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ABSTRACT: Oxidation of L[1-C]methionine ([C]-Met) in liver mitochondria can be quantified by measuring exhaled CO2. We hypothesized that CO2 recovery after i.v. administered [C]-Met would provide a noninvasive measure of liver function in pediatric intestinal failure-associated liver disease (IFALD). After Institutional Review Board (IRB) approval, 27 patients underwent L[1-C]-Met breath tests ([C]-MBTs), five of whom underwent repeat testing after clinical changes in liver function. Sterile, pyrogen-free [C]-Met was given i.v. Six breath samples collected during 120 min were analyzed for CO2 enrichment using isotope ratio mass spectrometry. Pediatric end-stage liver disease (PELD) scores were recorded, and total carbon dioxide (CO2) production was measured by indirect calorimetry. Twenty-seven patients (median age = 5.3 mo) underwent a total of 34 [C]-MBTs without adverse events. Fourteen patients had documented liver biopsies (five with cirrhosis and nine with cholestasis or fibrosis). The [C]-MBT differentiated patients with and without cirrhosis (medians 210 and 350, respectively, p = 0.04). Serial [C]-MBTs in five patients reflected changing PELD scores. i.v. administering the stable isotope [C]-Met with serial breath sampling provides a useful, safe, and potentially clinically relevant evaluation of hepatic function in pediatric IFALD. The [C]-MBT may also help quantify progression or improvement of IFALD.
Pediatric Research 10/2010; 68(4):349-54. · 2.70 Impact Factor
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ABSTRACT: Adverse drug events (ADEs) are a common complication of medical care resulting in high morbidity and medical expenditure. Population level estimates of outpatient ADEs are limited. Our objective was to provide national estimates and characterizations of outpatient ADEs and determine risk factors associated with these events.
Data are from the National Center for Health Statistics which collects information on patient visits to outpatient clinics and emergency departments throughout the United States. We examined visits between 1995 and 2005 and measured the national annual estimates of and risk factors for outpatient ADEs requiring medical treatment.
The national annual number of ADE-related visits was 4 335,990 (95%CI: 4 326 872-4 345 108). Visits for ADEs to outpatient clinics increased over the study period from 9.0 to 17.0 per 1000 persons (p-value for trend < 0.001). In multivariate analyses, factors associated with ADE visits included patient age (OR: 2.13; 95%CI: 1.63-2.79 for 65 years and older), number of medications taken by patient (OR: 1.88; 95%CI: 1.58-2.25 for five medications or more), and female gender (OR: 1.51; 95%CI: 1.34-1.71). Overall, outpatient ADEs resulted in 107,468 (95%CI: 89 011-125 925) hospital admissions annually, with older patients at highest risk for hospitalization (p-value for trend < 0.001).
Both patient age and polypharmacy use are risk factors for ADE-related healthcare visits, which have substantially increased in outpatient clinics between 1995 and 2005. The incidence of ADEs has particularly increased among patients 65 years and older with as many as 1 in 20 persons seeking medical care for an ADE.
Pharmacoepidemiology and Drug Safety 09/2010; 19(9):901-10. · 2.53 Impact Factor
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ABSTRACT: The diagnostic evaluation, patient stratification, and prenatal counseling for congenital obstructive uropathy remain sub-optimal. Matrix metalloproteinase (MMP) expression profiles are emerging as a valuable diagnostic tool in assorted disease processes. We sought to determine whether congenital obstructive uropathy impacts MMP expression in fetal urine.
Fetal lambs (n = 25) were divided in two groups: group I (n = 12) underwent a sham operation and group II (n = 13) underwent creation of a complete urinary tract obstruction. Gelatin zymography panels for 4 MMP species were performed on fetal urine in both groups at comparable times post-operatively. Statistical analysis was by the Fisher's exact test (P < .05).
Overall fetal survival was 80% (20/25). A variety of significant differences in MMP expression between the two groups were identified. The following profiles were present only in obstructed animals: any MMP other than MMP-2 (P = .029), including any MMP other than 63 kDa and 65 kDa (P = .009); 2 or more MMPs excluding MMP-2s (0.029); and 3 or more MMPs (P = .029).
Limited matrix metalloproteinase expression is present in the urine of normal ovine fetuses. Fetal obstructive uropathy impacts urinary MMP expression in various distinguishable patterns. Prenatal urinary MMP profiling may become a practical and valuable diagnostic tool in the evaluation of congenital obstructive uropathy.
Journal of Pediatric Surgery 01/2010; 45(1):70-3. · 1.45 Impact Factor
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ABSTRACT: We measured the relative impact of influenza and respiratory syncytial virus (RSV) infections in young children in terms of emergency department (ED) visits, clinical care requirements, and overall resource use.
Patients who were aged <or=7 years and treated in the ED of a tertiary care pediatric hospital for an acute respiratory infection were enrolled during 2 winter seasons between 2003 and 2005. We quantified health care resource use for children with influenza or RSV infections, and extrapolated results to estimate the national resource use associated with influenza and RSV infections.
Nationally, an estimated 10.2 ED visits per 1000 children were attributable to influenza and 21.5 visits per 1000 to RSV. Children who were aged 0 to 23 months and infected with RSV had the highest rate of ED visits with 64.4 visits per 1000 children. Significantly more children required hospitalization as a result of an RSV infection compared with influenza, with national hospitalization rates of 8.5 and 1.4 per 1000 children, respectively. The total number of workdays missed yearly by caregivers of children who required ED care was 246965 days for influenza infections and 716404 days for RSV infections.
For young children, RSV is associated with higher rates of ED visits, hospitalization, and caregiver resource use than is influenza. Our results provide data on the large number of children who receive outpatient care for influenza and RSV illnesses and serve to inform analyses of prevention programs and treatments for both influenza and RSV disease.
PEDIATRICS 12/2009; 124(6):e1072-80. · 4.47 Impact Factor
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ABSTRACT: Adverse drug events (ADEs) are a common complication of medical care, but few pediatric data are available describing the frequency or epidemiology of these events. We estimated the national incidence of pediatric ADEs requiring medical treatment, described the pediatric population seeking care for ADEs, and characterized the events in terms of patient symptoms and medications implicated.
Data were obtained from the National Center for Health Statistics, which collects information on patient visits to outpatient clinics and emergency departments throughout the United States. We analyzed data for children 0 to 18 years of age seeking medical treatment for an ADE between 1995 and 2005.
The mean annual number of ADE-related visits was 585922 (95% confidence interval [CI]: 503687-668156) of which 78% occurred in outpatient clinics and 12% occurred in emergency departments. Children 0 to 4 years of age had the highest incidence of ADE-related visits, accounting for 43.2% (95% CI: 35.6%-51.2%) of visits. The most common symptom manifestations were dermatologic conditions (45.4% [95% CI: 36.9%-54.1%]) and gastrointestinal symptoms (16.5% [95% CI: 11.1%-23.8%]). The medication classes most frequently implicated in an ADE were antimicrobial agents (27.5% [95% CI: 21.5%-34.5%]), central nervous system agents (6.5% [95% CI: 4.0%-10.5%]), and hormones (6.1% [95% CI: 3.1%-11.6%]). While ADEs related to antimicrobial agents were most common among children 0 to 4 years old and decreased in frequency among older children, ADEs resulting from central nervous system agents and hormones increased in frequency among children 5 to 11 and 12 to 18 years old.
ADEs result in a substantial number of health care visits, particularly in outpatient clinics. The incidence of ADEs and medications implicated vary by age, indicating that age-specific approaches for monitoring and preventing ADEs may be most effective.
PEDIATRICS 10/2009; 124(4):e744-50. · 4.47 Impact Factor
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ABSTRACT: Adult studies of celiac disease (CD) have shown that duodenal mucosal histopathological changes may be patchy, and the diagnostic utility of duodenal bulb biopsies is believed to be limited. Few related pediatric data exist.
We assessed the prevalence of variable biopsy findings and duodenal bulb involvement in children with CD, as well as its association with clinical parameters. A total of 198 consecutive cases of CD diagnosed at the Children's Hospital during 2001-2005 were analyzed. All biopsies were scored by a pathologist blinded to the clinical data using the Marsh criteria. Mucosal changes were classified as focal if changes consistent with CD and normal mucosa were found within a single biopsy fragment. Patchiness was defined as variation of at least one Marsh grade between separate fragments in a biopsy set.
The median age was 9.3 years; 62% were female. An average of 3.6 biopsy samples was obtained per case. In 101 cases, biopsy samples were obtained from the duodenal bulb and the second portion of the duodenum. Focality was present in biopsy samples collected from 36 (18%) cases. Patchiness was found in 105 (53%) cases, and at least 1 normal biopsy fragment was present in 71 (36%) cases. In 10 cases, only the bulb biopsies were diagnostic of CD. There was no association with the clinical features examined.
Duodenal involvement in pediatric CD is frequently patchy and may show variable severity even within a single biopsy fragment. Variability cannot be predicted by clinical characteristics. Multiple endoscopic biopsies, including the duodenal bulb, should be obtained in suspected pediatric CD cases to maximize diagnostic yield.
The American Journal of Gastroenterology 10/2009; 105(1):207-12. · 7.28 Impact Factor
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ABSTRACT: The purpose of our study was to examine the reliability of nurse reports of adverse events related to procedural sedation in children. A descriptive, correlational design was used to analyze for inter-rater agreement between prospective adverse event reporting and that identified on independent review of the medical record. All sedation documentation at a pediatric hospital over one calendar year was reviewed, and inter-rater reliability of reporting was analyzed using K statistics. Five thousand forty-five sedation documentation records were reviewed. An adverse event rate of 6.52% was identified: 1.92% of adverse events were serious, and 4.60% were minor. Although overall agreement between nurse reports and independent review was greater than 99%, subanalysis suggested greater agreement for serious events than for minor ones (K values: 0.85 vs 0.49, P < .01). The results of our study revealed that minor adverse events associated with procedural sedation were under-reported, despite clear perianesthesia documentation in the medical record that an event had occurred. Improved education for perianesthesia nurses regarding the importance of monitoring both for serious and minor adverse events will help to identify opportunities to improve sedation protocols.
Journal of perianesthesia nursing: official journal of the American Society of PeriAnesthesia Nurses / American Society of PeriAnesthesia Nurses 10/2009; 24(5):300-6.
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ABSTRACT: Agitation that occurs in children receiving standard procedural sedation regimens may indicate inadequate patient comfort and compromise procedural success. Although agitation in uninterrupted pediatric procedures is recognized to occur, it is not generally tracked as an adverse event, and there have been no formal studies to determine its rate of incidence.
We identified intraprocedural agitation in a large cohort of children undergoing standardized sedation regimens in a tertiary care pediatric hospital over a calendar year and compared it with rates of well-accepted quality measures of sedation using odds ratio analysis, with 95% confidence intervals (CIs). All analyses excluded those patients who were documented to fail to sedate or to wake before the procedure was over-2 tracked adverse events that involve agitation and aborted, interrupted, or incomplete procedures.
Agitation occurred in 433 of 5045 (8.6%) procedures during the study period, including 306 (6.1%) who had an uninterrupted, complete procedure. In contrast, severe adverse events during sedation, including cardiovascular resuscitation and allergic reactions, were exceedingly rare (0.9 %). When excluding patients who woke during the procedure or who failed to sedate, we found that the odds ratio for the association between agitation and tracked adverse events was 2.9 (95% CI = 1.7-4.8; P < .001).
A clinically significant number of children appear agitated during standard procedural sedation and analgesia. In addition, agitation in children undergoing uninterrupted procedures was associated with other adverse events. Identifying risk factors for agitation is fundamental to improving the quality of procedural sedation in children.
Clinical Pediatrics 09/2009; 49(1):35-42. · 1.15 Impact Factor
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ABSTRACT: Parenteral nutrition is known to cause liver injury in babies. The aim of this study is to investigate the effects of different lipid emulsions on parenteral nutrition-associated cholestasis in infants. In addition, there may be a relationship between the lipid emulsion and triglyceride levels. Furthermore, triglyceride levels may correlate with direct bilirubin and albumin, as markers of liver impairment and nutritional status. Patients with parenteral nutrition-associated cholestasis who were treated with a fish oil-based lipid emulsion (n = 18) were prospectively followed for triglyceride, direct bilirubin, and albumin levels and compared with patients who were maintained on a soy-based lipid emulsion (n = 59). Triglyceride levels decreased in the fish oil cohort from a mean of 140 mg/dL at wk 0 to 40 mg/dL at wk 20 but remained unchanged at approximately 140 mg/dL in the soybean cohort. Triglyceride levels of patients treated with fish oil declined over time, while those receiving soybean oil did not. Also, changes in triglyceride levels over time were directly correlated with direct bilirubin and inversely related to albumin levels. These findings may indicate an added benefit of reduced triglyceride levels for patients treated with fish oil and this effect coincides with markers for improved liver function and nutritional status.
Pediatric Research 09/2009; 66(6):698-703. · 2.70 Impact Factor
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ABSTRACT: The objective was to determine the safety and efficacy of a fish oil-based intravenous lipid emulsion (ILE) in the treatment of parenteral nutrition-associated liver disease (PNALD).
PNALD can be a lethal complication in children with short bowel syndrome (SBS). ILE based on soybean oil administered with parenteral nutrition (PN) may contribute to its etiology.
We performed an open-labeled trial of a fish oil-based ILE in 42 infants with SBS who developed cholestasis (serum direct bilirubin >2 mg/dL) while receiving soybean oil-based ILE. Safety and efficacy outcomes were compared with those from a contemporary cohort of 49 infants with SBS and cholestasis whose PN course included soybean ILE only. The primary efficacy end-point was time to reversal of cholestasis (direct bilirubin <=2 mg/dL).
Three deaths and 1 liver transplantation occurred in the fish oil cohort, compared with 12 deaths and 6 transplants in the soybean oil cohort (P = 0.005). Among survivors not transplanted during PN, cholestasis reversed while receiving PN in 19 of 38 patients in the fish oil cohort versus 2 of 36 patients in the soybean oil cohort. Based on Cox models, subjects receiving fish oil-based ILE experienced reversal of cholestasis 6 times faster (95% CI: 2.0-37.3) than those receiving soybean oil-based ILE. The provision of fish oil-based ILE was not associated with hypertriglyceridemia, coagulopathy, or essential fatty acid deficiency. Moreover, hypertriglyceridemic events and abnormal international normalized ratio levels were more common among controls.
Fish oil-based ILE is safe, may be effective in treating PNALD, and may reduce mortality and organ transplantation rates in children with SBS.
Annals of surgery 08/2009; 250(3):395-402. · 7.90 Impact Factor
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ABSTRACT: Low birth weight is the most important risk factor for developing necrotizing enterocolitis (NEC). We aimed to establish birth weight-based benchmarks for in-hospital mortality in neonates with NEC.
Five hundred eleven centers belonging to the Vermont Oxford Network prospectively evaluated 71,808 neonates with birth weight of 501 to 1500 g between January 2005 and December 2006. The primary outcome variable was in-hospital mortality.
Birth weight was divided into 4 categories by 250-g increments. The NEC risk (P < .001) and mortality (P < .001) decreased with higher birth weight category. Necrotizing enterocolitis was associated with a significant odds ratio for death for each category (P < .001). Across groups, the odds ratio for NEC mortality increased with higher birth weight category (category 1 = 1.6 vs category 4 = 9.9; P < .001).
The in-hospital mortality rate of neonates with NEC remains high and is significantly related to birth weight category. Although the risk and absolute mortality of NEC decrease with higher birth weight, the odds ratios indicate that NEC has a relatively greater impact upon mortality at higher birth weight. These data afford birth weight-based mortality benchmarks that may be useful in assessing single center NEC outcomes and facilitating comparisons between centers.
Journal of Pediatric Surgery 07/2009; 44(6):1072-5; discussion 1075-6. · 1.45 Impact Factor
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ABSTRACT: Graft-vs-host disease (GvHD) is a known complication of in utero bone marrow transplantation. However, GvHD has been difficult to study owing to frequent fetal demise. We describe the first consistent murine model of GvHD with postnatal survival after in utero hematopoietic cell transplantation.
A 50/50 mixture of bone marrow and splenocytes (10(6)) from 6-week-old C57/BL6 (H2-b) mice was injected intraperitoneally into Balb/c (H2-d) fetuses at e14 to 16. Live born pups were followed for clinical GvHD. Peripheral blood and hematopoietic organ chimerism was confirmed by flow cytometry and polymerase chain reaction. Organ samples were isolated for histology.
Twenty-seven (75%) of 36 surviving pups displayed clinical GvHD by 2 weeks compared with 9 developmentally normal pups. Mean difference in weight between the 2 groups was 2.9 g at 7 days and 5.2 g at 14 days of life (P < .0001). All 27 pups with clinical GvHD and 1 normal-appearing pup had blood chimerism ranging from 1.5% to 65%. Eight of the 9 normal-appearing pups had 0% chimerism. Histologic analysis revealed findings of GvHD in liver, spleen, small intestine, and skin specimens of only chimeric pups.
A consistent murine model of GvHD can be achieved after in utero transplantation of major histocompatibility complex-mismatched bone marrow and splenocytes. Future studies will use this model to examine approaches to prevent GvHD after in utero stem cell transplantation.
Journal of Pediatric Surgery 07/2009; 44(6):1102-7; discussion 1107. · 1.45 Impact Factor
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ABSTRACT: We aimed at determining whether osseous grafts engineered from amniotic mesenchymal stem cells (aMSCs) could be used in postnatal sternal repair.
Leporine aMSCs were isolated, identified, transfected with green fluorescent protein (GFP), expanded, and seeded onto biodegradable electrospun nanofibrous scaffolds (n = 6). Constructs were dynamically maintained in an osteogenic medium and equally divided into 2 groups with respect to time in vitro as follows: 14.6 or 33.9 weeks. They were then used to repair full-thickness sternal defects spanning 2 to 3 intercostal spaces in allogeneic kits (n = 6). Grafts were submitted to multiple analyses 2 months thereafter.
Chest roentgenograms showed defect closure in all animals, confirmed at necropsy. Graft density as assessed by microcomputed tomographic scans increased significantly in vivo, yet there were no differences in mineralization by extracellular calcium measurements preimplantation and postimplantation. There was a borderline increase in alkaline phosphatase activity in vivo, suggesting ongoing graft remodeling. Histologically, implants contained GFP-positive cells and few mononuclear infiltrates. There were no differences between the 2 construct groups in any comparison.
Engineered osseous grafts derived from amniotic mesenchymal stem cells may become a viable alternative for sternal repair. The amniotic fluid can be a practical cell source for engineered chest wall reconstruction.
Journal of Pediatric Surgery 07/2009; 44(6):1120-6; discussion 1126. · 1.45 Impact Factor
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Chi-Fu Jeffrey Yang,
Michele Lee, Clarissa Valim,
Melissa A Hull,
Jing Zhou,
Brian A Jones,
Kathy Gura,
Sharon Collier,
Clifford Lo,
Christopher Duggan,
Tom Jaksic
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ABSTRACT: Parenteral nutrition-associated liver disease (PNALD) is a serious condition affecting many children with short bowel syndrome. The aim of this study was to longitudinally assess serum alanine aminotransferase (ALT), a marker for hepatocyte injury, in enterally fed children with PNALD.
Retrospective chart review of 31 patients treated from 1999 to 2006 by the Center for Advanced Intestinal Rehabilitation at Children's Hospital Boston (Mass). Inclusion criteria included PN duration of greater than 3 months with subsequent tolerance of full enteral nutrition and evidence of PN-associated liver injury. Time to normalize ALT and direct bilirubin were estimated using Kaplan-Meier and Cox proportional hazards methods.
Mean age PN cessation was 6 months (range, 2-14 months). Median PN duration was 18 weeks (interquartile range [IQR], 13-33 weeks), and median follow-up was 24 weeks (IQR, 14-48 weeks). After transition to full enteral nutrition, 74% of children normalized direct bilirubin, whereas only 50% normalized ALT. Kaplan-Meier median time to direct bilirubin and ALT normalization were 13 weeks and 35 weeks, respectively (P = .001).
Children with PNALD who have achieved PN independence have persistent ALT elevation despite normal direct bilirubin levels. This implies that hepatic injury may be ongoing beyond the time of bilirubin normalization in this cohort of patients.
Journal of Pediatric Surgery 07/2009; 44(6):1084-7; discussion 1087-8. · 1.45 Impact Factor
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ABSTRACT: Although bowel length is an important prognostic variable used in the management of children with short bowel syndrome (SBS), reliable measurements can be difficult to obtain. Plasma citrulline (CIT) levels have been proposed as surrogate markers for bowel length and function. We sought to evaluate the relationship between CIT and parenteral nutrition (PN) independence in children with SBS.
A retrospective chart review performed for all patients seen in a multidisciplinary pediatric intestinal rehabilitation clinic with a recorded CIT between January 2005 and December 2007 (n = 27).
Median age at time of CIT determination was 2.4 years. Diagnoses included necrotizing enterocolitis (26%), intestinal atresias (19%), and gastroschisis (22%). Citrulline levels correlated well with bowel length (R = 0.73; P < .0001) and was a strong predictor of PN independence (P Wilcoxon = 0.002; area under the receiver operating characteristic curve = 0.88; 95% confidence interval, 0.75-1.00). The optimal CIT cutoff point distinguishing patients who reached PN independence was 15 micromol/L (sensitivity = 89%; specificity = 78%).
Plasma CIT levels are strong predictors of PN independence in children with SBS and correlate well with a patient's recorded bowel length. A cutoff CIT level of 15 micromol/L may serve as a prognostic measure in counseling patients regarding the likelihood of future PN independence.
Journal of Pediatric Surgery 05/2009; 44(5):928-32. · 1.45 Impact Factor
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ABSTRACT: Serial transverse enteroplasty (STEP) is a novel technique to lengthen and taper bowel in patients with intestinal failure. First described in 2003, initial data and reports have demonstrated favorable short-term outcomes, but there is limited published data on long-term outcomes of the procedure. Our aim was to assess clinical and nutritional outcomes after the STEP procedure.
After obtaining institutional review board approval, we reviewed all records of patients (n = 16) who underwent the STEP procedure at our institution from February 2002 to February 2008. Patients were observed for a median time of 23 months (range, 1-71) postoperatively. Analyses of z scores for weight, height, and weight-for-height, and progression of enteral calories were performed using longitudinal linear models with random effects.
Of the 16 patients (10 male), the median age at time of surgery was 12 months (interquartile range, 1.5-65.0). The mean increase in bowel length was 91% +/- 38%. After the STEP procedure, patients had increased weight-for-age z scores of 0.03 units per month (P = .0001), height for age z scores of 0.02 units per month (P = .004), and weight-for-height z scores of 0.04 units per month (P = .02). Patients had improved enteral tolerance of 1.4% per month (P < .0001). Six patients (38%) transitioned off parenteral nutrition (median, 248 days). Long-term complications included catheter-related bacteremia (n = 5), gastrointestinal bleeding (n = 3), and small bowel obstruction (n = 1). Two patients ultimately underwent transplantation. There were no deaths.
In pediatric patients with intestinal failure, the STEP procedure improves enteral tolerance, results in significant catch-up growth, and is not associated with increased mortality.
Journal of Pediatric Surgery 05/2009; 44(5):939-43. · 1.45 Impact Factor
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ABSTRACT: Monitoring hepatic function in children with short bowel syndrome (SBS) and parenteral nutrition-associated liver disease (PNALD) is currently limited to conventional blood testing or liver biopsy. Metabolism of the stable isotope L[1-(13)C]methionine occurs exclusively in liver mitochondria and can be noninvasively quantified in expired breath samples. We hypothesized that the (13)C-methionine breath test ((13)C-MBT) could be a safe, noninvasive, and valid measure of hepatic mitochondrial function in children with SBS and PNALD.
Baseline breath samples were collected in 8 children with SBS before intravenous administration of 2 mg/kg of L[1-(13)C]methionine. Six paired breath samples were obtained at 20-minute intervals. The (13)CO(2) enrichment was analyzed using isotope ratio mass spectrometry.
All 8 patients (5 males; mean age, 8.9 months) tolerated the (13)C-MBT without adverse events. Two patients underwent serial testing. One patient, tested before and after resolution of cholestasis, demonstrated increased cumulative percentage dose (4.7% to 6.6%) and area under the curve (AUC) (270-303). A second patient with progressive PNALD demonstrated decreased cumulative percentage dose (from 7.8% to 5.9%) and AUC (from 335 to 288).
The (13)C-MBT is a feasible, safe, and potentially clinically relevant measure of hepatic mitochondrial function in children with SBS and PNALD.
Journal of Pediatric Surgery 02/2009; 44(1):236-40; discussion 240. · 1.45 Impact Factor
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ABSTRACT: We aimed to identify risk factors for neonatal surgical airway intervention among fetuses with prenatally diagnosed cervical masses.
An 8-year retrospective review identified 23 consecutive patients with a prenatal diagnosis of a neck mass, managed at a single tertiary center. Variables analyzed included anticipated diagnosis, extent of the mass, need for any surgical airway intervention in the neonatal period, final histopathology data, and survival. Statistical analysis was based on the Fisher and Fisher-Freeman-Halton exact tests (significance set at P < or = .05) and exact 95% confidence intervals for risk differences.
Eight patients underwent termination of pregnancy or were lost to follow-up. The imaging-based prenatal diagnosis was confirmed postnatally in 93% (14/15) of the remaining patients. Final diagnoses included lymphatic malformation (8), teratoma (6), and esophageal duplication (1). Teratomas were associated with a significantly higher risk for neonatal airway intervention than lymphatic malformations (67% vs 11%, P = .02). The majority of such procedures were performed under ex utero intrapartum treatment. Survival was 93% (14/15).
Cervical teratomas are significantly more likely to demand surgical airway intervention in the neonate, typically under ex utero intrapartum treatment, than cervical lymphatic malformations. These findings should be considered in the prenatal counseling for fetal cervical masses.
Journal of Pediatric Surgery 01/2009; 44(1):76-9. · 1.45 Impact Factor
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ABSTRACT: Many pediatric endoscopists are adopting propofol in their practices, with the expectation that propofol will increase their overall efficiency.
To compare the efficiency of propofol versus midazolam and fentanyl by measuring elapsed times between initial intravenous administration and patient discharge at a pediatric teaching hospital.
Endoscopy times were prospectively collected for consecutive patients who were undergoing either anesthesiologist-administered propofol or endoscopist-administered midazolam and fentanyl. The effect of the type of sedation on these times was assessed by using multiple linear regression by adjusting for other candidate predictors, including concomitant use of other sedatives, endotracheal intubation by anesthesiologists, and the presence of fellow trainees.
Time to onset of sedation (time sedation started to scope in), procedure time (endoscope in to endoscope out), discharge time (endoscope out to hospital discharge), and total time (sedation started to hospital discharge).
The times for 134 children (mean age 12 +/- 5 years) to receive propofol sedation were compared with those of 195 children (13 +/- 5 years) who received midazolam and fentanyl. Midazolam and fentanyl cases disproportionately included EGDs (P < .001) and patients who were classified as American Society of Anesthesiologists I (P < .03). Patients who received propofol had shorter times until sedated, similar procedure times, longer discharge times, and comparable total times. Multivariate analyses confirmed that fellow participation prolonged the procedure times (P < .0001), and endotracheal intubation prolonged propofol times (P <. 01), but adjusting for these did not change the comparison results.
Anesthesiologist-administered propofol sedation in a pediatric teaching endoscopy unit may not lead to faster hospital times when compared with endoscopist-administered midazolam and fentanyl. These results are not explained by controlling for patient characteristics, the presence of a trainee, the sedative doses, or endotracheal intubation for airway management.
Gastrointestinal endoscopy 06/2008; 67(7):1067-75. · 6.71 Impact Factor
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Kathleen M Gura,
Sang Lee, Clarissa Valim,
Jing Zhou,
Sendia Kim,
Biren P Modi,
Danielle A Arsenault,
Robbert A M Strijbosch,
Suzanne Lopes,
Christopher Duggan,
Mark Puder
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ABSTRACT: Parenteral nutrition-associated liver disease can be a progressive and fatal entity in children with short-bowel syndrome. Soybean-fat emulsions provided as part of standard parenteral nutrition may contribute to its pathophysiology.
We compared safety and efficacy outcomes of a fish-oil-based fat emulsion in 18 infants with short-bowel syndrome who developed cholestasis (serum direct bilirubin level of > 2 mg/dL) while receiving soybean emulsions with those from a historical cohort of 21 infants with short-bowel syndrome who also developed cholestasis while receiving soybean emulsions. The primary end point was time to reversal of cholestasis (3 consecutive measurements of serum direct bilirubin level of < or = 2 mg/dL).
Among survivors, the median time to reversal of cholestasis was 9.4 and 44.1 weeks in the fish-oil and historical cohorts, respectively. Subjects who received fish-oil-based emulsion experienced reversal of cholestasis 4.8 times faster than those who received soybean emulsions and 6.8 times faster in analysis adjusted for baseline bilirubin concentration, gestational age, and the diagnosis of necrotizing enterocolitis. A total of 2 deaths and 0 liver transplantations were recorded in the fish-oil cohort and 7 deaths and 2 transplantations in the historical cohort. The provision of fish-oil-based fat emulsion was not associated with essential fatty acid deficiency, hypertriglyceridemia, coagulopathy, infections, or growth delay.
Parenteral fish-oil-based fat emulsions are safe and may be effective in the treatment of parenteral nutrition-associated liver disease.
PEDIATRICS 03/2008; 121(3):e678-86. · 4.47 Impact Factor
