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Long chain fatty acids (LCFAs) appear to be powerful stimulants for small bowel adaptation in patients with short bowel syndrome (SBS). However, the dietary lipid content may alter intestinal lipid transport. The aim of this study was to investigate the effects of a high fat diet (HFD) on in vivo lipid absorption and molecular and cellular mechanisms of LCFAs uptake by the remaining bowel. Male Sprague-Dawley rats (240–280) were randomly assigned to one of three groups: sham rats fed normal chow (sham-NC), SBS rats fed NC (SBS-NC) and SBS rats fed HFD (SBS-HFD). SBS rats underwent a 75% small bowel resection. Rats were sacrificed on day 3 or 14. Body weight, fat intake and fat clearance (total fecal fat) were measured twice a week. Fat absorbability was calculated as intake minus clearance and was expressed as percent of intake. Total RNA from the mucosa of duodenum, jejunum and ileum was extracted using TRIZOL Reagent. Northern blot analysis was performed to determine FAT/CD36 mRNA levels. Enterocyte LCFA transport was measured on day 14. LCFA uptake was determined by measuring cellular [3H]-oleate uptake over time (4–120 s). Mean (±SE) FAT/CD36 mRNA levels and oleate uptake kinetic parameters were analyzed using ANOVA. Fat absorbability diminished after bowel resection, suggesting fat malabsorption. Remaining bowel in SBS-NC rats responded by an increase in FAT/CD36 mRNA levels in the duodenum and ileum on day 3, and the duodenum and jejunum on day 14 compared to sham-NC animals, and was accompanied by an increase in enterocyte LCFA transport in all segments. Exposure to a HFD for 14 days resulted in significantly increased fat absorbability after 3 days compared to SBS-NC rats. However, FAT/CD36 mRNA levels (vs. SBS-NC) decreased in all segments on day 3. On day 14, FAT/CD36 mRNA levels were decreased in the duodenum and ileum and were accompanied by reduced oleate uptake by isolated enterocytes in the ileum (vs. SBS-NC). In a rat model of SBS, early high fat diet increased lipid absorptive capacity of the intestinal remnant as seen by increased fat absorbability. The main mechanisms of this effect may be an acceleration of structural intestinal adaptation resulting in an increased number of enterocytes. However, at molecular and cellular levels HFD decreased mucosal FAT/CD36 mRNA levels and oleic acid uptake by isolated enterocytes.

Background Despite randomized controlled trials and meta-analyses, it remains unclear whether laparoscopic pyloromyotomy (LP) carries a higher risk of incomplete pyloromyotomy and mucosal perforation compared with open pyloromyotomy (OP). Methods Multicenter study of all pyloromyotomies (May 2007–December 2010) at nine high-volume institutions. The effect of laparoscopy on the procedure-related complications of incomplete pyloromyotomy and mucosal perforation was determined using binomial logistic regression adjusting for differences among centers. Results Data relating to 2830 pyloromyotomies (1802 [64%] LP) were analyzed. There were 24 cases of incomplete pyloromyotomy; 3 in the open group (0.29%) and 21 in the laparoscopic group (1.16%). There were 18 cases of mucosal perforation; 3 in the open group (0.29%) and 15 in the laparoscopic group (0.83%). The regression model demonstrated that LP was a marginally significant predictor of incomplete pyloromyotomy (adjusted difference 0.87% [95% CI 0.006–4.083]; P =0.046) but not of mucosal perforation (adjusted difference 0.56% [95% CI −0.096 to 3.365]; P =0.153). Trainees performed a similar proportion of each procedure (laparoscopic 82.6% vs. open 80.3%; P =0.2) and grade of primary operator did not affect the rate of either complication. Conclusions This is one of the largest series of pyloromyotomy ever reported. Although laparoscopy is associated with a statistically significant increase in the risk of incomplete pyloromyotomy, the effect size is small and of questionable clinical relevance. Both OP and LP are associated with low rates of mucosal perforation and incomplete pyloromyotomy in specialist centers, whether trainee or consultant surgeons perform the procedure.

Objective Hirschsprung-associated enterocolitis (HAEC) is one of the most troublesome problems encountered after a pullthrough. We hypothesized that prophylactic administration of probiotics after a pullthrough procedure would decrease the incidence of HAEC. Study Design A prospective, double-blind, placebo-controlled, randomized trial was conducted at 2 children's hospitals. Infants undergoing pullthrough were randomized to probiotic or placebo for a period of 3months post-pullthrough. Primary outcome was incidence of post-operative HAEC. Other outcomes included severity of HAEC by clinical grade, number of HAEC episodes and extent of aganglionosis. Pearson Chi Square analysis, as well as logistic regression, was used for statistical analysis. Results Sixty-two patients were recruited (Sites: A=40; B=22). One was lost to follow up and one immediate post-op death was not included in final analysis. Probiotics were administered to 32 patients. Distribution of placebo/probiotics was equal between sites (P=0.858). Mean age at pullthrough was 6.5±8.1(±SD) months. The incidence of HAEC was 28.3%. The incidence of HAEC was not statistically different between probiotic and placebo study groups. Conclusions Incidence of HAEC was not reduced with prophylactic probiotics. Future studies are needed to better determine the etiology and possible ways of preventing this complex condition.

Extracorporeal life support (ECLS) is usually reserved for infants ≥34weeks estimated gestational age (EGA) owing to concerns about increased mortality and incidence of intracranial hemorrhage (ICH). We sought to characterize survival, rates of ICH, and complications in34week EGA neonates placed on ECLS.752 neonates of EGA 29-34weeks were identified in the Extracorporeal Life Support Organization (ELSO) Registry (1976-2008). Data analyzed included birthweight, survival, pre-ECLS conditions, ventilatory parameters and complications (including ICH and other neurological outcomes). Data were compared using t-test, Chi-square and logistic regression analyses.When compared to survival rates of 34week EGA neonates (58%), survival was statistically different for 29-33week EGA (48%, p=0.05). No significant difference in ICH incidence was seen between the 29-33week and 34week groups (21% vs. 17%, respectively), but a significant difference was seen in the incidence of cerebral infarct between groups (22% for 29-33weeks vs. 16% for 34weeks; p=0.03). ICH and survival did not correlate with EGA during logistic regression analysis.Though rates of survival and cerebral infarction were worse at 29-33weeks EGA compared with 34weeks, these differences were modest and may be clinically acceptable. This suggests that EGA34weeks may not be an absolute contraindication to use of ECLS.III.

Deep venous thrombosis (DVT) is a frequent complication in infants with central venous catheters (CVCs). We performed this study to identify risk factors and risk-reduction strategies of CVC-associated DVT in infants.Infants younger than 1 year who had a CVC placed at our center from 2005 to 2009 were reviewed. Patients with ultrasonically diagnosed DVT were compared to those without radiographic evidence.Of 333 patients, 47% (155/333) had femoral, 33% (111/333) had jugular, and 19% (64/333) had subclavian CVCs. Deep venous thromboses occurred in 18% (60/333) of patients. Sixty percent (36/60) of DVTs were in femoral veins. Femoral CVCs were associated with greater DVT rates (27%; 42/155) than jugular (11%; 12/111) or subclavian CVCs (9%; 6/64; P.01). There was a 16% DVT rate in those with saphenofemoral Broviac CVCs vs 83% (20/24) in those with percutaneous femoral lines (P.01). Multilumen CVCs had higher DVT rates than did single-lumen CVCs (54% vs 6%, P.01), and mean catheter days before DVT diagnosis was shorter for percutaneous lines than Broviacs (13 ± 17 days vs 30 ± 37 days, P = .02). Patients with +DVT had longer length of stay (86 ± 88 days vs 48 ± 48 days, P.01) and higher percentage of intensive care unit admission (82% vs 70%, P = .02).Deep venous thrombosis reduction strategies in infants with CVCs include avoiding percutaneous femoral and multilumen CVCs, screening percutaneous lines, and early catheter removal.

Purpose Vertical expandable prosthetic titanium rib (VEPTR) insertion and expansion has been advocated to increase thoracic volume and pulmonary function in patients with thoracic insufficiency syndrome. We reviewed our experience with VEPTR implantation to determine if lung function and growth is augmented, to determine the children's functional status, and if the scoliosis is controlled. Methods From 2006 to 2010, 29 insertions and 57 expansions were performed in 26 patients at our institution. Demographic data were reviewed in conjunction with complications, scoliosis angles, pulmonary function tests (PFTs), and computed tomography–guided 3D reconstructions to determine lung volumes; and quality of life scores were determined using a modified Scoliosis Research Society (SRS) questionnaire preoperatively and postoperatively. The groups were also stratified by age (because of lung growth potential), disease (congenital or infantile scoliosis, Jeune syndrome, neuromuscular, other structural thoracic disorders), and sex. Analyses using SPSS (SPSS, Chicago, Ill) were performed with P Results Each patient underwent 3.03 ± 1.8 surgeries, spending 0.97 ± 1.8 days in the intensive care unit and 4.41 ± 6 days in the hospital for each procedure. Mean age was 90.7 ± 41 months. Of the 36 complications, most were because of infection (12), half requiring operative repair (hardware removal). The average PFT percent predicted values for forced expiratory volume in 1 second, forced vital capacity, and RV were 54.6 ± 22, 58.1 ± 24, and 145.3 ± 112, respectively, preoperatively and 51.8 ± 20, 55.9 ± 20, and 105.6 ± 31, respectively, postoperatively. The lung volumes measured by computed tomography when corrected for age do not increase significantly postoperatively. The mean Cobb measurement for the preoperative major curves was 64.7° and postoperatively was 46.1° for those curves measured preoperatively, for a 29% curve improvement. All postoperative curves had a mean of 56.4° and 58.1° at final follow-up, a 3% curve increase. The SRS scores for patients remained unchanged and no statistical difference was seen from preoperative to postoperative values. No statistically significant difference was seen in complications, PFT (forced expiratory volume in 1 second, forced vital capacity, RV), lung volumes, scoliosis angles, and SRS scores between sex, age, and disease categories. Conclusion There was mild improvement in scoliosis angles but no improvement in lung function and volume. Scoliosis Research Society scores indicate that the children have near normal function both before and after VEPTR placement. Pulmonary function, lung volume, and patient subjective assessments did not increase dramatically after VEPTR placement, although scoliosis angles improved.

BACKGROUND: Severe congenital diaphragmatic hernia (CDH) requiring extracorporeal membrane oxygenation (ECMO) is associated with high mortality. Timing of CDH repair relative to ECMO therapy remains controversial. Our hypothesis was that survival would significantly differ between those who underwent repair during ECMO and those who underwent repair after ECMO therapy. METHODS: We examined de-identified data from the CDH Study Group (CDHSG) registry from 1995–2005 on patients who underwent repair and ECMO therapy (n=636). We used Cox regression analysis to assess differences in survival between those repaired during and after ECMO. RESULTS: Five covariates were significantly associated with mortality: timing of repair relative to ECMO (P=0.03), defect side (P=0.01), ECMO run length (P

Purpose: The purpose of the study was to assess the treatment strategies and outcome of right-sided congenital diaphragmatic hernia (R-CDH), particularly extracorporeal membrane oxygenation (ECMO). Methods: We reviewed the cases of 42 patients treated for R-CDH at our institution from 1991 to 2006. We gathered demographic information, documented ECMO use and the type of surgical repair, and compared outcomes with predicted survival as calculated by the CDH Study Group's equation. Results: Of the 35 patients included in our statistical analysis (7 were excluded), 12 (34%) were born at our institution, all of whom were prenatally diagnosed with R-CDH. Nineteen patients (54%) required ECMO therapy. Extracorporeal membrane oxygenation was initiated after repair of the R-CDH in 2 patients (11%). Of those patients who went on ECMO before repair, 4 patients (21%) were repaired on ECMO, 9 patients (47%) underwent repair after ECMO, and 4 patients (21%) underwent ECMO but died before their R-CDH could be repaired. Primary repair of the diaphragm was possible in 15 cases (56%), and primary closure of the abdominal incision was possible in 15 of the 23 open repairs (65%). The mean predicted survival for all 35 patients was 63%, whereas 28 (80%) actually survived. Logistic regression showed a significant association between the presence of cardiac defects and mortality (odds ratio = 0.008, P = .014). Conclusions: Our data suggest that patients with R-CDH have high ECMO utilization and may experience greater relative benefit from ECMO as evidenced by their higher-than-expected overall survival. Extracorporeal membrane oxygenation may be found to have a distinctive role in managing R-CDH. More high-powered series are needed to elucidate differences between R-CDH and left-sided CDH that may dictate alternate forms of management.

The prenatal or postnatal factors that predict complex gastroschisis in patients (atresia, volvulus, necrotic bowel and bowel perforation) remain controversial. We evaluated the prognostic value of prenatal ultrasonographic parameters and early postnatal factors in predicting clinical outcomes.We analyzed maternal and neonatal records of 46 gastroschisis patients treated from 1998 to 2007. Information regarding demographics, prenatal ultrasound data when available, intrapartum and postnatal course was abstracted from medical records. Outcome variables included survival, ventilator days, TPN days, time to full enteral feeds, complications and length of stay. Univariate or multivariate analysis was used, with P0.05 considered as significant.A total of 75% of complex patients were categorized within 1 week of life. Interestingly, prenatal bowel dilation (17 mm) and thickness (3 mm) did not correlate with outcome or risk stratification into simple versus complex (P0.05). Complex patients had increased morbidity compared to simple patients (sepsis 58 versus 18%; P = 0.021, NEC 42 versus 9%; P = 0.020, short bowel syndrome 58 versus 3%; P = 0.0001, ventilator days 24 versus 10; P = 0.021; TPN days 178 versus 38; P = 0.0001 and days to full feeds 171 versus 31; P = 0.0001; and length of stay 90 versus 39 days, P = 0.0001).Prenatal bowel wall dilation and/or thickness did not predict complex patients or adverse outcome. Complex gastroschisis patients can be identified postnatally and have substantial morbidity.

Background Infants with severe congenital diaphragmatic hernia (CDH) requiring extracorporeal membrane oxygenation (ECMO) have a high morbidity and mortality. We hypothesized that placement of an abdominal wall silo and staged abdominal wall closure may reduce problems associated with decreased abdominal domain in CDH. Methods We performed a retrospective review and identified 7 CDH patients requiring ECMO who had a silastic abdominal wall silo between 2003 and 2006. Variables analyzed included survival, ECMO duration, duration of silo, time to discharge, and long-term outcome. Results Predicted mean survival for the entire cohort using the published CDH Study Group equation was 47% (range, 9%-86%). All 7 patients (100%) survived. Extracorporeal membrane oxygenation duration averaged 15 days (range, 5-19 days). Four of the patients (58%) were repaired with a silo on ECMO, and 3 (42%) had their repair after ECMO. The abdominal wall defect was closed at a mean of 21 days (range, 4-41 days). Hospital stay after silo placement averaged 54 days (range, 20-170 days) with no infections or wound complications. Conclusions Abdominal wall silo placement in infants with CDH requiring ECMO appears to be an effective strategy for decreased abdominal domain. Further studies are warranted to determine the efficacy of such a strategy for these high-risk CDH patients.

Purpose The transanal endorectal pull-through (TERPT) is becoming the most popular procedure in the treatment of Hirschsprung disease (HD), but overstretching of the anal sphincters remains a critical issue that may impact the continence. This study examined the long-term outcome of TERPT versus conventional transabdominal (ABD) pull-through for HD. Methods Records of 41 patients more than 3 years old who underwent a pull-through for HD (TERPT, n=20; ABD, n=21) were reviewed, and their families were thoroughly interviewed and scored via a 15-item post–pull-through long-term outcome questionnaire. Patients were operated on between the years 1995 and 2003. During this time, our group transitioned from the ABD to the TERPT technique. Total scoring ranged from 0 to 40: 0 to 10, excellent; 11 to 20 good; 21 to 30 fair; 31 to 40 poor. A 2-tailed Student t test, analysis of covariance, as well as logistic and linear regression were used to analyze the collected data with confidence interval higher than 95%. Results Overall scores were similar. However, continence score was significantly better in the ABD group, and the stool pattern score was better in the TERPT group. A significant difference in age at interview between the 2 groups was noted; we therefore reanalyzed the data controlling for age, and this showed that age did not significantly affect the long-term scoring outcome between groups. Conclusion Our long-term study showed significantly better (2-fold) results regarding the continence score for the abdominal approach compared with the transanal pull-through. The stool pattern and enterocolitis scores were somewhat better for the TERPT group. These findings raise an important issue about the current surgical management of HD; however, more cases will need to be studied before a definitive conclusion can be drawn.

Purpose Laparoscopy has recently been used to treat intussusception that cannot be reduced radiologically. The effectiveness and practical nature of this approach has been questioned. Methods This study retrospectively analyzed the authors' experience with this laparoscopic approach and compared this to the conventional open laparotomy procedure. Results Sixteen patients were treated via laparoscopy, with 2 of these requiring conversions to an open procedure (12.5%). Twenty-five patients underwent an open reduction. Operative time was not significantly different ( P = .698) between the laparoscopic (49.56 ± 26.40 minutes) and open groups (45.00 ± 24.74). Length of stay, however, was significantly reduced ( P = .005) in the laparoscopic group (3.00 ± 1.31 days) compared to the open group (4.52 ± 1.98). Total hospital charges were lower in the laparoscopic group ($8171 ± 2595) compared to the open group ($11,672 ± 5466); this difference was not significant ( P = .088). There were no significant differences in intra- or postoperative complication rates ( P = .637) between the 2 approaches. Conclusions Although there remains a group who will require a conversion to an open procedure, the laparoscopic approach should be considered a safe and effective option for all children who do not respond to a radiological reduction.

Total parenteral nutrition (TPN) results in a loss of mucosal immune function by alterations in both phenotype and function of intraepithelial lymphocytes (IEL). We hypothesized that the observed changes with TPN administration are caused by the lack of enteral feeding, and not to the TPN solution itself.Mice received oral feeding (Control), TPN alone (TPN), or TPN plus oral feeding (TPN+Food). Mice were killed after 7 days, and bacteriological cultures from spleen, liver, and mesenteric lymph nodes obtained, with bacterial translocation (BT) being defined as a positive culture. IEL phenotype was analyzed by flow cytometry. IEL messenger RNA (mRNA) cytokine expression used reverse transcriptase polymerase chain reaction (RT-PCR). Apoptosis was detected by terminal deoxynucleotidyl transferase biotin-dUTP nick end labeling (TUNEL) staining.BT significantly (P0.05, with analysis of variance [ANOVA]) increased in the TPN group (53%) compared with Control (9%) and TPN+Food (14%) groups. TPN also resulted in a significant (P0.01) increase in epithelial cell apoptosis: TPN 7.6 +/- 1.1% versus Control 2.9 +/- 1.1% and TPN+Food 2.1 +/- 0.3% (mean +/- SD). Height of the villus-crypt complex was significantly decreased in TPN mice (315 +/- 16 microm) compared with Control (431 +/- 27 microm) and TPN+Food (421 +/- 26 microm) groups. IEL phenotypes significantly changed with TPN administration: CD4+ CD8- as well as CD4+ CD8+ subpopulations were reduced compared with Control or TPN+Food mice; as were the CD8alphabeta+ thymus-dependent, and CD8+ CD44+ mature IEL. IEL cytokine mRNA expression was also significantly altered with TPN: IL-2 and IL-10 expression declined, and IL-4 IL-6, interferon gamma (IFN-gamma), transforming growth factor beta-1 (TGF-beta1), and tumor necrosis factor-alpha (TNF-alpha) were increased, when compared with Control or TPN+Food mice.This study demonstrates that the major factor responsible for TPN-induced BT and IEL-changes is the lack of enteral feeding and not the administration of the TPN solution itself.

Background/purpose Over the last 4 years, the authors changed their management of acute nonperforated appendicitis from emergent surgery within the first 2 to 6 hours of admission to initiation of antibiotic therapy with operation within 24 hours of admission in those seen in the late evening or early morning. They examined, therefore, whether a delay in operation for acute appendicitis would affect outcome measures of patient morbidity and resource use. Methods The medical records of 126 patients with acute appendicitis occurring between 1998 and 2001 were retrospectively reviewed. Incidence of perforation at surgery, length of stay (LOS), hospital charges, operating time, and complications as a function of duration between emergency room (ER) triage and operation (ER-OR) or admission and operation (Admit-OR) were analyzed by Student's t test, and regression analysis with P less than .05 considered significant. Results Thirty-eight children (26%) were operated on within 6 hours of ER triage, whereas the remaining 88 children (74%) were operated on between 6 and 24 hours from ER triage. No significant difference was noted in perforation rate, LOS, costs, or operative time, nor were substantial changes in complications noted between those with an ER-OR ≤6 hours and greater than 6 hours. Likewise, no significant differences in these outcome measures were noted for Admit-OR greater than 6 when compared with ≤6 hours. Only costs with ER-OR greater than 12 hours and LOS with Admit-OR greater than 6 hours were significantly (without Bonferroni correction) different than ≤ 6 hours. Multivariable linear regression analysis identified only LOS as a significant predictor of time to OR. Conclusions In children with acute appendicitis, delaying surgery until the daytime hours did not significantly affect operating time, perforation rate, or complications. Delayed management allows greater efficiency and effective use of physician and hospital resources, including decreased resident involvement in operations during the night.

The aim of this study was to utilize clinical outcome methodology through multivariable analysis of perioperative factors to predict a successful Kasai-portoenterostomy (PE).Records of 81 patients treated for biliary atresia (BA) were reviewed. Outcome was defined as successful if the patient was alive and had no liver transplant (LT). To predict future successful or failed PE, patients were categorized at 6 months post-PE into 2 groups: Success: direct bilirubin (DB) less than 2.0 mg/dL; Failure: DB greater than 2 mg/dL, or the patient was listed/had undergone LT, or had died. Groups were analyzed for positive or negative predictive values (PPV, NPV) at 2 and 5 years after PE. Cox regression was used to determine risk factors for PE.PE was successful in 38% and failed in 62%. PPV of future success was 96% at 2 years post-PE and 95% at 5 years post-PE, NPV of failure was 76% and 74%, respectively. Bridging liver fibrosis at the time of PE and postoperative cholangitic episodes were interdependent risk factors for a failed PE (P.05). Other covariates showed no significant relationship for PE outcome.Classifying of patients 6 months postoperatively allowed us to determine a successful PE outcome. Bridging liver fibrosis at the time of the Kasai, and the increased number of postoperative cholangitic episodes were predictive of a poor PE outcome.

Proinflammatory cytokines and secretory phospholipase A(2) (sPLA(2)) are elevated in patients with inflammatory bowel disease (IBD). We previously reported that the proinflammatory cytokine IL-6 increased the expression of sPLA(2) (a hydrolyzer of phosphatidylcholine) and decreased membrane integrity in an intestinal epithelial cell culture model. To determine the physiological effects of the IL-6 mediated increase in sPLA(2) on decreased epithelial layer integrity, we investigated alterations of intracellular/secretory phospholipid (PL) composition in a cell culture model. In addition, since other PLs may also mediate epithelial membrane activity, we investigated the effect of IL-6 on PL activity in a Caco-2 enterocyte culture model. Caco-2 cells were incubated for 72 h with IL-6 or media alone (control). Both media and cell lysate were analyzed for PL composition using thin-layer chromatography. The PL composition in the media did not show any differences between the two groups ( p0.1). Total intracellular PL contents were also unchanged; however, IL-6 led to significant changes in PL composition including an increase in phosphatidylethanolamine (PE) and sphingomyelin (SM) and a decrease in phosphatidylcholine (PC) and lysophosphatidylcholine (LPC) ( p0.05). Both PE and SM are known as inflammatory signaling factors involved in human IBD. Our study suggests that the decreased membrane integrity seen with IL-6 application may occur via intracellular PL alterations, rather than through the direct effects of sPLA(2).

Long chain fatty acids (LCFAs) appear to be powerful stimulants for small bowel adaptation in patients with short bowel syndrome (SBS). However, the dietary lipid content may alter intestinal lipid transport. The aim of this study was to investigate the effects of a high fat diet (HFD) on in vivo lipid absorption and molecular and cellular mechanisms of LCFAs uptake by the remaining bowel. Male Sprague-Dawley rats (240–280) were randomly assigned to one of three groups: sham rats fed normal chow (sham-NC), SBS rats fed NC (SBS-NC) and SBS rats fed HFD (SBS-HFD). SBS rats underwent a 75% small bowel resection. Rats were sacrificed on day 3 or 14. Body weight, fat intake and fat clearance (total fecal fat) were measured twice a week. Fat absorbability was calculated as intake minus clearance and was expressed as percent of intake. Total RNA from the mucosa of duodenum, jejunum and ileum was extracted using TRIZOL Reagent. Northern blot analysis was performed to determine FAT/CD36 mRNA levels. Enterocyte LCFA transport was measured on day 14. LCFA uptake was determined by measuring cellular [3H]-oleate uptake over time (4–120 s). Mean (±SE) FAT/CD36 mRNA levels and oleate uptake kinetic parameters were analyzed using ANOVA. Fat absorbability diminished after bowel resection, suggesting fat malabsorption. Remaining bowel in SBS-NC rats responded by an increase in FAT/CD36 mRNA levels in the duodenum and ileum on day 3, and the duodenum and jejunum on day 14 compared to sham-NC animals, and was accompanied by an increase in enterocyte LCFA transport in all segments. Exposure to a HFD for 14 days resulted in significantly increased fat absorbability after 3 days compared to SBS-NC rats. However, FAT/CD36 mRNA levels (vs. SBS-NC) decreased in all segments on day 3. On day 14, FAT/CD36 mRNA levels were decreased in the duodenum and ileum and were accompanied by reduced oleate uptake by isolated enterocytes in the ileum (vs. SBS-NC). In a rat model of SBS, early high fat diet increased lipid absorptive capacity of the intestinal remnant as seen by increased fat absorbability. The main mechanisms of this effect may be an acceleration of structural intestinal adaptation resulting in an increased number of enterocytes. However, at molecular and cellular levels HFD decreased mucosal FAT/CD36 mRNA levels and oleic acid uptake by isolated enterocytes.

Enteral probiotics such as Lactobacillus casei GG (LGG) have been used in the treatment of a variety of intestinal disorders in infants and children, including diarrhea, malabsorption, and Clostridium difficile colitis. Previous studies have identified the gene locus for mucin (MUC-2) and its expression in Caco-2 cells. Others have demonstrated that mucin, located on the surface of the intestinal epithelium, inhibits bacterial translocation (BT). We previously demonstrated that both mucin and the probiotic bacterium LGG have an inhibitory effect on BT in both an in-vitro Caco-2 cell model and a neonatal rabbit model. We hypothesized that the decline in BT by LGG is mediated by up-regulation of epithelial MUC-2. Human enterocyte Caco-2 cells were grown to confluence and incubated at 37 degrees C with either medium (control group) or 10(4) or 10(8) LGG for 180 min. Non-adherent LGG was washed away. Caco-2 cells were then lysed, purified, and quantified for MUC-2 protein and mRNA. The addition of LGG to the enterocyte monolayer surface resulted in significantly ( P0.05) increased MUC-2 expression compared to the untreated monolayers. Protein densities for MUC-2 significantly ( P0.05) increased with LGG. Density (expressed as ratio to control group) was 8.6 +/- 1.3 in the low-dose group (10(4) LGG) and 15.6 +/- 2.3 in the high-dose group (10(8) LGG). LGG may thus bind to specific receptor sites on the enterocyte and stimulate the up-regulation of MUC-2, resulting in increased inhibition of BT.

Low-fat diets (LFD) are used extensively in many different clinical conditions. However, the effect of this diet on lipid absorption and cellular long-chain fatty-acid (LCFA) transport is unknown. Fatty-acid translocase (FAT), the rat homologue of human CD36, is one of several LCFA plasma-membrane transport proteins that may play an important role in intestinal lipid uptake. The purpose of this study was to investigate the effects of a LFD on intestinal expression of FAT/CD36, enterocyte fatty-acid transport, and in-vivo lipid absorption in rats following bowel resection. Adult male Sprague-Dawley rats were divided into five experimental groups: normal rats fed normal chow(NR-NC) (10 kcal% fat), normal rats fed a LFD (NR-LFD) (3 kcal% fat), sham rats fed normal chow (Sham-NC), short-bowel syndrome rats fed normal chow (SBS-NC), and SBS rats fed a LFD (SBS-LFD). SBS rats underwent 75% small-bowel resection, while sham animals underwent bowel transection and reanastomosis. Food intake, fecal mass, and fecal fat were measured over the last 3 days before death on day 14. Final body weight, plasma lipids and protein, and tissue total lipids in liver, adipose tissue, and intestine were determined at death. Total RNA from the mucosa of the duodenum, jejunum, and ileum was extracted for Northern blot analysis to determine fatty-acid translocase (FAT)/CD36 mRNA levels. An established cellular LCFA transport assay was used to determine isolated enterocyte [3H]-oleate uptake. Students t-test was used to determine statistical significance (P < 0.05). NR-LFD rats demonstrated a small increase in overall food absorption and no change in fat absorption compared to NR-NC animals. A significant decrease in FAT/CD36 mRNA levels was seen in the duodenum and jejunum in NF-LFD rats (vs NR-NC) and was accompanied by reduced LCFA transport by isolated enterocytes from the jejunum and ileum. SBS-LFD rats demonstrated decreased FAT/CD36 mRNA levels in all three segments and a concomitant decrease in LCFA uptake enterocytes compared to the SBS-NC group. In addition, SBS-LFD rats showed significantly lower final body weight and plasma lipids compared to SBS-NC animals.

Enteral probiotics such as Lactobacillus casei GG (LGG) have been used in the treatment of a variety of intestinal disorders in infants and children, including diarrhea, malabsorption, and Clostridium difficile colitis. We have previously demonstrated that the probiotic bacterium LGG has an inhibitory effect on bacterial translocation (BT) in a neonatal rabbit model. However, this in-vivo model is limited for investigating the cellular and molecular mechanisms responsible for probiotic inhibition of BT. The purpose of this study was to determine the efficacy of LGG in reducing the rate of Escherichia coli C25 (E. coli C25) translocation using an in-vitro enterocyte cell-culture model. Human colonic carcinoma (Caco-2) enterocytes were seeded in porous filters in the apical chamber of a two-chamber cell-culture system and grown for 14 days to confluence. The monolayers were incubated at 37 degrees C with LGG for 180 min. Non-adherent LGG was washed away prior to a 120-min incubation period with 10(5) CFU E. coli C25. E. coli that had translocated across the enterocyte monolayer were quantified by growing basal-chamber media samples on gram-negative bacteria-specific MacConkey's agar. In order to determine monolayer integrity, transepithelial electrical resistance (TEER) was measured across Caco-2 cells treated with LGG and E. coli. Statistical analysis was by ANOVA with P0.05 considered significant. LGG inhibited E. coli translocation at all LGG concentrations tested. The TEER ratio was not significantly altered by addition of LGG or E. coli (0.9 +/- 0.03 vs 0.8 +/- 0.05). These results demonstrate that the probiotic bacterium LGG inhibits BT of E. coli C25 in a dose-dependent manner in an in-vitro cell-culture model. This model should be valuable in investigating the cellular and molecular mechanisms involved in the inhibition of pathological enteral bacteria by probiotic agents.

The clinical use of probiotic agents such as enteral Lactobacillus to enhance intestinal defense against potential luminal pathogens has been tested in vivo; however, an understanding of the mechanisms responsible for the observed protection is lacking. The purpose of this study was to evaluate the effects of Lactobacillus on bacterial translocation (BT) in a neonatal animal model. Newborn New Zealand white rabbit pups were enterally fed a 10% Formulac solution inoculated with or without a 108 suspension of ampicillin-resistant Escherichia coli K1 (E. coli K1A) and/or Lactobacillus casei GG (Lacto GG). Pups received either no bacteria (n = 10), Lacto GG (n = 8), E. coli K1A (n = 26), or a combination of Lacto GG and E. coli K1A (n = 33). On day 3, representative tissue specimens from the mesenteric lymph nodes (MLN), spleen (SPL), and liver (LIV) were aseptically harvested in addition to a small-bowel (SB) sample that was rinsed to remove luminal contents. The specimens were then cultured in organism-specific media. Statistical analysis was by one-way ANOVA with P values less than 0.05 considered significant. Neonatal rabbits receiving Lacto GG-supplemented formula exhibited a 25% decrease (P

The introduction of managed care in the 1980s caused increased pressure to reduce costs for hospitalized patients. The authors hypothesized that these market forces have resulted in a decreased hospital stay and utilization of sophisticated diagnostic testing in children treated for appendicitis. If true, the impact of this paradigm shift on patient outcome is unknown.Hospital records for 913 pediatric patients treated for appendicitis from 1974 to 1998 were reviewed retrospectively. Patients were stratified into those with perforated appendicitis (PA) and nonperforated appendicitis (NPA). Demographics, perioperative hospital course, diagnostic testing, complications, and long-term outcomes were analyzed after stratification into time intervals.Over time, children with NPA were treated with shorter antibiotic courses (P.05) and were placed on a regular diet earlier (P.05). These changes in treatment resulted in an earlier discharge (P.05). The amount of time to become afebrile with a normal white blood cell count (WBC) did not change over time. Children with PA exhibited similar results with shorter antibiotic courses (P.05), earlier dietary intake (P.05) and earlier hospital discharge (P.05) over time. In all children with appendicitis there was no significant difference in the rate of wound infections, abscesses requiring drains, readmission, or reoperations overtime. The utilization of abdominal radiographs (83%) and ultrasonography (USN; 40%) was high and remained unchanged over time. Utilization of computed tomography (CT scan) was low (4.3%) in the early decades and was not used as a preoperative test from 1991 to 1994. Given the high diagnostic accuracy of a pediatric surgeon for this disease, Bayesian analysis indicates that USN utilization rates should be 15%.The market pressures of managed care have resulted in a new treatment paradigm with an earlier discharge of all children with appendicitis. There has been no concomitant increase in the complication rate in either group as a result of this paradigm shift. Bayesian analysis indicates that USN and abdominal radiographs are overutilized in our institution.

Increased morbidity and mortality rates in children injured by firearms has been well documented during this past decade. The aim of this study was to determine the socioeconomic factors affecting firearm ownership in families with children living in suburban/rural versus inner-city environments, and to identify predictors of firearm ownership in these families.Parents of children less than 19 years old seen in a suburban (n = 751) or inner-city hospital (n = 406) anonymously completed a questionnaire regarding firearm ownership.Firearm ownership was 54% in rural locations, versus 18% among inner-city residents (P.05). Firearm ownership in white households was 45% versus 20% in African-American households (P.05). Mean number of all types of firearms in white households was 3.38 versus 1.78 in black households (P.001). Firearm ownership was 19% in the less than $20,000 income bracket, significantly lower than households with greater incomes, and was significantly lower in households in which parents had the least education (19.7%) versus those with college degrees (38.5%; P.05). Firearm owners of rifles and shotguns significantly more often cited hunting, collection, and target shooting as reasons for owning firearms, in contrast to revolver owners who cited protection and collection as reasons for firearm ownership (P.05).Firearm ownership is higher in rural, caucasian versus inner-city African-American residents and is significantly less in households with lower income and educational levels. Significant predictors for firearm ownership were number of parents in households, educational level of parents, and population of residence.

The high incidence of bacterial translocation in newborns is thought to be caused, in part, by the immaturity of the intestinal mucosal barrier. Recently, intestinal mucus phospholipids (PL) have been reported to be important factors in the function of this mucosal barrier. The aim of this study was to quantify changes, with age, in the intestinal mucus PL of the newborn rabbit.Mucus was gently scraped from the small intestinal mucosal surface of rabbits of different ages (0, 7, 14, and 28 days old and adult; n = 6 for all groups). PL was extracted from the mucus and was separated by two-dimensional thin-layer chromatography. The isolated phospholipid spots were quantified for their phosphorus content.Total PL content of the mucus decreased significantly with age (day 0, 21+/-2; day 7, 16+/-4; day 14, 9+/-3; day 28, 2+/-1; adult, 1+/-1 micromol/g wet mucus; P = .0001). Phosphatidylcholine and phosphatidylethanolamine levels in the adult rabbits were significantly lower in comparison with the 0-, 7-, and 14-day-old pups (P.05). In contrast, lysophosphatidylcholine and lysophosphatidylethanolamine were significantly higher in the 28-day-old and adult rabbits in comparison with the 0-, 7-, and 14-day-old pups (P.05). Phosphatidylinositol + phosphatidylserine levels in 7-day-old rabbits was significantly higher compared with adult rabbits. There was no significant difference in the composition of sphingomyeline between groups.Significant changes in the content and composition of the intestinal mucus phospholipids were observed during the first month of life in rabbits.

Background: The effect of circumcision on feeding behavior in the newborn period is unknown. We hypothesized that circumcision would not have a significant effect on newborn feeding. Methods: This prospective study analyzed the effect of circumcision on neonatal feeding behavior. Inclusion criteria were healthy male infants WHO were exclusively bottle-fed and underwent a circumcision before discharge from the newborn nursery. We collected data (N = 42) on gestational age, birth weight, Apgar scores, maternal age, gravid status, anesthesia used during delivery, analgesia used after circumcision, time of circumcision, and volume and frequency of feeding before and after circumcision. Data were analyzed by using paired t tests, multivariable regression analysis, and analysis of variance (with SPSS version 18). Significance was P < .05 (2-tailed α). Results: Descriptive statistics for the entire group (N = 42) are as follows: mean ± SD gestational age: 38.7 ± 1.2 weeks; mean birth weight: 3.3 ± 0.4 kg; maternal age: 26.7 ± 6.3 years; baseline feeding (mean of first 2 feedings before circumcision): 24.5 ± 9.9 mL; mean first feeding after circumcision: 21.7 ± 11.9 mL; and mean second feeding: 26.7 ± 13.5 mL. Forty-eight percent of patients increased their feeding volume after circumcision compared with baseline, and 52% of patients decreased their feeding volume, which persisted with the second feeding. There was no statistical difference between the baseline and first feeding (P = .11) or second feeding (P = .22). Conclusions: Our data suggest that circumcision does not alter feeding after circumcision. This information will be useful in counseling families regarding circumcision in the newborn period.

Primary endorectal pull-through (ERPT) has become an increasingly popular method of caring for neonates and young infants who have Hirschsprung's disease. This study evaluated the long-term stooling patterns and continence rates of patients who had a primary ERPT as a young infant. The records of 24 infants who underwent a primary ERPT for Hirschsprung's disease were reviewed. The patients' families (those patients over 3 years of age, n = 12) underwent a detailed interview that graded continence from 0 (poor) to 10 (normal). Mean age at ERPT was 15 +/- 17 days (range, 2 to 67). Mean follow-up was 1,036 +/- 614 days. Nine patients suffered from 20 episodes of enterocolitis. Stooling frequency declined rapidly in the first 6 months after the ERPT (r2 = 1.00) and more slowly after this time (r2 = 0.79). Continence was graded as normal (10) in one, good (6 to 9 points) in nine, and fair (1 to 5) in two patients, both of whom had total colonic disease. The authors conclude that a primary ERPT in the young infant who has Hirschsprung's disease can yield excellent results including normalization of stooling frequency and good to excellent levels of continence.

Background: Neonates are at high risk for the development of parenteral nutrition-associated cholestasis when receiving a prolonged course of total parenteral nutrition (TPN). Although this cholestasis is of unknown etiology, it may result from a lack of gastrointestinal hormone formation, including cholecystokinin, which normally occurs after enteral feedings. Methods: Two groups of neonates were studied. The treatment group consisted of 21 consecutive, prospectively enlisted neonates receiving TPN for > 14 days. The nontreatment group consisted of 21 infants from the 2 years preceding the study who were matched to the treatment group by gestational age, diagnosis, and duration of TPN. The major outcome determinant was direct bilirubin. Cholestasis was defined as a direct bilirubin >2.0 mg/dL and was considered severe if the direct bilirubin was >5.0 mg/dL after other causes were ruled out. Results: The mean direct bilirubin levels in the nontreated group progressively rose over time, whereas the mean direct bilirubin in the treated group remained level. The incidence of infants with a direct bilirubin >2.0 mg/dL was 24% and 43% in the CCK+ and CCK- groups, respectively, and was not significant (p =.14). The percentage of infants with a direct bilirubin >5.0 mg/dL was 9.5% and 38% in the treatment and nontreatment groups, respectively, and was significant, p =.015. Conclusions: Levels of direct bilirubin were lower in the treated compared with the nontreated group. These findings suggest that cholecystokinin prophylaxis in high-risk neonates may help prevent the development of parenteral nutrition-associated cholestasis.

From 1974 to 1995, 19 children with achalasia of the esophagus have been treated at our institution. Presenting symptoms included vomiting (n = 14), dysphagia (n = 13), failure to thrive (n = 6), and odynophagia (n = 1). Diagnosis was established by a barium swallow in 19, with eight also undergoing esophageal manometry. Six boys and 13 girls with an average age of 10 years (range, 1.3 to 17.6) underwent a transthoracic, modified anterior Heller esophagomyotomy (HM). Five underwent a concomitant, modified, Belsey fundoplication (BF). Follow-up ranging from 6 months to 21 years (mean, 9 years) was accomplished in all 19 patients by both office visits and telephone interviews. Early postoperative follow-up showed initial swallowing difficulty in two (14%) patients with a HM alone and in four out of five (80%) patients treated with a HM and BF. All patients (n = 5) with a HM and BF and one with a HM alone required one esophageal dilation during the first postoperative year. These initial swallowing difficulties resolved in all six patients during this first postoperative year. Late postoperative follow-up, however, indicates occasional, mild dysphagia in two out of five with an HM and BF resulting in complete relief of presenting symptoms in 17 of the 19 patients (90%). All patients rated their overall result as either excellent (68%) or good (32%) with none rating it as fair or poor. None of the 19 patients had clinical evidence of gastroesophageal reflux, although five patients had evidence of nonpathologic reflux noted during upper gastrointestinal x-ray. Recurrent vomiting, asthma, wheezing, or esophagitis symptoms have not been reported by any patients. No patients required reoperation, and there were no deaths or postoperative complications. Modified Heller esophagomyotomy is safe (0% mortality) and effective (90% relief of symptoms) in children with achalasia. A concurrent modified Belsey fundoplication results in early and late mild postoperative dysphagia that was responsive to esophageal dilation. The transthoracic, modified Heller esophagomyotomy without a fundoplication is currently our treatment of choice for achalasia in children.

Although physician-reported complications following circumcision are very low, parental satisfaction is not well documented. This study examined parental opinions and compared these with those of the medical professional. Physicians independently assessed complications and cosmetic outcome following the circumcision. Six weeks post-circumcision, parental report of complications, cosmetic outcome, and overall satisfaction were assessed. Newborn infants (n = 710) were prospectively recruited and underwent either a Gomco [n = 552 (78 %)] or Plastibell® [n = 158 (22 %)] circumcision. Physician assessed complication rates were equivalent (Gomco 4.3 % versus Plastibell 5.1 %; p = 0.67), however, parental assessment found a much lower complication rate for Gomco 5.6 % versus Plastibell 12.0 % (p

Purpose A major determinant of survival in patients with congenital diaphragmatic hernia (CDH) is severity of pulmonary hypoplasia. This study addresses the comparative effectiveness of prenatal methods of lung assessment in predicting mortality, extracorporeal membrane oxygenation (ECMO), and ventilator dependency. Methods We retrospectively reviewed all patients born with isolated CDH between 2004 and 2008. Lung-to-head ratio (LHR) and observed-to-expected LHR (OELHR) were obtained from prenatal ultrasounds. Percent-predicted lung volume (PPLV) was obtained from fetal MRI (fMRI). Postnatal data included in-hospital mortality, need for ECMO, and ventilator dependency at day-of-life 30. Results Thirty-seven patients underwent 81 prenatal ultrasounds, while 26 of this sub-cohort underwent fMRI. Gestational age during imaging study was associated with LHR ( p =0.02), but not OELHR ( p =0.12) or PPLV ( p =0.72). PPLV, min-LHR, and min-OELHR were each associated with mortality ( p =0.03, p =0.02, p =0.01), ECMO ( p p p =0.03), and ventilator dependency ( p p p =0.02). For each outcome, PPLV was a more discriminative measure, based on Akaike's information criterion. Using longitudinal analysis techniques for patients with multiple ultrasounds, OELHR remained associated with mortality ( p =0.04), ECMO ( p =0.03), and ventilator dependency ( p =0.02), while LHR was associated with ECMO ( p =0.01) and ventilator dependency ( p =0.02) but not mortality ( p =0.06). Conclusion When assessing fetuses with CDH, OELHR and PPLV may be most helpful for counseling regarding postnatal outcomes.

Purpose: We have previously demonstrated that spontaneous bacterial translocation (BT) occurs, in newborn rabbits and correlates strongly with small bowel colonization (BC). Birth stress, specifically hypoxia, is believed to increase this pathologic process and thus lead to sepsis. This study investigated the relationship between BT and acute hypoxia in newborn rabbits. Methods: Four hundred seventeen rabbit pups (aged 0, 2 to 4, 6, and 28 days) were divided into four groups according to the type of hypoxic stress: 9% O 2 for 1 hour, 9% O 2 + 12% CO 2 for 1 or 4 hours, and 21% O 2 (control animals). The animals were killed 1.5 or 20 hours after the stress. Sterile specimens of mesenteric lymph nodes (MLN), spleen, liver, small bowel, and large bowel were incubated aerobically at 37°C for 24 hours in thioglycolate broth, and subsequently plated on both MacConkey and Colistin Naladixic Acid media. After 24 hours, the growth on both plates was recorded. χ 2 analysis was used, and P values of less than .05 were considered significant. Results: BC of the small bowel and BT to the MLN were low in the first 4 days of life in the hypoxic groups (range, 0% to 21% BC, 0% to 6% BT) and the control group (range, 4% to 30% BC, 3% to 12% BT). After an increase in BC at 6 days of age, the rate of BT increased to 25% to 29% in control animals. The rate of BT in the hypoxic groups (25%) did not differ significantly from that of the controls ( P > .05). Additionally, killing at 20 hours ( v 1.5 hours) was not associated with an increase in the incidence of BT. None of the stress groups had a significant increase in BT compared with the controls. Importantly, although 4 hours of 9% O 2 + 12% CO 2 resulted in a 30% mortality rate, the incidence of BT was no higher than that of the control animals (13% v 29%; P > .05). Conclusion: Severe hypoxic stress in newborn rabbits does not increase the incidence of BT. Because the incidence of BT correlates with that of BC, and because BC is the same in the control and hypoxic animals, the sepsis observed in hypoxic newborns probably is not related to an increased incidence of BT.

Sepsis is a significant cause of morbidity and mortality in neonates, and in a significant number of cases no predisposing factors can be identified. We hypothesize that bacterial translocation (BT) may be the etiology of neonatal sepsis when no source is identified. Mesenteric lymph nodes (MLN), spleen (SPL), and liver (LIV) were harvested from 36 rabbit pups ranging in age from 4 to 24 days and divided into three groups based on their age: group I, 4-6 days; group II, 13-15 days; and group III, 22-24 days. Tissues from each organ were homogenized and placed in both aerobic and anaerobic environments. After 48 h the number of colony-forming units/g tissue was identified. The total percentage of positive growth was significantly higher in group ! for MLN (33%) and LIV (23%) when compared to groups II and III (

Objective The purpose of this study was to develop a simple and accurate approach for risk stratification of fetal lung lesions that are associated with respiratory compromise at birth. Study Design We conducted a retrospective review of 64 prenatal lung lesions that were managed at a single fetal care referral center (2001-2011). Sonographic data were analyzed and correlated with perinatal outcomes. Results Hydrops occurred in only 4 cases (6.3%). Among fetuses without hydrops, the congenital pulmonary airway malformation volume ratio (CVR) was the only variable that was associated significantly with respiratory compromise and the need for lung resection at birth ( P 1.0, the sensitivity, specificity, positive predictive value, and negative predictive value for respiratory morbidity were 90%, 93%, 75%, and 98%, respectively. Conclusion Nonhydropic fetuses with a maximum CVR >1.0 are a subgroup of patients who are at increased risk for respiratory morbidity and the need for surgical intervention. These patients should be delivered at a tertiary care center with pediatric surgery expertise to ensure optimal clinical outcomes.

Background Fifteen percent of infants with congenital diaphragmatic hernia (CDH) are born with a coexisting cardiac anomaly. The purpose of this study was to evaluate contemporary outcomes in this patient population and to identify potential risk factors for in-hospital mortality. Methods Data from all CDH neonates with congenital heart disease managed at a single pediatric tertiary care referral center between 1997 and 2011 were retrospectively analyzed. Results Forty (18%) of 216 CDH patients had a cardiac anomaly. This group was associated with a significant decrease in overall survival when compared with patients without cardiac anomaly (55% versus 81%; p = 0.001). There was no association between type of cardiac anomaly and mortality based on risk stratification according to the Risk Adjustment for Congenital Heart Surgery and The Society of Thoracic Surgeons–European Association for Cardiothoracic Surgery scoring systems ( p = 0.86 and p = 0.87, respectively). Birth weight was similarly no different between survivors and nonsurvivors (2.8 ± 0.6 kg versus 2.8 ± 0.9 kg, respectively; p = 0.98). There was a trend toward increased extracorporeal membrane oxygenation use among nonsurvivors ( p = 0.13). Infants with hemodynamic stability enabling subsequent cardiac repair were associated with lower mortality ( p = 0.04). Survivors had a wide spectrum of long-term morbidity, but most had some evidence of neurodevelopmental impairment. Conclusions This large single-institution series suggests that the overall prognosis of infants with concomitant CDH and congenital heart disease can be quite variable, regardless of the type of heart anomaly. Hemodynamic instability and need for extracorporeal membrane oxygenation correlate with higher mortality. Although some long-term survivors have excellent outcomes, most suffer from chronic, long-term morbidities.

Seventy-four New Zealand white rabbit pups were divided into four groups: group I, 2 days of age (n = 9); group II, 3 to 5 days of age (n = 24); group III, 6 to 8 days of age (n = 27); and group IV, 10 to 13 days of age (n = 14). Mouth swabs (MS), rectal swabs (RS), small bowel specimens (SB), and large bowel specimens (LB) were obtained from each rabbit, incubated for 24 hours in thioglycolate broth, and plated on blood agar in aerobic and anaerobic environments. After 24 hours, growth on blood agar plates were observed. All MS specimens and all but one RS specimen showed positive growth. Growth of both LB and SB specimens increased significantly with age (P < .04). In addition, SB growth was significantly less than RS or MS growth in groups I, II, and III (P < .05). LB growth was significantly less than RS or MS growth in group I (P < .01) and tended to be less in groups II and III (62.5% v 100% and 93% v 100%, respectively). These data show that nearly half of normal rabbits under 6 days of age have sterile small and large intestines despite almost 100% growth from rectal and mouth swabs. These findings partially explain the absence of spontaneous bacterial translocation in young rabbit pups (under 4 days of age) and have important implications for the prophylaxis and treatment of neonatal sepsis.

The natural history of fundoplication in young children with gastroesophageal reflux (GER) had not been analyzed previously. The authors reviewed the charts of 160 children who underwent gastric fundoplication (GF) before the age of 2 years (mean age [±SD], 9 ± 7 months; range, 1 week to 2 years), from 1974 to 1992. Reflux was documented by upper gastrointestinal series in 124 patients, by 24-hour pH probe monitor in 98 patients, and by both in 68 patients. Clinical indications for GF included failure to thrive (FTT) in 68%, emesis (Ems) in 58%, and aspiration pneumonia (Asp) in 53%. Neurological impairment (NI) was present in 47% of all patients, and 13% had esophageal atresia (EA). The type of GF used was a Nissen fundoplication in 79% and an anterior fundoplication (AF) in 21%. Of the 160 patients, 24 (15%) died of unrelated causes. Of the remaining 136, follow-up of at least 2 years was obtained for 96 (mean follow-up period, 5.3 ± 3.0 years; range, 2 to 15 years). Clinical resolution of symptoms/findings after GF occurred in 87% of children with FTT, 92% with Ems, 70% with Asp, and 71% overall. A second fundoplication was required for 15 children (16%) because of documented recurrent reflux. The type of GF, the age of the patient, and the presence of EA or NI did not significantly affect the success of GF. This experience demonstrates that (1) in young children there is no inordinate increase in recurrence after GF, (2) GF (AF or Nissen) is an effective means of treating GER in children under 2 years of age, even those with EA or NI.

Purpose Patients with congenital diaphragmatic hernia (CDH) requiring extracorporeal life support (ECLS) are at increased risk for acute kidney injury (AKI). We hypothesized that AKI would be associated with increased mortality. We further hypothesized that vasopressor requirement, nephrotoxic medications, and infections would be associated with AKI. Methods We performed a retrospective chart review in all patients with CDH requiring ECLS from 1999 to 2009 (n = 68). Patient variables that could potentiate renal failure were collected. We used a rise in creatinine from baseline by the RIFLE (risk, 1.5×; injury, 2×; failure, 3×; loss; and end-stage renal disease) criteria to define AKI. Statistical analysis was performed via SPSS (SPSS, Chicago, IL) using Student t test and χ 2 analysis, with P Results Survival to hospital discharge was 37 (54.4%) of 68. Acute kidney injury was identified in 48 (71%) of 68 patients, with 15 (22% of all patients) qualifying as injury and 33 (49% of all patients) qualifying as failure by the RIFLE criteria. Patients who qualified as failure by the RIFLE criteria had a significant decrease in survival (27.3% with failure vs 80% without failure; P = .001). Patients who qualified as failure also had increased length of ECLS (314 ± 145 vs 197 ± 115 hours; P = .001) and decreased ventilator-free days in the first 60 days (1.39 ± 5.3 vs 20.17 ± 17.4 days; P = .001). There was no significant difference in survival when patients qualified as risk or injury. Conclusions This is the first report using a systematic definition of AKI in patients with CDH on ECLS. There is a high incidence of AKI in these patients, and when it progresses to failure, it is associated with higher mortality, increased ECLS duration, and increased ventilator days. This highlights the importance of recognizing AKI in patients with CDH requiring ECLS and the potential benefit of preventing progression of AKI or early intervention.

Research on the rates of alcohol and drug misuse as well as developmentally appropriate screening and intervention approaches in a hospitalized pediatric trauma population are lacking. The purpose of this study was to identify the rate of alcohol misuse in an admitted trauma population of adolescents aged 11 years to 17 years and to identify key correlates of alcohol misuse in this population including age, gender, and injury severity.A prospective clinical study of 230 injured youth (aged 11-17 years) comprising both hospitalized and emergency department (ED) population was performed, and the patients were screened for the Alcohol Use Disorders Identification Test (AUDIT), blood alcohol levels (BALs), and drinking and driving index. The main outcome measures were rates of alcohol misuse characterized by a positive BAL or a positive AUDIT.Thirty percent hospitalized trauma patients screened positive for alcohol misuse. Five patients had a positive BAL without a positive AUDIT score. Binge drinking was the most commonly positive domain of the AUDIT tool. In hospitalized trauma patients who are older than 14 years (p = 0.005), it was significantly associated with a positive AUDIT score, but the injury severity score, gender, mechanism of injury, or positive BAL were not significant predictors. In the ED sample, 15.8% of patients had a positive AUDIT score. One-way analysis of variance among the ED group showed that ageor=14 was the single predictor of a positive AUDIT score. Twenty-three percent of hospitalized patients had been in a car, where the driver had been drinking. The average AUDIT scores in this group was 5.3 versus 1.0 (p0.001), compared with those who had not ridden in a car with a driver who had been drinking.Injured youth admitted to a pediatric trauma center are a high-risk population. Alcohol misuse is a significant cofactor for trauma for these patients, and effective developmentally appropriate interventions are justified and needed.

Purpose Advances in percutaneous endoscopic gastrostomy (PEG) and laparoscopic (LAP) techniques, including LAP-assisted PEG, offer alternatives to the standard open gastrostomy technique. This study compares the outcomes of the PEG and LAP techniques. Methods All gastrostomy tube placements were reviewed at our institution from January 2004 to October 2008. Demographic, procedural, and outcome data were collected. Univariate and logistic regression statistical analysis was performed with SPSS (SPSS, Chicago, IL), and P ≤ .05 considered significant. Results Of 238 gastrostomy tubes placed, 134 were PEG (56.3%) and 104 were LAP (43.7%). Most tubes were inserted for failure to thrive (74.4%) and feeding difficulties (52.1%). Patient weight and age were increased and operative time decreased for PEG compared with other methods. Percutaneous endoscopic gastrostomy patients also had a statistically higher number of postoperative complications, requiring a return trip to the operating room ( P = .02). Conclusion Minimally invasive PEG and LAP techniques have supplanted the open technique for most patients. Operative time for PEG placement is shorter than other methods, and patients chosen for the PEG method of placement are older and of greater weight. However, there were significant and more serious postoperative complications requiring a second operation in the PEG group when compared with the LAP group.

Background Guidelines for termination of resuscitation in prehospital traumatic cardiopulmonary arrest (TCPA) have recently been published for adults. Clinical criteria for termination of care include absent pulse, unorganized electrocardiogram (ECG), fixed pupils (all at the scene), and cardiopulmonary resuscitation (CPR) greater than 15 minutes. The goal of this study was to evaluate these guidelines in a pediatric trauma population. Methods Pediatric trauma patients with documented arrest were included in the study. Data assessed were duration of CPR, ECG rhythm, pulse assessment, pupil response, transport times, and standard injury criteria (eg, mechanism of injury). Survivors were compared to nonsurvivors using descriptive statistics, χ 2 , and Pearson correlation. Results Between 2000 and 2009, 30 patients were identified as having had a TCPA. Of the 30 with a prehospital TCPA, there were 9 females and 21 males (0.2-18 years old). The average (SD) injury severity score was 35.4 (20.6). Twenty-four patients (80%) did not survive. Severe traumatic brain injury was associated with nonsurvivors in 78%. One-way analysis of variances demonstrated that CPR greater than 15 minutes ( P = .011) and fixed pupils ( P = .022) were significant variables to distinguish between survivors and nonsurvivors, whereas ECG rhythm ( P = .34) and absent pulse ( P = .056) did not, 42 ± 28 minutes for nonsurvivors and 7 ± 3 minutes for survivors. Conclusion Criteria for termination of resuscitation correctly predicted 100% of those who died when all the criteria were met. More importantly, no survivors would have had resuscitation stopped. Duration of CPR seems to be a strong predictor of mortality in this study.

Because hypoxia is one of the most common major stresses to which a neonate is exposed, we postulated that it alone might be the cause of intestinal bacterial translocation, which could be the underlying etiology of neonatal sepsis. An animal model, in which hypoxia is the sole stress, was developed in our laboratory and tested in 18 puppies to determine the effect of hypoxia and reoxygenation on intestinal bacterial translocation. In group I (n = 8), following laparotomy and cannulation of the superior mesenteric vein (SMV), the FIO2 was decreased from 21% to 9% for 90 minutes followed by reoxygenation at 21% for 120 minutes. The abdomen was closed and the animals were allowed to recover. After 24 hours the mesenteric lymph nodes (MLNs), spleen, and liver were harvested for bacterial determination and the ileum and jejunum for histological evaluation. Group II (n = 7) was treated the same as group I with the FIO2 maintained at 21%. Group III (n = 3) animals were killed, without intervention, for bacterial analysis. In group I, the systemic PO2 decreased by 75%, SMV PO2 decreased by 64%, and oxygen delivery to the small bowel decreased by 80% in comparison with group II. The mean arterial pressure and cardiac output were not significantly different between group I and group II; however, the mucosal blood flow was decreased by 60% (P less than .001) in group I. Arterial and SMV blood lactic acid levels were unchanged in group I in comparison with group II, suggesting that anaerobic metabolism was not initiated in the splanchnic circulation during hypoxia.(ABSTRACT TRUNCATED AT 250 WORDS)

Anorectal malformations (ARMs) are associated with a large number of functional sequale that may affect a child's long-term quality of life (QOL). The purposes of this study were to better quantify patient functional stooling outcome and to identify how these outcomes related to the QOL in patients with high imperforate anus.Forty-eight patients from 2 children's hospitals underwent scoring of stooling after 4 years of life. Scoring consisted of a 13-item questionnaire to assess long-term stooling habits (score range: 0-30, worst to best). These results were then correlated with a QOL survey as judged by a parent or guardian.Mean (SD) age at survey was 6.5 (1.6) years. Comparison of QOL and clinical scoring showed no signficant difference between the 2 institutions (P.05). There was a direct correlation between the QOL and stooling score (Pearson r(2) = 0.827; beta coefficient = 24.7, P.001). Interestingly, functional stooling scores worsened with increasing age (Pearson r(2) = 0.318, P = .02). Patients with associated congenital anomalies had a high rate of poor QOL (44% in poor range; P = .001). Stooling scores decreased significantly with increasing severity/complexity of the ARM (P = .001).A large number of children experience functional stooling problems, and these were directly associated with poor QOL. In contrast to previous perceptions, our study showed that stooling patterns are perceived to worsen with age. This suggests that children with ARMs need long-term follow-up and counseling.

In this study, we compared the skin adhesive 2-octylcyanoacrylate to subcuticular suture for closure of pediatric inguinal hernia incisions to determine if skin adhesive improves wound cosmesis, shortens skin closure time, and lowers operative costs.We prospectively randomized 134 children undergoing inguinal herniorrhaphy at our institution to have skin closure with either skin adhesive (n = 64) or subcuticular closure (n = 70). Data collected included age, sex, weight, type of operation, total operative time, and skin closure time. Digital photographs of healing incisions were taken at the 6-week postoperative visit. The operating surgeon assessed cosmetic outcome of incisions using a previously validated visual analog scale, as well as an ordinate scale. A blinded assessment of cosmetic outcome was then performed by an independent surgeon comparing these photographs to the visual analog scale. Operating room time and resource use (ie, costs) relative to the skin closure were assessed. Comparisons between groups were done using Student's t tests and chi(2) tests.Children enrolled in the study had a mean +/- SE age of 3.7 +/- 0.3 years and weighed 16 +/- 0.8 kg. Patients were predominantly male (82%). Patients underwent 1 of 3 types of open hernia repair as follows: unilateral herniorrhaphy without peritoneoscopy (n = 41; 31%), unilateral herniorrhaphy with peritoneoscopy (n = 55; 41%), and bilateral herniorrhaphy (n = 38; 28%). Skin closure time was significantly shorter in the skin adhesive group (adhesive = 1.4 +/- 0.8 minutes vs suture = 2.4 +/- 1.1 minutes; P = .001). Mean wound cosmesis scores based on the visual analog scale were similar between groups (adhesive = 78 +/- 21; suture=78 +/- 18; P = .50). Material costs related to herniorrhaphy were higher for skin adhesive (adhesive = $22.63 vs suture = $11.70; P.001), whereas operating room time costs for adhesive skin closure were lower (adhesive = $9.33 +/- 5.33 vs suture = $16.00 +/- 7.33; P.001). Except for a 7% incidence of erythema in both groups, there were no complications encountered.There is no difference in cosmetic outcome between skin adhesive and suture closure in pediatric inguinal herniorrhaphy. Material costs are increased because of the high cost of adhesive relative to suture. This is partially offset, however, by the cost savings from reduction in operating room time.

Purpose The Canadian C-spine (cervical spine) Rule (CCR) and the National Emergency X-Radiography Utilization Low-Risk Criteria (NLC) are criteria designed to guide C-spine radiography in trauma patients. It is unclear how these 2 rules compare with young children. Methods This study retrospectively examined case-matched trauma patients 10 years or younger. Two cohorts were identified—cohort A where C-spine imaging was performed and cohort B where no imaging was conducted. The CCR and NLC criteria were then applied retrospectively to each cohort. Results Cohort A contained 125 cases and cohort B with 250 cases. Seven patients (3%) had significant C-spine injuries. In cohort A, NLC criteria could be applied in 108 (86.4%) of 125 and CCR in 109 (87.2%) of 125. National Emergency X-Radiography Utilization Low-Risk Criteria suggested that 70 (58.3%) cases required C-spine imaging compared to 93 (76.2%) by CCR. National Emergency X-Radiography Utilization Low-Risk Criteria missed 3 C-spine injuries, and CCR missed one. In cohort B, NLC criteria could be applied in 132 (88%) of 150 and CCR in 131 (87.3%) of 150. The NLC criteria identified 8 cases and CCR identified 13 cases that would need C-spine radiographs. Fisher's 2-sided Exact test demonstrated that CCR and NLC predictions were significantly different ( P = .002) in both cohorts. The sensitivity of CCR was 86% and specificity was 94%, and the NLC had a sensitivity of 43% and a specificity of 96%. Conclusions Although CCR and NLC criteria may reduce the need for C-spine imaging in children 10 years and younger; they are not sensitive or specific enough to be used as currently designed.

We examined the clinical literature on congenital abdominal wall defects to confirm our impression that gastroschisis had become more common than omphalocele. We then examined the teratology literature and noted that congenital abdominal wall defects were frequently induced by teratogens. This lead us to review the antenatal history of 19 infants with gastroschisis and 54 control infants born with a congenital anomaly unrelated to gastroschisis. When compared to controls, mothers of infants with gastroschisis were more likely to have used aspirin during pregnancy and to have been taking oral contraceptives at the time of conception. Additionally, an increased incidence of illegal drug use (particularly cocaine) was noted among the study mothers. We conclude that gastroschisis is becoming the more common congenital abdominal wall defect, and that it could be related to exposure to an environmental teratogen.

Objective: To describe the long-term changes in the traumatized spleen following conservative man- agement in pediatric patients. Methods: Between 1991 and 1997, 92 children were imaged with splenic trauma. The study population includes the 25 boys and 11 girls with follow-up computed tomography (CT) imaging at our institution. The follow-up CT studies were evalu- ated to determine the evolution of splenic injury. Re- sults: On initial CT there were 6 grade I, 12 grade II, 9 grade III, and 9 grade IV-V splenic injuries. In follow- up 11 spleens were normal (30 %), including at least one in each grade of severity of injury. Splenic abnor- malities were identified on follow-up in 25 children. These findings comprised clefts in 8 children, small cysts in 4, and devascularized segments involving less than 1c m 3 in 6, 1-2 cm 3 in 2, and 2-4 cm 3 in 5 children. Con- clusions: All grades of splenic injury can resolve com- pletely on subsequent CT imaging. In this series 30 % of patients had a normal follow-up CT. The most com- mon persistent abnormalities included clefts and devas- cularized areas less than 4 cm 3 .

Computed tomographic (CT) scanning has mostly replaced x-rays as an imaging modality, but concerns exist because of excess radiation, missed injuries, and whether it is the definitive procedure for intubated patients. The purpose of this study was to characterize missed cervical spine injuries (CSIs).All pediatric (18) trauma patients from 2004 to 2006 were analyzed. Age, sex, Injury Severity Score (ISS), mechanism, time, and missed injuries were reviewed. Flexion/extension views were used in patients with prolonged intubation. Descriptive statistics, chi(2), Student's t test, and bivariate correlation were used.There were 1307 pediatric trauma patients admitted with 318 imaged for potential CSI. Computed tomography was the sole imaging study in 200, x-rays in 64, and both in 54. Time to C-spine clearance was similar for all modalities (P.05). For CT, 34 (10.7%) were initially positive for CSI with 7 false-positives (FPs) and no false-negative (FN). There were 18 patients with CSI identified by x-ray, with 5 FPs and 5 FNs (missed injuries). The 5 FNs missed by x-ray were all positive by CT scan and required no intervention. None of the flexion/extension views revealed an additional injury. Sex, intubated patients, ISS, age, type, and injury location were not predictive of a missed injury (P.05).The sensitivity of CT scan was 1.0, specificity was 0.976, and the positive predictive value was 79.4%. The sensitivity of plain x-ray was 61.5%, the specificity was 1.6%, and the positive predictive value was 61.5%.Our data suggest that CT scans should be the primary modality to image a CSI. Flexion/extension views did not add to the decision making for C-spine clearance after CT evaluation.

Substance abuse (SA) is a significant cofactor for adolescent injury. Characterization of this population will help define a list of variables that are critical for designing interventions. The purpose of this study is to determine the frequency of SA testing and describe the injury characteristics of the adolescent trauma SA population.A urine drug screening (alcohol, cannabis, and opiates) protocol for all injured adolescents (14-17 years old) was used. Four years of data were analyzed. Three groups were defined: not tested (NT), negative (NEG), and positive (POS). Transfers from an outside hospital and those who received opiate pain medication before drug screening were excluded. A patient may have had more than one positive test. Tests were analyzed to compare sex, injury severity score (ISS), survival, mechanism, and length of stay (LOS).Four hundred forty-three patients met the criteria (308 males and 135 females). Mean ISS was 13.5 +/- 0.5 SEM with a 2.9% mortality rate. One hundred ninety-three of 443 (44%) were screened (m = 120, f = 73) with 39% testing positive in each group. Twenty-nine percent of positive tests were opiates, 11.2% alcohol, and 20% cannabis. No sex differences for alcohol, cannabis, or opiate use were noted. There were no differences between the NT and the NEG/POS groups with respect to sex, LOS, or mechanism of injury. Fourteen-year olds were less likely to be drug screened. Mean ISS score was lower in the NT group (11.4 +/- 0.6 vs 15.7 +/- 1.0, P.005). For the NEG and POS group analysis, a positive drug screen was not predicted by age, sex, ISS score, outcome, or LOS. Bicycle crashes were predictive of a positive drug screen (P.005). Survival rates were not different between any of the groups.Forty percent of the patients screened positive, thus, supporting screening in adolescent trauma patients. Selective criteria based on injury characteristics are not justified.

Pilonidal sinus disease is associated with a high rate of recurrence and complications. The Karydakis (KAR) method, whereby an asymmetric subcutaneous flap obliterates the anal crease, has been shown to be effective in adults. The goal of this study is to assess the efficacy of the KAR procedure in the operative treatment of children with pilonidal sinus disease compared to those treated via a midline excision (ME). Sixty-eight cases of pediatric pilonidal sinus excision were reviewed over the past 10 years. Data abstracted included surgical approach, complication rate and recurrence rate. Student's t-test or the Chi square test was used for statistical analysis, with P0.05 being considered significant. An ME was performed in 44 patients; the KAR method was used in 24 patients. Mean age at diagnosis was 14.4 +/- 4.2 years for the ME group compared to 15.7 +/- 4.3 years for the KAR patients (P = 0.18). Mean operative time was significantly longer with the KAR method (58.7 +/- 25.6 min) compared to 46.3 +/- 18.6 for the primary ME (P = 0.04). Despite the increased operative dissection, there was no difference (P = 0.42) in early post-operative complication rates between groups (25% in the KAR group compared to 34.8% in the ME group). Initial drainage of an abscess had no significant effect upon the recurrence/complication rate in either group. Recurrence rate alone was lower in patients operated on via the KAR approach 0% versus 11.0% using the ME (P = 0.153). Recurrence and complication rates were lower for those patients with a pilonidal sinus treated by the KAR method compared to the ME, but the results did not reach significance. In conclusion, this study does show a potential benefit for children treated with the KAR method for pilonidal sinus. This study mimics the data obtained in adult patients and suggests that a larger study is likely to achieve significance.

Purpose Ingrown toenails in children are a common problem with a high recurrence rate. The objective of this retrospective data review was to compare simple excision of the nail matrix with excision plus phenol (EPP) application in the treatment of ingrown toenails. Methods The charts of 69 children who underwent surgical treatment of one or more ingrown toenails from 1994 to 2000 were reviewed. The primary procedure was noted (excision alone [EA] vs EPP) and dates of recurrences and reoperations were recorded. Parents were then surveyed by phone regarding complications, cosmetic outcome, and overall satisfaction with the procedure. Five scale categories, ranging from "strongly agree" to "strongly disagree", were used, with responses of "strongly agree" and "agree" considered as a good outcome. Either Student's t test or the χ 2 test ( P Results Thirty-one patients (45%) were in the EPP group whereas the remaining 38 had EA. Mean length of follow-up was 4.3 years for the EA group and 2.1 years for the EPP group. There was no difference in age at operation or length of follow-up between the 2 groups. Boys were predominant in both groups. The survey response rate was 50/69 (73%). The recurrence rate of ingrown toenails in the EA group was 42% vs 4% in the EPP group ( P = .003). There were no significant differences in parental response with regard to operative experience ( P = .31) and the cosmetic result ( P = .13), with most of the respondents (78%) indicating a good outcome for both questions. Conclusions The addition of phenol to the surgical excision of ingrown toenail significantly reduced the incidence of recurrence, with similar patient satisfaction and an equivalent cosmetic result.