Laura R. Vick

Acute, subacute, and chronic cervical lymphadenitis in children

Lymphadenopathy refers to any disease process involving lymph nodes that are abnormal in size and consistency. Lymphadenitis specifically refers to lymphadenopathies that are caused by inflammatory processes. Cervical lymphadenopathy is a common problem in the pediatric age group and is largely inflammatory and infectious in etiology. Although most patients are treated successfully by their primary care physician, surgical consultation is frequently required for patients who fail to respond to initial therapy or for those in whom there is an index of suspicion for a neoplastic process. This article addresses current approaches to the diagnosis and management of cervical lymphadenitis in children.

Gastric electrical stimulation for children with intractable nausea and gastroparesis

PURPOSE Gastric electrical stimulation (GES) has been performed in adults as a treatment of refractory nausea and vomiting in patients who have failed medical treatment, but has not been used in children. METHODS Nine patients with chronic nausea and vomiting with a mean age of 14 years were evaluated for temporary GES. All 9 patients subsequently underwent placement of a temporary followed by permanent GES device. Symptoms were recorded at baseline, after temporary GES, and then after permanent GES using a Likert scale for gastroparesis. Statistical analysis was performed using a paired Students t test. RESULTS At baseline, all patients were symptomatic and most had delayed solid gastric emptying. As a group, there was a significant improvement in combined symptoms score (P = .04), nausea (P = .039), and vomiting (P = .0016). Gastric emptying and electrogastrogram values did not change significantly. Follow-up ranged from 8 to 42 months, with 7 of the 9 patients reporting sustained improvement in symptoms and improved quality of life. CONCLUSIONS Gastric electrical stimulation can be successfully applied to adolescents with intractable nausea and gastroparesis symptoms who fail medical therapy. There is a significant improvement in symptoms over a prolonged period, and there are no adverse effects of the GES. Long-term efficacy of this therapy in children needs to be established.

Recombinant factor VIIa as an adjunct in nonoperative management of solid organ injuries in children

BACKGROUND Ongoing bleeding after blunt solid organ injury in children may require invasive therapy in the form of either angiographic or operative control. We report our experience in the use of a procoagulant, recombinant activated factor VII (rFVIIa), for controlling persistent bleeding in blunt abdominal trauma in children. METHODS After institutional review board approval, the records of 8 children with blunt abdominal trauma, persistent bleeding, and managed nonoperatively with rFVIIa were reviewed. RESULTS All 8 patients presented to our institution after sustaining blunt abdominal trauma and solid organ injury. All children had evidence of persistent bleeding with a drop in hematocrit and elevation in heart rate. Patients received a single dose of rFVIIa at 75 to 90 microg/kg (1 patient had 24 microg/kg) and had successful control of their bleeding without any further therapeutic intervention. Only 3 patients required a blood transfusion after rFVIIa administration--2 who had subarachnoid hemorrhages and the third during pelvic fixation. There were no cases of thromboembolic events after treatment with rFVIIa. CONCLUSIONS Recombinant factor VIIa is a useful adjunctive therapy in pediatric patients with evidence of ongoing hemorrhage from blunt abdominal injury and may reduce the need for invasive therapeutic procedures and transfusions.

Partial splenectomy prevents splenic sequestration crises in sickle cell disease

PURPOSE Acute splenic sequestrations (SSs) are potentially fatal complications in sickle cell disease (SCD). Total splenectomies in young patients may predispose them to a higher risk of overwhelming infections, whereas partial splenectomy may maintain immunocompetence. We present our series of partial splenectomies in patients with multiple SS episodes. METHODS We retrospectively reviewed the records of 6 patients who underwent open partial splenectomies for SS. Data on their clinical courses were collected and analyzed. RESULTS None of the 6 patients had SS postprocedure, down from 2.1 +/- 1.0 (P = .003) sequestrations per year and 3.5 +/- 1.4 (P = .002) total sequestrations per patient. The transfusion requirements were significantly reduced postoperatively (10.2 +/- 5.6 vs 2.0 +/- 3.1 per year; P = .002). There was no increase in the infection-related hospital admissions during the period of follow-up (1.5 +/- 1.8 vs 0.8 +/- 0.8 per year after partial splenectomy; P = .363). The upper pole was preserved in all cases with blood supply off the main splenic artery. CONCLUSIONS Partial splenectomy decreases the risk of SS in SCD and reduces the need for blood transfusions. Infection rates did not increase after the procedure during the follow-up period. Partial splenectomy should be considered for patients who experience multiple acute SS crises or have long-term transfusion requirements.

Instability of Fellowship Intentions During General Surgery Residencies

PURPOSE To determine whether PGY-1 future fellowship preferences are stable during progression through residency. METHODS Residents who took the American Board of Surgery In-Training Examination (ABSITE) were surveyed about fellowships. Three data files were created: categorical and nondesignated preliminary trainees at all postgraduate years (PGY); categorical PGY-1 and chief residents; and individual categorical residents with paired PGY-1 and PGY-5 responses. Gender was self-reported; residency characteristics were retrieved via program identifier codes. Annual frequency distributions were generated by specialty and for other, any fellowship (AF), and no fellowship (NF). RESULTS Categorical plus contains more than 80,000 responses. Undecided leads PGY-1 intentions at all times, which reached 55% by 2007 and decreased near linearly as PGY level advances. The AF rates increase by PGY level in a decelerating curve. The other rates accelerate at PGY-3 and beyond. The NF rates are low for PGY-1 and 2, nearly double from PGY-3 to 4, and double again from PGY-4 to 5. The categorical group contains more than 20,000 residents with their demographics. The undecided group predominates for both genders, but more women were undecided by 2003. Specialty distribution varies with gender; women were overrepresented in oncology, pediatric, plastic, and other. The undecided group leads choices of university and independent PGY-1 residents, with university overrepresentation in all areas except colorectal, plastic, and no fellowship. Small, medium, and large program PGY-1 residents all choose undecided first but diverge thereafter. Over 12,000 paired categorical PGY-1 and PGY-5 responses reveal that most PGY-1 residents (78%) change future specialties by PGY-5. Undecided residents most often choose no fellowship (25%), vascular (12%), or other (12%). CONCLUSION PGY-1 residents are increasingly unsure about future fellowships. PGY-1 preferences are unstable whether examined in groups or as individuals. Gender and residency characteristics are linked to differing selection patterns. PGY-1 residents rarely predict accurately their PGY-5 fellowship choices. Early specialization paradigms may disadvantage some residents and residency groups and risk greater attrition rates.

Factors in fellowship selection: effect of services and fellows.

PURPOSE General Surgery residents are increasingly pursuing fellowships. We examine whether perceived subspecialty content, dedicated services, and fellows impact fellowship choices. METHODS Specialty content was assessed through a survey linking 228 operations to 9 content areas. The presence of dedicated services and fellows and the post-residency activities of graduates 1997-2006 were collected from 2 program directors. RESULTS A total of 75% of residents (26 University of Mississippi, UM; 22 Vanderbilt University, VU) completed surveys. Five dedicated services and 2 fellowships at UM and VU were identical; VU had an additional 4 services and 3 fellowships. UM and VU residents similarly associated 184 operations (81%) with General Surgery. Agreement was not linked to services or fellows. A total of 44% of UM graduates and 68% of VU graduates pursued fellowships. The top choice at UM was Plastic/Hand (14%, versus 6% VU) and Oncology/Endocrine at VU (19%, versus 2% UM). Differences in specialties selected could not be linked consistently to dedicated services or fellows. CONCLUSION Dedicated services and fellows appear to have little impact on fellowship specialty selection by chief residents. There may be a generic effect of dedicated services favoring fellowship versus no fellowship. Differential faculty mentoring skills may influence specific fellowship choices.

Effect of Dakin's Solution on Components of a Dermal Equivalent

BACKGROUND The use of Dakins solution on open wounds remains controversial in clinical practice. Here we investigated the effect of Dakins solution on collagen degradation and fibroblast migration using a dermal equivalent. MATERIALS AND METHODS Acid solubilized or neutralized collagen was combined with four dilutions of Dakins solution (0.5%, 0.25%, 0.125%, 0.0125%), with and without serum, at room temperature and 37 degrees C. Collagen degradation was examined at 0, 1, and 24 h using 8% SDS-page gels. Cell migration was determined using dermal equivalents where fibroblasts were incorporated into 3D collagen gels and exposed to Dakins solution with and without serum. The cells were assessed for viability and cell migration at 24 and 48 h. RESULTS Dakins at 0.0125% resulted in little or no collagen degradation compared with a higher concentration of 0.5%, where collagen was either partially or completely degraded. Likewise, cell migration was completely inhibited at higher concentrations, while fibroblasts in a 3D matrix at 0.0125% were still able to migrate at 24 and 48 h, albeit in fewer numbers compared with controls. Serum had a protective effect for both collagen degradation and cell migration when added together with the Dakins solutions. A time and temperature dependent effect was also noted, with longer contact and higher temperatures being more detrimental. CONCLUSIONS Collagen degradation and fibroblast migration is affected by the concentration of Dakins solution, the presence or absence of serum, time exposure and temperature. Use of Dakins solution in clinical settings should take these findings into consideration in clinical practice.