Burton H. Harris

National pediatric trauma registry

The National Pediatric Trauma Registry (NPTR) is a multi-institutional database designed to compile information concerning all aspects of pediatric trauma care. The registry is designed and operated in a manner that maximizes data accuracy and provides this information to all participating investigators. The growth of the database has allowed the NPTR to provide the first accurate epidemiologic description of pediatric trauma as a national disease, as well as to develop national norms for pediatric trauma care. The registry presently contains 10,177 patients, and is undergoing revisions (phase II) to allow a more focused evaluation of various aspects of the clinical care and rehabilitation of the pediatric trauma patient.

Prenatal Diagnosis and the Pediatric Surgeon: The Impact of Prenatal Consultation on Perinatal Management

PURPOSE Pediatric surgeons are increasingly called on by obstetrical colleagues to counsel parents about the implications of a prenatal ultrasound finding. Our understanding of the natural history of many prenatally diagnosed surgical conditions has grown significantly in recent years. Whether prenatal surgical consultation can influence perinatal course had not been investigated. METHODS During an 21-month period, 12,865 prenatal ultrasound studies were performed on a total of 4,551 patients, and 221 prenatal surgical consultations were obtained through a newly established fetal treatment program at a tertiary care prenatal diagnostic center. To evaluate the impact of prenatal pediatric surgical consultation on perinatal course, the authors reviewed changes in management including termination of pregnancy, in utero intervention, and altered site, mode, or timing of delivery. RESULTS Two hundred twenty-one fetuses were referred for consultation; their 234 congenital anomalies included genitourinary (36%), thoracic (16%), intraabdominal (14.5%), abdominal wall (10.6%), neurological (9%), skeletal (6%), and head and neck (2.5%) defects; 2.5% had tumors and 2.5% were twin pregnancies. Pregnancy was terminated in 9.5% of cases, because of patient request, chromosomal abnormality, or dismal prognosis. In 3.6%, the decision to terminate was changed as a result of consultation. Site of delivery was changed as a result of consultation in 37% to facilitate postnatal evaluation and initiate immediate treatment. Mode of delivery was changed in 6.8% to prevent dystocia, hemorrhage into a tumor, as in sacrococcygeal teratoma, or to provide an emergency airway, as in cervical teratoma. The timing of delivery was changed in 4.5% to avoid further damage to fetal organs in cases of obstructive uropathy, gastroschisis, sacrococcygeal teratoma with high-output failure, and hydrocephalus. Five percent (11) underwent treatment in utero for fetal hydrothorax, obstructive uropathy, twin-twin transfusion syndrome, or lymphangioma. The overall perinatal mortality rate was 2.5%. CONCLUSION Prenatal pediatric surgical consultation may have a significant impact on the perinatal management of the fetus with a surgically correctable congenital anomaly. Providing obstetric colleagues and families with valuable insight into the surgical management of anomalies allows fetal intervention when appropriate, and delivery in an appropriate setting, by the safest mode of delivery, and at the gestational age appropriate to minimize effects of the anomaly.

Incarceration of inguinal hernia in infants prior to elective repair

The low morbidity and good results of elective herniorrhaphy in children are adversely affected by incarceration. Since incarceration is a potentially avoidable complication, we reviewed 908 consecutive cases to determine its incidence and consequences in children awaiting elective operation for an inguinal hernia. Eighty-five of the 908 children presented with an incarcerated hernia. Thirty of these 85 patients (35%) were known to have an inguinal hernia prior to incarceration, and 25 of the 30 were awaiting elective hernia repair. The median time from surgical office visit to planned operation was 22 days, but the mean interval from office visit to incarceration was 8 days. Eighty-five percent of the children with incarcerated hernias were infants under 1 year of age. Seventy-one of the 85 patients with an incarcerated hernia (84%) had successful manual reduction. They were all admitted and had a mean hospital stay of 2.5 days. Emergency operation after unsuccessful attempts at reduction was required in the other 14 children, increasing the average length of stay to a mean of 4.0 days. Significant complications, including infarction of the testis or ovary, bowel obstruction, intestinal necrosis, wound infection, and recurrent hernia, occurred in 26 of the 85 children (31%). We conclude that incarceration is a preventable problem. Even patients scheduled for hernia repair are at risk and the operation should be performed soon after the diagnosis is made. Infants are the highest priority group, since 35% of children less than 12 months of age experienced incarceration while awaiting elective surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

The hidden morbidity of pediatric trauma

In an attempt to characterize the emotional and behavioral consequences of severe multisystem injury on pediatric trauma patients and members of their immediate family, 54 former trauma patients and their families were studied at least 1 year after discharge. Of those in a home setting, 60% had residual personality changes. Physical and cognitive handicaps, often multiple, were present in 50%; and social, affective, and learning disabilities were present in like number. Only 20% of the 50 children are in a regular school class; the other 80% require special-needs education. An unexpected finding was the effect of the accident on uninjured siblings, 66% of whom were reported to have developed emotional disturbances, school problems and aggressive personality changes. Parents reported a worsening of their martial relationship in 32% of cases, and new social and financial problems in 60%. Twenty-one mothers who were previously employed have stopped working to care for their child and 20% of families have exhausted their savings or gone into debt. Although a variety of support services were available to these families, they reported little use of extended care facilities, visiting nurses, and counselors. There is a hidden morbidity in pediatric trauma. It manifests years after injury, not only as physical disability but also as changes in cognition, personality and behavior, and as family stress. Since success in pediatric trauma care is the restoration of the child as nearly as possible to his premorbid state, these data suggest that more attention and resources should be directed to the late consequences of multisystem injury in children.

Renal cell carcinoma in association with tuberous sclerosis in children

Tuberous sclerosis, a genetically transmitted multisystem neurocutaneous disorder, is associated with renal lesions in 50% of cases. The expected lesions are angiomyolipomas or renal cysts; renal cell carcinoma has been encountered in adults who have tuberous sclerosis, but is very rare in children. The authors report the case of a 5-year-old girl with tuberous sclerosis for whom atypical computed tomography findings led to the diagnosis of renal carcinoma at an early age. This experience suggests that children with tuberous sclerosis may need earlier screening.

Experimental hemorrhage and blunt trauma do not increase circulating tumor necrosis factor.

Tumor necrosis factor (TNF) is a potent cytokine mediator of the shock states associated with sepsis and burn injury. This experimental study was done to determine whether circulating TNF plays a major role in the vasomotor collapse seen following experimental hemorrhage and blunt injury. Twenty anesthetized pigs were divided into two groups. Ten animals were bled 60% of their calculated blood volume in 15 minutes. Animals in Group IA (n = 5) had no treatment, and Group IB animals (n = 5) were given twice the shed volume as crystalloid 30 minutes after hemorrhage. The other animals, groups IIa and IIb (n = 5 each), were first subjected to a blunt injury to the thigh sufficient to cause a midshaft femur fracture, then bled and similarly treated. In both groups, mean arterial pressure (MAP), cardiac output (CO), and serum TNF activity by L929 bioassay were measured at 15-minute intervals for 120 minutes after hemorrhage or hemorrhage and blunt injury. An additional three animals were infused with 4 x 10(8)/kg heat-killed E. coli to validate the TNF assay. All bled animals sustained a fall in MAP and CO to a mean of 33% of baseline values, with or without fracture. Group IB and IIB animals responded to fluid resuscitation by restoration of MAP and CO to 85%-97% of the baseline values. Tumor necrosis factor was not detectable before injury and remained undetectable in all these animals during the 120 minutes of the experiment despite hemorrhage alone or combined hemorrhage and blunt trauma, with or without fluid resuscitation. The test animals receiving the E. coli responded with markedly elevated TNF levels, which peaked at 90 minutes after injection.(ABSTRACT TRUNCATED AT 250 WORDS)

Carotid artery thrombosis and stroke after blunt pharyngeal injury.

A 2-year-old child fell on a toothbrush, sustaining a pharyngeal injury. Eighteen hours later, localizing symptoms of a cerebrovascular accident became evident. Magnetic resonance angiography showed occlusion of the internal carotid artery and a cerebral infarction. She was treated with anticoagulation and made a complete recovery. Pharyngeal injuries may be complicated by internal carotid artery thrombosis and embolus. Management includes prompt diagnosis, anticoagulation, and carotid artery exploration in selected cases.

A pediatric trauma model of continuous hemorrhage

This report describes a new experimental model of hemorrhage in immature animals. Puppies were subjected to continuous hemorrhage equivalent to 1% of calculated blood volume per minute. In the control group there was no change in mean arterial pressure, central venous pressure, cardiac output, hematocrit, pH, or core temperature. In the experimental group the response to hemorrhage was gradual and in proportion to blood loss until 25% to 30% blood volume reduction. At this critical point, the fall in mean arterial pressure and cardiac output accelerated and death occurred. These observations suggest that the response to blood loss has break points beyond which sudden deterioration is rapid and dramatic. This model of hemorrhage should be useful for future study of the effects of treatment of hemorrhagic shock in immature subjects.

Rational surgery for tumors of the ovary in children

Summary Six malignant ovarian tumors (8%) were found during 77 operations for cysts and tumors of the ovary in children. Two of the six patients already had widespread abdominal metastases. The other four with localized disease were treated by unilateral salpingoovariectomy and are alive and free of disease. Ovarian cancer in children is rare, and apparently is found either very early or very late in its course. This experience suggests that the initial operation should be restricted to unilateral salpingoovariectomy. Abdominal hysterectomy and contralateral salpingoovariectomy can be completed soon thereafter if the surgical specimen shows a malignant tumor which has spread beyond the confines of the ovary.

The development of pyloric stenosis during transpyloric feedings

Three infants, ages 3 to 4 months, had nasojejunal feeding tubes placed for recurrent aspiration and/or feeding intolerance after upper gastrointestinal cineradiographs (ugi) had documented gastroesophageal reflux (GER) with normal pyloric channels and prompt gastric emptying. The tubes had been in place for 3 and 4 weeks, respectively, in the first two infants when classic hypertrophic pyloric stenosis (HPS) was found during fundoplication and gastrostomy tube placement. The last child had a failed attempt at nasogastric tube feedings following 3 months of nasojejunal tube feedings. A repeat ugi suggested HPS, which was confirmed by pyloric ultrasound. This infant underwent pyloromyotomy alone. The late presentation of HPS in these infants suggests that transpyloric tubes might cause the development of HPS and exacerbate the symptoms of preexisting GER. In infants who are expected to eat by mouth, pyloromyotomy alone might allow the reinstitution of orogastric feedings without the perioperative morbidity of fundoplication and gastrostomy tube placement.