76 results on '"Chwals WJ"'
Search Results
2. Hyperglycemia management strategy in the pediatric intensive care setting.
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Chwals WJ
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- 2008
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3. Effect of ambient temperature on physical compatibility of neonatal total parenteral nutrition admixtures.
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Chwals WJ
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- 2009
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4. Energy expenditure in critically ill infants.
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Chwals WJ
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- 2008
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5. Predicted energy expenditure in critically ill children: problems associated with increased variability.
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Chwals WJ, Bistrian B, Chwals, W J, and Bistrian, B R
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- 2000
6. Vascular access for home intravenous therapy in children.
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Chwals WJ and Chwals, Walter J
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- 2006
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7. Surgical Necrotizing Enterocolitis and Spontaneous Intestinal Perforation Lead to Severe Growth Failure in Infants.
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Speer AL, Lally KP, Pedroza C, Zhang Y, Poindexter BB, Chwals WJ, Hintz SR, Besner GE, Stevenson DK, Ohls RK, Truog WE, Stoll BJ, Rysavy MA, Das A, Tyson JE, and Blakely ML
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- Humans, Male, Female, Infant, Infant, Newborn, Drainage methods, Laparotomy methods, Spontaneous Perforation surgery, Spontaneous Perforation etiology, Growth Disorders etiology, Infant, Premature, Enterocolitis, Necrotizing surgery, Enterocolitis, Necrotizing complications, Intestinal Perforation surgery, Intestinal Perforation etiology
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Objective: We aimed to determine the incidence of growth failure in infants with necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP) and whether initial laparotomy versus peritoneal drainage (PD) impacted the likelihood of growth failure., Summary Background Data: Infants with surgical NEC and SIP have high mortality, and most have neurodevelopmental impairment and poor growth. Existing literature on growth outcomes for these infants is limited., Methods: This is a preplanned secondary study of the Necrotizing Enterocolitis Surgery Trial dataset. The primary outcome was growth failure (Z-score for weight <-2.0) at 18 to 22 months. We used logistic regression, including diagnosis and treatment, as covariates. Secondary outcomes were analyzed using the Fisher exact or Pearson χ2 test for categorical variables and the Wilcoxon rank sum test or one-way ANOVA for continuous variables., Results: Among 217 survivors, 207 infants (95%) had primary outcome data. Growth failure at 18 to 22 months occurred in 24/50 (48%) of NEC infants versus 65/157 (42%) SIP (P=0.4). The mean weight-for-age Z-score at 18 to 22 months in NEC infants was -2.05±0.99 versus -1.84±1.09 SIP (P=0.2), and the predicted mean weight-for-age Z-score SIP (Beta -0.27; 95% CI: -0.53, -0.01; P=0.041). Median declines in weight-for-age Z-score between birth and 18 to 22 months were significant in all infants but most severe (>2) in NEC infants (P=0.2)., Conclusions: This first ever prospective study of growth outcomes in infants with surgical NEC or SIP demonstrates that growth failure is very common, especially in infants with NEC, and persists at 18-22 months., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)
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- 2024
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8. Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multicenter Randomized Clinical Trial.
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Blakely ML, Tyson JE, Lally KP, Hintz SR, Eggleston B, Stevenson DK, Besner GE, Das A, Ohls RK, Truog WE, Nelin LD, Poindexter BB, Pedroza C, Walsh MC, Stoll BJ, Geller R, Kennedy KA, Dimmitt RA, Carlo WA, Cotten CM, Laptook AR, Van Meurs KP, Calkins KL, Sokol GM, Sanchez PJ, Wyckoff MH, Patel RM, Frantz ID 3rd, Shankaran S, D'Angio CT, Yoder BA, Bell EF, Watterberg KL, Martin CA, Harmon CM, Rice H, Kurkchubasche AG, Sylvester K, Dunn JCY, Markel TA, Diesen DL, Bhatia AM, Flake A, Chwals WJ, Brown R, Bass KD, St Peter SD, Shanti CM, Pegoli W Jr, Skarda D, Shilyansky J, Lemon DG, Mosquera RA, Peralta-Carcelen M, Goldstein RF, Vohr BR, Purdy IB, Hines AC, Maitre NL, Heyne RJ, DeMauro SB, McGowan EC, Yolton K, Kilbride HW, Natarajan G, Yost K, Winter S, Colaizy TT, Laughon MM, Lakshminrusimha S, and Higgins RD
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- Enterocolitis, Necrotizing mortality, Enterocolitis, Necrotizing psychology, Feasibility Studies, Female, Humans, Infant, Extremely Low Birth Weight, Infant, Newborn, Infant, Premature, Infant, Premature, Diseases mortality, Infant, Premature, Diseases psychology, Intestinal Perforation mortality, Intestinal Perforation psychology, Male, Neurodevelopmental Disorders diagnosis, Survival Rate, Treatment Outcome, Drainage, Enterocolitis, Necrotizing surgery, Infant, Premature, Diseases surgery, Intestinal Perforation surgery, Laparotomy, Neurodevelopmental Disorders epidemiology
- Abstract
Objective: The aim of this study was to determine which initial surgical treatment results in the lowest rate of death or neurodevelopmental impairment (NDI) in premature infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP)., Summary Background Data: The impact of initial laparotomy versus peritoneal drainage for NEC or IP on the rate of death or NDI in extremely low birth weight infants is unknown., Methods: We conducted the largest feasible randomized trial in 20 US centers, comparing initial laparotomy versus peritoneal drainage. The primary outcome was a composite of death or NDI at 18 to 22 months corrected age, analyzed using prespecified frequentist and Bayesian approaches., Results: Of 992 eligible infants, 310 were randomized and 96% had primary outcome assessed. Death or NDI occurred in 69% of infants in the laparotomy group versus 70% with drainage [adjusted relative risk (aRR) 1.0; 95% confidence interval (CI): 0.87-1.14]. A preplanned analysis identified an interaction between preoperative diagnosis and treatment group (P = 0.03). With a preoperative diagnosis of NEC, death or NDI occurred in 69% after laparotomy versus 85% with drainage (aRR 0.81; 95% CI: 0.64-1.04). The Bayesian posterior probability that laparotomy was beneficial (risk difference <0) for a preoperative diagnosis of NEC was 97%. For preoperative diagnosis of IP, death or NDI occurred in 69% after laparotomy versus 63% with drainage (aRR, 1.11; 95% CI: 0.95-1.31); Bayesian probability of benefit with laparotomy = 18%., Conclusions: There was no overall difference in death or NDI rates at 18 to 22 months corrected age between initial laparotomy versus drainage. However, the preoperative diagnosis of NEC or IP modified the impact of initial treatment., Competing Interests: The authors report no conflict of interests., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)
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- 2021
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9. Commentary regarding the impact of malnutrition (nutritional imbalance) on pediatric surgical outcome.
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Chwals WJ
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- 2021
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10. Necrotizing Enterocolitis: Using Regulatory Science and Drug Development to Improve Outcomes.
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Caplan MS, Underwood MA, Modi N, Patel R, Gordon PV, Sylvester KG, McElroy S, Manzoni P, Gephart S, Chwals WJ, Turner MA, and Davis JM
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- Biomarkers analysis, Child, Clinical Trials as Topic, Enterocolitis, Necrotizing diagnosis, Enterocolitis, Necrotizing therapy, Humans, Practice Guidelines as Topic, Probiotics therapeutic use, Treatment Outcome, Drug Development, Enterocolitis, Necrotizing drug therapy
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- 2019
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11. Evaluating the Impact of Delaying Parenteral Nutrition in Critically Ill Children.
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Chwals WJ
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- Child, Humans, Liver, Prevalence, Prognosis, Critical Illness, Parenteral Nutrition
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- 2018
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12. Bariatric Surgery Needs a Seat at the Children's Table: Bridging the Perception and Reality of the Role of Bariatric Surgery in the Treatment of Obesity in Adolescents.
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Chernoguz A and Chwals WJ
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- Adolescent, Exercise, Humans, Recurrence, Weight Loss, Bariatric Surgery methods, Pediatric Obesity surgery
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The long-term morbidity of obesity in adolescents is well recognized nationally and represents a major health concern for the population of the near future. Traditional medical management of obesity focuses on addressing behavioral modification, dietary and exercise programs, and, to a lesser degree, pharmaceuticals. Although these strategies are relatively effective, they suffer from the lack of sustained benefit, a high relapse rate, and, in case of pharmacotherapy, potentially dangerous adverse effects. Bariatric surgery in adolescents has often been characterized as a risky intervention with unknown long-term benefits. However, recent data establish that a sustained, clinically meaningful effect on weight loss, as well as a reduction in chronic morbidities related to obesity, can be achieved. The role of bariatric surgery as an accepted adjunctive strategy in the treatment of obesity in adolescents is becoming more recognized; however, a number of barriers exist that prevent the timely evaluation of adolescents with obesity for potential surgical intervention. We examine these barriers in light of recent advancements to help better define the role of bariatric surgery in the treatment of obesity in adolescent population., (Copyright © 2018 Elsevier Inc. All rights reserved.)
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- 2018
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13. Overfeeding-associated hyperglycemia and injury-response homeostasis in critically ill neonates.
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Tian T, Coons J, Chang H, and Chwals WJ
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- Critical Illness, Energy Intake physiology, Female, Humans, Hyperglycemia therapy, Infant, Newborn, Infant, Premature, Infant, Premature, Diseases therapy, Male, Outcome Assessment, Health Care, Parenteral Nutrition, Total methods, Retrospective Studies, Homeostasis physiology, Hyperglycemia etiology, Infant, Premature, Diseases etiology, Intensive Care, Neonatal methods, Parenteral Nutrition, Total adverse effects, Stress, Physiological physiology
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Background: Injury severity induces a proportionate acute metabolic stress response, associated with increased risk of hyperglycemia. We hypothesized that excess caloric delivery (overfeeding) during high stress states would increase hyperglycemia and disrupt response homeostasis., Methods: Gestational age, daily weight, total daily caloric intake, serum C-reactive protein (CRP), prealbumin, and blood glucose concentrations in all acutely-injured premature NICU infants requiring TPN over the past 3years were reviewed. Injury severity was based on CRP and patients were divided into high (CRP ≥50mg/L) versus low (CRP <50mg/L) stress groups. Glycemic variability was used to measure disruption of homeostasis., Results: Overall sample included N=563 patient days (37 patients; 42 episodes). High stress group pre-albumin levels negatively correlated with CRP levels (R=-0.62, p<0.005). A test of equal variance demonstrated significantly increased high stress glycemic variability (Ha:ratio>1, Pr(F>f)=0.0353). When high stress patients were separated into high caloric intake (≥70kg/kcal/day) versus low caloric intake (<70kg/kcal/day), maximum serum glucose levels were significantly higher with overfeeding (230.33±55.81 vs. 135.71±37.97mg/dL, p<0.004)., Conclusion: Higher injury severity induces increased disruption of response homeostasis in critically ill neonates. TPN-associated overfeeding worsens injury-related hyperglycemia in more severely injured infants., Type of Study: Retrospective study., Level of Evidence: Level II., (Copyright © 2018. Published by Elsevier Inc.)
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- 2018
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14. A Unique Case of Mediastinal Teratoma with Mature Pancreatic Tissue, Nesidioblastosis, and Aberrant Islet Differentiation: a Case Report and Literature Review.
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Agrawal T, Blau AJ, Chwals WJ, and Tischler AS
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- Biomarkers, Tumor analysis, Cell Differentiation, Child, Glucagon metabolism, Humans, Immunohistochemistry, Islets of Langerhans pathology, Male, Nesidioblastosis pathology, Mediastinal Neoplasms pathology, Pancreas pathology, Teratoma pathology
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Mediastinal teratomas with elements of mature pancreatic tissue are rare. Only a very few cases of pancreatic tissue with nesidioblastosis in teratoma have been reported. Here, we report a case of a 12-year-old male who presented with pleural effusion and was revealed to have a large anterior mediastinal mass. Biopsy of the mass revealed benign mature teratoma. After biopsy, the teratoma ruptured into the right thoracic cavity. It was then excised and sent to pathology for further evaluation. Preoperatively, there was no evidence of hyperinsulinemia or hypoglycemia. Postoperatively, there was no change in blood glucose levels. Histologically, the mass showed large areas of mature pancreatic tissue flanking a small intestine-like structure. Numerous endocrine cell islets, poorly defined groups of neuroendocrine cells and ductular-insular complexes characteristic of nesidioblastosis were dispersed in the exocrine pancreatic parenchyma. In addition, other parts of the tumor containing keratinizing squamous epithelium with cutaneous adnexal glands, small intestine, and bronchus including cartilage and respiratory epithelium were observed. Some islets contained two or more cell types while others were monophenotypic. Immunohistochemical staining showed pronounced expression of pancreatic polypeptide, moderate expression of somatostatin and insulin and nearly complete absence of glucagon-containing cells. The selective deletion of glucagon might hold clues to an important regulatory mechanism in pancreatic development.
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- 2016
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15. Are CT scans obtained at referring institutions justified prior to transfer to a pediatric trauma center?
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Benedict LA, Paulus JK, Rideout L, and Chwals WJ
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- Accidental Falls statistics & numerical data, Accidents, Traffic statistics & numerical data, Adolescent, Child, Child, Preschool, Cohort Studies, Craniocerebral Trauma diagnostic imaging, Diagnostic Tests, Routine statistics & numerical data, Female, Glasgow Coma Scale, Guideline Adherence, Humans, Infant, Infant, Newborn, Male, Massachusetts, Practice Guidelines as Topic, Tertiary Care Centers, Triage, Young Adult, Hospitals, Pediatric, Patient Transfer standards, Referral and Consultation, Tomography, X-Ray Computed statistics & numerical data, Trauma Centers, Unnecessary Procedures statistics & numerical data, Wounds and Injuries diagnostic imaging
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Purpose: To assess whether pediatric trauma patients initially evaluated at referring institutions met Massachusetts statewide trauma field triage criteria for stabilization and immediate transfer to a Pediatric Trauma Center (PTC) without pre-transfer CT imaging., Methods: A 3-year retrospective cohort study was completed at our level 1 PTC. Patients with CT imaging at referring institutions were classified according to a triage scheme based on Massachusetts statewide trauma field triage criteria. Demographic data and injury profile characteristics were abstracted from patient medical records and our pediatric trauma registry., Results: A total of 262 patients with 413 CT scans were reviewed from 2008 to 2011. 172 patients scanned (66%, 95% CI: 60%, 71%) met criteria for immediate transfer to a pediatric trauma center. Notably, 110 scans (27% of the total performed at referring institutions) were duplicated within four hours upon arrival to our PTC. GCS score <14 (45%) was the most common requirement for transfer, and CT scan of the head was the most frequent scan obtained (53%)., Conclusion: The majority of pediatric trauma patients were subjected to CT scans at referring institutions despite meeting Massachusetts trauma triage guidelines that call for stabilization and immediate transfer to a pediatric trauma center without any CT imaging., (© 2014.)
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- 2014
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16. Management of patients with combined tracheoesophageal fistula, esophageal atresia, and duodenal atresia.
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Nabzdyk CS, Chiu B, Jackson CC, and Chwals WJ
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Introduction: Patients with combined esophageal atresia (EA), tracheoesophageal fistula (TEF), and duodenal atresia (DA) pose a rare management challenge., Presentation of Case: Three patients with combined esophageal atresia (EA), tracheoesophageal fistula (TEF), and duodenal atresia safely underwent a staged approach inserting a gastrostomy tube and repairing the EA/TEF first followed by a duodenoduodenostomy within one week. None of the patients suffered significant pre- or post-operative complications and our follow-up data (between 12 and 24 months) suggest that all patients eventually outgrow their reflux and respiratory symptoms., Discussion: While some authors support repair of all defects in one surgery, we recommend a staged approach. A gastrostomy tube is placed first for gastric decompression before TEF ligation and EA repair can be safely undertaken. The repair of the DA can then be performed within 3-7 days under controlled circumstances., Conclusion: A staged approach of inserting a gastrostomy tube and repairing the EA/TEF first followed by a duodenoduodenostomy within one week resulted in excellent outcomes., (Copyright © 2013 The Authors. Published by Elsevier Ltd.. All rights reserved.)
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- 2014
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17. Management of pediatric patients with refractory constipation who fail cecostomy.
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Bonilla SF, Flores A, Jackson CC, Chwals WJ, and Orkin BA
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- Adolescent, Anastomosis, Surgical, Child, Chronic Disease, Colon innervation, Colon physiopathology, Colon surgery, Constipation therapy, Disease Management, Female, Follow-Up Studies, Gastrointestinal Motility, Humans, Ileum surgery, Male, Retrospective Studies, Treatment Failure, Young Adult, Cecostomy methods, Cecostomy statistics & numerical data, Colectomy methods, Constipation surgery, Enema methods
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Background: Antegrade continence enema (ACE) is a recognized therapeutic option in the management of pediatric refractory constipation. Data on the long-term outcome of patients who fail to improve after an ACE-procedure are lacking., Purpose: To describe the rate of ACE bowel management failure in pediatric refractory constipation, and the management and long term outcome of these patients., Methods: Retrospective analysis of a cohort of patients that underwent ACE-procedure and had at least 3-year-follow-up. Detailed analysis of subsequent treatment and outcome of those patients with a poor functional outcome was performed., Results: 76 patients were included. 12 (16%) failed successful bowel management after ACE requiring additional intervention. Mean follow-up was 66.3 (range 35-95 months) after ACE-procedure. Colonic motility studies demonstrated colonic neuropathy in 7 patients (58%); abnormal motility in 4 patients (33%), and abnormal left-sided colonic motility in 1 patient (9%). All 12 patients were ultimately treated surgically. Nine patients (75%) had marked clinical improvement, whereas 3 patients (25%) continued to have poor function issues at long term follow-up., Conclusions: Colonic resection, either segmental or total, led to improvement or resolution of symptoms in the majority of patients who failed cecostomy. However, this is a complex and heterogeneous group and some patients will have continued issues., (Copyright © 2013 Elsevier Inc. All rights reserved.)
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- 2013
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18. Early minimal enteral supplementation in severely burned children receiving parenteral nutrition.
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Chwals WJ
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- Humans, Burns therapy, Parenteral Nutrition
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- 2013
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19. Paediatric torsed extralobar sequestration containing calcification: Imaging findings with pathological correlation.
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Zucker EJ, Tracy DA, Chwals WJ, Solky AC, and Lee EY
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- Bronchopulmonary Sequestration diagnostic imaging, Calcinosis diagnostic imaging, Child, Humans, Male, Tomography, X-Ray Computed, Torsion Abnormality diagnostic imaging, Ultrasonography, Bronchopulmonary Sequestration pathology, Calcinosis pathology, Torsion Abnormality pathology
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- 2013
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20. Prevention of inappropriate caloric repletion in critically ill children.
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Chwals WJ
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- Female, Humans, Male, Critical Illness therapy, Energy Intake, Energy Metabolism, Overnutrition epidemiology
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- 2011
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21. Long-term outcome after partial external biliary diversion for progressive familial intrahepatic cholestasis.
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Halaweish I and Chwals WJ
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- Cholestasis, Intrahepatic complications, Humans, Infant, Jaundice etiology, Jaundice surgery, Liver Transplantation, Pruritus etiology, Pruritus surgery, Retrospective Studies, Surgical Stomas adverse effects, Survival Analysis, Treatment Outcome, Biliary Tract Surgical Procedures adverse effects, Biliary Tract Surgical Procedures methods, Cholestasis, Intrahepatic surgery, Jejunostomy adverse effects, Jejunostomy methods
- Abstract
Background: Though patients with progressive familial intrahepatic cholestasis (PFIC) typically require liver transplantation, initial surgical treatment includes partial biliary diversion (PBD) to relieve jaundice-associated pruritus. This study was undertaken to describe long-term PFIC outcome data, which are currently sparsely reported., Methods: Retrospective review of 7 patients diagnosed with PFIC who underwent PBD between 2004 and 2008 was directed toward long-term postoperative outcome including resolution of jaundice/pruritus, stoma complications, interval to transplantation, and death., Results: Six patients who underwent PBD experienced short-term resolution of jaundice and pruritus. Four patients experienced persistent stoma-related complications requiring a total of 14 revisions. Three symptom-free patients have not yet required liver transplantation post-PBD (average, 70 months; range, 59-78 months). Two patients underwent orthotopic liver transplantation (average, 44 +/- 18 months post-PBD). Two patients died at home because of gastroenteritis-associated dehydration before transplantation., Conclusion: Partial biliary diversion for PFIC is effective as a bridge to liver transplantation in improving jaundice and pruritus but may be associated with a high incidence of stoma-related complications. Persistent or recurrent pruritus after PFIC is associated with an increased risk of stoma prolapse or reflux. Insufficiently replaced stomal losses over time may increase the risk of dehydration-related complications in association with gastroenteritis., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)
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- 2010
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22. Relationship of serum C-reactive protein and blood glucose levels with injury severity and patient morbidity in a pediatric trauma population.
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Brunengraber LN, Robinson AV, and Chwals WJ
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- Acute-Phase Reaction, Adolescent, Biomarkers, Child, Child, Preschool, Female, Hospitals, Pediatric statistics & numerical data, Humans, Inflammation blood, Inflammation etiology, Intensive Care Units, Pediatric, Length of Stay statistics & numerical data, Liver metabolism, Male, Retrospective Studies, Trauma Centers statistics & numerical data, Wounds and Injuries physiopathology, Blood Glucose analysis, C-Reactive Protein analysis, Trauma Severity Indices, Wounds and Injuries blood
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Purpose: Serum markers of inflammation and of glucose production are known to reflect the immediate metabolic response to injury. We hypothesized that monitoring of the early C-reactive protein (CRP) and blood glucose (BG) concentrations would correlate with clinical morbidity and outcome measures in pediatric trauma patients., Methods: A five-year retrospective chart review of pediatric trauma patients admitted to our Level I pediatric trauma center was conducted to establish the relationships between early (first 3 hospital days) serum CRP and BG concentrations, Injury Severity Score (ISS), and hospital length of stay (HLOS). Statistical significance (P < 0.05) was determined using Student's t-test., Results: Forty-two trauma patients (8.0 +/- 5.2 years) were evaluated. The early inflammatory response (CRP >or= 10 vs <10 mg/dl) was significantly correlated to the glycemic response (BG;121 +/- 24 vs 97.3 +/- 14.2 mg/dl, P < 0.05). Severely injured patients (ISS >or= 25 vs <25) were significantly more hyperglycemic (BG;156 +/- 56.9 vs 125 +/- 31.6 mg/dL, P = 0.003). Both increased inflammatory response (CRP;8.1 +/- 6.4 vs 2.5 +/- 3.5 mg/dL) and increased glycemic response (BG;111 +/- 15.9 vs 97.4 +/- 11.7 mg/dL) were independently and significantly associated with prolonged hospitalization (HLOS > 7 vs
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- 2009
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23. Computed tomography before transfer to a level I pediatric trauma center risks duplication with associated increased radiation exposure.
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Chwals WJ, Robinson AV, Sivit CJ, Alaedeen D, Fitzenrider E, and Cizmar L
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- Abdominal Injuries epidemiology, Child, Child, Preschool, Compact Disks, Craniocerebral Trauma epidemiology, Equipment Failure, Female, Forms and Records Control, Glasgow Coma Scale, Humans, Intensive Care Units, Pediatric statistics & numerical data, Male, Radiation Dosage, Radiology Information Systems, Retrospective Studies, Tomography, X-Ray Computed adverse effects, Tomography, X-Ray Computed standards, Trauma Severity Indices, Abdominal Injuries diagnostic imaging, Craniocerebral Trauma diagnostic imaging, Hospitals, Community statistics & numerical data, Hospitals, Pediatric statistics & numerical data, Patient Transfer, Tomography, X-Ray Computed statistics & numerical data, Trauma Centers statistics & numerical data, Unnecessary Procedures
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Introduction: Community hospitals commonly obtain computed tomographic (CT) imaging of pediatric trauma patients before triaging to a level I pediatric trauma center (PTC). This practice potentially increases radiation exposure when imaging must be duplicated after transfer., Methods: A retrospective review of our level 1 PTC registry from January 1, 2004, to December 31, 2006, was conducted. Level I and II trauma patients were grouped based on whether they had undergone outside CT examination (head and/or abdomen) at a referring hospital (group 1) or received initial CT examination at our institution (group 2). Subgroups were analyzed based on whether duplicate CT examination was required at our PTC (Fischer's Exact test)., Results: A duplicate CT scan (within 4 hours of transfer) was required in 91% (30/33) of group 1 transfer patients, whereas no group 2 patient required a duplicate scan (0/55; P < .0001). There was no significant difference within the groups for weight, age, or intensive care unit length of stay., Conclusion: A significant number of pediatric trauma patients who receive CT scans at referring hospitals before transfer to our level I PTC require duplicate scans of the same anatomical field(s) after transfer, exposing them to increase potential clinical risk and cost.
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- 2008
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24. Appendiceal fecalith is associated with early perforation in pediatric patients.
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Alaedeen DI, Cook M, and Chwals WJ
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- Appendectomy statistics & numerical data, Appendicitis surgery, Causality, Child, Comorbidity, Female, Humans, Incidence, Male, Ohio epidemiology, Appendicitis epidemiology, Fecal Impaction epidemiology
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Purpose: A fecalith is a fecal concretion that can obstruct the appendix leading to acute appendicitis. We hypothesized that the presence of a fecalith would lead to an earlier appendiceal perforation., Methods: Between January 2001 and December 2005, the charts of all patients younger than 18 years old who underwent appendectomy at our institution were reviewed. Duration of symptoms and timing between presentation and operation were noted along with radiologic, operative, and pathologic findings., Results: There were 388 patients who met the study criteria. A fecalith was present in 31% of patients (n = 121). The appendix was perforated in 57% of patients who had a fecalith vs 36% in patients without a fecalith (P < .001). The overall rate of interval appendectomies was 12%. A fecalith was present on the initial radiologic studies of 36% of the patients who had interval appendectomies, and the appendix was perforated significantly sooner in these patients when compared to those without a fecalith (91 vs 150 hours; P = .036)., Conclusion: The presence of fecalith is associated with earlier and higher rates of appendiceal perforation in pediatric patients with acute appendicitis. An expedient appendectomy should therefore be performed in the pediatric patient with a radiologic evidence of fecalith.
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- 2008
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25. Total parenteral nutrition-associated hyperglycemia correlates with prolonged mechanical ventilation and hospital stay in septic infants.
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Alaedeen DI, Walsh MC, and Chwals WJ
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- Blood Glucose analysis, Humans, Infant, Newborn, Infant, Premature, Intensive Care Units, Neonatal, Length of Stay, Nutritional Status, Retrospective Studies, Treatment Outcome, Hyperglycemia complications, Hyperglycemia etiology, Parenteral Nutrition, Total adverse effects, Respiration, Artificial, Sepsis
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Purpose: We studied the effects of total parenteral nutrition (TPN)-associated hyperglycemia on the clinical outcome in premature septic infants in the neonatal intensive care unit., Methods: The charts of all premature infants weighing less than 1500 g upon admission to the neonatal intensive care unit between January 1, 2002, and December 31, 2002, with sepsis, ventilator dependence, and feeding intolerance were studied. Maximum serum glucose concentrations were compared with duration of TPN, mechanical ventilation, hospital length of stay, and survival using Pearson regression analysis and Student's t test., Results: Thirty-seven patients met the search criteria. The average caloric intake for all infants at the time of blood culture-proven sepsis was 83 +/- 19 kcal/kg per day. The maximum serum glucose concentration (milligrams per deciliter) after having positive blood cultures (sepsis) was positively correlated with the duration of TPN (r = 0.45, P = .005), length of dependence on mechanical ventilation (r = 0.45, P = .006), and hospital length of stay (r = 0.36, P = .03). The average maximum serum glucose level was significantly higher in the nonsurviving infants (241 +/- 46 vs 141 +/- 48, P < .0001)., Conclusion: Hyperglycemia correlated with prolonged ventilator dependency and increased hospital length of stay in premature septic infants. Avoidance of excessive nutrient delivery and tight glycemic control during periods of acute metabolic stress may improve outcome in this patient population.
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- 2006
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26. Postoperative outcomes of extremely low birth-weight infants with necrotizing enterocolitis or isolated intestinal perforation: a prospective cohort study by the NICHD Neonatal Research Network.
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Blakely ML, Lally KP, McDonald S, Brown RL, Barnhart DC, Ricketts RR, Thompson WR, Scherer LR, Klein MD, Letton RW, Chwals WJ, Touloukian RJ, Kurkchubasche AG, Skinner MA, Moss RL, and Hilfiker ML
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- Drainage, Enterocolitis, Necrotizing mortality, Hospital Mortality, Humans, Infant, Newborn, Intestinal Perforation mortality, Laparotomy, Prospective Studies, Surgical Wound Dehiscence epidemiology, Treatment Outcome, Enterocolitis, Necrotizing surgery, Infant, Very Low Birth Weight, Intestinal Perforation surgery
- Abstract
Objective: Purposes of this study were: 1) to compare mortality and postoperative morbidities (intra-abdominal abscess, wound dehiscence, and intestinal stricture) in extremely low birth weight (ELBW) infants who underwent initial laparotomy or drainage for necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP); 2) to determine the ability to distinguish NEC from IP preoperatively and the importance of this distinction on outcome measures; and 3) to evaluate the association between extent of intestinal disease determined at operation and outcome measures., Background: ELBW infants who undergo operation for NEC or IP have a postoperative, in-hospital mortality rate of approximately 50%. Whether to perform laparotomy or drainage initially is controversial. Also unknown is the importance of distinguishing NEC from IP and the current ability to make this distinction based on objective data available prior to operation., Methods: A prospective, multicenter cohort study of 156 ELBW infants at 16 neonatal intensive care units (NICU) within the NICHD Neonatal Research Network., Results: Among the 156 enrolled infants, 80 underwent initial peritoneal drainage and 76 initial laparotomy. Mortality rate was 49% (76 of 156). Ninety-six patients had a preoperative diagnosis of NEC and 60 had presumed IP. There was a high level of agreement between the presumed preoperative diagnosis and intraoperative diagnosis in patients undergoing initial laparotomy (kappa = 0.85). The relative risk for death with a preoperative diagnosis of NEC (versus IP) was 1.4 (95% confidence interval, 0.99-2.1, P = 0.052). The overall incidence of postoperative intestinal stricture was 10.3%, wound dehiscence 4.4%, and intra-abdominal abscess 5.8%, and did not significantly differ between groups undergoing initial laparotomy versus initial drainage., Conclusions: Survival to hospital discharge after operation for NEC or IP in ELBW neonates remains poor (51%). Patients with a preoperative diagnosis of NEC have a relative risk for death of 1.4 compared with those with a preoperative diagnosis of IP. A distinction can be made preoperatively between NEC and IP based on abdominal radiographic findings and the patient's age at operation. Future randomized trials that compare laparotomy versus drainage would likely benefit from stratification of treatment assignment based on preoperative diagnosis.
- Published
- 2005
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27. C-Reactive protein-determined injury severity: length of stay predictor in surgical infants.
- Author
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Alaedeen DI, Queen AL, Leung E, Liu D, and Chwals WJ
- Subjects
- Female, Humans, Infant, Male, Predictive Value of Tests, C-Reactive Protein analysis, Length of Stay statistics & numerical data, Severity of Illness Index, Surgical Procedures, Operative adverse effects
- Abstract
Background/purpose: Serum C-reactive protein (CRP) levels reflect the severity of the metabolic response to injury in critically ill children. During this period, caloric overfeeding can increase complications and delay recovery. The authors hypothesized that by avoiding excessive caloric delivery, the effect of injury severity would be the major factor determining clinical outcome., Methods: Twenty-eight surgical infants who had indirect calorimetry measurements while in the Neonatal Intensive Care Unit between August 2000 and January 2002 were studied. Serum CRP concentrations, mean energy expenditure (MEE), respiratory quotient (RQ), length of hospital stay (LOS), and caloric intake (I) at the time of indirect calorimetry were recorded. Data were analyzed using the Pearson product-moment correlation., Results: Peak serum CRP was significantly correlated to LOS in all patients (r = 0.79, P < .0001). When net caloric balance (I-MEE) did not exceed 5 kcal/kg/d (n = 9), peak serum CRP was correlated positively with RQ (r = 0.66, P = .05). When I-MEE exceeded 5 kcal/kg/d (n = 19), the positive correlation of serum CRP with RQ was diminished (r = 0.23, P = .33)., Conclusions: CRP-measured injury severity is a major determinant of clinical outcome in surgical infants. In addition, overfeeding causes additional RQ elevation.
- Published
- 2004
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28. Regulation of the cellular and physiological effects of glutamine.
- Author
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Chwals WJ
- Subjects
- Animals, Cell Division drug effects, Cell Division physiology, Critical Illness therapy, Humans, Kidney metabolism, Molecular Structure, Glutamine metabolism, Glutamine pharmacology, Glutamine physiology
- Abstract
Glutamine is the most abundant amino acid in humans and possesses many functions in the body. It is the major transporter of amino-nitrogen between cells and an important fuel source for rapidly dividing cells such as cells of the immune and gastrointestinal systems. It is important in the synthesis of nucleic acids, glutathione, citrulline, arginine, gamma aminobutyric acid, and glucose. It is important for growth, gastrointestinal integrity, acid-base homeostasis, and optimal immune function. The regulation of glutamine levels in cells via glutaminase and glutamine synthetase is discussed. The cellular and physiologic effects of glutamine upon the central nervous system, gastrointestinal function, during metabolic support, and following tissue injury and critical illness is also discussed.
- Published
- 2004
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29. The management of overweight and obese children.
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Chwals WJ
- Subjects
- Adolescent, Age Distribution, Body Composition, Body Mass Index, Child, Female, Health Surveys, Humans, Male, Obesity epidemiology, Prevalence, Risk Assessment, Severity of Illness Index, Sex Distribution, United States epidemiology, Diet, Reducing, Life Style, Obesity prevention & control, Obesity therapy, Primary Prevention organization & administration
- Published
- 2004
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30. Thoracoscopic thymectomy in children with myasthenia gravis.
- Author
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Skelly CL, Jackson CC, Wu Y, Hill CB, Chwals WJ, and Liu DC
- Subjects
- Adolescent, Child, Female, Humans, Male, Retrospective Studies, Myasthenia Gravis surgery, Thoracoscopy, Thymectomy methods
- Abstract
Although conservative medical management is the mainstay in the treatment of myasthenia gravis (MG), severest forms of the disease often require surgical thymectomy. Thoracoscopic thymectomy (TT) represents a minimally invasive alternative to traditional thymectomy via sternotomy. We present our preliminary experience with TT as definitive treatment for severe forms of MG. The charts of 5 children (4 girls and 1 boy; age range, 11-17 years) who underwent TT for MG were retrospectively reviewed. TT was typically performed via left thoracoscopy using 4- or 5-mm ports with 1 of the ports enlarged at the end of the procedure for specimen retrieval. Thymic veins were identified and ligated with surgical clips in all cases. Surgical parameters assessed were the following: operating time, intra- and postoperative complications, length of postoperative stay, and resolution of symptoms. Follow-up ranged from 6 months to 2 years. All 5 TTs were successfully completed. In 1 case, right-sided thoracoscopy was added to ensure complete gland excision. Surgical pathology in all cases demonstrated complete excision. Mean operating time was 121 minutes (range 88 minutes to 188 minutes). There were no intra- or postoperative complications. Length of postoperative stay averaged 1.6 days (range, 1 to 3 days). Four of 5 (80%) had clear resolution of symptoms with 1 showing minimal resolution at 6 months. Thoracoscopic thymectomy is a safe and potentially attractive alternative to traditional thymectomy via median sternotomy in severe forms of myasthenia gravis. Complete thymectomy, the goal of traditional surgical treatment for myasthenia gravis, can effectively by achieved via this minimally invasive technique.
- Published
- 2003
31. Primary insertion of a silastic spring-loaded silo for gastroschisis.
- Author
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Wu Y, Vogel AM, Sailhamer EA, Somme S, Santore MJ, Chwals WJ, Statter MB, and Liu DC
- Subjects
- Humans, Infant, Newborn, Digestive System Surgical Procedures methods, Gastroschisis surgery
- Abstract
Gastroschisis is traditionally managed by emergency primary closure, with a temporary silo reserved for large defects unable to be closed primarily. We recently have begun primary Silastic (Dow Coming, Midland, MI) spring-loaded silo (SLS) closure followed by elective closure and report our preliminary experience. A total of 15 infants (weight range, 2.1-13.5 kg) at 2 different institutions were treated by SC by 3 different surgeons between 1998 and 2002. A 3-, 4-, or 5-cm (ring diameter) silo was used depending on size of abdominal wall defect. Elective closure was performed in the operating room or at the bedside. Surgical parameters assessed included success of SLS, peak inspiratory pressures (PIPs) pre- and post-SLS closure, total time of staged closure with SLS, time to full feedings, and intra- and postoperative complications. Fifteen of 15 infants were successfully treated by SLS closure followed by elective closure. Two of 15 (13.3%) experienced temporary dislodgement of the silo prior to permanent closure. In both cases, the silo was safely reinserted at the bedside. Comparison of PIP values measured at various stages of SLS closure revealed no significant difference (P > 0.05). Mean times to final fascial closure (3.7 days) and full enteral feedings (22 days) were similar to historical controls obtained from the surgical literature. In 1 case where there was associated intestinal atresia, SLS closure was effective in permitting concomitant elective closure and re-establishment of bowel continuity. All children are alive and well at the time of this report. SLS closure permits safe, gentle, and gradual reduction of the exposed viscera leading to successful permanent abdominal wall closure. Respiratory embarrassment and hemodynamic instability associated with emergent (primary) closure of large abdominal wall defects can thus be avoided.
- Published
- 2003
32. Minimally invasive surgery for pediatric solid neoplasms.
- Author
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Sailhamer E, Jackson CC, Vogel AM, Kang S, Wu Y, Chwals WJ, Zimmerman BT, Hill CB, and Liu DC
- Subjects
- Adolescent, Biopsy, Child, Child, Preschool, Female, Humans, Infant, Male, Neoplasms diagnosis, Postoperative Complications, Laparoscopy adverse effects, Neoplasms surgery, Thoracoscopy adverse effects
- Abstract
The role of minimally invasive surgery (MIS) in children with solid neoplasms is slowly evolving. MIS appears to be an ideal way to obtain diagnostic information (i.e., tissue biopsy) in children with solid neoplasms, but its role as an ablative/curative technique is controversial. We examined the safety, reliability, and outcome of decisions made on the basis of MIS performed in children with solid neoplasms. A total of 28 children (19 boys and nine girls; age range, 14 months to 17 years) with solid neoplasms underwent 29 MIS procedures between July 1, 2000 and June 30, 2002. Complications, biopsy results, and outcomes were reviewed. Successful ablation via MIS was defined as clear microscopic margins on permanent pathology and no evidence of remnant disease on follow-up diagnostic radiological examination. There were 20 thoracoscopic and nine laparoscopic procedures. Laparoscopy included purely diagnostic without tissue biopsy or simply determination of resectability (two), incisional biopsy (two), and excisional biopsy (five; two adrenalectomy and three oophorectomy). Thoracoscopy included 15 lung biopsies and five biopsies of mediastinal masses. Diagnostic accuracy was 100 per cent in all cases. MIS as an ablative technique was successful in 10 of 10 cases. No children were found retrospectively to have been inadequately treated via MIS. We conclude that MIS can be used safely and successfully to diagnose children with suspicious solid neoplasms. Furthermore MIS may have a role as an ablative/curative technique in carefully selected circumstances.
- Published
- 2003
33. Bile decompression in children with histopathological evidence of pre-existing liver cirrhosis.
- Author
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Jackson CC, Wu Y, Chenren S, Somme S, Chwals WJ, and Liu DC
- Subjects
- Biopsy, Child, Child, Preschool, Choledochal Cyst complications, Female, Humans, Infant, Infant, Newborn, Liver Cirrhosis, Biliary etiology, Liver Function Tests, Male, Choledochal Cyst surgery, Liver Cirrhosis, Biliary pathology, Recovery of Function
- Abstract
Although it is agreed upon by most that adequate and timely bile decompression can preserve or even improve existing liver function much debate centers on whether pre-existing liver cirrhosis can also be reversed. To help answer this question we analyzed data on 47 children with choledochal cyst disease (CD) who underwent simultaneous liver biopsy during bile decompression surgery. We collected data on two groups of children with CD spanning two different time periods: January 1985 through November 1994 (Group A) and June 1995 through November 1999 (Group B). In Group A 37 children (16 boys and 21 girls ages 5 days to 10 years) underwent simultaneous liver biopsy during elective definitive surgery for CD. In Group B ten children (five boys and five girls age one month to 7 years) underwent liver biopsy twice: first during initial cyst decompression for acute obstruction and second during elective definitive surgery after resolution of acute disease. Degree of liver cirrhosis was based on a modified World Health Organization classification system (0-IV). In Group A 15/37 (40.5%) had significant liver cirrhosis at time of biopsy (III or IV) with altered liver function in all cases; eight of nine had normal liver function on follow-up, six were lost to follow-up. In Group B seven of ten (70%) had less liver cirrhosis on pathology at second operation with three unchanged; nine of ten (90%) regained normal liver function. We conclude that bile duct obstruction is the main cause of liver cirrhosis in children with CD. Adequate and timely bile decompression can restore normal liver function and even reverse severe cirrhosis.
- Published
- 2002
34. A single-incision laparoscopic technique for retrieval and replacement of disconnected ventriculoperitoneal shunt tubing found in the peritoneum.
- Author
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Jackson CC, Chwals WJ, and Frim DM
- Subjects
- Child, Equipment Failure, Feasibility Studies, Female, Humans, Peritoneum, Intracranial Hypertension surgery, Laparoscopy methods, Ventriculoperitoneal Shunt methods
- Abstract
A 7-year-old girl presented with signs and symptoms of increased intracranial pressure 2 years after insertion of a ventriculoperitoneal (VP) shunt. Evaluation revealed disconnection of the distal shunt catheter and migration into the peritoneal cavity. A single-incision laparoscopic procedure was performed to locate and remove the disconnected shunt tubing, and the new shunt catheter was inserted through the laparoscopic port site. Laparoscopy is being used more frequently for evaluation and repair of distal VP shunt malfunctions, but generally still requires multiple incisions for port placement and insertion of the new shunt catheter. The single-incision technique used here is technically feasible, allows excellent visualization of the peritoneal cavity and does not require any incisions beyond the previous one used for initial shunt insertion., (Copyright 2002 S. Karger AG, Basel)
- Published
- 2002
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35. Surgery-associated complications in necrotizing enterocolitis: A multiinstitutional study.
- Author
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Chwals WJ, Blakely ML, Cheng A, Neville HL, Jaksic T, Cox CS Jr, and Lally KP
- Subjects
- Gestational Age, Humans, Infant, Infant, Newborn, Infant, Premature, Postoperative Complications classification, Prolapse, Prospective Studies, Surgical Wound Dehiscence etiology, Surgical Wound Infection etiology, Enterocolitis, Necrotizing surgery, Postoperative Complications etiology
- Abstract
Purpose: This study was designed to evaluate the wound and stomal complication rate associated with surgical intervention in infants with necrotizing enterocolitis (NEC)., Methods: Comprehensive demographic and perioperative data were collected prospectively from 4 separate university hospitals on 51 infants with surgically treated NEC. The postoperative complication rate included wound (infection, dehiscence) and stomal (prolapse, retraction, necrosis, stricture) problems. For analysis, patients were grouped based on gestational age less than 28 weeks (group I, n = 30) and >/=28 weeks (group II, n = 21). Z-score analysis was used for intergroup evaluation., Results: Significantly more infants in group I (21 of 30 [70%] versus group II, 6 of 21 [29%]; P <.001) were treated initially with Penrose drainage alone, but most eventually underwent laparotomy (group I, 28 of 30 [93%] versus group II, 19 of 21 [91%]; P value, not significant). The combined stomal/wound complication rate was significantly higher in group I (14 of 30 [47%]) versus group II (6 of 21 [29%]; P <.025). Of 51 patients, one operation was required in 23 (45%), 2 in 18 (35%), 3 in 8 (16%), and 4 in 2 (4%)., Conclusions: Although the stomal/wound complication rate was significantly higher in group I, both groups had very substantial complication rates, emphasizing the vulnerability of this infant population. Parents, especially of very premature babies, should be advised that multiple operations are likely and that complications should be expected., (Copyright 2001 by W.B. Saunders Company.)
- Published
- 2001
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36. Intraventricular pressure dynamics in ventriculocholecystic shunting: a telemetric study.
- Author
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Frim DM, Lathrop D, and Chwals WJ
- Subjects
- Child, Preschool, Equipment Failure, Follow-Up Studies, Humans, Infant, Infant, Newborn, Postprandial Period physiology, Reoperation, Cerebrospinal Fluid Pressure physiology, Cerebrospinal Fluid Shunts instrumentation, Gallbladder physiopathology, Gallbladder Emptying physiology, Hydrocephalus surgery, Infant, Premature, Diseases surgery, Telemetry instrumentation
- Abstract
Extracranial cerebrospinal fluid shunting is the current mainstay of therapy for hydrocephalus. The generally preferred extracranial site for cerebrospinal fluid absorption is the peritoneal space; however, the cardiac atrium and the pleura are also commonly used. On occasion other CSF recipient sites, such as the gallbladder, are used secondarily when the more common absorptive spaces are unavailable or unsuitable. The gallbladder, though, exhibits its own pressure dynamics in response to physiological stimuli. The effects of gallbladder contraction on intraventricular pressure (IVP) in the presence of a ventriculocholecystic (VGB) shunt are unknown. We had the opportunity to place a VGB shunt in a 4-year-old child who was coupled to a noninvasive telemonitor. After a period of acclimation, we examined the IVP dynamics of that shunting system both pre- and postprandially. We found that before ingestion of food, the gallbladder provides a CSF recipient site similar to that of the peritoneal space. However, after ingestion of a meal containing fat, we found that IVP rose more than 10 cm water in a stereotypic fashion consistent with postprandial gallbladder contraction. The increase in IVP lasted for several hours reaching a peak at approximately 75 min postprandially. We conclude that the VGB shunt is a viable alternative for extracranial cerebrospinal fluid shunting; however, one must be aware of the peculiar dynamics of this shunt in relation to food ingestion and the potential for unusually high IVPs., (Copyright 2001 S. Karger AG, Basel)
- Published
- 2001
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37. The role of insulin-like growth factor I, growth hormone, and plasma proteins in surgical outcome of children with congenital heart disease.
- Author
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Pons Leite H, Gilberto Henriques Vieira J, Brunow De Carvalho W, and Chwals WJ
- Abstract
OBJECTIVE: To evaluate postoperative serum concentrations of growth hormone (GH), insulin-like growth factor I (IGF-I), C-reactive protein (CRP), and prealbumin as predictors of clinical outcome as defined by the incidence of 30-day postoperative mortality, the postoperative length of pediatric intensive care unit (PICU) stay, and the risk of postoperative infection in infants of high surgical risk undergoing operative correction of congenital cardiac defects. DESIGN: Prospective, observational study. SETTING: PICU of a university hospital. PATIENTS: A high surgical risk group of 36 children admitted for elective cardiac surgery. INTERVENTION: Measures of serum levels of IGF-I, basal GH, prealbumin, and CRP. These parameters were followed from the hospital admission until the discharge from the PICU at specific time points: preoperative and on the second, fifth, and tenth postoperative days. MEASUREMENTS AND MAIN RESULTS: Surgical stress response was marked by an increase of GH and CRP levels and a fall in prealbumin levels on the second postoperative day. Prealbumin, CRP, and GH returned to preoperative levels on average 10 days following surgery; the values of IGF-I, which had decreased on the fifth day, remained below those values observed before the surgery. Patients whose PICU stay was = 10 days showed significant decreases in GH and CRP serum levels and an increase in IGF-I and prealbumin levels on postoperative day 5 compared with the patients who stayed > 10 days. The sustained high CRP (>/= 8.4 mg/dL, p <.05) and GH (>/= 66 mIU/L, p <.03) values on the fifth day were associated with increased mortality in contrast with patients in whom the values were returning to preoperative levels. CONCLUSIONS: Serial monitoring of serum GH, IGF-I, CRP, and prealbumin levels may be useful as a means to a) stratify the acute metabolic response to surgically induced injury insult and b) predict clinical outcome as defined by the length of stay in the PICU and the likelihood of 30-day survival following open-heart surgery in infants.
- Published
- 2001
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38. Institutional Review Board approval for prospective experimental studies on infants and children.
- Author
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Roggin KK, Chwals WJ, and Tracy TF
- Subjects
- Chi-Square Distribution, Child, Child, Preschool, Documentation, Helsinki Declaration, Humans, Infant, Newborn, Informed Consent, Regression Analysis, Human Experimentation, Pediatrics, Professional Staff Committees, Prospective Studies, Surgical Procedures, Operative
- Abstract
Background/purpose: The Declaration of Helsinki requires Institutional Review Board (IRB) approval for experimental studies on human subjects. The authors questioned whether published prospective surgical experimental studies document IRB approval for infants and children., Methods: Prospective studies were identified in 5 surgical and 2 major pediatric journals from 1997 through 1999. Documentation of IRB approval was recorded. Results were analyzed using Pearson chi(2) tests and a multivariate regression model. Statistical significance was defined as P less than .05., Results: A total of 149 prospective experimental studies on pediatric subjects were evaluated; the majority being interventional or therapeutic studies (105 of 149). More than 75% were from academic medical centers (125 of 149), grant-supported (110 of 149), and appeared in surgical journals (110 of 149). Slightly less than 25% of studies (40 of 149) documented IRB approval. Observational studies, grant support, and publication in nonsurgical journals all correlated positively with IRB approval and were statistically significant variables (P<.001, P<.001, P<.001, respectively). Interventional or therapeutic, institutionally or privately-funded studies found in surgical journals were most likely to avoid IRB documentation (P<.001)., Conclusions: The majority of prospective pediatric studies in the surgical journals omit IRB documentation. Strict requirements for specific IRB approval and documentation in compliance with the Declaration of Helsinki would allow higher ethical standards for the clinical investigation of infants and children.
- Published
- 2001
- Full Text
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39. Salivary gland choristoma of the anterior chest wall.
- Author
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Shin CE, Kim SS, and Chwals WJ
- Subjects
- Child, Choristoma surgery, Female, Humans, Thoracic Diseases surgery, Choristoma diagnosis, Salivary Glands, Thoracic Diseases diagnosis
- Abstract
Salivary gland choristoma (heterotopic salivary gland tissue) is a rare condition that occurs at various locations within the head and neck. Diagnostic criteria and embryogenesis of this entity remain unclear. Presented herein is the first reported case of salivary gland choristoma on the anterior chest wall. Surgical treatment is recommended.
- Published
- 2000
- Full Text
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40. Anabolic recovery relative to degree of prematurity after acute injury in neonates.
- Author
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Tueting JL, Byerley LO, and Chwals WJ
- Subjects
- Humans, Infant, Newborn, Liver metabolism, Postoperative Period, Energy Metabolism, Infant, Premature physiology, Sepsis metabolism, Stress, Physiological metabolism
- Abstract
Purpose: In contrast to full-term infants, premature neonates generate accelerated growth rates after birth in an attempt to "catch up" to normal weight-for-age levels. Because this catch-up ability is related to gestational age, the authors postulated that there would be significant differences in anabolic recovery based on the degree of prematurity. To evaluate this hypothesis in surgical and septic neonates, we used serial postoperative prealbumin (PA) serum concentrations as an index of the return to anabolic metabolism after surgical stress., Methods: Serum PA concentrations were measured on the day of surgery (DOS) and daily for a 10-postoperative day (POD) period in 73 acutely ill neonates after surgery. These infants were divided into two groups: mature infants with gestational ages > or =35 weeks (average, 38.2+/-1.84; n = 55), and premature infants with gestational ages < or =34 weeks (average, 29.7+/-2.93; n = 18). Infants were subgrouped based on insult type into either surgery (n = 56), or sepsis (n = 17). Statistical significance between groups at the given postoperative times was established using independent unpaired t tests assuming unequal variances., Results: There was no significant difference in the daily nitrogen and caloric intake between the groups. Although recovery of hepatic prealbumin synthesis after the resolution of injury insult increased progressively in both gestational age groups, premature infants increased prealbumin production significantly earlier and to a greater degree than their nearer-term counterparts., Conclusions: These results suggest an earlier return of anabolic protein metabolism after acute injury in premature neonates versus infants that are born nearer term in both the surgery and the sepsis subgroups. These findings may be useful in modifying strategies for protein and nutritional repletion in acutely stressed preterm infants.
- Published
- 1999
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41. Pediatric wound infections: a prospective multicenter study.
- Author
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Horwitz JR, Chwals WJ, Doski JJ, Suescun EA, Cheu HW, and Lally KP
- Subjects
- Child, Child, Preschool, Female, Humans, Incidence, Infant, Infant, Newborn, Male, Prospective Studies, Risk Factors, Surgical Procedures, Operative, Surgical Wound Infection epidemiology
- Abstract
Objective: Surgical wound infections remain a significant source of postoperative morbidity. This study was undertaken to determine prospectively the incidence of postoperative wound infections in children in a multi-institutional fashion and to identify the risk factors associated with the development of a wound infection in this population., Summary Background Data: Despite a large body of literature in adults, there have been only two reports from North America concerning postoperative wound infections in children., Methods: All infants and children undergoing operation on the pediatric surgical services of three institutions during a 17-month period were prospectively followed for 30 days after surgery for the development of a wound infection., Results: A total of 846 of 1021 patients were followed for 30 days. The overall incidence of wound infection was 4.4%. Factors found to be significantly associated with a postoperative wound infection were the amount of contamination at operation (p = 0.006) and the duration of the operation (p = 0.03). Comparing children who developed a wound infection with those who did not, there were no significant differences in age, sex, American Society of Anesthesiologists (ASA) preoperative assessment score, length of preoperative hospitalization, location of operation (intensive care unit vs. operating room), presence of a coexisting disease or remote infection, or the use of perioperative antibiotics., Conclusions: Our results suggest that wound infections in children are related more to the factors at operation than to the overall physiologic status. Procedures can be performed in the intensive care unit without any increase in the incidence of wound infection.
- Published
- 1998
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42. Nutritional support of the pediatric oncology patient.
- Author
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Andrassy RJ and Chwals WJ
- Subjects
- Cachexia, Child, Child, Preschool, Humans, Infant, Neoplasms complications, Neoplasms metabolism, Nutrition Disorders, Neoplasms therapy, Nutritional Support
- Abstract
The child with a malignancy frequently will have associated cachexia with significant weight loss and malnutrition. The reasons for this are multifactorial and may be related directly to the tumor, such as increased metabolic rate, circulating peptides leading to anorexia, and decreased intake due to poor appetite or gut involvement. There appears to be other reasons involved, including increased whole body protein breakdown, increased lipolysis, and increased gluconeogenesis. Release of certain cytokines, such as tumor necrosis factor, interleukin-1, interleukin-6, and others may increase the cancer cachexia. Malnutrition in these children leads to intolerance of chemotherapy and radiotherapy as well as increased local and systemic infections. For many years, oncologists were hesitant to provide nutrition support to cancer patients for fear that tumor growth would be enhanced. Pediatric oncologists learned early that starvation plays no positive role in cancer therapy. Adjunctive nutritional support, either enterally or parenterally, supports the patient during therapy with surgery, chemotherapy, or radiation. Many studies have now shown that the nutritionally replete patient tolerates therapy better and in some pediatric malignancies may enhance survival.
- Published
- 1998
- Full Text
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43. Neonatal lipid utilization increases with injury severity: recombinant human growth hormone versus placebo.
- Author
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Letton RW, Chwals WJ, Jamie A, and Charles B
- Subjects
- Double-Blind Method, Energy Metabolism, Enterocolitis, Pseudomembranous surgery, Hernia, Ventral congenital, Hernia, Ventral surgery, Humans, Oxidation-Reduction, Parenteral Nutrition, Total, Prospective Studies, Human Growth Hormone therapeutic use, Infant, Newborn metabolism, Lipid Metabolism, Postoperative Complications drug therapy, Postoperative Complications metabolism, Severity of Illness Index, Stress, Physiological drug therapy, Stress, Physiological metabolism
- Abstract
Increased lipid oxidation has been observed in injured adult and pediatric patients who receive growth hormone (GH). In infants, whose bodies make fat more readily (de novo lipogenesis), this effect has not been tested. After surgery for necrotizing enterocolitis or gastroschisis, 22 neonates (average gestational age, 35 weeks; average postnatal age, 7 days) were provided basal protein-calorie parenteral repletion, and were prospectively randomized to receive either recombinant human GH (rhGH, 0.2 mg/kg/d) or placebo for 6 days. Injury severity was established by serial serum C-reactive protein (CRP) levels (high v low stress: CRP > or = 6.0 mg/dL v < 6.0 mg/dL). Indirect calorimetry was used to measure energy expenditure (MEE), respiratory quotient (RQ), net lipid oxidation (Fe), and lipid oxidative O2 consumption (VO2f). Among the GH+ group, MEE, Fe, and VO2f were significantly higher for the high-stress patients (MEE: 52.87 +/- 13.35 v 42.57 +/- 9.47 kcal/kg/d; P < .03: Fe; 18.32 +/- 27.74 v 0.81 +/- 13.47 kcal/kg/d; P < .02; VO2f: 7.21 +/- 9.86 v 0.01 +/- 7.42 L/d, P < .02), and RQnp was significantly lower in the high-stress patients (RQnp: 0.93 +/- 0.14 v 1.05 +/- 0.11; P < .02). In addition, Fe and RQnp were directly proportional to carbohydrate intake (CHO) in the high-stress patients (CHO to Fe: Pearson r = -.701; CHO to RQnp: Pearson r = .714; P < .05). Lipid oxidation was directly proportional to stress severity, was higher in the GH group (18.32 v 11.91 kcal/kg/d for the placebo group), and was depressed in response to increased CHO intake in all groups. Lipid is an important energy source in acutely injured, especially severely stressed neonates. Lipid substrate utilization is improved with GH supplementation during acute metabolic stress. In addition, excess carbohydrate delivery reduces the amount of lipid utilized for energy metabolism. An appropriately balanced, mixed-fuel formula should be used for caloric repletion in this infant population.
- Published
- 1996
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44. Stratification of injury severity using energy expenditure response in surgical infants.
- Author
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Chwals WJ, Letton RW, Jamie A, and Charles B
- Subjects
- Analysis of Variance, Bacterial Infections metabolism, C-Reactive Protein analysis, Dietary Proteins administration & dosage, Disease, Energy Intake, Follow-Up Studies, Growth, Growth Disorders metabolism, Humans, Infant, Infant Nutritional Physiological Phenomena, Infant, Newborn, Inflammation metabolism, Parenteral Nutrition, Severity of Illness Index, Stress, Physiological blood, Stress, Physiological metabolism, Treatment Outcome, Energy Metabolism, Surgical Procedures, Operative
- Abstract
Aim of Study: Injury severity stratification has important clinical outcome significance and can influence nutritional management. Although surgery alone has been shown not to increase measured energy expenditure (MEE) substantially, large increases in MEE can result from severe underlying acute illness, which frequently necessitates surgery (like sepsis or intense inflammation). The authors hypothesized that the magnitude and duration of the MEE response to surgery associated with a severe preoperative acute injury would exceed that of surgery in which no substantial preoperative stress was present, thus representing an index of overall injury severity in surgical infants., Methods: MEE (kcal/kg/d) was determined on postoperative days (POD) 2, 5, and 8 in 12 infants (average age, 47 days) after two separate injury insults (at least 8 days apart). In each patient, one operation resulted in a peak serum C-reactive protein (CRP) concentration of less than 6.5 mg/dL (low stress), and the second operation, preoperatively associated with sepsis or a major inflammatory insult, resulted in a peak CRP of more than 6.5 mg/dL (high stress). Data were paired so that each child served as his or her own control. The initial basal protein-calorie delivery was similar in both groups., Main Results: The mean peak CRP values were 14.1 +/- 10.7 mg/dL (high stress) and 4.1 +/- 2.3 mg/dL (low stress) and returned to normal levels earlier (before POD 8) after injury insult in the low-stress group. Analysis of energy expenditure on POD 2 demonstrated significantly elevated mean MEE values in the high-stress group (58.0 +/- 12.2 kcal/kg/d v 39.4 +/- 9.5 kcal/kg/d in the low-stress group; P = .0001). In contrast, analysis of POD 8 energy expenditure showed significantly lower mean MEE values in the high-stress group (50.7 +/- 12.0 kcal/kg/d) v (66.4 +/- 15.1 kcal/kg/d in the low-stress group; P = .0118) group., Conclusion: The early (POD 2) hypermetabolic response to injury as determined by MEE effectively differentiated the two stress groups. This finding suggests that acute underlying illness is an important determinant of postoperative MEE. Furthermore, in the low-stress group, serial CRP levels returned to normal earlier, associated with significantly greater late (POD 8) MEE values. Because MEE is directly proportional to growth rate in healthy infants, and growth is retarded during acute metabolic stress, these findings suggest that increased energy is utilized for growth recovery following the earlier resolution of the acute injury response in the low-stress group. These data indicate that serial postoperative MEE can be used to stratify injury severity and may be an effective parameter to monitor the return of normal growth metabolism in surgical infants.
- Published
- 1995
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45. Early postoperative alterations in infant energy use increase the risk of overfeeding.
- Author
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Letton RW, Chwals WJ, Jamie A, and Charles B
- Subjects
- Abdomen surgery, C-Reactive Protein analysis, Carbon Dioxide metabolism, Dietary Carbohydrates metabolism, Dietary Fats metabolism, Energy Intake, Glucose metabolism, Growth, Humans, Infant, Lipids biosynthesis, Motor Activity, Nitrogen urine, Oxidation-Reduction, Oxygen Consumption, Postoperative Period, Respiration, Risk Factors, Stress, Physiological metabolism, Thoracic Surgery, Energy Metabolism, Infant Food, Infant Nutritional Physiological Phenomena, Surgical Procedures, Operative
- Abstract
Aim of Study: Energy needs in infants are decreased after surgery because of growth inhibition (resulting from catabolic stress metabolism), decreased insensible losses, and inactivity. Using standardized formulas that account for growth, activity, and insensible losses during this stress period can lead to overfeeding in excess of 200% of the actual measured requirement. Overfeeding during this acute injury period can result in increased CO2 production from lipogenesis. This study determined the effects of a reduced rate of mixed caloric repletion on infant energy use during the early postoperative period., Methods: C-reactive protein (CRP), oxygen consumption (VO2), carbon dioxide production (VCO2), measured energy expenditure (MEE), and total urinary nitrogen (TUN) were measured serially in seven infants (average age, 78 days) during the first 72 hours after abdominal or thoracic surgery. Nonprotein respiratory quotient (RQnp), and values for oxidation of carbohydrate (Ce) and fat (Fe) were calculated. Injury severity was stratified based on serum CRP concentrations of > or = 6.0 mg/dL (high stress) or < 6.0 mg/dL (low stress). Recovery from acute stress was analyzed by comparing studies in which CRP had decreased to < or = 2.0 mg/dL (resolving stress group) with those in which CRP values were greater than 2.0 mg/dL (acute stress group)., Results: Average total caloric intake (64.56 +/- 18.51 kcal/kg/d; approximately 50% of predicted energy requirement) exceeded average MEE (42.90 +/- 9.98 kcal/kg/d) by approximately 50%. Average TUN was 0.18 +/- 0.07 g/kg/d (high stress 0.2 +/- 0.05 versus low stress 0.16 +/- 0.09 g/kg/d). Average RQnp was 1.05 +/- 0.13 and average Ce was 37.28 +/- 16.86 kcal/kg/d. The average calculated Fe was 0.0 +/- 12.27 kcal/kg/d, reflecting approximately equal amounts of fat oxidized compared with fat generated from excess glucose (lipogenesis). When individual studies were analyzed at a CRP cutpoint of 2.0 mg/dL, overfeeding (RQ > 1.0) was significantly less likely in the resolving (2/6 studies, 33.4%) versus acute stress (9/13 studies, 69.2%, Z test P < .001) group. Five of seven (5/7) patients (9/19 individual studies) had negative Fe values (average -9.89 +/- 10.02) reflecting net lipogenesis. The RQnp for these nine studies was 1.14 +/- 0.11 versus 0.97 +/- 0.09 for the remaining 10, and this difference was significant (P < .01). A significant correlation existed between carbohydrate intake and VCO2 (Pearson r = .6951, P < .01). In addition, there was a good correlation between carbohydrate intake and VCO2 (Pearson r = .6591, P < .01). The coefficient of variation for MEE was 8.0% (low stress) versus 30.2% (high stress)., Conclusion: Lipogenesis with increased CO2 production is substantial, even at reduced caloric delivery rates that exceeded MEE by only 50%, during the early postoperative acute metabolic stress period in infants. These data suggest that caloric requirements during stress are likely equal to or only minimally in excess of actual MEE. Intersubject variability, especially in more severely stressed infants, underscores the importance of serial measurements of energy expenditure to enable precise caloric delivery and avoid overfeeding. In the absence of calorimetric measurement, the data suggest that PBMR (predicted basal metabolic rate) should be used to estimate caloric delivery until CRP values are < or = 2.0 mg/dL.
- Published
- 1995
- Full Text
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46. Patterns of power mower injuries in children compared with adults and the elderly.
- Author
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Letton RW and Chwals WJ
- Subjects
- Adolescent, Adult, Age Factors, Aged, Aged, 80 and over, Artificial Limbs, Child, Preschool, Debridement, Female, Humans, Male, Middle Aged, Accidents, Home, Amputation, Traumatic surgery, Leg surgery
- Abstract
Power mower trauma remains an alarmingly frequent cause of serious injury in young children. The patterns of mower-related injuries in children < 15 years old (n = 13) were compared with those of adults aged 15-64 (n = 16) and elderly victims > or = 65 years old (n = 6), who were similarly injured over the past 5 years. Children were more likely to be injured in accidents involving high-energy riding mowers. Of those children injured, 69% (9 of 13) were playing in the yard while 31% (4 of 13) were riding on the mower with a guardian when the injury occurred. Amputations in children were more frequent and more extensive than in the adults and included one forearm, two Symes, and three below-knee amputations. The need for transfusion was also significantly increased in children (62% vs. 6% adults, p < 0.005), who were also more likely to require prolonged hospitalization (11.8 days vs. 5 days in adults, p < 0.005). Aggressive efforts to increase public awareness regarding the cause and nature of power mower injuries are warranted to decrease the incidence of this debilitating but preventable trauma in young children.
- Published
- 1994
- Full Text
- View/download PDF
47. The metabolic response to surgery in neonates.
- Author
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Chwals WJ
- Subjects
- Acute Disease, Child Development, Critical Illness, Energy Metabolism, Humans, Infant Nutritional Physiological Phenomena, Infant, Newborn, Monitoring, Physiologic, Proteins metabolism, Stress, Physiological etiology, Stress, Physiological mortality, Surgical Procedures, Operative mortality, Survival Rate, Treatment Outcome, Stress, Physiological metabolism, Surgical Procedures, Operative adverse effects
- Abstract
Over the past 35 years, surgery-associated mortality in the neonate has declined from greater than 60% to less than 10%. This progress is attributable, almost entirely, to a better understanding of the pathophysiologic changes that can occur during the perioperative period. It is increasingly apparent that the acute metabolic response to injury plays a central role in determining the clinical outcome of the critically ill infant. This article highlights recent developments as they relate to the infant response to acute injury and to show how this knowledge might be used to improve the care of these patients.
- Published
- 1994
- Full Text
- View/download PDF
48. Overfeeding the critically ill child: fact or fantasy?
- Author
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Chwals WJ
- Subjects
- Acute Disease, Child, Clinical Protocols, Critical Illness mortality, Energy Intake, Energy Metabolism, Enteral Nutrition methods, Growth physiology, Homeostasis physiology, Humans, Infant, Newborn, Liver physiopathology, Parenteral Nutrition methods, Respiration physiology, Stress, Physiological metabolism, Stress, Physiological mortality, Stress, Physiological therapy, Survival Rate, Wounds and Injuries metabolism, Wounds and Injuries mortality, Wounds and Injuries therapy, Child Nutritional Physiological Phenomena, Critical Illness therapy, Enteral Nutrition adverse effects, Nutritional Requirements, Parenteral Nutrition adverse effects
- Abstract
Overfeeding occurs when the administration of calories and/or specific substrate exceeds the requirements to maintain metabolic homeostasis. These requirements are substantially altered during periods of injury-induced acute metabolic stress. Excess nutritional delivery during this period can further increase the metabolic demands of acute injury and place an added burden on the lungs and liver. The result is to increase pulmonary and hepatic pathophysiology, as well as to increase the risk of mortality. It is important, therefore, to ensure that caloric intake not exceed demand. Precise caloric delivery is best determined during acute injury states by measuring energy expenditure. Due to substantial interpatient variability, estimates of energy needs on the basis of disease categories, subject age, or body composition can be misleading and usually result in overfeeding. The delivery of caloric amounts normally required for healthy infants is inappropriate for acutely-stressed, critically ill infants in whom total energy requirements are much lower due to inhibited growth, reduced insensible losses, and decreased activity. Such nutritional administration can result in overfeeding by 200% of measured energy expenditure. Overfeeding cannot reverse tissue catabolism until the acute metabolic stress response has resolved. In these acutely-stressed infants, measured energy expenditure constitutes the total energy requirement, and caloric delivery in excess of this amount should be avoided until metabolic stress parameters indicate resolution of the acute injury state. Enteral delivery should be used in preference to parenteral feeding. Even if total caloric delivery cannot be achieved enterally, the provision of a small amount of the total energy budget via the enteral route is generally possible and is likely advantageous.(ABSTRACT TRUNCATED AT 250 WORDS)
- Published
- 1994
49. Hamartomas of the chest wall in infants.
- Author
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Dounies R, Chwals WJ, Lally KP, Isaacs H Jr, Senac MO, Hanson BA, Mahour GH, and Sherman NJ
- Subjects
- Biopsy, Bone Diseases complications, Bone Diseases epidemiology, Bone Diseases surgery, Bone Neoplasms etiology, Diagnosis, Differential, Female, Follow-Up Studies, Hamartoma complications, Hamartoma epidemiology, Hamartoma surgery, Humans, Infant, Infant, Newborn, Male, Recurrence, Respiratory Insufficiency etiology, Sarcoma etiology, Scoliosis etiology, Tomography, X-Ray Computed, Bone Diseases diagnosis, Hamartoma diagnosis, Ribs
- Abstract
Chest wall hamartomas in infancy are rare lesions with distinct clinical, radiologic, and pathologic characteristics. Four cases treated at Children's Hospital of Los Angeles are presented and previously reported cases are reviewed. Chest wall hamartomas arise antenatally and present as hard, immobile masses, which may cause respiratory insufficiency. An extrapleural mass arising from the ribs can be seen radiographically. Histologically, these lesions are hypercellular and consist of a disorganized array of mesenchymal tissues endogenous to the chest wall. Rapid growth may occur, but usually is self-limited. Chest wall hamartomas are usually benign. This series includes the malignant transformation of one of these lesions. En bloc resection is curative, but the large residual chest wall defect frequently results in scoliosis.
- Published
- 1994
- Full Text
- View/download PDF
50. Detection of postoperative sepsis in infants with the use of metabolic stress monitoring.
- Author
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Chwals WJ, Fernandez ME, Jamie AC, Charles BJ, and Rushing JT
- Subjects
- Bacterial Infections blood, Bacterial Infections microbiology, Body Temperature, Case-Control Studies, Catheters, Indwelling adverse effects, Cohort Studies, Colony Count, Microbial, Female, Forecasting, Humans, Infant, Infant, Newborn, Infant, Premature, Leukocyte Count, Male, Postoperative Complications blood, Retrospective Studies, Sensitivity and Specificity, Tumor Necrosis Factor-alpha analysis, Bacterial Infections diagnosis, C-Reactive Protein analysis, Monitoring, Physiologic, Postoperative Complications diagnosis, Prealbumin analysis, Stress, Physiological blood
- Abstract
Objectives: To evaluate the ability of serial protein metabolic monitoring to detect postoperative injury due to serious bacterial infection in infants by comparing changes observed in these protein parameters with more conventionally accepted indexes of infection., Design: Retrospective review of infants whose postoperative course was complicated by bacterial infection compared with a matched cohort of infants in whom bacterial infection did not develop postoperatively., Setting: Neonatal and pediatric intensive care units at the Wake Forest University Medical Center, Winston-Salem, NC., Patients: Critically ill infants (N = 40) recovering from major surgical intervention., Main Outcome Measures: Serum C-reactive protein, prealbumin, and tumor necrosis factor concentrations were compared with the white blood cell count, immature-total neutrophil ratio, and body temperature obtained within 24 hours before and following the new onset of culture-established postoperative bacterial infection in 13 infants. These infants were compared with a matched cohort of 27 infants in whom postoperative bacterial infection did not develop., Results: Only C-reactive protein (P = .0001) and prealbumin (P = .0003) levels were significantly altered in association with the onset of serious bacterial infection (paired t test). The C-reactive protein levels were clearly superior to all other variables in predicting postoperative infection (at cutoff point > 6.0 mg/dL; sensitivity, 92%; specificity, 96%). The predictive power of prealbumin level was lower, but acceptable (at cutoff point < or = 9.0 mg/dL; sensitivity, 85%; specificity, 74%)., Conclusions: Monitoring of serial protein metabolic stress with C-reactive protein and prealbumin levels in infants following operations is more effective than the white blood cell count, immature-total neutrophil ratio, or temperature in detecting serious postoperative infections.
- Published
- 1994
- Full Text
- View/download PDF
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