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K D Newman

Publications and source records attributed to K D Newman.

At least 19 recordsLinked to original sources
PubMed2002

Lessons learned from a failed multi-institutional randomized controlled study.

BACKGROUND/PURPOSE: In 1996, the Surgical Sections of the Children's Cancer Group (CCG) and the Pediatric Oncology Group (POG) received National Cancer Institute funding to conduct a prospective, randomized, controlled, surgeon-directed study to evaluate the role of minimally invasive surgery (MIS) in children with cancer. Because of lack of patient accrual, the study was closed in 1998. The purpose of this study is to evaluate and describe those factors that impacted on study failure to ensure future successful clinical trials. METHODS: One hundred forty surgeons representing the surgical membership of CCG and POG as well as 111 institutions within CCG and POG were asked to complete a questionnaire about the failed clinical trial. The questionnaire focused on study objectives, organization, and institutional review board (IRB) submission. It also examined the surgeon's ability to perform the minimal access operation, the influence of the pediatric oncologist, and the existence of preconceived biases by surgeons, oncologists, and families. Statistical analysis was performed as appropriate. RESULTS: Eighty-six of 140 (62%) surgeons responded to the questionnaire. Only 23% of the potential protocols were submitted for IRB approval. Of responding surgeons, 39% were not actively performing MIS when the study opened. A surgeon's support of the study was directly related to when the surgeon received the protocols (P <.001) and whether the participating surgeon was actively participating in MIS (P <.016). The oncologist's knowledge and support of the study affected IRB submission and approval (P <.02) and was influenced by whether MIS was practiced at the institution (P <.05). The majority of responding surgeons believed the experimental question was relevant (P <.05). However, responding surgeons believed that a preconceived bias existed within both their local surgical and oncology communities favoring a particular surgical approach (P <.001), but this bias did not extend to the families (P >.05). CONCLUSION: The study failed because of lack of accrual for a variety of reasons: failure to submit to the institution's IRB, lack of surgical expertise with MIS procedures, and preconceived surgeon bias toward either an endoscopic or traditional open approach.

Humans↗
PubMed2001

MRI imaging of fetal neck masses with airway compromise: utility in delivery planning.

We present two cases of fetal neck masses that were initially diagnosed by ultrasound and further evaluated with prenatal MRI. MRI findings aided in further delineating the neck masses, increasing confidence in the final diagnosis (cervical teratoma and cystic hygroma). With the fetal airway typically filled with fluid that is of high signal on T2-weighted sequences, MRI images in three planes could identify whether the fetal larynx and trachea were partially or completely compressed by the neck tumor. This information was particularly useful in determining if a controlled delivery such as ex utero intrapartum treatment (EXIT) was necessary and aided the surgeons in planning their approach to establishing airway control in the delivery room.

Adult↗
PubMed2001

The use of a bioactive skin substitute decreases length of stay for pediatric burn patients.

BACKGROUND: To optimize burn care for children, the authors introduced a protocol incorporating the use of a bioactive skin substitute, TransCyte (Advanced Tissue Sciences, La Jolla, CA). This study was designed to determine whether this management plan was safe, efficacious, and decreased hospital inpatient length of stay (LOS) compared with conventional burn management in children. METHODS: All pediatric burns greater than 7% total body surface area (TBSA) that occurred after October 1999 underwent wound closure with TransCyte (n = 20). These cases were compared with the previous 20 consecutive burn cases greater than 7% TBSA that received standard therapy. Standard therapy consisted of application of antimicrobial ointments and hydrodebridement. The following information was obtained: burn mechanism, age, size of burn, requirement of autograft, and LOS. Data were analyzed using the student's t test. RESULTS: Data for age, percent TBSA burn and LOS are reported as means +/- SEM. The children who received standard therapy were 2.99 +/- 0.7 years compared with those receiving TransCyte were 3.1 +/- 0.8 years. There was no difference between the treatment groups with regard to percent TBSA burn: standard therapy, 14.3 +/- 1.4% TBSA versus TransCyte, 12.7 +/- 1.3% TBSA. There was no difference in the type of burns in each group, the majority were liquid scald type, 70% in the standard therapy group versus 90% in the TransCyte group. Only 1 child in the TransCyte group required autografting (5%) compared with 7 children in the standard therapy group (35%). Children treated with TransCyte had a statistically 6 significant decreaed LOS compared with those receiving standard therapy, 5.9 +/- 0.9 days versus 13.8 +/- 2.2 days, respectively (P =.002). CONCLUSIONS: This is the first study using TransCyte in children. The authors found that this protocol of burn care was safe, effective, and significantly reduced the LOS. This new approach to pediatric burn care is effective and improves the quality of care for children with burns.

Burn Units↗
PubMed2000

Cytoplasmic delivery of a macromolecular fluorescent probe by poly(d, l-lactic-co-glycolic acid) microspheres.

A macromolecular fluorescent probe encapsulated in poly(d, l-lactic-co-glycolic acid) (PLGA) microspheres was used as a model for studying cytoplasmic delivery of antigens. We hypothesized that Texas red dextran loaded in PLGA microspheres would be delivered to the cytoplasm and that cytoplasmic delivery would be affected by polymer molecular weight. Cellular localization of the Texas red dextran was investigated at two different molecular weights of PLGA: 6000 and 60,000 g/mol. Intracellular degradation and processing of Texas red dextran-loaded PLGA microspheres by mouse peritoneal macrophages was monitored both in vitro and in vivo for a 7-day period using confocal laser scanning microscopy (CLSM). The results revealed cytoplasmic delivery of the fluorescent probe at both molecular weights of PLGA. Furthermore, the CLSM images showed that both in vitro and in vivo, the kinetics of microsphere degradation and cytoplasmic delivery were more rapid for the 6000 g/mol PLGA microspheres than the 60,000 g/mol PLGA microspheres. Hence, this study provides physical evidence that PLGA microspheres are capable of cytoplasmic delivery and that delivery to the cytosol can be controlled by modifying formulation parameters such as polymer molecular weight.

Animals↗
PubMed2000

Differentiated thyroid cancer: clinical characteristics, treatment, and outcome in patients under 21 years of age who present with distant metastases. A report from the Surgical Discipline Committee of the Children's Cancer Group.

BACKGROUND/PURPOSE: Young patients with differentiated thyroid cancer typically present with regional lymph node involvement (60% to 80%), and 10% to 20% have distant metastases. This study characterizes the clinical presentation, treatment, and outcome in patients with differentiated thyroid cancer who were less than 21 years of age at diagnosis and who presented with distant parenchymal metastases. METHODS: A retrospective, multi-institutional data base that included 327 patients in this age group with differentiated thyroid carcinoma was searched for patients who presented with distant metastases, and 83 cases (25%) were found. The median time to first disease progression was 2.4 years (range, 0.1 to 12.4 years) and the overall median follow-up was 10.9 years (range, 1.0 to 42.1 years). RESULTS: The median age at diagnosis was 14.6 years (range, 6.6 to 20.8 years); 69% were girls and 92% were white. In 12%, there was a history of prior head and neck irradiation, and 10% of these patients had a family history of carcinoma. Preoperative needle biopsies were performed in 25%. Regional lymph nodes were positive in 90%, and extrathyroidal extension occurred in 48%. The site of distant metastases included the lungs in all patients. Total thyroidectomy, subtotal thyroidectomy, lobectomy, and nodule excision was done in 66%, 24%, 3%, and 8% of patients, respectively. There was no residual cervical disease after surgery in 75%, whereas 14% had microscopic and 11% had gross residual. Histopathologic subtypes included papillary-follicular (48%), papillary (42%), and follicular (10%). The median tumor size was 3.0 cm (range, 0.4 to 11.0 cm). In this group, 100% of patients received adjuvant iodine 131I therapy, and the overall survival rate at 10 years was 100%. The progression-free survival rate was 76% at 5 years and 66% at 10 years from diagnosis. CONCLUSIONS: A significant number of young patients with thyroid cancer present with distant metastases and will require radioiodine therapy. This should be considered when planning the surgical approach because total or subtotal thyroidectomy facilitates 131I imaging and treatment. Although about one third of these patients will experience relapse or disease progression, the overall mortality rate is low.

Adolescent↗
PubMed1998

Ovalbumin peptide encapsulated in poly(d,l lactic-co-glycolic acid) microspheres is capable of inducing a T helper type 1 immune response.

An ovalbumin (OVA) peptide, consisting of residues 323-339, was incorporated into poly(d,l lactic-co-glycolic acid) (PLGA) microspheres and administered to mice. It was hypothesized that microencapsulation of the peptide in PLGA microspheres would avoid the need for traditional adjuvants and bias the immune response towards a type 1 T helper (Th1) response. An immunomodulator, monophosphoryl lipid A (MPLA), was incorporated into the microspheres to determine its efficacy in enhancing a Th1 response. The specificity of the immune response was determined using a T cell proliferation assay. The type of T helper response was determined by analysis of the cytokine secretion profiles of the proliferating T cells. Following s.c. immunization, the results revealed a T cell-specific immune response for the encapsulated OVA peptide both with and without MPLA. The cytokine profiles revealed high levels of IFN-gamma with very low levels of IL-4 and IL-10, suggesting a Th1 response. Furthermore, incorporation of MPLA in the peptide loaded PLGA microspheres resulted in an increase in the production of IFN-gamma. Hence, peptide-loaded PLGA microspheres are capable of eliciting a specific Th1 immune response, which may be further enhanced in the presence MPLA.

Amino Acid Sequence↗
PubMed1998

Delivery of MUC1 mucin peptide by Poly(d,l-lactic-co-glycolic acid) microspheres induces type 1 T helper immune responses.

Synthetic peptides corresponding to the variable tandem repeat domain of the cancer-associated antigen MUC1 mucin are candidates for cancer vaccines. In our investigation mice were immunized via subcutaneous injection with poly(d,l-lactic-co-glycolic acid) (PLGA) microspheres containing a MUC1 mucin peptide. It was hypothesized that microencapsulation of the MUC1 mucin peptide would prime for antigen-specific Th1 responses while avoiding the need for traditional adjuvants and carrier proteins. Furthermore, an immunomodulator, monophosphoryl lipid A (MPLA), was incorporated into the peptide-loaded PLGA microspheres based on its ability to enhance Th1 responses. The results revealed T cell specific immune responses. The cytokine secretion profiles of the T cells consisted of high levels of interferon-gamma with undetectable levels of interleukin-4 and interleukin-10. Moreover, incorporation of MPLA in the MUC1 peptide-loaded PLGA microspheres resulted in an increase in interferon-gamma production. The antibody response was negative for IgM and IgG in the absence of MPLA; however, in the presence of MPLA antibody production was negative for IgM with a minimal IgG response consisting of IgG2a, IgG2b, and IgG3. Based on the antibody and cytokine profiles, it was concluded that MUC1 mucin peptide-loaded PLGA microspheres are capable of eliciting specific Th1 responses, which may be enhanced through the use of MPLA.

Amino Acid Sequence↗
PubMed1998

Differentiated thyroid cancer: determinants of disease progression in patients <21 years of age at diagnosis: a report from the Surgical Discipline Committee of the Children's Cancer Group.

OBJECTIVE: This study was done to define the extent of disease and evaluate the effect of staging and treatment variables on progression-free survival in patients with differentiated thyroid carcinoma who were less than 21 years of age at diagnosis. SUMMARY BACKGROUND DATA: Differentiated thyroid cancer in young patients is associated with early regional lymph node involvement and distant parenchymal metastases. Despite this, the overall long-term survival rate is greater than 90%, which suggests that biologic rather than treatment factors have a greater effect on outcome. METHODS: Variables analyzed for their impact on progression-free survival in a multi-institutional cohort of 329 patients included age, antecedent thyroid irradiation, extrathyroidal tumor extension, size, nodal involvement, distant metastases, technique of thyroid surgery and lymphatic dissection, initial treatment with 131Iodine, residual cervical disease, and histopathologic subtype. Surgical complications were correlated with the specific procedures completed on the thyroid gland or cervical lymphatics. RESULTS: The overall progression-free survival rate was 67% (95%, CI: 61%-73%) at 10 years with 2 disease-related deaths. Regional lymph node and distant metastases were present in 74% and 25% of patients, respectively. Progression-free survival was less in younger patients (p = 0.009) and those with residual cervical disease after thyroid surgery (p = 0.001). Permanent hypocalcemia was more frequent after total or subtotal thyroidectomy (p = 0.001) while wound complications increased after radical neck dissections (p < 0.00001). CONCLUSIONS: The progression-free survival rate was better after a complete resection and in older patients. Progression-free survival rate was the same after lobectomy or more extensive thyroid procedures, but comparison was confounded by the increased use of total or subtotal thyroidectomy in patients with advanced disease. The risk of permanent hypocalcemia increased when total or subtotal thyroidectomy was done. Thyroid lobectomy alone may be appropriate for patients with small localized lesions while total or subtotal thyroidectomy should be considered for more extensive tumors.

Adolescent↗
PubMed1997

The management of choledocholithiasis in children in the era of laparoscopic cholecystectomy.

Although laparoscopic cholecystectomy has become the procedure of choice for gallbladder removal in children, the treatment of children who have choledocholithiasis remains unclear. For adults who have suspected choledocholithiasis, preoperative endoscopic retrograde cholangiopancreatography (ERCP) is a well-described and effective approach, however, its use for common bile duct stones in children has not been defined. The authors reviewed the records of 131 consecutive children undergoing laparoscopic cholecystectomy on two surgical services to define the efficacy of ERCP followed by laparoscopic cholecystectomy in managing choledocholithiasis in children. Fourteen children were suspected of having common duct stones noted on preoperative ultrasound scan and laboratory data. At ERCP, six children had no stones visualized; eight had stones and underwent stone extraction and sphincter dilation or sphincterotomy. All 14 underwent laparoscopic cholecystectomy a mean of 3.8 days after ERCP. None of the 14 had evidence of retained stones. Only one of 117 children undergoing primary laparoscopic cholecystectomy had unsuspected common bile duct stones and was treated with laparoscopic common bile duct exploration and stone removal. A management plan incorporating ERCP followed by early laparoscopic cholecystectomy is a safe and effective strategy for children who have choledocholithiasis.

Adolescent↗
PubMed1997

Hepatic tumors in children.

Although there is broad consensus that complete resection is the cornerstone of successful management of hepatic malignancies in children, the optimal timing and integration of surgery and chemotherapy remain controversial. Excellent cure rates have been achieved with complete resection followed by multiagent chemotherapy for hepatoblastoma. Future studies are directed toward the identification of "poor risk" patients with protocols designed to improve survival for children with advanced disease and with hepatocellular carcinoma. A multidisciplinary team approach to the care of children with hepatic malignancies using the latest guidelines from clinical trials offers the best opportunity for successful outcomes.

Carcinoma, Hepatocellular↗
PubMed1996

Seeding of vascular grafts with genetically modified endothelial cells. Secretion of recombinant TPA results in decreased seeded cell retention in vitro and in vivo.

BACKGROUND: Seeding of small-diameter vascular grafts with endothelial cells (ECs) genetically engineered to secrete fibrinolytic or antithrombotic proteins offers the potential to improve graft patency rates. METHODS AND RESULTS: Sheep venous ECs were transduced with a retroviral vector encoding human tissue plasminogen activator (TPA). The ECs were seeded onto 4-mm-ID synthetic (Dacron) grafts. Retention of the seeded ECs was measured 2 hours after placement of the seeded grafts both in vitro in a nonpulsatile flow system and in vivo (in sheep) as femoral and carotid interposition grafts. On exposure to flow in vitro, ECs transduced with TPA were retained at a significantly lower rate (median, 67%) than either untransduced ECs (81%) or ECs transduced with a control retroviral vector producing beta-galactosidase (beta-Gal) (80%) (P < .05 for TPA versus either control). On implantation in vivo, ECs transduced with TPA were retained at a very low rate (median, 0%), significantly less than the retention of ECs transduced with the beta-Gal vector (32%; P < .00001). Decreased in vivo retention of ECs transduced with TPA correlated modestly with increased in vitro cellular passage level (r2 = .48; P < .0001) but not with in vivo blood flow rate (P = .45). Addition of the protease inhibitor aprotinin to the cell culture and graft perfusion media resulted in a significant (P < .05) increase in in vitro retention of ECs transduced with TPA. CONCLUSIONS: Increased TPA expression significantly decreases seeded EC adherence in vitro and in vivo. Gene therapy strategies for decreasing graft thrombosis may require expression of antithrombotic molecules that lack proteolytic activity.

Animals↗
PubMed1996

Video-assisted thoracic surgery (VATS) for children with pulmonary metastases from osteosarcoma.

BACKGROUND: Video-assisted thoracic surgery (VATS) may complement open thoracotomy in children with osteosarcoma requiring pulmonary metastasectomy. METHODS: The records of children with metastatic pulmonary osteosarcoma considered for initial VATS intervention (n = 9) were reviewed. RESULTS: Two children did not have VATS exploration: one child with multiple bilateral nodules and another child with a deep parenchymal nodule. VATS provided diagnostic biopsy material in all cases when used (n = 7). Two children had benign inflammatory lesions; four children had VATS-directed wedge resections of solitary malignant lesions; and one child had VATS biopsy of diffuse parenchymal and pleural pulmonary disease not amenable to resection. The mean operative time and hospital length of stay were 1.78 +/- 0.54 h and 3.5 +/- 1.8 days, respectively. There were two complications of VATS: bleeding in a child, requiring a transfusion, and a latent pneumothorax in a patient after removal of the chest tube. CONCLUSION: VATS is safe, serves as an excellent diagnostic modality, complements the open thoracotomy, and may enable the surgeon to avoid more extensive procedures in selected cases.

Adolescent↗
PubMed1996

Ultrasonography as an adjunct in the diagnosis of acute appendicitis: a 4-year experience.

This study was designed to evaluate the sensitivity and specificity of abdominal ultrasonography as a diagnostic modality in a large series of children who presented with possible appendicitis. From August 1990 to July 1994, 452 children (203 boys, 249 girls) with an average age of 11 years (range, 1 to 20 years) underwent graded compression ultrasonography of the right lower quadrant of the abdomen for the evaluation of possible appendicitis. In the first 18 months of the study all patients with the possible diagnosis of appendicitis (group I; 180 patients) had abdominal ultrasonography after members of the surgical team evaluated and documented their findings in the medical record. In the second study period (30 months), abdominal ultrasonography was recommended only when the clinical diagnosis of acute appendicitis was equivocal (group II; 272 patients). Abdominal ultrasonography was performed using the graded compression technique with a 5.0-MHz linear array transducer. A positive ultrasound study for appendicitis was defined as the presence of an enlarged noncompressible appendix with an outer wall to outer wall diameter of greater than 6 mm, the presence of a complex mass, or the presence of an appendicolith. The sonographic data were correlated with surgical and pathological findings. Appendicitis was confirmed in 112 of the 452 cases. In 17 of these, the appendix was perforated. In the overall group of 452 children, abdominal ultrasonography had a sensitivity of 90%, specificity of 96%, and accuracy of 95%. There was no significant morbidity in the 11 patients with a false-negative study result. All 11 patients had an uncomplicated appendectomy. There were 11 false-positive results; 10 of these patients had a negative laparotomy result (negative laparatomy rate, 8.9%). For the two groups, the sensitivity and specificity of ultrasonography in the diagnosis of appendicitis were equivalent (group 1: 88% sensitivity, 96% specificity; group 2: 92% sensitivity, 97% specificity). On the basis of the high sensitivity and specificity rates, ultrasonography of the appendix can be a useful adjunct to standard examination in the diagnosis of acute appendicitis.

Abdominal Pain↗
PubMed1995

Minimally invasive surgery in children with cancer.

BACKGROUND: The safety and efficacy of minimally invasive oncologic procedures in children have not been well defined and only limited anecdotal experience has been published. METHODS: A retrospective review of all patients undergoing either a laparoscopic or thoracoscopic procedure at Childrens Cancer Group institutions between December 1, 1991, and October 1, 1993, was performed. RESULTS: Eighty-five children underwent 88 minimally invasive surgical procedures as part of the evaluation or treatment for cancer at 15 participating centers. In 25 patients, laparoscopy was performed and 60 patients underwent 63 thoracoscopic operations. Tissue biopsies were taken in 67 cases and diagnostic material was obtained in 99% of the biopsies. Seven complications occurred, all within the thoracoscopic group. These included conversion of six operations to an open procedure. One patient developed atelectasis postoperatively. CONCLUSIONS: In pediatric patients with suspected cancer, laparoscopy was highly accurate with minimal morbidity; thoracoscopy was nearly as efficient with slightly higher morbidity. Both modalities are useful for assessment of resectability, for staging purposes, and for evaluation of recurrent or metastatic disease.

Adolescent↗
PubMed1995

In vivo gene transfer into injured carotid arteries. Optimization and evaluation of acute toxicity.

BACKGROUND: Adenoviral vectors are very attractive agents for use in in vivo arterial gene transfer. In a previous study, we demonstrated high-efficiency adenovirus-mediated gene transfer into medial smooth muscle cells of balloon-injured rat carotid arteries. We now further characterize this system by investigating the reproducibility of recombinant gene expression, the presence of acute adenovirus-associated toxicity in the vessel wall, and the optimal virus concentration for transduction. METHODS AND RESULTS: Balloon-injured rat carotid arteries were incubated with (1) an adenovirus expressing a beta-galactosidase gene (Av1LacZ4), (2) a related adenovirus without the recombinant gene (Addl312), or (3) control solutions. Recombinant gene expression was determined 3 days after gene transfer by measurement of beta-galactosidase activity in vessel extracts and by counting of smooth muscle cells in microscopic sections that were histochemically stained to detect recombinant beta-galactosidase activity. Adenovirus-associated toxicity was assessed in microscopic cross sections by counting of total smooth muscle cell nuclei in the media (to identify cell loss) and characterization of medial cellular infiltrates with histochemical stains for specific inflammatory cells (neutrophils, lymphocytes, macrophages, and monocytes). Maximum recombinant gene expression after incubation with Av1LacZ4 was produced by virus concentrations ranging from 2 x 10(10) to 5 x 10(10) plaque-forming units (pfu)/mL. Surprisingly, use of a higher concentration of Av1LacZ4 virus (1 x 10(11) pfu/mL) resulted in loss of recombinant gene expression. In addition, infusion of either Av1LacZ4 or Addl312 at 1 x 10(11) pfu/mL resulted in statistically significant decreases in medial smooth muscle cell number (53% decrease, P < 0.01 for Av1LacZ4; 39% decrease, P < .05 for Addl312) compared with vessels infused with control solution. This decrease in smooth muscle cell number was not present after the infusion of virus at lower concentrations. The number of neutrophils in vessel cross sections was significantly increased (fivefold; P < .05) after infusion of Av1LacZ4 at 1 x 10(11) pfu/mL compared with vessels infused with control solution. Lymphocytes, macrophages, and monocytes were present only in low numbers in all vessel cross sections and were not increased consequent to adenovirus infusion. CONCLUSIONS: This model of focal in vivo adenovirus-mediated gene transfer into the media of injured arteries is highly reproducible and allows high-level recombinant gene expression over a fairly narrow range of virus concentrations. Acute adenovirus-associated tissue toxicity, as demonstrated by medial smooth muscle cell loss and neutrophilic infiltrates, places an upper limit on virus concentration and associated recombinant gene expression and suggests the presence of a "window" of virus concentration in which either therapeutic or biological effects of recombinant genes can be studied in the absence of associated acute toxicity.

Adenoviridae↗
PubMed1995

A proposed classification of vaginal anomalies and their surgical correction.

A classification of vaginal anomalies has been derived, which permits logical operative decisions. This tool allows the assignment of increasingly involved reconstructive operations to progressively more complex vaginal anatomies. The outcome of this approach in 49 vaginal reconstructions performed in 36 patients over a 25-year period has been analyzed. The cause was found to be congenital adrenal hyperplasia in 21 patients, gonadal dysgenesis in four, and cloaca in two; nine children had other causes. Based on the following anatomic classification and the authors' clinical experience, the following approaches to reconstruction can be recommended. Eight infants with labial fusion (type I) underwent simple introitoplasty. Fourteen patients with distal urogenital sinus (type II) underwent flap vaginoplasty using labioscrotal tissue and/or a posteriorly based flap. Pull-through vaginoplasty was used in 10 children with distal vaginal atresia and proximal urethrovaginal fistula (type III). Four patients with absence of the vagina (type IV) required segmental colon vaginoplasty. Thirteen revisions have been required in nine patients thus far. The follow-up period is 1 to 17 years, and despite the need for reoperation, all but two patients have excellent or satisfactory results based on anatomic and functional considerations. The choice for and timing of vaginal reconstruction rests on precise anatomic evaluation. The complexity of vaginal reconstruction in the growing child and the essentiality of psychosocial adjustment to appropriate sexual identity and function mandate long-term comprehensive follow-up. Optimal care for each patient requires experience and continuity to take the child through diagnosis, surgical reconstruction, stressful adolescence, and into adulthood with full attention to anatomic, physiological, and psychological support.

Adrenal Hyperplasia, Congenital↗
PubMed1995

Experience with abdominal wall closure for patients with congenital diaphragmatic hernia repaired on ECMO.

Congenital diaphragmatic hernia (CDH) and its attendant lack of abdominal domain can create major technical challenges with respect to diaphragmatic and abdominal wall reconstruction, especially in seriously ill infants who require extracorporeal membrane oxygenation (ECMO). The authors reviewed the medical records of all infants with CDH repaired on ECMO at their institution (group 1, 15 patients), and compared them with infants having CDH repair before ECMO (group 2, 20 patients) and with those who had CDH repair but did not require ECMO (group 3, 15 patients). Thirty-seven of 50 patients survived (74%): 10 in group 1, 12 in group 2, and all 15 in group 3. There was a statistically significant difference (P < .001) with respect to the requirement of a polytetrafluoroethylene (PTFE) diaphragmatic patch for patients in group 1 versus those in both groups 2 and 3. There was also a significant difference in the number of patients in whom the abdomen could not be closed (P < .001 for group 1 v groups 2 and 3). Infants who require ECMO before CDH repair are more likely to have large diaphragmatic defects that require prosthetic reconstruction, and abdominal wall closure problems resulting from loss of abdominal domain, which further complicate the management of the physiological derangements from pulmonary hypoplasia and persistent pulmonary hypertension.

Abdominal Muscles↗