Robert T. Schaller

Early recognition of neonatal abdominal wall necrotizing fasciitis

Necrotizing fasciitis (NF) of the abdominal wall occurring in newborns is associated with a 50% mortality rate. Improved survival requires early diagnosis followed by aggressive surgical débridement. During a 10-year period, we treated 7 infants who developed NF. During the same period, 32 infants were admitted with omphalitis that did not progress to NF. The patients with omphalitis and those with NF were compared. Tachycardia, abnormal white blood cell counts, induration, and violaceous skin discoloration were seen exclusively in the NF patients. Polymicrobial infections were documented in 28% of the omphalitis patients and 86% of the NF patients. All omphalitis patients survived, whereas 5 of 7 (71%) NF patients died. Adjuvant hyperbaric oxygen therapy was used for 4 infants with NF, 2 of whom survived (50%). NF is a highly morbid disease, that can be distinguished from other infant abdominal wall infections by the skin changes, white blood cell counts, heart rate, and microbiologic results. Prompt diagnosis of NF improves survival when combined with aggressive surgical débridement.

Development of carcinoma of the thyroid in iodine-deficient mice.

The hypothesis that chronic over‐stimulation of the thyroid results in the formation of thyroid neoplasms was tested. After 6 to 12 months of iodine deficiency, 61 of 78 mice demonstrated extreme hypertrophy and hyperplasia of the thyroid. Eleven others had thyroids morphologically consistent with papillary adenocarcinoma. After 18 months of iodine deficiency, necropsy in 8 of 30 mice revealed malignant neoplasms of the thyroid. Initially, iodine deficiency was accompanied by diffuse hypertrophy and hyperplasia of the thyroid, which later became nodular. This progressed to cyst formation, papillary hyperplasia and nodular “solid cell” hyperplasia, sometimes followed by malignant change. These abnormalities appeared to be completely reversed by the addition of potassium iodide to the deficient diet up to 9 months. After 18 months nodular hyperplasia persisted despite treatment with iodine. Iodine deficiency results in decreased synthesis of thyroxin. A deficiency of circulating thyroid hormone causes increased production of TSH by the pituitary, which results in chronic overstimulation of the thyroid gland. Presumably this is the basic mechanism responsible for the development of these abnormalities.

Thermal injury caused by hot pack application in hypothermic children

A three-year 1 l-month-old boy fell through a layer of ice into a pond. When retrieved about 15 minutes later, he was apneic and pulseless. Cardiopulmonary resuscitation (CPR) was begun. and two varieties of hot packsS§ were placed on his abdomen and back to initiate field rewarming. On arrival at the emergency department a physician noticed that one hot pack was painfully hot and removed the packs. After 20-30 minutes of continued CPR, a heart beat without perfusion was noted. After 45 minutes in the emergency department, effective perfusion and spontaneous respiration returned, but core temperature had fallen to 29°C. Further warming was done in a bath of 38-39°C water. Burns were noticed at the sites of one type of hot pack+ prior to transfer to intensive care (Fig. 1). Subsequent therapy included intracranial pressure monitoring and therapy with hyperventilation, paralysis, mannitol, and pentobarbital coma. During a 1 ‘iz-month hospitalization, he slowly regained speech and ambulation, but developed a hyperactive behavior disorder and did not regain his pre-injury mental development. Several well-circumscribed third degree burns were present on his anterior and posterior trunk and inner arms. They required serial excision, pigskin coverage, and eventual homografting.

Gastroschisis wringer clamp: a safe, simplified method for delayed primary closure.

When primary abdominal wall closure in a newborn with gastroschisis cannot be accomplished safely, placement of a reinforced Silastic silo facilitates delayed primary closure (DPC). In this report we describe our experience with the gastroschisis wringer clamp (GWC). The GWC is an autoclavable, 140-g, aluminum alloy device reminiscent of an old wringer washing machine. It consists of two apposing serrated rollers that pull the Silastic silo through a slotted base plate. This protects the intestine and converts the circular defect into a vertical slit to ease DPC. The GWC is adjusted daily on the awake newborn in the nursery and the magnitude of each adjustment is gauged by the infants cardiac and pulmonary status. For the past 10 years we have cared for 116 newborns with gastroschisis. The average birth weight was 2,530 g (range, 1,380 to 3,300 g). Eighty-six infants (74.1%) have undergone primary closure. The remaining 30 infants (25.9%) were treated by placement of a Silastic silo and application of the GWC, forming the basis of this report. The DPC operation was performed an average of 6.7 days (range, 3 to 23 days) following the application of the silo. Extubation was usually possible prior to the DPC, with the mean length of mechanical ventilation being 3.8 days. Three patients developed serious complications including two dehiscences of the silo-fascia interface. There were no deaths in this group of 30 patients. The GWC offers many technical advantages and can be easily reversed when the infants cardiopulmonary status deteriorates. We advocate its adoption as a method of choice in the newborn with gastroschisis who requires DPC.

Reversal of Post-Thymectomy Wasting Syndrome with Multiple Thymus Grafts in Diffusion Chambers.

Summary Wasting syndrome in neonatally thymectomized mice is reversed by multiple newborn syngeneic or allogeneic thymus grafts in diffusion chambers. Recovery from the syndrome is associated with incomplete lymphoid tissue development but restoration of normal immune capacity in affected mice. Thymic humoral factor apparently responsible for these results does not appear to be strainspecinc. The authors are indebted to Mrs. Marjory Kyte for technical assistance.