Mindy B. Statter

Omphalopagus Twins With Covered Cloacal Exstrophy

The incidence of conjoined twins is approximately 1/100,000 births and 70% of the twins are female.’ Approximately 40 to 60% of conjoined twins are stillborn and an additional 35% survive only 1 day. These early deaths generally occur in the most severely malformed twins, especially those with thoracopagus joining and major cardiopulmonary malformation. Approximately 35% of the twins are the omphalopagus type, which comprises a wide spectrum ranging from shared liver, intestines and bladder to a mere skin bridge.* We report the anatomical findings and separation of the eighteenth reported case of minimally conjoined omphalopagus twins.3

Targeting pediatric pedestrian injury prevention efforts: teasing the information through spatial analysis

BACKGROUNDnPediatric pedestrian injuries remain a major cause of childhood death, hospitalization, and disability. To target injury prevention efforts, it is imperative to identify those children at risk. Racial disparities have been noted in the rates of pediatric pedestrian injury and death. Children from low-income families living in dense, urban residential neighborhoods have a higher risk of sustaining pedestrian injury. Geographic information systems (GIS) analysis of associated community factors such as child population density and median income may offer insights into prevention.nnnMETHODSnUsing trauma registry E-codes for pedestrian motor vehicle crashes, children younger than 16 years were identified, who received acute care and were hospitalized at the University of Chicago Medical Center, a Level I pediatric trauma center, after being struck by a motor vehicle from 2002 to 2009. By retrospective chart review and review of the Emergency Medical Services run sheets, demographic data and details of the crash site were collected. Crash sites were aggregated on a block by block basis. A hot spot analysis was performed to localize clusters of injury events. Using Gi* statistical method, spatial clusters were identified at different confidence intervals using a fixed distance band of 400 m (≈ ¼ mile). Maps were generated using GIS with 2000 census data to evaluate race, employment, income, density of public and private schools, and density of children living in the neighborhoods surrounding our medical center where crash sites were identified. Spatial correlation is used to identify statistically significant locations.nnnRESULTSnThere were 3,521 children admitted to the University of Chicago Medical Center for traumatic injuries from 2002 to 2009; 27.7% (974) of these children sustained injuries in pedestrian motor vehicle injuries. From 2002 to 2009, there were a total of 106 traumatic deaths, of which 29 (27.4%) were due to pedestrian motor vehicle crashes. Pediatric pedestrian motor vehicle crash sites occurred predominantly within low-income, predominantly African-American neighborhoods. A lower prevalence of crash sites was observed in the predominantly higher income, non-African-American neighborhoods.nnnCONCLUSIONSnSpatial analysis using GIS identified associations between pediatric pedestrian motor vehicle crash sites and the neighborhoods served by our pediatric trauma center. Pediatric pedestrian motor vehicle crash sites occurred predominantly within low-income, African-American neighborhoods. The disparity in prevalence of crash sites is somewhat attributable to the lower density of children living in the predominantly higher income, non-African-American neighborhoods, including the community immediately around our hospital. Traffic volume patterns, as a denominator of these injury events, remain to be studied.

The umbilical mass: a rare neonatal anomaly

Umbilical anomalies are a rare presentation in the pediatric patient. The differential diagnosis includes anomalies resulting from urachal and vitelline duct derivatives such as urachal sinus, urachal cyst, urachal diverticulum, patent urachus, herniated Meckel’s diverticulum, umbilico-enteric fistula, or umbilical polyp. In this article, a case presentation of an umbilical anomaly along with the differential diagnosis and management options are discussed. Based upon this review of the literature, the authors propose a management algorithm for treating children with umbilical anomalies.

A high prevalence of methicillin-resistant Staphylococcus aureus among surgically drained soft-tissue infections in pediatric patients

Over the past decade, methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a global problem, prompting extensive surveillance efforts. A previous study of S. aureus isolates at our institution revealed alarming increases in the prevalence of MRSA with no sign of plateau. However, evidence of MRSA in pediatric surgical patients remains largely anecdotal, as there are no published reports of institutional MRSA surveillance in the pediatric surgical literature. We conducted a retrospective review of incision and drainage (I and D) procedures at our institution from 1998 through 2004. All I and D procedures performed at the University of Chicago Children’s Hospital were identified and the patients’ charts reviewed for pertinent information. A total of 99 I and D procedures were performed during the study period, ranging from 5 in 1998 to 32 in 2004. Among cultures with positive growth, 52 (65.8%) were MRSA, 14 (17.7%) were methicillin-sensitive S. aureus, and 13 (16.5%) were miscellaneous species. The number of MRSA isolates increases from 2 in 1998 to 20 in 2004, the largest increase occurring during the last 3xa0years of the study. A large proportion of MRSA isolates were resistant to antimicrobials from other classes, with over 70% being resistant to both erythromycin and cefazolin. A majority of MRSA isolates (71.4%) were obtained from patients with no record of prior hospitalization. Our analysis confirms a high prevalence of MRSA among soft-tissue infections requiring surgical drainage. In addition, a majority of MRSA isolates were resistant to multiple antimicrobials and were isolated from children without a previous documented exposure to the hospital milieu. Thus, pediatric surgeons should be aware of MRSA prevalence and resistance patterns in the local communities.

Modern treatment modalities for neonatal and pediatric respiratory failure

BACKGROUNDnRespiratory failure secondary to a variety of causes remains a significant cause of morbidity and mortality in the pediatric population. Newer therapies are appearing frequently in an attempt to decrease the number of deaths from this disease state. We briefly review the current literature on some of the newer modalities including: high-frequency ventilation, surfactant, liquid ventilation, and nitric oxide. We then present our experience from the past 11 years in the most invasive, yet successful, therapy for acute respiratory failure-extracorporeal membrane oxygenation (ECMO).nnnMETHODSnRetrospective review of all patients treated with ECMO from September 1983 to December 1994 was undertaken. Data were collected from bedside ECMO flow sheets and the standardized data entry forms submitted to the Extracorporeal Life Support Organization. All statistical analyses were performed using a standard statistical software program.nnnRESULTSnDuring the study period, 194 neonates and 47 pediatric patients were treated with ECMO. The survival rate in the neonatal population is 82% and in the pediatric population it is 40%. The neonatal patients required an average of 153 hours of support while the pediatric patients required 220 hours (P = 0.008).nnnCONCLUSIONSnWhile the newer treatment modalities discussed may have an important role in treating neonatal and pediatric respiratory failure in the near future, ECMO remains a cornerstone of the modern treatment modalities. Although somewhat invasive, ECMO is effective therapy with increasing survival rates each year.

Trends in pediatric ostomy surgery: intestinal diversion for necrotizing enterocolitis and biliary diversion for biliary hypoplasia syndromes.

Ostomies are placed in children for different indications than in the older population. Many ostomies of childhood are placed because of congenital or neonatal problems that require temporary or long-term diversion to stabilize the neonatal patient. Necrotizing enterocolitis, the most common reason for placement of neonatal colostomies and ileostomies, is increasing in frequency as more prematurely born infants survive. Recently, there has been an increase in treatment of various biliary hypoplasia syndromes with biliary cutaneous diversion. Children with biliary hypoplasia syndromes are a challenging group of patients who frequently can be helped by ostomies. This article reviews current information on biliary cutaneous diversion for the biliary hypoplasia syndromes and intestinal diversion for necrotizing enterocolitis.

Nitrogen balance during extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) has been used as a support system for neonates with pulmonary failure since 1975. During ECMO, thermal regulation, pulmonary gas exchange, and cardiac output can be partially or nearly completely provided by the circuit. The presumed resultant decrease in energy requirement has prompted the question of whether infants are in a catabolic or anabolic state of metabolism while on ECMO. Directly measuring the metabolic rate in babies on ECMO is difficult. However, studying the nitrogen balance in these infants may suggest an answer. Nitrogen balance was studied in 21 neonates spanning a single ECMO teams experience at two institutions. Children were studied at the Ochsner Clinic from 1986 to 1990 and at the University of Chicago Wyler Childrens Hospital from 1990 to the present. The infants received total parenteral nutrition (TPN) as their only nutritional source during the entire ECMO course. During this time, 24-h urine collections were analyzed for urea nitrogen (UUN). The daily nitrogen balance was calculated by subtracting nitrogen output (estimated as the UUN) from nitrogen input (the measured amino acid content of the intravenous feeding). Fecal losses were not included in the nitrogen output since the infants were not enterally fed and rarely had stools while on ECMO. The kilojoules (1 kilocalorie = 4.2 kilojoules) and protein provided by the parenteral nutrition varied. Nitrogen intake exceeded nitrogen output by ECMO day 2 (the initial nitrogen balance determination). Infants receiving as little as 0.4 g/kg protein and 168 kJ/kg daily remained in positive nitrogen balance.

Surgical Conditions Presenting with Diarrhea

This chapter will focus on those surgical conditions that present with diarrhea in the child and the adult. The diarrheal disorders will be classified as acute or chronic, typed as bloody or non-bloody, with suggested management for children and adults, respectively.