Kevin P. Moriarty

Anesthetic management of the exit (ex utero intrapartum treatment) procedure

The EXIT (ex utero intrapartum treatment) procedure is used to maintain fetal-placental circulation during partial delivery of a fetus with a potentially life-threatening upper airway obstruction. We performed the EXIT procedure on a fetus with a large intra-oral cyst. Sevoflurane was used as the anesthetic because of its rapid titratability. Sevoflurane provided excellent maternal and fetal anesthesia. Modifications to previously described monitoring techniques for the EXIT procedure were also used.

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.

Guns and states: pediatric firearm injury.

BACKGROUND A recent report indicates that firearm-related injuries are responsible for 30% of pediatric trauma fatality. The literature is however limited in examining pediatric firearm injuries and variations in state gun control laws. Therefore, we sought to examine the association between pediatric firearm injuries and the Stand-Your-Ground (SYG) and Child Access Protection (CAP) laws. METHODS All pediatric (age, 0–20 years) hospitalizations with firearm injuries were identified from the Kids’ Inpatient Database from 2006 and 2009. States were compared for SYG and CAP laws. RESULTS A total of 19,233 firearm injury hospitalizations were identified, with 64.7% assault, 27.2% accidental, and 3.1% suicide injury. Demographics for assault injury were as follows: mean age of 17.6 years, 88.4% male, 44.4% black, 18.2% Hispanic, 70.5% from metropolitan areas, and 50.1% from the poorest median income neighborhoods. Suicide injury cases were more likely to be white (57.8% vs. 16.6%, p < 0.001) and female (15.1% vs. 9.8%, p < 0.001). States with the SYG law were associated with increased accidental injury (odds ratio [OR], 1.282; p < 0.001). There was no statistical association between CAP law and the incidence of accidental injury or suicide. Multivariate logistic regression analysis found other predictive demographic factors for firearm injury: black (OR, 6.164), urban areas (OR, 1.557), poorest median income neighborhoods (OR, 2.785), male (OR, 28.602), and 16 years or older (OR, 37.308). Total economic burden was estimated at more than

Capsulectomy: A Cure for the Page Kidney

1 billion dollars, with a median length of stay of 3 days, 8.4% discharge to rehabilitation, and 6.2% in-hospital mortality. CONCLUSION Pediatric firearm injuries continue to be a significant source of morbidity, mortality, and economic burden. A significant increase in accidental firearm injuries in states with the SYG law may highlight inadvertent effects of the law. Race, sex, and median income are additional contributing factors. Advocacy and focused educational efforts for specific socioeconomic and racial groups may potentially reduce firearm injuries. LEVEL OF EVIDENCE Prognostic study, level II.

Primary repair of facial dog bite injuries in children

Hypertension is a known complication after renal trauma. The cause of posttraumatic hypertension can be renal scarring, infarction, hydonephrosis, infection, vascular injury, and parenchymal compression. The authors report on the case of a 16-year-old boy who experienced hypertension after blunt renal trauma. He had a dense fibrous pseudocapsule causing renal parenchymal compression, which lead to hypertension, a Page kidney. Evaluation with computed tomographic (CT) scan, radioisotope renal scan, renal Doppler, and angiogram confirmed the diagnosis. Removal of the renal capsule and the constricting fibrous pseudocapsule was curative.

Preoperative chemoembolization for unresectable hepatoblastoma.

Objectives: The management of dog bite wounds is controversial, and current data on risk of infection are variable and inconsistent. Furthermore, the use of prophylactic or empiric antibiotics for the treatment of these wounds is debatable. We investigate the rate of wound infections and other complications after primary repair of pediatric facial dog bite injuries. Methods: We reviewed 87 consecutive patients aged 18 years or younger who had facial dog bite injuries from January 2003 to December 2008. Variables examined were age, sex, setting of repair, number of sutures used for repair, whether surgical drains were used, and antibiotic administration. End points measured were incidence of wound infection, need for scar revision, and any wound complications. Results: The mean age of patients was 6.8 years, and the majority were women (53%). All facial injuries were primarily repaired at the time of presentation either in the emergency department (ED; 46%), operating room (OR; 51%), or an outpatient setting (3%). All patients received an antibiotic course, none of the patients developed wound infection, and no subsequent scar revisions were performed. Three patients repaired in the OR underwent placement of a total of 4 closed-suction drains. The mean (SD) age of patients repaired in the OR was significantly younger than those repaired in the ED (5.7 [3.9] vs 8.0 [4.5] years, respectively; P < 0.01). The number of sutures used were greater for patients repaired in the OR than in the ED (66.4 [39.6] vs 21.7 [12.5], respectively; P < 0.01). Conclusions: Intuitively, younger patients and patients with greater severity injuries are more likely to undergo repair in the OR, and this was supported by our data. Overall, we found that primary repair of pediatric facial dog bite injuries, including complex soft-tissue injuries, is safe when performed in conjunction with antibiotic administration; however, further cross-specialty studies are needed to fully characterize these end points in a larger population.

Differential collagen I gene expression in fetal fibroblasts

Abstract Complete surgical resection offers the only chance for cure in patients with hepatoblastoma (HB). Patients with unresectable lesions are given preoperative chemotherapy in an attempt to create a resectable lesion. We present a case of an 11-month-old with an unresectable stage III HB unresponsive to systemic chemotherapy. Transfemoral hepatic-artery chemoembolization resulted in a surgically resectable tumor. The patient underwent a right trisegmentectomy with complete resection of the tumor and remains tumor-free 24 months postoperatively. Salvage chemoembolization can be an effective preoperative modality to convert an unresectable tumor into a resectable one.

Hyaluronic acid-dependent pericellular matrices in fetal fibroblasts: implication for scar-free wound repair.

PURPOSE Fetal wound healing is characterized by the regeneration of normal dermis and the absence of scar. Transforming growth factor beta-1 (TGF-beta1) is a ubiquitous cytokine with potent fibrogenic effects in both postnatal and fetal wounds. Supplementing fetal wounds with TGF-beta1 results in increased fibrosis consisting primarily of collagen I. We hypothesized that the lack of scar formation in fetal wounds may be caused by differential collagen I gene (COL1A1) expression. The authors examined basal collagen Ia gene expression in human fetal, newborn, and adult dermal fibroblasts after stimulation with exogenous TGF-beta1. METHODS Subconfluent human dermal fibroblasts from fetal, newborn, and adult cell lines were incubated for 24 hours, then stimulated by incubation for 4 hours with 1 ng/mL of human recombinant TGF-beta1, or with media alone for basal collagen gene expression, and then placed in guanidium isothyocyanate buffer. To quantitate COL1A1 gene expression, total cellular RNA was extracted and subjected to northern and slot blot hybridization analysis with Dig-labeled COL1A1 probes. The membrane was exposed to x-ray film for 15 minutes and developed. RESULTS Scant COL1A1 gene transcript was detected in control fetal fibroblasts. Brief stimulation with of TGF-beta1 upregulated the COL1A1 gene transcription in fetal fibroblasts. Gene expression for COL1A1 in both postnatal cell lines appeared similar in treated and untreated cells. Housekeeping control (GAPDH) confirmed no difference in total amount of RNA at the start or end of the experiment. CONCLUSION COL1A1 gene expression is notably absent in unstimulated fetal fibroblasts, but is upregulated by TGF-beta1. In contrast, postnatal fibroblasts demonstrate significant constitutive COL1A1 gene expression at baseline and unchanged after TGF-beta1 stimulation. This differential regulation may contribute to the ability of fetal wounds to regenerate without scar and explain the effect of exogenous TGF-beta1 to increase fibroplasia in fetal dermal incisional wounds.

Accurate placement of central venous catheters using a 16-cm catheter.

Fetal fibroblasts are intrinsically different from postnatal fibroblasts. We studied the differences in expression, size, and assembly of pericellular matrices in human fetal and postnatal fibroblasts, as well as the effect of fetal fibroblast‐conditioned media as a source of migration stimulating factor on pericellular matrix formation. Fibroblasts in their fifth to fifteenth passages were cultured for 24 hours before analysis. Streptomyces hyaluronidase (0.1 U/ml), monoclonal mouse anti‐human CD‐44std, or anti‐human CD‐4 antibodies were added and incubated for 1 hour (at 4° and 37° C) before analysis of the pericellular matrices with the use of a particle exclusion technique. The pericellular matrix/cell body ratio of fetal fibroblasts was significantly larger than that of newborn (p < 0.002) and adult (p < 0.001) fibroblasts. Hyaluronidase disrupted the pericellular matrices in all three cell lines. Assembly of the pericellular matrices was blocked by anti‐human CD‐44std antibody but not by anti‐human CD‐4 antibody at both 4° and 37° C. Incubation of fibroblast cell lines in fetal fibroblast‐conditioned media did not increase pericellular matrix/cell body ratio but did increase the percentage of fibroblasts expressing a detectable pericellular matrix in adult (p < 0.01), newborn (p < 0.001), and fetal (p < 0.005) fibroblasts. We conclude that fibroblasts produce hyaluronic acid‐dependent pericellular matrices which require interaction with a hyaluronic acid‐binding protein for assembly. Large pericellular matrices are one intrinsic factor characterizing a unique fetal fibroblast phenotype.

Transanastomotic feeding tubes in repair of esophageal atresia

We determine if use of 16-cm central venous catheters (CVC) minimizes dangerous intracardiac catheter placements. We conducted a prospective study in a large community teaching hospital. Consecutive patients (n = 127) who required a CVC via either the internal jugular (IJV) or the subclavian vein (SCV) were assessed using 16 (n = 102) or 20-cm (n = 25) catheters. The main outcome measurements were (1) intracardiac placement of central venous catheters, and (2) relationship of right- or left-sided internal jugular or subclavian vein insertions to intracardiac catheter placement. Use of a 20-cm CVC resulted in 14 of 25 (56%) intracardiac placements compared with 11 of 102 (11%) using a 16-cm catheter (p < 0.0001). All intracardiac placements with the 16-cm CVC were from right-sided approaches: IJV 7 of 38 (16%), SCV 4 of 18 (18%). Use of a 16-cm CVC to access the central circulation from either the SCV or the IJV results in a significantly greater proportion of safe catheter placements than using longer CVCs, and it should become the standard of care.