Neonatal gut barrier and multiple organ failure: role of endotoxin and proinflammatory cytokines in sepsis and necrotizing enterocolitis.

Background/purpose: Failure of the gut barrier and endotoxemia have been implicated in sepsis and multiple organ failure (MOF) syndromes in adults. The contributions of endotoxin (ETX) and proinflammatory cytokines (CKs) to the pathophysiology of disease and the outcomes of infants in the neonatal intensive care unit (NICU) are not clear. We measured ETX and CK concentrations in infants who presented with clinical signs of sepsis and/or necrotizing enterocolitis (NEC) to study their impact on MOF and outcomes.

Portal venous gas and surgical outcome of neonatal necrotizing enterocolitis.

Purpose: The prognostic significance of portal venous gas (PVG) in neonatal necrotizing enterocolitis (NEC) for operative intervention (OP), neonatal complications, and mortality remains uncertain. The authors designed a long-term prospective study to describe the natural history of PVG related to these outcomes and to test the hypothesis that PVG does not mandate OP.

Methods: All infants admitted to a single center between October 1991 and February 2003 were evaluated weekly to identify all cases of NEC (defined as Bell stage II or higher).

Rotavirus-associated necrotizing enterocolitis: an insight into a potentially preventable disease?

Purpose: The aim of this study was to test the hypothesis that rotavirus-associated necrotizing enterocolitis (NEC + RV) differs from NEC associated with other organisms (NEC-RV).

Methods: Neonates with modified Bell stage II or higher NEC were identified. Demographic, clinical, and outcome information was collected prospectively.

Surgical management of bowel perforations and outcome in very low-birth-weight infants (< or =1,200 g).

Purpose: The efficacy of peritoneal drainage (PD) as an alternative to laparotomy (LAP) in the management of bowel perforation (PRF) in very low-birth-weight infants (VLBW < or = 1,200 g) remains uncertain. The authors hypothesized that survival of VLBW infants with PRF depends on the severity of illness rather than on the initial surgical approach.

Methods: Demographic, clinical, and outcome data on all VLBW infants were abstracted prospectively over a 12(1/2)-year period.

Infection control: avoiding the inevitable.

Infection, while a major cause of morbidity, should not be considered an inevitable consequence of injury. Good aseptic technique, compulsive attention to detail, and thorough understanding of the points addressed in the following list of critical points are the best guarantee that infection will not add avoidable morbidity to misfortune. Critical points regarding infectious problems in care of the injured child: 1.

Pediatric cervical spine injuries: defining the disease.

Background/purpose: Pediatric cervical spine injuries are uncommon. Most previous studies have been hampered by the small number of patients available for evaluation. The purpose of this study is to determine the incidence and characteristics of pediatric cervical spine injury utilizing a multiinstitutional pediatric trauma database, and to assess the impact of age and level of spine injury on mortality rate.

Nosocomial pneumonia in the pediatric trauma patient: a single center's experience.

Objectives: To evaluate a single center's experience with the frequency rate, patterns of occurrence, and impact on outcome of nosocomial pneumonia in the critically injured child.

Design: Retrospective review of prospectively collected data.

Setting: Level I university trauma center with a pediatric trauma intensive care unit.

Infectious complications in critically injured children.

Purpose: Infection will complicate the care of a significant number of injured adults. Trauma is the leading cause of mortality in the pediatric population, yet little information is available regarding the incidence of infection in this group. This study evaluates infectious complications in the critically injured child.

Complications of retained internal bolster after pediatric percutaneous endoscopic gastrostomy.

Purpose: Percutaneous endoscopic gastrostomy (PEG) has been widely accepted as an efficacious means of nutritional support in the infant and child. A well-described technique uses the Gauderer-Ponsky tube (CR Bard Incorporated, Tewksbury, MA) drawn antegrade through the gastric wall and secured by an internal and external SILASTIC (Dow Corning; Midland, MI) bolster. The majority of reported complications attendant to its use occur secondary to insertion.

Altered monocyte calcium dynamics in sepsis.

Purpose: This study was designed to evaluate monocyte calcium concentration and mobilization in normal and septic surgical patients.

Methods: Monocytes were isolated from 15 "septic" surgical patients, washed, and loaded with the fluorescent calcium chelator, FURA-2. Monocytes from 20 normal volunteers served as controls.

Acute abdomen. The teenage girl.

The evaluation of abdominal pain in the adolescent female is a common and often challenging problem. The unique anatomy and biology of the postmenarcheal teenager necessitates the consideration of a broad variety of additional genitourinary problems not encountered in the male. Further complicating this issue, the differential diagnoses involves not only pathological considerations, but normal physiological processes that may, in and of themselves, be symptomatic.

Blunt hepatic injury in adolescents: age makes a difference.

This analysis of mortality from blunt hepatic injury was performed to define outcome in the adolescent age group in relation to that recorded for children and adults. Children (age 0-10 years) were selected from a multi-institutional trauma registry, adults (age > or = 21 years) from the registry of a Level I trauma center, and adolescents (age 11-20 years) from both. Groups were compared by injury frequency, proportion of severe hepatic injuries (code 864.

Nitric oxide synthase inhibition negates septic-induced alterations in cytoplasmic calcium homeostasis and membrane dynamics.

This study was undertaken to evaluate the role of nitric oxide (NO) in the sepsis-induced disruption of intracellular calcium homeostasis and membrane dynamics. Anticoagulated whole blood was obtained from 10 healthy volunteers. Equal aliquots were incubated with saline (control), 2 microg/mL Escherichia coli endotoxin (lipopolysaccharide), 8 microg/mL NO inhibitor, N-monomethyl arginine (NMA), and endotoxin plus NO inhibitor (lipopolysaccharide/NMA).

Death from pelvic fracture: children are different.

This study compares outcome from pelvic fractures in children with that of adults. Data for 23,700 children registered in the National Pediatric Trauma Registry (NPTR) were compared with those of 10,720 adults recorded over 5 years in the registry of our level I trauma center. Patients were categorized by open versus closed fracture and by fracture type as defined by a modification of the Key and Conwell system.

Leukocyte modulation inhibits endotoxin-induced disruption of intracellular calcium homeostasis.

Objective: Sepsis is associated with disruption of intracellular calcium homeostasis. The specific mechanisms responsible for these changes remain unclear. This study attempts to modify endotoxin-induced alterations in erythrocyte intracellular calcium dynamics through modulation of the activated leukocyte and its products.

Effect of sepsis on erythrocyte intracellular calcium homeostasis.

Objectives: To examine erythrocyte intracellular calcium dynamics in clinical sepsis and experimental endotoxemia.

Design: Prospective, multiexperimental study utilizing in vitro manipulation and evaluation of human erythrocytes.

Setting: University research laboratory.

Selective management of pediatric esophageal foreign bodies.

Esophageal foreign body is a relatively common consultation from the Pediatric Emergency Room. This study evaluates optimal selective management of esophageal foreign bodies in the pediatric patient. Eighty-six children have been referred for esophageal foreign body.

Sepsis-induced alterations in the erythrocyte membrane.

Sepsis is known to alter red blood cell (RBC) deformability, and this change in flexibility may play a role in the pathophysiology of the hemodynamic alterations characteristic of the septic syndrome. The etiology of this red cell change is unclear. This study evaluates erythrocyte size and cell membrane fluidity during clinical (septic surgical patients) and experimental (endotoxin incubation) sepsis.

The effect of endotoxin on neonatal erythrocyte intracellular calcium concentration.

Erythrocyte membrane deformability is dependent on the maintenance of "normal" intracellular calcium (Ca) levels. Red cell flexibility is known to be altered in the septic neonate. In turn, this adversely affects viscosity and compromises flow in the microcirculation.

The effect of endotoxin on the neonatal erythrocyte.

Intestinal ischemia is considered a major factor in the development of necrotizing enterocolitis (NEC). Despite this, the majority of affected infants lack documentation of clinical events associated with obvious gut hypoperfusion. Recent evidence in adults suggests that endotoxin may impair flow in the microcirculation through alterations in erythrocyte deformability.

Role of the leukocyte in endotoxin-induced alterations of the red cell membrane. Second place winner of the Conrad Jobst Award in the Gold Medal paper competition.

Sepsis and endotoxemia are known to be associated with alterations in the red cell membrane that result in diminished flexibility. This decreased flexibility may be responsible, in part, for the microcirculatory abnormalities accompanying sepsis. The etiology of these sepsis-associated changes remains unclear.

The nature and reversibility of hypothermia-induced alterations of blood viscosity.

This study evaluates the nature and reversibility of the increase in whole blood viscosity known to be induced by hypothermia. Anticoagulated samples were obtained from normal volunteers and were assayed for cellular deformability by 4.7 microns membrane filtration of whole blood (n = 12) and washed RBCs (n = 10).

Does patient age or intestinal pathology influence the bacteria found in cases of necrotizing enterocolitis?

To evaluate the relationship between bacterial colonization in neonatal peritonitis and patient age or intestinal pathology, we retrospectively reviewed peritoneal culture results from 96 infants having surgery for necrotizing enterocolitis. Microorganisms recovered mirrored those usually found as fecal flora within the neonatal intensive care unit. These reflect, in turn, the abnormal colonization intrinsic to care in the intensive care nursery.

A randomized clinical trial of ampicillin, gentamicin and clindamycin versus cefotaxime and clindamycin in children with ruptured appendicitis.

This prospective, randomized, double-blind study compares the efficacy, safety and cost-effectiveness of ampicillin, gentamicin and clindamycin (AGC) or cefotaxime and clindamycin (CC) for the treatment of children with complicated appendicitis. Ninety-seven children were randomized. Forty-seven were assigned to the AGC regimen and 50 received CC.

The role of pentoxifylline in endotoxin-induced alterations of red cell deformability and whole blood viscosity in the neonate.

Endotoxin induces alterations in the neonatal red cell membrane that result in decreased deformability and an increase in whole blood viscosity. These rheologic alterations are detrimental to flow in the microcirculation. Pentoxifylline (PTX), a methyl xanthine derivation, increases red cell deformability presumably through its effect on intracellular adenosine 5-triphosphate.