A minimally invasive approach with a 1-stage operation has become the most common strategy for the surgical management of the typical baby with HD. Opinions vary about the amount of colonic resection, length of the rectal cuff, and site of initiation of the anorectal dissection, and these represent potential points for future studies. PMID: 19524750 [PubMed - in process]

Properties of secondary and tertiary human enteric nervous system neurospheres.

Related Articles Properties of secondary and tertiary human enteric nervous system neurospheres. J Pediatr Surg. 2009 Jun;44(6):1249-55; discussion 1255-6 Authors: Lindley RM, Hawcutt DB, Connell MG, Edgar DH, Kenny SE Advances in enteric nervous system (ENS) stem cell biology have raised the possibility of treating Hirschsprung's disease with ENS stem/progenitor cell (ENSPC) transplantation. This study aimed to expand ENSPC numbers by the growth and redissociation of neurospheres and assess their differential potential. METHODS: Human ENS neurospheres were cultured as previously described and redissociated to generate secondary and tertiary neurospheres. Neurospheres were assessed for the presence of neuronal (PGP9.5), glial (S100), and stem cell (p75, nestin markers). The degree of immunofluorescence was quantified using the ImageJ program. Secondary/tertiary neurospheres were transplanted into mouse distal colon grown in tissue culture. RESULTS: Secondary/tertiary neurospheres could be generated with exponentially increasing numbers. Tertiary neurospheres showed a significant increase in the proportion of p75 staining but a significant decrease in the proportion of S100 staining. After transplantation, secondary/tertiary neurosphere-derived cells positive for PGP9.5 and S100 could be identified. CONCLUSIONS: It is possible to exponentially expand neurosphere and therefore ENSPC numbers by repeated dissociation and culture. There is a loss of S100-positive cells in secondary/tertiary neurospheres, but the ENSPCs remain capable of differentiating into neurons and glia when transplanted into an embryonic gut environment. PMID: 19524749 [PubMed - in process]

Clinical significance of isolated intraperitoneal fluid on computed tomography in pediatric blunt abdominal trauma.

Related Articles Clinical significance of isolated intraperitoneal fluid on computed tomography in pediatric blunt abdominal trauma. J Pediatr Surg. 2009 Jun;44(6):1242-8 Authors: Christiano JG, Tummers M, Kennedy A PURPOSE: The finding of isolated free intraperitoneal fluid (FIPF) on computed tomography of the abdomen (CTA) in children after blunt trauma is of unclear clinical significance and raises suspicion for a solid or hollow viscus injury. In our institution, pediatric blunt trauma patients presenting with isolated FIPF on CTA who are hemodynamically stable and have no peritoneal signs on initial physical examination (iPE) have been historically approached nonoperatively. We reviewed our level 1 trauma center experience with this subset of the trauma population and sought to (1) justify an initial nonoperative approach and (2) identify early predictors of the eventual need for surgical exploration. METHODS: Data on all trauma patients less than 14 years of age admitted to our hospital from 2001 to 2006 after Blunt Abdominal Trauma (BAT) whose screening CTA showed FIPF and no other radiographic signs of solid or hollow viscus injury were retrieved from the local trauma registry. Clinical progress, operative findings, and follow-up were obtained by hospital and office chart review, as well as telephone contact. Mechanism of injury (MOI); Injury Severity Score (ISS); Revised Trauma Score; Pediatric Trauma Score (PTS); the presence of abdominal tenderness or external signs of injury on iPE; and quantity, location, and density of the FIPF were statistically analyzed as possible early predictors of the eventual need for surgical exploration. RESULTS: A total of 670 children admitted to our institution after blunt trauma were evaluated with CTA during the time of enrollment. Isolated FIPF was found in 94 individuals (14%). Mean age was 9.7 (+/-SD 3.2) years; 52% were males. Motor vehicle crash was the most common MOI. Mean PTS was 10.6 (+/-SD 1.8). Mean ISS was 10.2 (+/-SD 7.2). Free intraperitoneal fluid was most commonly found in only one intraperitoneal region (93%). Most patients (97%) were discharged home without undergoing a surgical procedure. Three other patients developed peritonitis on serial physical examination and were surgically explored. Hollow viscus injuries were found in 2 of these individuals and treated with primary repair or segmental bowel resection. All surgical patients enjoyed a full recovery, with no postoperative complications. The presence of abdominal tenderness on iPE and the quantity of FIPF on initial CTA were the only studied variables to reach statistical significance as predictors of the eventual need for operative intervention. Follow-up after hospital discharge was obtained in 46.8% (44/94) and averaged 124.9 weeks. CONCLUSION: To the best of our knowledge, this is the largest series of pediatric blunt trauma patients with isolated FIPF on CTA ever reported. Our findings justify an initial nonoperative approach for the management of these individuals. Abdominal tenderness on iPE and the quantity of FIPF on initial CTA were predictors of the eventual need for operative intervention. PMID: 19524748 [PubMed - in process]

Value of computed tomographic angiography in neck and extremity pediatric vascular trauma.

Related Articles Value of computed tomographic angiography in neck and extremity pediatric vascular trauma. J Pediatr Surg. 2009 Jun;44(6):1236-41; discussion 1241 Authors: Hogan AR, Lineen EB, Perez EA, Neville HL, Thompson WR, Sola JE PURPOSE: We sought to define the sensitivity and specificity of computed tomographic angiography (CTA) in pediatric vascular injuries. METHODS: All neck and extremity CTAs performed in pediatric patients at a level 1 trauma center were reviewed from 2001 to 2007. RESULTS: Overall, 78 patients were identified with an average age of 15.0 +/- 4.0 (0-18 years). Males outnumbered females 3.6:1. CTA was performed for 41 penetrating and 37 blunt traumas. Most penetrating injuries were due to missile wounds (71%) or stab wounds (17%). Eleven major vascular injuries resulted from penetrating trauma. For penetrating trauma, CTA was 100% sensitive and 93% specific. CTA for penetrating trauma had a positive predictive value (PPV) of 85% and negative predictive value (NPV) of 100%. Most blunt injuries were due to motor vehicle accidents (57%), followed by pedestrian hit by car (27%). Eight major vascular injuries resulted from blunt trauma. For blunt trauma, CTA was 88% sensitive and 100% specific. CTA for blunt trauma had a PPV of 100% and an NPV of 97%. The accuracy for penetrating and blunt trauma was 95% and 97%, respectively. CONCLUSIONS: CTA is highly sensitive, specific, and accurate for pediatric neck and extremity vascular trauma. PMID: 19524747 [PubMed - in process]

Eliminating disparity in evaluation for abuse in infants with head injury: use of a screening guideline.

Related Articles Eliminating disparity in evaluation for abuse in infants with head injury: use of a screening guideline. J Pediatr Surg. 2009 Jun;44(6):1229-34; discussion 1234-5 Authors: Rangel EL, Cook BS, Bennett BL, Shebesta K, Ying J, Falcone RA PURPOSE: Minority and disadvantaged children are evaluated for nonaccidental trauma (NAT) at higher rates than other children. At our institution, we implemented a guideline to perform skeletal surveys to screen for occult fractures in all infants with unwitnessed head injury (UHI). The goal was to determine if this guideline decreased disparities in the screening of African American (AA) and uninsured children. PATIENTS AND METHODS: For 54 months, rates of skeletal surveillance and abuse determination were compared between AA and white infants admitted with UHI before and after implementation of our guideline. Logistic regression was used to control for confounders. RESULTS: Before the guideline, AAs underwent skeletal surveillance more than whites (n = 208; 90.5% vs 69.3%; P = .01), with 20% of screened infants determined to be probable victims of NAT. Whites with private insurance were less likely to be screened compared to those without private insurance (50.0% vs 88.1%; P < .001). After the guideline, AA and whites were surveyed equally (n = 52; 92.3% vs 84.6%; P = 1.0), with 22% found to be probable cases of NAT. CONCLUSIONS: This is the first report of a successful policy-based intervention to decrease disparity in care. The maintenance of a stable rate of NAT determination despite increased screening suggests more victims of abuse may be identified with guideline use, and therefore, this may be an additional benefit of the guideline. PMID: 19524746 [PubMed - in process]

Postconcussive symptoms in hospitalized pediatric patients after mild traumatic brain injury.

Related Articles Postconcussive symptoms in hospitalized pediatric patients after mild traumatic brain injury. J Pediatr Surg. 2009 Jun;44(6):1223-8 Authors: Blinman TA, Houseknecht E, Snyder C, Wiebe DJ, Nance ML BACKGROUND: Mild traumatic brain injury (MTBI) is common in the pediatric population. The symptom complex that might be expected in children after MTBI is not well documented. We sought to clarify the frequency and severity of concussive symptoms reported by children who required hospitalization for MTBI. METHODS: Pediatric blunt trauma patients (age, 11-17 years) admitted for treatment of MTBI (GCS 14-15) were prospectively enrolled over a 2-year period. Consented patients were administered a 22-question Likert-based concussion symptom scale (normal, total score 0-8). The symptom scale was repeated at the time of routine follow-up trauma clinic visit. The frequency and severity of concussive symptoms were analyzed at both time-points. RESULTS: For the 2-year period, 116 children participated in the study including 63 who returned for clinic follow-up. The overall population had mean age of 14.1 years (median 14) and was 69.8% male. The mean symptom score (sum of Likert scores [scale 0-6] for 22 questions) was 27.9 (median, 23.5) at hospitalization and 9.2 (median, 4.0) at follow-up. An abnormal symptom score (>8) was reported in 83.6% of hospitalized patients and 38.1% at follow-up. Girls had a significantly higher mean symptom score at initial testing than boys (33.9 vs 25.3, respectively; P < .05). This difference disappeared by the time of follow-up (girls 9.2 vs boys 9.1, P = .98) The most common initial symptom was headache (71.5% of patients) and most severe (highest mean score) was fatigue (mean, 2.0; median, 2.0). At follow-up, the most common symptom was excess sleep (38.1%) and most severe symptom falling asleep (mean, 1.0; median, 0). There were no significant differences in initial scores based on reported loss of consciousness, prior concussion history, or GCS 14 vs 15. CONCLUSIONS: Symptoms after MTBI are quite common at the time of hospitalization. Symptom scores improve to near normal for most by outpatient follow-up. The most common symptom was headache, but the most severe was fatigue, in this hospitalized pediatric population. Thoughtful assessment and follow-up of this patient population are warranted. PMID: 19524745 [PubMed - in process]

Injury patterns among obese children involved in motor vehicle collisions.

Related Articles Injury patterns among obese children involved in motor vehicle collisions. J Pediatr Surg. 2009 Jun;44(6):1218-22; discussion 1222 Authors: Haricharan RN, Griffin RL, Barnhart DC, Harmon CM, McGwin G PURPOSE: The purpose of this study was to compare injury patterns among obese children to their nonobese counterparts involved in motor vehicle collisions. METHODS: A nationwide data collection program containing occupant, collision, and injury details from police-reported tow-away crashes between 1997 and 2006 were used. Risk ratios (RRs) and associated 95% confidence intervals (CIs) were adjusted for age, sex, restraint, seat track position, vehicle curb weight, and total velocity change. RESULTS: An estimated 9 million children aged 2 to 17 years (20.2% obese) were involved in motor vehicle collisions during the study period. Among 2-to-5-year-olds, obesity increased the risk of severe head (RR, 3.67; 95% CI, 1.03-13.08) and thoracic (2.27; 1.01-5.08) injuries. Among 6-to-9-year-olds, obesity increased risk of thoracic (2.31; 1.08-4.95) and lower extremity (LE) injuries (1.89; 1.03-3.47). Among 10-to-13-year-olds, obesity increased the risk of severe thoracic (1.98; 1.08-3.65) and LE (6.06; 2.23-16.44) injuries. Among 14-to-17-year-olds, obesity increased risk of severe LE injuries (1.44; 1.04-2.00) but decreased risk of abdominal (0.20; 0.07-0.60) and head (0.33; 0.18-0.60) injuries, very similar to the pattern reported in obese adults. CONCLUSION: The pattern of obesity-associated injuries changes from a higher risk of head and thoracic injuries among young children to a pattern in late teenagers that is similar to obese adults. PMID: 19524744 [PubMed - in process]

Cannot exclude torsion--a 15-year review.

Related Articles Cannot exclude torsion--a 15-year review. J Pediatr Surg. 2009 Jun;44(6):1212-6; discussion 1217 Authors: Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N BACKGROUND: Ovarian torsion remains a challenging diagnosis, often leading to delayed operative intervention and resultant ovarian loss. METHODS: Charts of patients with ovarian operative cases were retrospectively reviewed at a free-standing children's hospital over 15 years. Torsion was based on intraoperative findings. RESULTS: Of 328 operative ovarian cases, 97 (29.6%) demonstrated torsion. Mean patient age was 9.2 years (2 days to 17 years, +/-0.54 SEM), with 52% occurring between 9 and 14 years. Of the patients, 97% presented in pain. Presence of a pelvic mass 5 cm or larger on imaging had 83% sensitivity for torsion: an ultrasound reading was only 51% sensitive. Elevated white blood cell count was the only preoperative characteristic associated with prompt operative intervention. Utilization of laparoscopy increased during the latter half of the study (18%-42%, P < .0434). There was a positive trend, although insignificant, in the use of laparoscopy and ovarian salvage. Pathology was overwhelmingly benign (infarction [46%], cysts [33%], and benign neoplasms [19%]). CONCLUSION: Torsion was responsible for one third of all operative ovarian cases. Sonography is not reliable in diagnosis or exclusion of ovarian torsion. Thus, a strategy of earlier and liberal use of Diagnostic Laparoscopy (DL), particularly with a pelvic mass of approximately 5 cm, may improve ovarian salvage. Because pathology is predominantly benign, the edematous detorsed ovary is safe to salvage. PMID: 19524743 [PubMed - in process]

Conflicts in wound classification of neonatal operations.

Related Articles Conflicts in wound classification of neonatal operations. J Pediatr Surg. 2009 Jun;44(6):1206-11 Authors: Vu LT, Nobuhara KK, Lee H, Farmer DL BACKGROUND/PURPOSE: This study sought to determine the reliability of wound classification guidelines when applied to neonatal operations. METHODS: This study is a cross-sectional web-based survey of pediatric surgeons. From a random sample of 22 neonatal operations, participants classified each operation as "clean," "clean-contaminated," "contaminated," or "dirty or infected," and specified duration of perioperative antibiotics as "none," "single preoperative," "24 hours," or ">24 hours." Unweighted kappa score was calculated to estimate interrater reliability. RESULTS: Overall interrater reliability for wound classification was poor (kappa = 0.30). The following operations were classified as clean: pyloromyotomy, resection of sequestration, resection of sacrococcygeal teratoma, oophorectomy, and immediate repair of omphalocele; as clean-contaminated: Ladd procedure, bowel resection for midgut volvulus and meconium peritonitis, fistula ligation of tracheoesophageal fistula, primary esophageal anastomosis of esophageal atresia, thoracic lobectomy, staged closure of gastroschisis, delayed repair and primary closure of omphalocele, perineal anoplasty and diverting colostomy for imperforate anus, anal pull-through for Hirschsprung disease, and colostomy closure; and as dirty: perforated necrotizing enterocolitis. CONCLUSIONS: There is poor consensus on how neonatal operations are classified based on contamination. An improved classification system will provide more accurate risk assessment for development of surgical site infections and identify neonates who would benefit from antibiotic prophylaxis. PMID: 19524742 [PubMed - in process]

Infectious risk to ventriculo-peritoneal shunts from gastrointestinal surgery in the pediatric population.

Related Articles Infectious risk to ventriculo-peritoneal shunts from gastrointestinal surgery in the pediatric population. J Pediatr Surg. 2009 Jun;44(6):1201-4; discussion 1204-5 Authors: Mortellaro VE, Chen MK, Pincus D, Kays DW, Islam S, Beierle EA PURPOSE: The infectious implication of abdominal surgeries on ventriculo-peritoneal (VP) shunts, including simultaneous shunt placement and management of shunt infections, has been ill defined in children. METHODS: We conducted a 9-year retrospective review of pediatric patients with VP shunts who underwent abdominal surgeries. RESULTS: Forty-two patients fit criteria. The median age at shunt placement was 1.75 years, and the median time between shunt placement and abdominal surgery was 24 days. The most common procedures included gastrostomy (17), fundoplication (15), and appendectomy (3). Seven patients had simultaneous abdominal surgery and shunt placement. All patients received preoperative antibiotics. Two children developed shunt infections, both occurred after appendectomy. Both were treated with antibiotics, with one requiring shunt removal. Median length of stay was 24 days but 28 days for those with infections. Thirty-eight patients were discharged home, 3 to chronic care facilities, and 1 died. CONCLUSIONS: Infections did not occur in children with VP shunts undergoing elective abdominal procedures or procedures simultaneously with shunt insertion. Infections were seen only with emergent appendectomies, suggesting that performing gastrointestinal procedures at the time of VP shunt insertion is safe. Children with VP shunts undergoing emergent surgery for peritoneal infection warrant close observation for shunt infection. PMID: 19524741 [PubMed - in process]

A prospective study of methicillin-resistant Staphylococcus aureus colonization in children scheduled for elective surgery.

Related Articles A prospective study of methicillin-resistant Staphylococcus aureus colonization in children scheduled for elective surgery. J Pediatr Surg. 2009 Jun;44(6):1197-200; discussion 1200 Authors: Vegunta RK, Gray B, Wallace LJ, Mongkolrattanothai K, Mankin P, Stanfill AB, Pearl RH BACKGROUND: Staphylococcus aureus is a major cause of surgical wound infections. To obtain contemporary data on S aureus, we performed a prospective study of colonization and infection in children scheduled for elective surgical procedures. METHODS: A nasal swab and clinical information were obtained at the presurgical outpatient visit. At operation, nasal and perianal swabs were obtained. S aureus were isolated and characterized. RESULTS: We enrolled 499 patients from June 2005 to April 2007. Wound classes were 1 (73%), 2 (22%), 3 (5%), and 4 (0.2%). Prophylactic antibiotics were administered for 153 (31%). Postoperative length of stay ranged from 0 (77%) to 6 days, with 19 (4%) staying 4 days or more. Screening cultures grew S aureus for 186 procedures (36.6%); of these, 141 were methicillin-resistant S aureus (MRSA) (76% of all staphylococcal cultures or 28% of all procedures). Most MRSA had Staphylococcal Chromosomal Cassette mec type II and resistance to clindamycin-typical for hospital-associated strains. There were 10 (2%) surgical site infections, including 4 methicillin-sensitive S aureus, 1 MRSA, 2 with no growth, and 2 with no cultures. CONCLUSION: Methicillin-resistant S aureus colonization was common in asymptomatic children. Most strains appeared to be health care-associated and resistant to clindamycin. Wound infection rate remained low despite the high prevalence of staphylococcal colonization. PMID: 19524740 [PubMed - in process]

Percutaneous endoscopic gastrostomy buttons in children: superior to tubes.

Related Articles Percutaneous endoscopic gastrostomy buttons in children: superior to tubes. J Pediatr Surg. 2009 Jun;44(6):1193-6 Authors: Novotny NM, Vegeler RC, Breckler FD, Rescorla FJ BACKGROUND: There is a paucity of literature comparing outcomes of percutaneous endoscopic gastrostomy (PEG) tubes vs PEG buttons. Primary PEG buttons offer an advantage of being a single-step low-profile enteral access device with potentially fewer complications. METHODS: A retrospective review of patients undergoing PEG tubes and buttons (January 2006-August 2007) was performed. Power analysis demonstrated that 105 patients in each group were needed. Patient characteristics were collected in each group and evaluated by chi(2) and t tests. P values of less than .05 were considered significant. RESULTS: A total of 223 children having undergone PEG (110 tubes, 113 buttons) were identified. No differences were found in operative time, intraoperative complications, clogging, breakage, infections, emergency department visits, or hospital readmissions. However, children undergoing PEG button placement were more likely to spend only one night in the hospital vs PEG tube (60% vs 25%, respectively; P < .001). In addition, PEG buttons had fewer dislodgements (4 vs 15; P < .05). CONCLUSION: The PEG buttons are less likely to become dislodged than PEG tubes. Infection rates were not found to be different between groups. Children with PEG buttons were more likely to be discharged earlier than children with PEG tubes. Primary PEG buttons are clinically comparable to PEG tubes with less concern for dislodgements. PMID: 19524739 [PubMed - in process]

Return of the surgeon in the diagnosis of pyloric stenosis.

Related Articles Return of the surgeon in the diagnosis of pyloric stenosis. J Pediatr Surg. 2009 Jun;44(6):1189-92; discussion 1192 Authors: Copeland DR, Cosper GH, McMahon LE, Boneti C, Little DC, Dassinger MS, Kokoska ER, Jackson RJ, Smith SD BACKGROUND: The diagnosis of pyloric stenosis (PS) by physical examination is a lost art that has been replaced by radiology-performed ultrasound (US). The purpose of this study is to demonstrate that the diagnosis of PS can be made solely upon the surgeons US evaluation. METHODS: Surgical ultrasonographers included 2 senior general surgery residents and 2 pediatric surgery residents without prior formal US experience. These surgeons underwent proctored training in the use of US for PS. Measurements including channel length and muscle thickness were recorded at bedside. A positive examination included muscle thickness more than 4 mm and channel length more than 16 mm. Patients with positive results underwent pyloromyotomy. Negative results were confirmed with a repeat US through the radiology department, and infants without PS were subsequently referred for appropriate medical management. RESULTS: Thirty-two consecutive patients with suspected PS were evaluated using surgeon-performed ultrasonography. All examinations were diagnostically accurate. There were no false-positive or false-negative result. Seven patients (22%) were correctly determined to be negative for PS. The remaining 25 infants underwent successful pyloromyotomy with resolution of symptoms. CONCLUSION: Surgeons who have undergone focused training to perform US for PS can diagnose the condition without confirmatory testing by a radiologist. PMID: 19524738 [PubMed - in process]

Influence of extracorporeal membrane oxygenation on subsequent surgeries after congenital diaphragmatic hernia repair.

Related Articles Influence of extracorporeal membrane oxygenation on subsequent surgeries after congenital diaphragmatic hernia repair. J Pediatr Surg. 2009 Jun;44(6):1186-8 Authors: Breckler FD, Molik KA, West KW PURPOSE: Congenital diaphragmatic hernia (CDH) is a complex anomaly requiring intensive pulmonary and hemodynamic management. Survival has increased in this population placing them at risk for subsequent morbidities including surgery. The purpose of this study is to review the need for subsequent surgeries in the CDH population. METHODS: After receiving institutional review board approval, a retrospective chart review of all CDH patients between 1980 and 2007 was conducted noting subsequent surgeries and the impact of extracorporeal membrane oxygenation (ECMO) on the types of surgical procedures. Comparison of groups was done by Fisher's Exact test or nonparametric Wilcoxon rank-sum test where appropriate. A P value of less than .05 was considered significant. RESULTS: Data were analyzed for 227 of 294 patients during this period. Extracorporeal membrane oxygenation support was used in 45% of patients. Subsequent surgery was required in 117 patients. Seventy patients in the ECMO group (69%) required a subsequent operation. The most common operative procedures included inguinal hernia/orchiopexy, antireflux, and recurrent diaphragmatic hernias. CONCLUSION: In this series, ECMO survivors are at a high risk for requiring subsequent surgeries compared to the total CDH group. This information can be used as an education tool for referring physicians and parents as they care for this group of children. PMID: 19524737 [PubMed - in process]

Chylothorax after congenital diaphragmatic hernia repair.

Related Articles Chylothorax after congenital diaphragmatic hernia repair. J Pediatr Surg. 2009 Jun;44(6):1181-5; discussion 1185 Authors: Gonzalez R, Bryner BS, Teitelbaum DH, Hirschl RB, Drongowski RA, Mychaliska GB PURPOSE: Chylothorax after congenital diaphragmatic hernia (CDH) repair contributes significantly to morbidity. Our aim was to identify factors contributing to chylothorax and effective treatment strategies. METHODS: We reviewed 171 patients with CDH from 1997 to 2008 and analyzed hernia characteristics, extracorporeal membrane oxygenation (ECMO) use, operative details, and treatment approaches for chylothorax. RESULTS: Ten (7%) patients developed chylothorax; all were left sided. Using univariate analysis, prenatal diagnosis, ECMO use, and patch repair were associated with development of chylothorax. Logistic regression analysis showed that patch repair was the only variable predictive of chylothorax (P = .028; confidence interval, 0.032-0.823). Although survival was not affected, patients with chylothorax had a significant increase in ventilator days and length of stay (t = 3.57; P = .000; t = 2.74; P = .007). All received thoracostomy and total parenteral nutrition. Six patients received octreotide, 5 of whom required pleurectomy because of failed medical management; the remaining patient died of overwhelming sepsis. CONCLUSIONS: The incidence of chylothorax at our institution was relatively low. Patch repair was associated with the formation of chylothorax. Morbidity was substantial, but survival was not significantly affected. Total parenteral nutrition and thoracostomy were appropriate initial treatments. Octreotide was not an effective adjunct. Refractory cases were successfully treated with pleurectomy. PMID: 19524736 [PubMed - in process]

Multivariate model for predicting recurrence in congenital diaphragmatic hernia.

Related Articles Multivariate model for predicting recurrence in congenital diaphragmatic hernia. J Pediatr Surg. 2009 Jun;44(6):1173-9; discussion 1179-80 Authors: Fisher JC, Haley MJ, Ruiz-Elizalde A, Stolar CJ, Arkovitz MS PURPOSE: Risk factors that predispose children with congenital diaphragmatic hernia (CDH) to recurrence remain poorly defined. We report a large series of recurrent CDH and ask whether prenatal patient factors or postnatal treatment variables better predict recurrence. METHODS: Two hundred thirty-eight neonates with unilateral CDH underwent repair from 1990 to 2006. Data were assessed by chi(2) and Mann-Whitney U tests. Multivariate regression identified independent predictors of recurrence. Statistical significance was set at P < .05. RESULTS: We identified 24 recurrences (10%). Median time from repair to recurrence diagnosis was 4.9 months. Patients with recurrence were older (P = .02) and more often required abdominal wall patches at initial repair (P = .01) compared to nonrecurrence patients. Postoperative length of stay (LOS) after initial repair (P < .01) and morbidity (P = .01) were greater in recurrence patients. Use of diaphragm patch at initial repair was greater in patients with recurrence but only approached statistical significance (P = .05). Only 2 variables independently predicted recurrence by multivariate regression as follows: abdominal (not diaphragm) wall patch during initial repair (odds ratio [OR] 3.50; P = .04) and postoperative LOS (OR, 1.012; P = .01). CONCLUSION: Neonates at risk for CDH recurrence are better identified by postnatal treatment variables than by prenatal patient factors. Although age at repair and diaphragm patch use are greater in recurrence patients, the only factors to independently predict recurrence were postoperative LOS and abdominal wall patch use. These data can help optimize follow-up regimens. PMID: 19524735 [PubMed - in process]

Congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation: does timing of repair matter?

Related Articles Congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation: does timing of repair matter? J Pediatr Surg. 2009 Jun;44(6):1165-71; discussion 1171-2 Authors: , Bryner BS, West BT, Hirschl RB, Drongowski RA, Lally KP, Lally P, Mychaliska GB PURPOSE: Severe congenital diaphragmatic hernia (CDH) requiring extracorporeal membrane oxygenation (ECMO) is associated with high mortality. Timing of CDH repair relative to ECMO therapy remains controversial. Our hypothesis was that survival would significantly differ between those who underwent repair during ECMO and those who underwent repair after ECMO therapy. METHODS: We examined deidentified data from the CDH study group (CDHSG) registry from 1995 to 2005 on patients who underwent repair and ECMO therapy (n = 636). We used Cox regression analysis to assess differences in survival between those who underwent repair during and after ECMO. RESULTS: Five covariates were significantly associated with mortality as follows: timing of repair relative to ECMO (P = .03), defect side (P = .01), ECMO run length (P < .01), need for patch repair (P = .03), birth weight (P < .01), and Apgar score at 5 minutes (P = .03). Birth year, inborn vs transfer status, diaphragmatic agenesis, age at repair, and presence of cardiac or chromosomal abnormalities were not associated with survival. Repair after ECMO therapy was associated with increased survival relative to repair on ECMO (hazard ratio, 1.407; P = .03). CONCLUSION: These data suggest that CDH repair after ECMO therapy is associated with improved survival compared to repair on ECMO, despite controlling for factors associated with the severity of CDH. PMID: 19524734 [PubMed - in process]

Tracheal innervation is abnormal in rats with experimental congenital diaphragmatic hernia.

Related Articles Tracheal innervation is abnormal in rats with experimental congenital diaphragmatic hernia. J Pediatr Surg. 2009 Jun;44(6):1159-64 Authors: Pederiva F, Lopez RA, Martinez L, Tovar JA BACKGROUND: Tracheobronchial motility influences lung development. Lung hypoplasia and lung sequelae accompany congenital diaphragmatic hernia (CDH) in which the vagus nerves and esophageal innervation are abnormal. As the vagus supplies tracheal innervation, this study tested the hypothesis that it might also be abnormal in rats with CDH. MATERIAL AND METHODS: Intrinsic ganglia were counted and measured in whole mount acetylcholinesterase-stained tracheas from CDH and control E21 fetal rats. The relative surfaces occupied by neural structures were measured in tracheal sections immunostained for p75(NTR) and PGP 9.5. PGP 9.5 protein and mRNA expression were determined. Mann-Whitney tests were used for comparisons between groups using P < .05 as significant. RESULTS: p75(NTR) staining showed the neural crest origin of tracheal innervation. Scarce neural structures and smaller ganglia were found in CDH fetuses. PGP 9.5 protein expression was decreased in CDH fetuses, whereas PGP 9.5 mRNA levels were increased in comparison with controls. CONCLUSIONS: Decreased density of neural structures and size of intramural ganglia, reduced expression of neural tissue and PGP 9.5 protein, and increased levels of PGP 9.5 mRNA reveal deficient tracheal innervation in rats with CDH. If similar anomalies exist in the human condition, they could contribute to explaining the pathogenesis of lung hypoplasia and bronchopulmonary sequelae. PMID: 19524733 [PubMed - in process]

Diagnosis of Wilms' tumor using near-infrared Raman spectroscopy.

Related Articles Diagnosis of Wilms' tumor using near-infrared Raman spectroscopy. J Pediatr Surg. 2009 Jun;44(6):1152-8; discussion 1158 Authors: Wills H, Kast R, Stewart C, Sullivan B, Rabah R, Poulik J, Pandya A, Auner G, Klein MD PURPOSE: Raman spectroscopy has distinguished malignant from normal tissues in several types of cancer. This is the first report of applying Raman spectroscopy to the diagnosis of Wilms' tumor. METHODS: Specimens of normal kidney, Wilms' tumor, xanthogranuloma, nephrogenic rests, and rhabdoid tumor were collected fresh from the operating room. Specimens of Wilms' tumor, normal kidney, and congenital mesoblastic nephroma were retrieved from the cryobank and thawed to room temperature. At least 12 Raman spectra were collected from each tissue sample. Histologic slides of each specimen were reviewed by pediatric pathologists. A computer algorithm based on discriminant function analysis (DFA) classified the Raman spectra of Wilms' tumor and the normal sample. RESULTS: Four hundred sixty-seven spectra were collected from 41 specimens. Using DFA, Raman spectroscopy differentiated Wilms' tumor from normal with 100% sensitivity and specificity and treated from untreated Wilms' tumor with 100% sensitivity and specificity. Using a DFA model built from cryopreserved specimens but applied to fresh Wilms' and normal samples, the sensitivity and specificity were 93.3% and 90.9%, respectively. CONCLUSION: Raman spectroscopy is an accurate technique for differentiating Wilms' tumor from normal kidney and treated from untreated Wilms' tumor. It has potential to diagnose in minutes what currently takes several hours to days. PMID: 19524732 [PubMed - in process]

Renal tumors in the second decade of life: results from the California Cancer Registry.

Related Articles Renal tumors in the second decade of life: results from the California Cancer Registry. J Pediatr Surg. 2009 Jun;44(6):1148-51 Authors: Grabowski J, Silberstein J, Saltzstein SL, Saenz N BACKGROUND: Renal tumors are rare in adolescents and young adults. The aim of this study was to characterize the histologic condition, epidemiology, and survival of renal tumors in patients aged 11 to 20 years old using a large, population-based database. METHODS: The California Cancer Registry was reviewed from the years 1988 to 2004. All renal tumors in patients aged 11 to 20 years old were identified. The data were analyzed with relation to patient age, sex and ethnicity, tumor histologic examination, and actuarial mortality rates. RESULTS: Seventy-seven primary renal malignancies were identified. Thirty-nine (51%) were renal cell carcinoma, 23 (30%) were Wilms' tumor, and 15 (20%) were other tumor types. The mean age of the patients with renal cell carcinoma was 16.7 years old, which was significantly older than the Wilms' tumor patients (13.9 years; P < .01). The 5-year cumulative survival rate of patients with renal cell carcinoma was 54%, which was worse than that of Wilms' tumor patients (77%). CONCLUSION: Primary renal malignancies are uncommon in the second decade of life. The most common tumor type in this age-group is renal cell carcinoma followed by Wilms' tumor. Patients with renal cell carcinoma tend to be older and have a lower survival than patients with other kidney tumors. PMID: 19524731 [PubMed - in process]

Cyclooxygenase 2 mediates the antiangiogenic effect of rapamycin in Ewing sarcoma.

Related Articles Cyclooxygenase 2 mediates the antiangiogenic effect of rapamycin in Ewing sarcoma. J Pediatr Surg. 2009 Jun;44(6):1139-46; discussion 1146-7 Authors: Lipskar AM, Glick RD, Huang J, Fisher JC, DeVoti J, Pica R, Edelman M, Steinberg BM, Soffer SZ BACKGROUND: Rapamycin can inhibit tumor growth and angiogenesis in various human cancers. Cyclooxygenase 2 (COX-2) is involved in the angiogenic process. We hypothesized that the antiangiogenic effect of rapamycin may be mediated by suppression of COX-2. METHODS: Ewing sarcoma (ES) cells were implanted in athymic mice. Selected animals were treated with rapamycin for 5 weeks. Tumor vascularity was assessed by lectin perfusion angiography and immunohistochemistry. Phosphorylation of mammalian target of rapamycin pathway proteins was determined by Western blot analysis. Staining of COX-2 protein was determined by immunohistochemistry, and expression of COX-2 messenger RNA levels was assessed with quantitative real-time (RT) polymerase chain reaction. RESULTS: Mean tumor weights were significantly reduced in the treated group (5.43 g +/- 1.43 SEM vs 0.49 g +/- 0.15 SEM, P < .003). There was abundant vasculature in the control group and blunted vascularity in the treated xenografts. The phosphorylation of p70s6k and Akt was not inhibited in the rapamycin-treated tumors. Cyclooxygenase 2 was suppressed in the treated xenografts at both the protein and messenger RNA levels. CONCLUSION: Low-dose rapamycin inhibits tumor growth and angiogenesis in human ES without inhibiting the phosphorylation of p70s6k and Akt. Cyclooxygenase 2 levels are inhibited by low-dose treatment of ES with rapamycin. Cyclooxygenase 2 suppression may mediate the antiangiogenic effect of rapamycin in Ewing sarcoma. PMID: 19524730 [PubMed - in process]

Outcome of splenectomy in children younger than 4 years with sickle cell disease.

Related Articles Outcome of splenectomy in children younger than 4 years with sickle cell disease. J Pediatr Surg. 2009 Jun;44(6):1134-8; discussion 1138 Authors: Lesher AP, Kalpatthi R, Glenn JB, Jackson SM, Hebra A PURPOSE: Removal of the spleen in patients younger than 4 years has been reported to carry an increased risk of postsplenectomy sepsis and has not been universally accepted. We reviewed our experience with splenectomy in children with acute splenic sequestration crisis (ASSC) younger than 4 years. METHODS: The study involved retrospective review of demographic and operative data, number of ASSC, operative complications, infections, and death. RESULTS: From 1993 to 2008, 53 patients (28 males, 25 females) younger than 4 years had open (43.8%) or laparoscopic (56.6%) splenectomy after one or more events of ASSC. Six (11.3%) were younger than 18 months, 28 (52.8%) were 18 to 24 months old, and 21 (39.6%) were 24 to 48 months old. Operative complications were diaphragm laceration (laparoscopy, n = 3; 5.7%) and reoperation for bleeding (open, n = 1; 1.8%). Length of stay was similar for laparoscopic (3.6 days) vs open (3.8 days) splenectomy. Mean postoperative follow-up was 5.6 years. In 353 postsplenectomy admissions, 3 (5.7%) patients had positive blood cultures requiring treatment. Three (5.7%) patients died within the 15-year study period; one (1.8%) had documented pneumococcal sepsis. DISCUSSION: The advantage of early splenectomy may outweigh the risks of long-term transfusion. Splenectomy in young children with sickle cell disease carries a low risk of postsplenectomy sepsis with appropriate vaccination and prophylactic antibiotics. We conclude that splenectomy in young children with ASSC is safe and effective, especially with penicillin prophylaxis and improved vaccination strategies. PMID: 19524729 [PubMed - in process]

Tissue-engineered arterial grafts: long-term results after implantation in a small animal model.

Related Articles Tissue-engineered arterial grafts: long-term results after implantation in a small animal model. J Pediatr Surg. 2009 Jun;44(6):1127-32; discussion 1132-3 Authors: Mirensky TL, Nelson GN, Brennan MP, Roh JD, Hibino N, Yi T, Shinoka T, Breuer CK BACKGROUND: Use of prosthetic vascular grafts in pediatric vascular surgical applications is limited because of risk of infection, poor durability, potential for thromboembolic complications, and lack of growth potential. Construction of an autologous neovessel using tissue engineering technology offers the potential to create an improved vascular conduit for use in pediatric vascular applications. METHODS: Tissue-engineered vascular grafts were assembled from biodegradable tubular scaffolds fabricated from poly-L-lactic acid mesh coated with epsilon-caprolactone and L-lactide copolymer. Thirteen scaffolds were seeded with human aortic endothelial and smooth muscle cells and implanted as infrarenal aortic interposition grafts in SCID/bg mice. Grafts were analyzed at time-points ranging from 4 days to 1 year after implantation. RESULTS: All grafts remained patent without evidence of thromboembolic complications, graft stenosis, or graft rupture as documented by serial ultrasound and computed tomographic angiogram, and confirmed histologically. All grafts demonstrated extensive remodeling leading to the development of well-circumscribed neovessels with an endothelial inner lining, neomedia containing smooth muscle cells and elastin, and a collagen-rich extracellular matrix. CONCLUSIONS: The development of second-generation tissue-engineered vascular grafts shows marked improvement over previous grafts and confirms feasibility of using tissue engineering technology to create an improved arterial conduit for use in pediatric vascular surgical applications. PMID: 19524728 [PubMed - in process]

Sternal repair with bone grafts engineered from amniotic mesenchymal stem cells.

Related Articles Sternal repair with bone grafts engineered from amniotic mesenchymal stem cells. J Pediatr Surg. 2009 Jun;44(6):1120-6; discussion 1126 Authors: Steigman SA, Ahmed A, Shanti RM, Tuan RS, Valim C, Fauza DO PURPOSE: We aimed at determining whether osseous grafts engineered from amniotic mesenchymal stem cells (aMSCs) could be used in postnatal sternal repair. METHODS: Leporine aMSCs were isolated, identified, transfected with green fluorescent protein (GFP), expanded, and seeded onto biodegradable electrospun nanofibrous scaffolds (n = 6). Constructs were dynamically maintained in an osteogenic medium and equally divided into 2 groups with respect to time in vitro as follows: 14.6 or 33.9 weeks. They were then used to repair full-thickness sternal defects spanning 2 to 3 intercostal spaces in allogeneic kits (n = 6). Grafts were submitted to multiple analyses 2 months thereafter. RESULTS: Chest roentgenograms showed defect closure in all animals, confirmed at necropsy. Graft density as assessed by microcomputed tomographic scans increased significantly in vivo, yet there were no differences in mineralization by extracellular calcium measurements preimplantation and postimplantation. There was a borderline increase in alkaline phosphatase activity in vivo, suggesting ongoing graft remodeling. Histologically, implants contained GFP-positive cells and few mononuclear infiltrates. There were no differences between the 2 construct groups in any comparison. CONCLUSIONS: Engineered osseous grafts derived from amniotic mesenchymal stem cells may become a viable alternative for sternal repair. The amniotic fluid can be a practical cell source for engineered chest wall reconstruction. PMID: 19524727 [PubMed - in process]

When patients choose: comparison of Nuss, Ravitch, and Leonard procedures for primary repair of pectus excavatum.

Related Articles When patients choose: comparison of Nuss, Ravitch, and Leonard procedures for primary repair of pectus excavatum. J Pediatr Surg. 2009 Jun;44(6):1113-8; discussion 118-9 Authors: Antonoff MB, Erickson AE, Hess DJ, Acton RD, Saltzman DA BACKGROUND/PURPOSE: Pectus excavatum is a common chest wall deformity, and several procedures have been developed for its correction. We allow patients to choose among Leonard, Nuss, and Ravitch procedures. This study aimed to determine which procedure most patients select and the resultant outcomes. METHODS: Charts were reviewed of all pectus excavatum repairs performed for 4 years by a practice covering a university-based children's hospital. Procedure choice, operative time, length of stay, analgesia, fees, and complications were recorded. RESULTS: The Ravitch procedure was chosen by 60.9% of our patients, Leonard procedure by 23.9%, and Nuss procedure by 15.2%. Operative times were not significantly different among the groups. The mean length of stay was 2.2 days (Ravitch), 1.5 days (Leonard), and 3.9 days (Nuss) (P < .005). Epidural analgesia/patient-controlled analgesia pump requirements were 50% (Ravitch), 5% (Leonard), and 100% (Nuss). The mean charges were $27,414 (Ravitch), $18,094 (Leonard), and $43,749 (Nuss) (P < .05). The overall complication rate was 16.3%. The complications among each group were as follows: Ravitch, 14.3%; Leonard, 9.1%; and Nuss, 35.7%. CONCLUSIONS: We allow patients to choose among Leonard, Ravitch, and Nuss procedures for repair of pectus excavatum. Most select the Ravitch procedure. Length of stay, fees, analgesic needs, and complication rate were highest among patients in the Nuss group; all of these variables were lowest in the Leonard group. PMID: 19524726 [PubMed - in process]

Prevalence of gastroschisis and associated hospital time continue to rise in neonates who are admitted for intensive care.

Related Articles Prevalence of gastroschisis and associated hospital time continue to rise in neonates who are admitted for intensive care. J Pediatr Surg. 2009 Jun;44(6):1108-12 Authors: Clark RH, Walker MW, Gauderer MW PURPOSE: The purpose of this study was to evaluate recent trends in the prevalence of gastroschisis. METHODS: The study used a retrospective review of a deidentified neonatal intensive care patient data set. To control for ascertainment bias, the prevalence of omphalocele was calculated to provide an internal comparison to another anomaly requiring surgical intervention. RESULTS: During the study period (1997-2007), there were 473,366 discharges from the neonatal intensive care unit in the data set. There were 2057 (5.3/1000 discharges) neonates who had a gastroschisis and 853 (1.8/1000 discharges) who had an omphalocele. Between 1997 and 2004, the reported rate of gastroschisis increased from 2.9 to 6.1/1000 discharges, a relative increase of 210% (P < .001). Since 2004, the values have remained relatively stable at between 5.5 and 6.2/1000 discharges. Between 1997 and 2007, the hospital days for patients with gastroschisis/total hospital days increased from 0.6% to 1.3%, a relative increase of 220% (P < .001). In contrast, the reported rate of neonates with and the number of hospital days attributed to neonates with omphalocele has not changed significantly. CONCLUSION: The prevalence and the number of hospital days needed to care for neonates with gastroschisis have continued to increase since 2001. PMID: 19524725 [PubMed - in process]

A murine model of graft-vs-host disease after in utero hematopoietic cell transplantation.

Related Articles A murine model of graft-vs-host disease after in utero hematopoietic cell transplantation. J Pediatr Surg. 2009 Jun;44(6):1102-7; discussion 1107 Authors: Misra MV, Gutweiler JR, Suh MY, Twark CM, Valim C, Perez-Atayde A, Kim HB PURPOSE: Graft-vs-host disease (GvHD) is a known complication of in utero bone marrow transplantation. However, GvHD has been difficult to study owing to frequent fetal demise. We describe the first consistent murine model of GvHD with postnatal survival after in utero hematopoietic cell transplantation. METHODS: A 50/50 mixture of bone marrow and splenocytes (10(6)) from 6-week-old C57/BL6 (H2-b) mice was injected intraperitoneally into Balb/c (H2-d) fetuses at e14 to 16. Live born pups were followed for clinical GvHD. Peripheral blood and hematopoietic organ chimerism was confirmed by flow cytometry and polymerase chain reaction. Organ samples were isolated for histology. RESULTS: Twenty-seven (75%) of 36 surviving pups displayed clinical GvHD by 2 weeks compared with 9 developmentally normal pups. Mean difference in weight between the 2 groups was 2.9 g at 7 days and 5.2 g at 14 days of life (P < .0001). All 27 pups with clinical GvHD and 1 normal-appearing pup had blood chimerism ranging from 1.5% to 65%. Eight of the 9 normal-appearing pups had 0% chimerism. Histologic analysis revealed findings of GvHD in liver, spleen, small intestine, and skin specimens of only chimeric pups. CONCLUSIONS: A consistent murine model of GvHD can be achieved after in utero transplantation of major histocompatibility complex-mismatched bone marrow and splenocytes. Future studies will use this model to examine approaches to prevent GvHD after in utero stem cell transplantation. PMID: 19524724 [PubMed - in process]

Selection of live-related liver transplantation candidates.

Related Articles Selection of live-related liver transplantation candidates. J Pediatr Surg. 2009 Jun;44(6):1096-100; discussion 1100-1 Authors: Rymeski BA, Flynn L, Dunn SP PURPOSE: Living donor liver transplantation (LR) is an important alternative for children. We compared our outcomes of LR and cadaveric (CAD) graft recipients, with attention to the pediatric end-stage liver disease (PELD) score and perioperative morbidity and mortality to identify appropriate candidates for LR. METHODS: Our transplant database and electronic medical records were searched for demographics and outcome measures. RESULTS: From 2000 to 2008, 81 children underwent liver transplantation from 37 LR and 44 CAD donors. There were no significant differences in graft or overall survival at 3 months or 1 year. The LR group was significantly younger (4.46 +/- 5.2 years vs 7.41 +/- 6.6 years; P = .03) and had a significantly lower PELD score (12.7 +/- 13 vs 22 +/- 12; P = .001) at the time of transplantation. Ten patients were transplanted for unresectable tumor in the LR group vs 4 CAD (P = .03). Significantly fewer LR recipients required return to the operating room in the first 30 days posttransplant (13.9% vs 34.1%; P = .03). The LR recipients had a higher rate of biliary stricture requiring reoperation (22.2% vs 2.3%; P = .005). CONCLUSIONS: The LR liver transplantation is highly selected for patients with a parent donor who will need transplant but do not yet have a high PELD score. A lower PELD score at operation may have contributed to the lower incidence of postoperative complications requiring reoperation. PMID: 19524723 [PubMed - in process]

Outcomes after the Ladd procedure in patients with heterotaxy syndrome, congenital heart disease, and intestinal malrotation.

Related Articles Outcomes after the Ladd procedure in patients with heterotaxy syndrome, congenital heart disease, and intestinal malrotation. J Pediatr Surg. 2009 Jun;44(6):1089-95; discussion 1095 Authors: Yu DC, Thiagarajan RR, Laussen PC, Laussen JP, Jaksic T, Weldon CB PURPOSE: Heterotaxy syndrome (HS) patients often present with congenital heart disease and intestinal malrotation. Controversy exists regarding the management of these patients. Risk of midgut volvulus, morbidity from elective operations, and overall prognosis must be weighed when considering a Ladd procedure on asymptomatic HS/intestinal malrotation patients. METHODS: This is a retrospective review comparing HS and non-heterotaxy syndrome (NHS) patients undergoing a Ladd procedure at Children's Hospital Boston (Mass) from January 1997 to September 2007. RESULTS: Thirty-one HS and 51 NHS patients were identified. After a Ladd procedure, HS patients remained in the hospital 12.9 days, had a 9.7% risk of small bowel obstruction, and a 9.7% in-hospital mortality. If allowed to develop abdominal symptoms, 27% of HS patients with intestinal malrotation had a midgut volvulus at surgery. Intra-HS group comparison demonstrated longer hospital stays in symptomatic patients (P = .01). Mortality was greater in the HS than NHS patients, but deaths were related to cardiac disease and not to the Ladd procedure. CONCLUSIONS: Elective Ladd procedures are well tolerated by HS patients. Given the risk of midgut volvulus and in light of improved survival beyond infanthood, once identified, HS patients with asymptomatic malrotation should be offered a prophylactic Ladd procedure. PMID: 19524722 [PubMed - in process]

Persistent alanine aminotransferase elevations in children with parenteral nutrition-associated liver disease.

Related Articles Persistent alanine aminotransferase elevations in children with parenteral nutrition-associated liver disease. J Pediatr Surg. 2009 Jun;44(6):1084-7; discussion 1087-8 Authors: Yang CF, Lee M, Valim C, Hull MA, Zhou J, Jones BA, Gura K, Collier S, Lo C, Duggan C, Jaksic T BACKGROUND: Parenteral nutrition-associated liver disease (PNALD) is a serious condition affecting many children with short bowel syndrome. The aim of this study was to longitudinally assess serum alanine aminotransferase (ALT), a marker for hepatocyte injury, in enterally fed children with PNALD. METHODS: Retrospective chart review of 31 patients treated from 1999 to 2006 by the Center for Advanced Intestinal Rehabilitation at Children's Hospital Boston (Mass). Inclusion criteria included PN duration of greater than 3 months with subsequent tolerance of full enteral nutrition and evidence of PN-associated liver injury. Time to normalize ALT and direct bilirubin were estimated using Kaplan-Meier and Cox proportional hazards methods. RESULTS: Mean age PN cessation was 6 months (range, 2-14 months). Median PN duration was 18 weeks (interquartile range [IQR], 13-33 weeks), and median follow-up was 24 weeks (IQR, 14-48 weeks). After transition to full enteral nutrition, 74% of children normalized direct bilirubin, whereas only 50% normalized ALT. Kaplan-Meier median time to direct bilirubin and ALT normalization were 13 weeks and 35 weeks, respectively (P = .001). CONCLUSION: Children with PNALD who have achieved PN independence have persistent ALT elevation despite normal direct bilirubin levels. This implies that hepatic injury may be ongoing beyond the time of bilirubin normalization in this cohort of patients. PMID: 19524721 [PubMed - in process]

Intestinal resection induces angiogenesis within adapting intestinal villi.

Related Articles Intestinal resection induces angiogenesis within adapting intestinal villi. J Pediatr Surg. 2009 Jun;44(6):1077-82; discussion 1083 Authors: Martin CA, Perrone EE, Longshore SW, Toste P, Bitter K, Nair R, Guo J, Erwin CR, Warner BW PURPOSE: Adaptive growth of the intestinal mucosa in response to massive gut loss is fundamental for autonomy from parenteral nutrition. Although angiogenesis is essential for cellular proliferation in other tissues, its relevance to intestinal adaptation is unknown. We tested the hypothesis that resection-induced adaptation is associated with new blood vessel growth. METHODS: Male C57Bl/6 mice underwent either a 50% small bowel resection or a sham (transection and reanastomosis) operation. After 1, 3, or 7 days, capillary density within the intestinal villi was measured using confocal microscopy. A messenger RNA reverse-transcriptase polymerase chain reaction (RT-PCR) array was used to determine angiogenic gene expression during adaptation. RESULTS: Mice that underwent small bowel resection had a significantly increased capillary density compared to sham-operated mice at postoperative day 7. This morphological alteration was preceded by significant alterations in 5 candidate genes at postoperative day 3. CONCLUSION: New vessel blood growth is observed in the adapting intestine after massive small bowel loss. This response appears to follow rather than initiate the adaptive alterations in mucosal morphology that are characteristic of adaptation. A better understanding of this progress and the signaling factors involved may improve therapeutic options for children with short gut syndrome. PMID: 19524720 [PubMed - in process]

Mortality of necrotizing enterocolitis expressed by birth weight categories.

Related Articles Mortality of necrotizing enterocolitis expressed by birth weight categories. J Pediatr Surg. 2009 Jun;44(6):1072-5; discussion 1075-6 Authors: Fitzgibbons SC, Ching Y, Yu D, Carpenter J, Kenny M, Weldon C, Lillehei C, Valim C, Horbar JD, Jaksic T PURPOSE: Low birth weight is the most important risk factor for developing necrotizing enterocolitis (NEC). We aimed to establish birth weight-based benchmarks for in-hospital mortality in neonates with NEC. METHODS: Five hundred eleven centers belonging to the Vermont Oxford Network prospectively evaluated 71,808 neonates with birth weight of 501 to 1500 g between January 2005 and December 2006. The primary outcome variable was in-hospital mortality. RESULTS: Birth weight was divided into 4 categories by 250-g increments. The NEC risk (P < .001) and mortality (P < .001) decreased with higher birth weight category. Necrotizing enterocolitis was associated with a significant odds ratio for death for each category (P < .001). Across groups, the odds ratio for NEC mortality increased with higher birth weight category (category 1 = 1.6 vs category 4 = 9.9; P < .001). CONCLUSION: The in-hospital mortality rate of neonates with NEC remains high and is significantly related to birth weight category. Although the risk and absolute mortality of NEC decrease with higher birth weight, the odds ratios indicate that NEC has a relatively greater impact upon mortality at higher birth weight. These data afford birth weight-based mortality benchmarks that may be useful in assessing single center NEC outcomes and facilitating comparisons between centers. PMID: 19524719 [PubMed - in process]

p21(waf1/cip1) deficiency does not perturb the intestinal crypt stem cell population after massive small bowel resection.

Related Articles p21(waf1/cip1) deficiency does not perturb the intestinal crypt stem cell population after massive small bowel resection. J Pediatr Surg. 2009 Jun;44(6):1065-71; discussion 1071 Authors: Longshore SW, Nair R, Perrone EE, Erwin CR, Guo J, Warner BW BACKGROUND: After small bowel resection (SBR), adaptation is initiated in intestinal crypts where stem cells reside. Prior studies revealed SBR-induced enterocyte proliferation requires the expression of p21(waf1/cip1). As deficient expression of p21(waf1/cip1) has been shown to result in reduced numbers of hematopoietic stem cells. We sought to test the hypothesis that p21(waf1/cip1)deficiency similarly perturbs the intestinal stem cell population after SBR. METHODS: Control (n = 21; C57Bl/6) and p21(waf1/cip1)-null mice (n = 30) underwent 50% proximal SBR or sham operation. After 3 days, the ileum was harvested and the crypt stem cell population evaluated by counting crypt base columnar cells on histologic sections, determining the expression of Musashi-1 and Lgr5, and profiling the transcriptional expression of 84 known stem cell genes. RESULTS: There were no significant differences in crypt base columnar cells, expression of Musashi-1 or Lgr5, or in stem cell gene expression after SBR in control mice. Furthermore, there were no differences in these markers between controls and p21(waf1/cip1)-null mice. CONCLUSION: In contrast with bone marrow stem cells, the stem cell population of the gut is unaffected by deficient expression of p21(waf1/cip1). Additional mechanisms for the role of p21(waf1/cip1) in small bowel proliferation and adaptation after massive SBR must be considered. PMID: 19524718 [PubMed - in process]

Probiotic fortified diet reduces bacterial colonization and translocation in a long-term neonatal rabbit model.

Related Articles Probiotic fortified diet reduces bacterial colonization and translocation in a long-term neonatal rabbit model. J Pediatr Surg. 2009 Jun;44(6):1061-4; discussion 1054 Authors: Copeland DR, McVay MR, Dassinger MS, Jackson RJ, Smith SD BACKGROUND: Probiotic fortified diet reduces bacterial colonization and translocation in a short-term neonatal rabbit model when continuously challenged with pathogen. The purpose of this study was to determine if live probiotic diet could remain effective at decreasing colonization/translocation of pathogens in a long-term neonatal rabbit model without ill effects of the probiotic outside the gastrointestinal (GI) tract. METHODS: Rabbit pups were born via cesarean delivery 1 day preterm and assigned to 2 diets: a newly formulated diet (controls) vs the same diet fortified with the live probiotic Lactoccocus lactis. Enterobacter cloacae was added to both preparations before each feed. Pups were gavage fed twice daily, and weights were recorded. Rabbits were sacrificed on day 7, and organs were harvested and cultured for target organism growth. RESULTS: The probiotic fortified diet resulted in a significant decrease in Enterobacter translocation to the liver and decreased colonization in the stomach and lungs. There was no evidence of Lactococccus translocation or colonization outside of the GI tract. CONCLUSION: This probiotic fortified diet was effective at decreasing pathogenic bacteria colonization and translocation in a long-term neonatal model. The addition of L lactis to the diet resulted in appropriate growth without any colonization or translocation of the probiotic outside of the GI tract. PMID: 19524717 [PubMed - in process]

Waardenburg syndrome with extended aganglionosis: report of 3 new cases.

Related Articles Waardenburg syndrome with extended aganglionosis: report of 3 new cases. J Pediatr Surg. 2009 Jun;44(6):E9-13 Authors: Karaca I, Turk E, Ortac R, Kandirici A PURPOSE: The Waardenburg-Shah syndrome is an autosomal recessive disease with varied penetration where Hirschsprung's disease and the Waardenburg syndrome are seen together. Although the length of the involved intestinal segment varies in this syndrome, most patients had total colonic aganglionosis with or without small bowel involvement. We present in this study 2 siblings and one first-degree relative for a total of 3 male patients with Waardenburg syndrome and total colonic aganglionosis with or without small bowel involvement, together with their clinical characteristics and treatment methods. PATIENTS: The patients who presented with intestinal obstruction findings within the first 48 hours after birth were operated on with 2 patients under elective conditions and 1 as an emergency. The ganglionic segment lengths were 6, 8, and 20 cm, respectively. Aganglionic enterostomy was performed, and the Ziegler operation was used for these patients. The enterostomies started to function on the third postoperative week, and they started to gain weight. However, all died because of sepsis on the 5th to 12th month. CONCLUSION: Waardenburg-Shah syndrome patients have a higher incidence of total colonic aganglionosis with or without small bowel involvement. The Ziegler operation may be used in patients with inadequate ganglionic bowel length to gain some time for the child to grow and to decrease total parenteral nutrition complications. PMID: 19524716 [PubMed - in process]

Seven-liter ovarian cyst in an adolescent treated by minimal access surgery: laparoscopy and open cystectomy.

Related Articles Seven-liter ovarian cyst in an adolescent treated by minimal access surgery: laparoscopy and open cystectomy. J Pediatr Surg. 2009 Jun;44(6):E5-8 Authors: Coccia ME, Rizzello F, Bracco GL, Scarselli G Laparoscopic approaches to giant ovarian cysts, particularly in adolescents, have critical management concerns as follows: risk of malignancy, risk of cyst rupture, and limited working space. A 15-year-old girl presented with a giant (>25 cm) ovarian serous cyst adenoma containing 7 L of fluid. At open laparoscopy, a giant, entirely cystic, smooth mass originating from the right ovary and lying between the symphysis and the xiphoid was observed. After intraabdominal fluid aspiration, open conservative cystectomy was performed, avoiding spillage. The patient made an uneventful postoperative recovery and was discharged on the second postoperative day. To our knowledge, this is the largest ovarian cyst treated conservatively in an adolescent. Minimal access surgery, laparoscopy and open cystectomy, can be safely proposed in this group of patients. Conservative surgery should always be evaluated for preservation of ovarian function in cases of giant ovarian cysts in adolescents. PMID: 19524715 [PubMed - in process]

Asymmetric sweating and flushing in infants with esophageal atresia.

Related Articles Asymmetric sweating and flushing in infants with esophageal atresia. J Pediatr Surg. 2009 Jun;44(6):E27-9 Authors: Cozzi DA, Mele E, Totonelli G, Ceccanti S, Frediani S, Cozzi F Of 136 infants with repaired esophageal atresia, one presented an unilateral facial flushing and 2 presented a flushing and sweating of one half of the body. The topography of these disorders and/or the associated clinical manifestations suggest that the asymmetry may be related to an instability of unilateral autonomic centers more than to a surgical injury of upper thoracic sympathetic chain during esophageal repair. PMID: 19524714 [PubMed - in process]

Neuroendocrine tumor of the common hepatic duct, mimicking a choledochal cyst in a 6-year-old child.

Related Articles Neuroendocrine tumor of the common hepatic duct, mimicking a choledochal cyst in a 6-year-old child. J Pediatr Surg. 2009 Jun;44(6):E23-5 Authors: Tonnhofer U, Balassy C, Reck CA, Koller A, Horcher E We report a rare case of a neuroendocrine tumor of the extrahepatic biliary tree in a child. A 6-year-old girl who presented with jaundice and pruritus was found to have elevated liver enzymes along with a cystic dilatation of the common hepatic duct. After further diagnostic testing, a working diagnosis of a type I choledochal cyst was established. Laparotomy revealed hydrops of the gall bladder, an elongated and dilated cystic duct and a cystic dilatation of the common hepatic duct. An unusually thickened common bile duct was also noted at the time. Follow-up histology revealed an invasive neuroendocrine tumor which lead to a second look operation in which extended resection and lymphadenectomy was performed. No histological or gross pathological evidence of lymph node metastasis was found. Postoperatively the patient continues doing well 2 years after the original diagnosis was established. Neuroendocrine tumors of the extrahepatic bile duct are extremely rare with only 4 pediatric cases of a total of 51 cases published in the literature. To our knowledge, this is the youngest patient reported so far. The rarity of this entity made it challenging to diagnose a case of a neuroendocrine tumor in an atypical location that radiologically mimicked a choledochal cyst. PMID: 19524713 [PubMed - in process]

Abdominotransanal approach to pouch colon associated with rectal atresia.

Related Articles Abdominotransanal approach to pouch colon associated with rectal atresia. J Pediatr Surg. 2009 Jun;44(6):E19-21 Authors: Kazez A, Ozel SK, Bakal U, Sarac M Pouch colon anomaly and high anorectal malformation are well-defined rare anomalies. The association of pouch colon anomaly with rectal atresia has previously been defined in only one case. In this study, a 2-day-old baby is presented with pouch colon anomaly without fistula and with rectal atresia. As a second case in the literature, this pathologic condition has been treated through the abdominotransanal route by using a single-stage endorectal coloanal pull-through. Being uncommon and having an important therapeutic approach, this case has been evaluated as worth presenting. PMID: 19524712 [PubMed - in process]

Mature teratoma arising from an intraabdominal testis in a 2-month-old boy: case report and review of intraabdominal testicular tumors in children.

Related Articles Mature teratoma arising from an intraabdominal testis in a 2-month-old boy: case report and review of intraabdominal testicular tumors in children. J Pediatr Surg. 2009 Jun;44(6):E15-8 Authors: Tanaka N, Yoneda A, Fukuzawa M Tumors arising in an undescended testis are rare in infants. We report a mature teratoma in an intraabdominal testis of a 2-month-old boy. He presented with a large left-sided abdominal mass and nonpalpable left testis. Abdominal ultrasound and computed tomography showed a well-defined, sizable cystic tumor with focal calcification in the lower abdomen. Tumor markers were all within normal limits. Surgical resection revealed a large tumor arising from an intraabdominal left testis, and histologic analysis identified a mature teratoma. The tumor was completely removed, and there was no recurrence at follow-up 3 years later. The histologic condition of prepubertal intraabdominal testicular (IAT) tumors is quite different from that of testicular tumors in childhood descended testes and postpubertal IAT tumors. A total of 30 cases of IAT tumors in children, including our case, were reviewed to elucidate this issue. PMID: 19524711 [PubMed - in process]

Successful embolization of a delayed splenic rupture following trauma in a child.

Related Articles Successful embolization of a delayed splenic rupture following trauma in a child. J Pediatr Surg. 2009 Jun;44(6):E1-4 Authors: Maurer SV, Denys A, Lutz N Delayed rupture of the spleen following trauma is an exceedingly rare phenomenon in children. In the case we have experienced, arterial embolization was successfully performed, surgery was avoided, and functional splenic tissue was preserved. Embolization is of value in the management of blunt splenic injuries in hemodynamically stable children, even after delayed rupture. The exact criteria for its use remain to be established. PMID: 19524710 [PubMed - in process]

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Amorphous mass of prolapsed bowel was connected by a precarious vascular pedicle, and its viability was doubtful.

Herniation through the falciform ligament: an unusual cause of ileal atresia.

Blunt posterior tracheal laceration and esophageal injury in a child.

Transanal rectosigmoid resection for severe intractable idiopathic constipation.

Treatment of fecal incontinence with a comprehensive bowel management program.

After the honeymoon comes divorce: long-term use of the antegrade continence enema procedure.

Improvement of quality of life in children with slow transit constipation after treatment with transcutaneous electrical stimulation.

Rectovestibular fistula--rarely recognized associated gynecologic anomalies.

Contemporary practice patterns in the surgical management of Hirschsprung's disease.

Properties of secondary and tertiary human enteric nervous system neurospheres.

Clinical significance of isolated intraperitoneal fluid on computed tomography in pediatric blunt abdominal trauma.

Value of computed tomographic angiography in neck and extremity pediatric vascular trauma.

Eliminating disparity in evaluation for abuse in infants with head injury: use of a screening guideline.

Postconcussive symptoms in hospitalized pediatric patients after mild traumatic brain injury.

Injury patterns among obese children involved in motor vehicle collisions.

Cannot exclude torsion--a 15-year review.

Conflicts in wound classification of neonatal operations.

Infectious risk to ventriculo-peritoneal shunts from gastrointestinal surgery in the pediatric population.

A prospective study of methicillin-resistant Staphylococcus aureus colonization in children scheduled for elective surgery.

Percutaneous endoscopic gastrostomy buttons in children: superior to tubes.

Return of the surgeon in the diagnosis of pyloric stenosis.

Influence of extracorporeal membrane oxygenation on subsequent surgeries after congenital diaphragmatic hernia repair.

Chylothorax after congenital diaphragmatic hernia repair.

Multivariate model for predicting recurrence in congenital diaphragmatic hernia.

Congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation: does timing of repair matter?

Tracheal innervation is abnormal in rats with experimental congenital diaphragmatic hernia.

Diagnosis of Wilms' tumor using near-infrared Raman spectroscopy.

Renal tumors in the second decade of life: results from the California Cancer Registry.

Cyclooxygenase 2 mediates the antiangiogenic effect of rapamycin in Ewing sarcoma.

Outcome of splenectomy in children younger than 4 years with sickle cell disease.

Tissue-engineered arterial grafts: long-term results after implantation in a small animal model.

Sternal repair with bone grafts engineered from amniotic mesenchymal stem cells.

When patients choose: comparison of Nuss, Ravitch, and Leonard procedures for primary repair of pectus excavatum.

Prevalence of gastroschisis and associated hospital time continue to rise in neonates who are admitted for intensive care.

A murine model of graft-vs-host disease after in utero hematopoietic cell transplantation.

Selection of live-related liver transplantation candidates.

Outcomes after the Ladd procedure in patients with heterotaxy syndrome, congenital heart disease, and intestinal malrotation.

Persistent alanine aminotransferase elevations in children with parenteral nutrition-associated liver disease.

Intestinal resection induces angiogenesis within adapting intestinal villi.

Mortality of necrotizing enterocolitis expressed by birth weight categories.

p21(waf1/cip1) deficiency does not perturb the intestinal crypt stem cell population after massive small bowel resection.

Probiotic fortified diet reduces bacterial colonization and translocation in a long-term neonatal rabbit model.

Waardenburg syndrome with extended aganglionosis: report of 3 new cases.

Seven-liter ovarian cyst in an adolescent treated by minimal access surgery: laparoscopy and open cystectomy.

Asymmetric sweating and flushing in infants with esophageal atresia.

Neuroendocrine tumor of the common hepatic duct, mimicking a choledochal cyst in a 6-year-old child.

Abdominotransanal approach to pouch colon associated with rectal atresia.

Mature teratoma arising from an intraabdominal testis in a 2-month-old boy: case report and review of intraabdominal testicular tumors in children.

Successful embolization of a delayed splenic rupture following trauma in a child.

Hospital opens new children's surgery center - The State

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