American Pediatric Surgical Association principles of pediatric trauma care.
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Child↗
Biomedical subjects
D R King
Publications and source records attributed to D R King.
Resection of the primary tumor is appropriate for children with stage IV-S neuroblastoma: an analysis of 37 patients.
Current recommendations for treatment of children with IV-S neuroblastoma (NB) indicate that "supportive care is the cornerstone of therapy" and resection of the primary tumor is not mandated. The presentation and clinical management of 37 IV-S NB patients from three pediatric oncology centers were retrospectively reviewed. The 22 boys and 15 girls presented at an average age of 107 days (range, 4 to 616 days). Primary tumor sites were identified in the adrenal gland in 19 children, the thorax in 5, the retroperitoneum in 4, and 1 each in the pelvis and kidney. At the time of presentation, metastatic disease was documented in the liver (27), bone marrow (19), skin (7), and regional lymph nodes (7). Massive hepatomegaly (below the umbilicus) was demonstrated in 18 patients. Twenty-eight children (76%) have survived on average 90 months following diagnosis. Eight patients (22%) died; six of disease and two of complications of therapy (mean, 9.6 months). One child was lost to follow-up. Only 3 of the 37 patients (8%) were managed solely by supportive care and all are alive. Extirpation of the primary tumor was accomplished in 24 individuals (65%). Twenty patients underwent excision at diagnosis and four had delayed resection with few postoperative complications and no deaths related to resection. One death resulted from progression of disease in a child who had tumor removal. Chemotherapy as a single treatment or in combination with radiation was used in 10 children with three children surviving (30%).(ABSTRACT TRUNCATED AT 250 WORDS)
Female↗
The surgical management of children with incompletely resected hepatic cancer is facilitated by intensive chemotherapy.
This prospective study was undertaken to evaluate the efficacy of continuous-infusion doxorubicin and cisplatin (CI-DOX/CPPD) for the treatment of children with incompletely resected hepatic cancer. Of the 46 evaluable patients, 32 had hepatoblastoma (70%) and 14 had hepatocellular carcinoma. Ten children had stage II tumors (microscopic residual), 25 were defined as stage III (gross residual), and 11 had distant metastasis (stage IV). Twelve patients underwent initial incomplete resection of their hepatic lesions and in the 34 others tumor biopsy specimens were obtained. Chemotherapy was administered and the majority of the children (70%) had an excellent clinical response with a decrease in both alpha-fetoprotein levels and measured tumor dimensions. The combination of CI-DOX/CPDD clearly facilitated surgical management, allowing for delayed hepatic resections in 20 of the 34 patients (59%) whose tumors were initially biopsied and considered to be unresectable. Overall survival in this study demonstrates a significant improvement in comparison to the historical controls. Twenty-one patients (46%) remain in complete clinical remission an average of 30 months following diagnosis (range, 17 to 40 months). The outcome of the children with hepatoblastoma was much better than those with hepatocellular carcinoma (63% v 17% survival). Survival of the 20 children who underwent delayed hepatic resections was not statistically different from the 12 patients whose hepatic tumors were removed at the initial laparotomy (41% v 58% survival). Although no obvious survival advantage was observed in those patients who underwent initial hepatic resections, there did appear to be an increased risk of postoperative complications in children whose tumors were resected following chemotherapy (8% v 25%).
Adolescent↗
Psychosocial adjustment and physical growth in children with imperforate anus or abdominal wall defects.
Pediatric surgeons have the unique responsibility of performing surgical procedures that will enable their patients to function normally throughout a lifetime. Good anatomic results may not ensure that this goal will be achieved. Using a battery of psychological testing instruments, we evaluated the academic achievement and psychosocial status of 56 children (mean age, 10.6 years) with imperforate anus (IA) and abdominal wall defects (AWDs). Physical growth was assessed by measurement of standard anthropometric parameters, and a parent questionnaire was used to define clinical status. As a group, the children presented with average intellectual ability. Achievement in both reading and math was in the normal range. In 12.5% of the children a reading learning disability was noted and 10.7% had a disability in math. On the basis of parental assessments, 25% of the children demonstrated externalizing behavior disorders (eg, conduct problems) and 29% displayed internalizing symptomatology (eg. withdrawal, anxiety). Social competency deficits were described in 23% of the children. Data obtained from the teachers were consistent with the parental assessments. No major differences between the IA and AWD patients in academic achievement, psychosocial status, or physical growth were discovered. Routine screening of these children for learning disabilities and behavior problems is recommended.
Abdominal Muscles↗
Pediatric cervical spine fractures: predominantly subtle presentation.
Previous description of cervical spine fractures in children have emphasized high mortality injuries to the upper cervical vertebra. Our experience suggests a much wider spectrum of injury. The medical records of all children with cervical spine fractures admitted to Children's Hospital between January 1, 1985 and December 31, 1989 were reviewed. The average age of the 50 patients was 11 years (range, 2.7 to 18.8 years) and 62% were boys. Motor vehicle-related accidents (54%), sports injuries (18%), and falls (12%) accounted for the majority of the fractures. Twenty-nine patients (58%) had an associated head injury. Fifty percent of the patients were transported from the accident scene and 44% were interhospital transfers. All patients receiving medical care prior to referral had appropriate cervical spine stabilization. On admission 30% of the patients were unresponsive. Thirty-one children were alert and verbal at the time of evaluation and 30 complained of neck pain and tenderness (97%). Twenty-five of the 31 patients (83%) had no demonstrable neurological deficit on initial physical examination. Lateral cervical spine radiographs were diagnostic in 49 children (98%). A relatively even distribution of fractures occurred at all levels of the cervical spine. The anatomic site of the injury did not correlate with age. Sixteen patients (32%) died. Of the 34 who survived, only 6 had a persistent neurological deficit. Children with cervical spine fractures have two distinct patterns of presentation: lethal or intact. The majority of children with cervical spine fractures presented with no complaints of neck pain and/or tenderness need a complete radiographic evaluation of their cervical spine.
Adolescent↗
Congenital gastrointestinal anomalies: psychosocial functioning of children with imperforate anus, gastroschisis, and omphalocele.
This study assessed the psychosocial status of 56 children aged 6-16 years with imperforate anus, gastroschisis, or omphalocele. Results indicate that (a) children were of average intellectual ability; (b) approximately 9% of the sample had learning disabilities; (c) although the mean maternal ratings of behavioral adjustment did not differ from those reported for children without anomalies, approximately 18% of the children had deviant adjustment scores; (d) a multivariate risk and resistance model accounted for a significant amount of the variance in children's adjustment; and (e) child, maternal, and family utilitarian and psychological risk and resistance resources contributed independently to children's overall behavioral adjustment.
Abdominal Muscles↗
Assessment of the potential toxicity of a poison for rabbits, pindone (2-pivalyl 1, 3 indandione), to domestic animals.
The toxicity of pindone, a rabbit poison, to horses, cattle, goats, chickens, dogs and cats was investigated, using extension of prothrombin time (PT) as an index of poisoning. The daily dose of pindone, administered for 5 days, ranged from 0.3 mg/kg for dogs to 2.5 mg/kg for chickens. This range of dose rates was considered to be indicative of the worst possible case that could arise following a campaign of baiting for rabbits. Although significant elevations in PT (more than double baseline values) were noted in all species other than horses, clinical signs of anticoagulant poisoning were not observed in any of the species tested. From the observed PT, cattle and cats appeared to be the most susceptible, and horses the least susceptible, to pindone toxicity. The half-lives of the elevated PT were calculated as 3.1 days for cattle, 2.8 days for goats and chickens, 1.9 days for horses and dogs and less than one day for cats. It is proposed that these half-lives can be used as a guide for determining the duration of treatment of pindone-affected animals.
Animals↗
Effective treatment of unresectable or metastatic hepatoblastoma with cisplatin and continuous infusion doxorubicin chemotherapy: a report from the Childrens Cancer Study Group.
The Childrens Cancer Study Group (CCSG) undertook a study (CCG-823F) to test the feasibility of administering continuous infusion doxorubicin (CI DOX) and cisplatin (CDDP) in patients with unresectable or incompletely resected hepatoblastoma (HB) or hepatocellular carcinoma (HCC). Chemotherapy consisted of CI DOX 20 mg/m2/d for days 1 to 4 and CDDP 100 mg/m2 on day 1 followed by a 21-day rest period. Second-look surgery was performed after the administration of four chemotherapy courses. Forty-seven (47) assessable patients were entered on study, 33 with HB and 14 with HCC; of these, 34 (26 HB and eight HCC) completed the initial four courses of chemotherapy. Of the 26 HB patients, 25 were evaluated as responding to chemotherapy before the scheduled second-look procedure and were considered surgically resectable at that time. Surgery was performed on 22 patients; three patients refused the second-look surgery. Nine patients had no evidence of residual malignant disease, seven underwent surgical resection of remaining tumor, four were left with microscopic residual disease, one had a partial resection with gross tumor left behind, and one remained unresectable. Nine HCC patients completed four chemotherapy courses. Eight patients achieved a partial remission and second-look surgery was attempted on seven. Only two had all malignant disease removed at the second procedure. Data from 225 courses of chemotherapy were evaluated for toxicity. Neutropenia (absolute granulocyte count less than 500/mL) was observed in 68 courses, and five of these episodes were associated with sepsis. Severe mucositis was documented in 21 courses, and hypomagnesemia (magnesium less than 1.2 mg) was noted in 30 patients. Two patients developed decreased left ventricular shortening fraction, which resolved when chemotherapy was discontinued. In summary, CI DOX plus CDDP is a well-tolerated and effective regimen in inducing surgical resectability in HB patients who are unresectable at diagnosis and significantly improves survival for this group of patients to 66.6%.
Adolescent↗
Alveolar bone loss in two children with short-bowel syndrome receiving total parenteral nutrition.
Two preschool children who were receiving total parenteral nutrition (TPN) for short-bowel syndrome (SBS) were noted to have radiographic evidence of alveolar bone loss in their primary dentition. Tooth mobility, gingival recession, and premature tooth loss were clinical findings in these children. Both had a 2-year history of recurrent infections and fluctuating serum electrolytes prior to identification of their dental problems.
Alveolar Bone Loss↗
A randomized clinical trial of ampicillin, gentamicin and clindamycin versus cefotaxime and clindamycin in children with ruptured appendicitis.
This prospective, randomized, double-blind study compares the efficacy, safety and cost-effectiveness of ampicillin, gentamicin and clindamycin (AGC) or cefotaxime and clindamycin (CC) for the treatment of children with complicated appendicitis. Ninety-seven children were randomized. Forty-seven were assigned to the AGC regimen and 50 received CC. Forty-two patients in the AGC group had an appropriate therapeutic outcome, whereas 48 of 50 children who received CC completed the trial successfully (p = NS). There were no differences between the groups with reference to the duration of antibiotic administration, fever, leukocytosis or length of hospitalization. Complications of therapy were uncommon and neither regimen demonstrated a significant advantage from an economic standpoint. We concluded that, in childhood, complicated appendicitis can be treated with either CC or AGC with equal efficacy.
Adolescent↗
The failed antireflux procedure: analysis of risk factors and morbidity.
Between 1976 and 1988 an antireflux procedure (ARP) was performed in 364 infants and children (Nissen, 358; Thal, 6). Recurrent gastroesophageal reflux (GER) necessitating reoperation occurred in 21 patients, a failure rate of 6%. Recurrent GER developed within 28 months of primary ARP in 18 (86%) children. The symptoms of GER became apparent following an episode of forceful emesis in 29% of patients, half of whom had a malpositioned gastrostomy tube. Recurrent GER developed in 28% of children with corrected esophageal atresia. A definitive etiology of ARP failure was identified in 18 (86%) cases: "slipped" fundoplication (15), no fundoplication visualized (2), and paraesophageal hernia (1). Perioperative morbidity, intraoperative blood loss, and length of surgery were significantly increased for secondary ARP. Mortality following reoperation was zero, but three late deaths occurred. Long-term control of GER has been achieved in 78% of children following the second operation.
Adolescent↗
The prognostic significance of basic anthropometric data in children with advanced solid tumors.
In pediatric cancer patients, malnutrition is commonly observed. This may represent the metabolic effect of the primary disease or it may be a consequence of multimodal therapy. This report evaluates the efficacy of using basic anthropometric measurements to predict morbidity during therapy. Twenty children with Wilms' tumor (Stage III, IV, and V) or neuroblastoma (Stage IV) diagnosed at Children's Hospital (Columbus, OH) between January 1983 and December 1985 were evaluated. When compared with the Wilms' tumor patients, the children with neuroblastoma had a significantly lower weight for age at diagnosis. At the completion of therapy, both weight-for-height and weight-for-age measurements were statistically lower in the neuroblastoma group (p less than 0.05). Significant differences were observed between the neuroblastoma and Wilms' tumor patients in the morbidity reported during therapy. Children with neuroblastoma had more frequent hospital admissions, spent a much greater proportion of their treatment time as hospital inpatients, experienced longer delays in therapy, and sustained many more complications. Each of the anthropometric indices was evaluated as a predictor of the complications observed during treatment. In the Wilms' tumor group, the patients with lower weight-for-height percentiles had an increased incidence of incomplete drug infusions, many more complications, more frequent hospital admissions, and an increase in the percentage of time spent as hospital inpatients. In the neuroblastoma group, the anthropometric measurements had no correlation with the subsequent development of complications. Nutritional staging based on anthropometric measurements recorded at diagnosis may be useful in predicting an increased risk of morbidity during therapy in children with Wilms' tumor.
Abdominal Neoplasms↗
Acute scrotum due to Haemophilus influenzae type b.
The acute scrotum in infants and children is generally due to torsion of the spermatic cord, torsion of the appendix testis, or acute epididymitis. An infant is presented who was found to have epididymitis and a scrotal abscess due to Haemophilus influenzae type b at the time of surgical exploration for suspected torsion of the spermatic cord.
Abscess↗
Arterial trauma in children: diagnosis and management.
Ninety-two children with arterial injuries were studied over a 14 year period, 66 boys and 26 girls, whose ages ranged from 14 months to 18 years. Thirty-eight children had associated nerve injuries and 21 had orthopedic injuries as well. Interval between initial evaluation and diagnosis of arterial injury ranged from immediate to six months--76% were treated within six hours of injury and 24% had a delay of greater than six hours before diagnosis. Arteriograms were performed on 20 (21%) of the children, and 13 of these were done late. Surgical treatment consisted of local debridement and end-to-end anastomosis, ligation, exploration with thrombectomy of distal branches, or bypass grafting with vein. Three children died in the immediate postoperative period, 83 had good functional results, and six had poor functional results. Four of these six had a delayed diagnosis of arterial injury, and had injuries in arteries adjacent to the elbow or knee. We conclude that early diagnosis of arterial injury and a more liberal use of arteriography is warranted in young trauma victims, especially in cases of fractures about the knee or elbow.
Adolescent↗
Parenteral nutrition with associated cholelithiasis: another iatrogenic disease of infants and children.
During the past decade, 246 infants and children treated at the Columbus Children's Hospital have required more than 4 weeks of parenteral nutrition (PN). Of the 178 survivors, 70 returned for evaluation. Sixty-eight either had adequate visualization of the gallbladder by ultrasound or had previous gallbladder surgery (39%). Of 68 children who did not survive, complete postmortem examinations or ultrasound studies were available for 16 (24%). A diagnosis of cholelithiasis was established in 11 of the 84 studied patients (13%). Six of these children (55%) have required cholecystectomy for relief of chronic abdominal pain, pancreatitis, or empyema of the gallbladder. One additional infant underwent cholecystostomy. Two of the four remaining patients are asymptomatic, one has episodes of abdominal colic, and one child expired of chronic hepatic insufficiency as a result of PN-associated cholestasis. Risk factors that predisposed these children to cholelithiasis included short bowel syndrome, lack of an ileocecal valve, and an increased number of abdominal operative procedures (P less than .05). Patients with biliary calculi also had a longer duration of parenteral feeding, and a higher incidence of both PN-associated cholestasis and necrotizing enterocolitis. The intergroup differences for these characteristics, however, did not achieve statistical significance. On the basis of this information, routine ultrasound examinations of the gallbladder are recommended for children maintained on PN for longer than 30 days. All patients presenting with abdominal pain who previously received PN should also be evaluated. Early elective cholecystectomy is suggested for children who develop PN-associated cholelithiasis.
Adolescent↗
Asthma in general practice.
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Adolescent↗
Discharge planning for children with perforated appendicitis.
Optimal management of children with perforated appendicitis remains a controversial clinical problem. Until very recently, the criteria for hospital discharge on our surgical service included the absence of fever and leukocytosis for a period of 48 hours following completion of antimicrobial therapy, uncomplicated wound healing, a normal rectal examination, and unimpaired gastrointestinal function. With the introduction of cost-containment programs, the necessity for the period of inpatient observation following cessation of antibiotics was questioned. The records of 87 consecutive children with perforated appendicitis were analyzed prospectively in order to determine if our discharge policies were medically sound and cost-effective. Seventy-five patients (86%) recovered uneventfully while 12 children required prolonged hospitalization for management of various postoperative complications. The 12 patients who developed complications were all identifiable early in the postoperative period because of persistent fever, leukocytosis, and elevated band counts. Of the 75 children who recovered uneventfully, all met standard discharge criteria on the final day of antibiotic therapy with the exception of completing the mandatory 48-hour period of inpatient observation. These children were maintained in the hospital a total of 142 additional days following discontinuation of antibiotics. The average cost per patient day for children with perforated appendicitis during the study period was $506.32, which represented unnecessary hospital charges of $71,897.44. It was concluded that inpatient observation following cessation of antibiotic therapy in children who experience an uneventful recovery from perforated appendicitis is neither necessary nor cost-effective.(ABSTRACT TRUNCATED AT 250 WORDS)
Appendicitis↗
Compliance with anticonvulsant therapy by epileptic youth. Relationships to psychosocial aspects of adolescent development.
Independence in daily life, family harmony as perceived by youths and their parents, and self-esteem were investigated in relation to anticonvulsant medication compliance in 25 epileptics aged 9-17 years. Medication compliance was assessed by monthly home saliva sampling for phenobarbital concentrations. Psychosocial issues were assessed by standardized instruments. Each psychosocial issue was highly correlated with compliance. Partial correlation analysis reveals that these findings are not explained by the subject's demographic or clinical characteristics. Medication noncompliance appears to be associated with a restriction of independence in daily life, lack of harmony in family relations, and low self-esteem in teenage epileptics. Clinicians should observe for these conditions and initiate patient and family counseling in order to maximize medication compliance and seizure control.
Adolescent↗