Enrique R. Grisoni

Transverse testicular ectopia

In transverse or crossed testicular ectopia, the affected gonad lies in the same canal as the normally descended testis. During a 5-yr span, three children with this form of ectopia were seen. All presented with a symptomatic right inguinal hernia and an empty scrotum on the left side. The ages at operation were 1, 3, and 5 mo. Only the first patient was reoperated. In this child, the diagnosis of transverse testicular ectopia was made during the herniorrhaphy and the ectopic, but otherwise normal, gonad returned to the abdominal cavity. A subsequent left orchidopexy through a celiotomy was done. In the last two patients, the correct diagnosis was made preoperatively. Both gonads were of equal size and normal, occupying the same hemiscrotum. A herniorrhaphy with fixation of the ectopic gonad to the opposite hemiscrotum was done in both. All three children are otherwise normal. Cases collected from the literature are discussed. The condition should be suspected if a unilateral hernia is associated with a contralateral, nonpalpable testis and may not be as rare as formerly thought.

Thrombosis and infection complicating central venous catheterization in neonates

To determine the risk of complication associated with Broviac central venous catheterization in neonates, we reviewed the records of 107 infants who were catheterized an average of 5 weeks after birth and cared for in our neonatal intensive care unit. Forty-five of the 107 neonates (42%) had one or more catheter-related complications. Infants with complications had significantly lower birth weights and gestational age, longer duration of catheterization, and more repeat catheterizations than infants without complications. The mortality rate in infants with complications was not different than that of infants without complications. The most common complications were thrombosis (23 neonates) and infection (20 neonates). The birth weight and the number of catheterizations were the best predictors of the risk of complications as determined by multiple regression analysis. We conclude that the risk of complication associated with central venous catheterization is high in our population of predominantly premature neonates; that the risk of complication is increased in neonates weighing less than 1,000 g or requiring more than one catheter; and that despite the high complication rate central venous catheterization was not associated with increased mortality in this population.

Incidence of thrombosis during central venous catheterization of newborns: A prospective study

Forty-two newborns were studied prospectively to determine the incidence of thrombosis due to central venous catheterization. Following Broviac catheter placement, the catheter tip, distal superior vena cava, and right atrium were evaluated by weekly two-dimensional echocardiograms. The presence of thrombosis was examined in relation to birth weight, gestational age, age and weight at the time of catheter placement, antithrombin III levels, and platelet counts. Six newborns (14%) were noted to have a thrombus by echocardiographic examination after the catheter had been in place for a median duration of 7 weeks. The infants with thrombus formation had significantly lower birth weights (887 +/- 231 v 1,409 +/- 766 g; P = .003) and gestational ages (27 +/- 2.4 v 30.3 +/- 4.3 weeks; P = .018) than those without thrombus. Their weights (757 +/- 203 v 1,832 +/- 1,098 g; P = .000) and ages (2.75 +/- 0.76 v 7.24 +/- 7.8 weeks; P = .002) at the time of catheter placement were also lower; the antithrombin III levels were lower at the time of catheter placement (0.32 +/- 0.08 v 0.06 +/- 0.31 U/mL; P = .001), but were normal for gestational and postnatal age. The presence of thrombosis was not related to the sex of the baby, the platelet count, or the duration of catheterization.

The New Injury Severity Score and the evaluation of pediatric trauma.

BACKGROUND To compare the effectiveness of the Injury Severity Score (ISS) and New Injury Severity Score (NISS) in predicting mortality in pediatric trauma patients. METHODS NISS, the sum of the squares of a patients three highest Abbreviated Injury Scale scores (regardless of body region), were calculated for 9,151 patients treated at four regional pediatric trauma centers and compared with previously calculated ISS values. The power of the two scoring systems to predict mortality was gauged through comparison of misclassification rates, receiver operating characteristic curves, and Hosmer-Lemeshow goodness-of-fit statistics. RESULTS Although there were significant differences in mean NISS and ISS values for each hospital, differences in the predictive abilities of the two scoring systems were insignificant, even when analysis was restricted to the subgroup of patients with severe or penetrating injuries. CONCLUSION The significant differences in the predictive abilities of the ISS and NISS reported in studies of adult trauma patients were not seen in this review of pediatric trauma patients.

Pediatric Blunt Liver Injury: Establishment of Criteria for Appropriate Management

There is no consensus regarding the most appropriate management of pediatric blunt liver injury. This study addresses this issue by reviewing our experience with blunt liver trauma in relationship to the grade of injury. Forty-one pediatric patients with blunt abdominal trauma and documented liver injury were managed from 1979 to 1989. Fifteen (37%) underwent celiotomy. Three children had extensive parenchymal injuries (grade IV or V) requiring resection and three others died intraoperatively, secondary to exsanguinating hemorrhage of associated injuries (grade V) to the hepatic veins and inferior vena cava. The need for celiotomy was obvious in these patients. In 9 of the 15 children who underwent exploration (60%), bleeding from the liver injury (grade II or III) had ceased by the time of celiotomy. These children did not appear to benefit from the operation. Twenty-six of the 41 patients (63%) were selected for nonoperative management because they were hemodynamically stable after initial resuscitation and did not show signs of associated intraabdominal injuries requiring surgical intervention. These children underwent evaluation by abdominal computed axial tomography scan (grade I, II, III, and IV injuries). Blood transfusions were given to keep the hematocrit above 30%. Seventeen of the 26 children managed nonoperatively (65%) did not require blood replacement. The mean (+/- SEM) transfusion volume for the remaining nine children was 14.8 +/- 2.5 mL/kg. Blunt liver injury represents a spectrum from a minimal parenchymal hematoma to massive liver disruption. We conclude that celiotomy is necessary for hepatic injury hemodynamically stable injured children with transfusion requirements less than 40 mL/kg can be managed nonoperatively in an appropriate setting.

Nonoperative management of liver injuries following blunt abdominal trauma in children

In a 4-year span, 12 patients with hepatic trauma were treated at our institution. After initial resuscitation, three underwent emergency celiotomy because of the severity of their injuries. This communication analyses the other nine. All of these had significant liver injuries and were managed nonoperatively. Hepatic injury was diagnosed and the severity defined by ultrasonography, radionuclide scintigraphy, or computed tomography (CT). These stable patients were initially admitted to the intensive care unit (ICU) and upon transfer to the ward, maintained on restricted activities. Seven of the nine children received blood transfusions. Although liver enzymes were initially elevated in each case, they returned to normal in 1 week. In-hospital and post-discharge imaging documented healing of the hepatic injuries in each case. Eight children are well at 3 months to 4 years follow-up. Only one of the nine nonoperatively managed patients died and this was secondary to severe head injuries. To date, there are no complications. Our nine children are added to the 23 nonoperatively treated pediatric hepatic injuries found in the literature.

Antenatal ultrasonography: The experience in a high risk perinatal center

During a 52-month span, 14,324 ultrasonographic examinations were performed on 9,453 pregnant patients. One-hundred and fifty-one anatomical malformations were found in 122 fetuses (1.29%). Our analysis of patients referred to the perinatal center for ultrasonography indicates that the number of high risk patients has increased, and a parallel increase of neonatal surgical anomalies has resulted. An analysis of fetuses concluded that anomalies of the: gastrointestinal tract had improved care, deaths occurred due to associated anomalies or severe prematurity; genitourinary system received earlier diagnosis and treatment; central nervous system/musculoskeletal system/hydrops--no difference in management, treatment or outcome was noted; teratoma/cystic hygroma--did not effect treatment; cardiovascular system--inutero medical treatment by digitalization of the mother was possible. Paradoxically, an increase in the mortality of diaphragmatic hernia patients was noted and concluded to be secondary to the extremely early detection of this anomaly.

Kawasaki syndrome: Report of four cases with acute gallbladder hydrops†

We studied gallbladder involvement in 19 patients with Kawasaki syndrome who presented over a 4-year period from 1979 to 1982. Diagnosis and follow-up of gallbladder disease were defined by real-time ultrasound. Complete spontaneous resolution of abdominal symptomatology related to the hydropic gallbladder occurred without complication and did not require surgical intervention. We suggest that the incidence of hydrops of the gallbladder in mucocutaneous lymph node syndrome is higher than commonly appreciated, since diagnosis may be missed unless ultrasound is performed.

Pediatric airbag injuries: The Ohio experience

BACKGROUND/PURPOSE We sought to determine if properly restrained children, less than 13 years of age, placed in the front passenger seat are at greater risk for trauma from airbag deployment than unrestrained children. METHODS The charts of children treated at any of 3 regional pediatric trauma centers in Ohio were reviewed for airbag injuries sustained in motor vehicle crashes between January 1995 and September 1998. Injury Severity Scores (ISS) were compared with Mann-Whitney Rank Sum Test and outcome data with Fishers Exact Tests. Statistical significance was set at P< or =.05. RESULTS Twenty-seven children aged 1 month to 12 years sustained airbag-related injuries. Sixty-one percent were girls. ISS ranged from 1 to 75 with a mean score (+/- SD) of 10 (14.5). All crashes were at reported speeds of less than 45 mph, and 64% were head-on collisions. No significant differences in the mean ISS (P = .074) occurred between groups. Both groups had similar closed head, ocular and facial injuries, extremity fractures, and number of deaths (P = 1.0). Abdominal organ injury was exclusive to the restrained group. Decapitation only occurred among unrestrained children. CONCLUSION Our data showed that airbags, with or without proper safety restraints, can lead to mortality or serious morbidity in children.

Nitric oxide synthesis inhibition: The effect on rabbit pyloric muscle

The relaxation mechanism of the pyloric smooth muscle is largely dependent on a nonadrenergic noncholinergic (NANC) inhibitory innervation mediated in part by nitric oxide (NO). The aim of the present study was to investigate the effect of NO antagonists on the contractility of the pyloric smooth muscle. In the clinical trial, 10 anesthetized experimental rabbits were infused intraarterially with the NO synthesis inhibitor N-nitro-L-arginine (L-NNA), at a concentration of 10(-4) mol/L; 10 controls received normal saline intraarterially. Pyloric contractility was assessed by balloon manometry. L-NNA infusion produced a dose-dependent increase in the frequency of the pyloric contraction. The maximal increase in frequency occurred during the slow L-NNA infusion rate of 146 ng/min (baseline-adjusted frequencies of experimental v control: 1.267 +/- 0.389 v 0.632 +/- 0.375; P = .001). The increased frequency level was sustained over the subsequent fast infusion rate of 292 ng/min (experimental v control: 1.362 +/- 0.604 v 0.704 +/- 0.579; P = .022). Both the duration and the amplitude of the pyloric contractions were not affected by the L-NNA infusion. These findings suggest that blockage of the L-arginine-NO pathway may have resulted in inhibition of the NANC-induced gastric muscle and relaxation of the pyloric sphincter. The authors speculate that the decreased NO production may be responsible for the sustained contraction of the pyloric smooth muscle with secondary hypertrophy, characteristic of hypertrophic pyloric stenosis.