Akron Children's Hospital Research Articles

The effects of educational interventions and the COVID-19 pandemic on the time to diagnosis in pediatric patients with primary central nervous system tumors.

Primary central nervous system tumors are a leading cause of death and disability amongst pediatric cancer patients. Akron Children's Hospital published data in 2018 on response time for brain tumor diagnosis and implemented components of an established program to decrease diagnostic delays and thereby reduce tumor- and treatment-related morbidities. This study evaluates if there was an improvement in the total diagnostic interval (TDI, time from symptom onset to diagnosis) after provider education. During the study, the COVID-19 pandemic forced alterations in care delivery. The impact this had on the TDI was also assessed. A retrospective chart review was performed, and patients were separated into 2008-2017 (historical) and 2018-2021 (posteducation) groups to assess the effect of educational interventions on TDI. The posteducation cohort was analyzed separately to assess the impact of COVID-19 pandemic. The 85 patients studied in the post-education group showed a median TDI of 31 days. Though not statistically significant (P = .939), this represents an 11-day decrease in median TDI compared to the historical group (42 days). In addition, the posteducation group showed an increase in the average number of healthcare provider visits (HCP, 2.4 historical to 3.2 posteducation, P = .009). The pre-COVID-19 group (median TDI 43.5 days) did not differ statistically from the post-COVID-19 group (30-day median TDI). The nonsignificant decrease in TDI and concurrent increase in HCP visits after implementation of education suggests a potential gap amongst providers in working-up primary CNS tumors. These results will influence expansion of education to further improve TDI.

Efficacy of intrathecal morphine administration in pediatric patients undergoing selective dorsal rhizotomy.

The purpose of this study was to evaluate the effectiveness of intrathecal morphine following selective dorsal rhizotomy in pediatric patients previously diagnosed with cerebral palsy. This was a retrospective, cohort analysis over the course of four years. The analysis consisted of a treatment group which received intrathecal morphine (5 mcg/kg) injection and a control group that did not receive the injection prior to dural closure. All patients underwent multilevel laminectomies for selective dorsal rhizotomy at Akron Children's Hospital. The effectiveness of the treatment was measured by total dose of hydromorphone administered on patient-controlled analgesia (PCA), number of days on oral narcotics, and cumulative dose of oral narcotic. Of the analyzed 15 pediatric patients, seven patients received intrathecal morphine injection while the other eight did not receive the treatment prior to dural closure. There was a difference of 1135 mcg in total PCA dose between the study group (3243 mcg) and the control group (4378 mcg). The total PCA dose based on weight was lower in the study group (163 mcg/kg) than in the control group (171 mcg/kg). Based on these findings, the administration of intrathecal morphine clinically reduces the opiate need in the first 96 hours post-operatively.

Evaluating Demographic Data to Improve Confidence in Equity Analytics in a Children's Hospital.

First, we reviewed how staff are trained to collect data at registration. Next, the electronic health record team standardized race and ethnicity fields with federal definitions. We found that fields were not consistently accessible across reporting tools. However, when present, all fields are sourced from the same electronic health record field. Finally, 6 months of encounters were analyzed and validated, with limitations to a seldom-populated Race 2 field. We compared data, including and excluding null values, to provide concise recommendations for standard visualizations. We uncovered many consistencies and a few inconsistencies that informed the next steps. The results informed 7 recommendations to align Akron Children's Hospital's advancement in analytics for health equity data: standardize race and ethnicity fields across all reporting tools, add Child Opportunity Index 2.0 to the enterprise data warehouse, utilize data at the time of the patient's encounter, include null fields (patient refused, unknown, and not specified) in analysis, increase reporting capabilities for social determinants of health (SDOH), standardize multiracial data visualizations, and optimize reliable upstream data collection to increase reliability for all health equity measures.

CORR Insights®: The Knee Injury and Osteoarthritis Outcome Score Does Not Have Adequate Structural Validity for Use With Young, Active Patients With ACL Tears.

1Division Director of Orthopedic Sports Medicine at Akron Children's Hospital, Akron, OH, USA J. Polousky ✉, Akron Children's Hospital, Considine Professional Building, 215 West Bowery Street, Level 7, Akron, OH 44308, USA, Email: [email protected] This CORR Insights® is a commentary on the article “The Knee Injury and Osteoarthritis Outcome Score Does Not Have Adequate Structural Validity for Use With Young, Active Patients With ACL Tears” by Marmura and colleagues available at: DOI: 10.1097/CORR.0000000000002158. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Vaccine Hesitancy and Low Immunization Rates in Children with Down Syndrome

To determine the prevalence of vaccine hesitancy and refusal among parents of children with Down syndrome and to determine how well the Parent Attitudes about Childhood Vaccines Survey (PACV) is associated with vaccine receipt among children with Down syndrome. We mailed the PACV to parents of children with Down syndrome who attend the Down Syndrome Clinic at Akron Children's Hospital and examined associations between PACV scores and immunization status at 19months of age. Of 120 surveys sent, 63 parents completed the PACV (52% response rate) of which 60 were linked to vaccination records. Of these 60 respondents, 55 children were ≥19months old. PACV scores were significantly correlated with days of underimmunization at 19months of age. All parents who refused all vaccines had PACV scores of ≥50. Only 58% of children were up to date for the combined 7 vaccine series at 19months of age. The PACV may be a valuable tool to identify vaccine hesitancy among parents of young children with Down syndrome. Special emphasis is needed to increase adherence with on-time vaccine recommendations for children with Down syndrome to optimize their health and to potentially avoid hospitalizations.

Longitudinal assessment of exercise capacity and quality of life outcome measures in cystic fibrosis: A year‐long prospective pilot study

Multiple outcomes measures including exercise capacity and quality of life are necessary to get complete and accurate picture of cystic fibrosis (CF) progression. In this pilot study, we investigated these measures in CF longitudinally for a year to determine (a) minimal clinically important difference (MCID) for 6-minute walk distance (6MWD) and CF Health-Related Quality of Life Questionnaire (CFQ-R) domains and (b) how 6MWD, CFQ-R, and spirometry change during times of exacerbation and baseline health and their relationship among each other. Subjects with moderate and severe CF (baseline FEV1 less than 70% predicted) at Akron Children's Hospital CF centre were followed for a full year longitudinally. All three tests (6MWT, CFQ-R, and spirometry) were done during each outpatient visit and weekly during inpatient admission. MCID was estimated for these parameters using distribution-based methods. Finally, data were examined visually using longitudinal graphs for each subject. Twelve CF subjects (eight [67%] males and age range 13-46years) were followed for a full year resulting in at least four encounters per subject. 6MWD (m) and CFQ-R respiratory had an MCID of 33m and 7.3, respectively. MCIDs for FEV1 (percentage predicted) and CFQ-R physical were 7.1 and 11.4, respectively. The longitudinal evaluation of multiple outcome measures during periods of disease exacerbation and baseline health showed that these parameters did not appear to change in accordance with each other. In this pilot study, MCIDs for 6MWD and CFQ-R domains were calculated for the first time to facilitate their use as additional outcome measures in CF. The disparity among multiple outcome measures highlights that these measures together may provide a more complete picture in CF than any single measure alone.

Comprehensive Sickle Cell Disease Management Is Associated with Superior Grade Attainment and High School Graduation Rates

Abstract Background: Sickle cell disease (SCD) in adolescents and young adults has been associated with low high school graduation rates. Complications of the disease may decrease school attendance, academic performance, and grade attainment. The graduation rate for patients with SCD enrolled in the Cooperative Study of Sickle Cell Disease (CSSD) was 71%. Poor educational outcomes might be due to a number of factors including socioeconomic status or days spent in the hospital due to illness. Neurological complications of SCD may also contribute. Stroke and microvascular ischemic events are detrimental to cognitive function and influence academic achievement and grade attainment. Patient and practitioner adherence to best practices, such as those described in the NHLBI 2014 guidelines vary widely, and the association of best practices with graduation rates has not been studied. We compared high school graduation rates of patients at Akron Children's Hospital Sickle Cell Disease Program (ACHSCDP) with national and local rates. Methods: We conducted a retrospective chart review of patients born between 1994 and 2000 who received care for all forms of SCD at ACHSCDP. Patients were identified through an onsite registry. Thirty-two patients were identified for chart review. We defined successful high school attainment as graduation from 12th grade, or having completed 11th grade by July 2018 and enrolled to begin 12th grade in Fall 2018, before or at 19 years of age. We determined successful high school attainment for patients at Akron Children's Hospital and assessed factors associated with success. Results: Patients born from 1994 to 2000 with sickle cell disease (SS, SC, SBeta-0, SBeta-+) were analyzed (n=32). Two patients transferred out of ACHSCDP prior to age 14 and were not included in our analysis. Of 30 patients studied, 14 were male and 16 were female. Twenty-six patients (86.7%) had graduated or were starting senior year as of July 2018. Of the 26 successful students, 12 (46.2%) had either an IEP or 504 (federally defined accommodation plan) in place. None of the 4 unsuccessful students had an IEP, however 1 student had a 504. Of the 26 successful students, 13 had HbSS, 1 had HbS/B o thal, 5 had HbS/B + thal, and 7 had HbSC. All 4 unsuccessful students had HbSS. Of the 26 successful students, clinical data from 4 years before graduation or 3 years before completion of the 11th grade revealed that the students were hospitalized an average of 5.77 days per year and visited the emergency department an average of 1.38 times per year. Of the 4 unsuccessful patients, data collected 4 years before the age of 19 revealed that the patients were hospitalized an average of 5.85 days per year and visited the emergency department an average of 1.37 times per year. Only one patient had a documented stroke, and this child successfully graduated from high school. Of the 26 successful students, 18 (69.2%) were enrolled in college after finishing high school and 3 students were in their senior year of high school. Discussion: In this cohort, a high percentage of patients (86.7%) graduated or were on track to graduate from high school. In the United States, approximately 90% of patients with SCD are African American. All patients analyzed here were African American. With this in mind, ACHSCDP patients' graduation rate compares favorably to estimated graduation rates across the US general population (84%), the U.S. African America population (76%), the U.S. sickle cell patient population (71%), the Ohio general population (84%), and the Ohio African American population (68%). The higher graduation rate among children at the ACHSCDP is associated with a multidisciplinary care model that prioritizes optimal hematologic care adhering to evidence based best practices including stroke risk screening and prevention, and use of hydroxyurea. In addition, team members assess for educations status and disease specific limitations at each encounter. A social worker advocates for educational needs. An outreach nurse makes school visits to educate staff and assist with implementation of federal accommodation plans. A teacher is available during inpatient stays to provide education in coordination with the patients' school. With comprehensive care, SCD is not a barrier to successful grade attainment, and academic distress in SCD patients should prompt re-evaluation of the patient's holistic medical care. Disclosures No relevant conflicts of interest to declare.

Calculated versus Measured MVV-Surrogate Marker of Ventilatory Capacity in Pediatric CPET.

Maximum voluntary ventilation (MVV), a surrogate marker of maximum ventilatory capacity, allows for measuring ventilatory reserve during cardiopulmonary exercise testing (CPET), which is necessary to assess ventilatory limitation. MVV can be measured directly during a patient maneuver or indirectly by calculating from forced expiratory volume in 1 s (FEV1 × 40). We investigated for a potential difference between calculated MVV and measured MVV in pediatric subjects, and which better represents maximum ventilatory capacity during CPET. Data were collected retrospectively from CPET conducted in pediatric subjects for exercise-induced dyspnea from January 2014 to June 2015 at Akron Children's Hospital. Subjects with neuromuscular weakness, morbid obesity, and suboptimal effort during the testing were excluded from the study. Thirty-five subjects (mean ± SD, age = 13.8 ± 2.7 yr, range = 7-18 yr) fulfilled the criteria. Measured MVV was significantly lower than calculated MVV (89.9 ± 26.4 vs 122.4 ± 34.5 L·min; P < 0.01). The ventilatory reserve based on measured MVV was also significantly lower than ventilatory reserve based on calculated MVV (12.4% ± 19.6% vs 36.1% ± 13.2%; P < 0.01). Calculated MVV (as well as ventilatory reserve based on calculated MVV) was significantly correlated with ventilatory parameters. By contrast, no significant correlations were found between measured MVV (or ventilatory reserve based on measured MVV) and ventilatory parameters except for peak ventilation (peak V˙E). The measured MVV was significantly lower than the calculated MVV in our pediatric subjects. The calculated MVV was a better surrogate of maximum ventilatory capacity as shown by significant correlation to other ventilatory parameters during CPET.

Pediatric advance care planning (pACP) for teens with cancer and their families: Design of a dyadic, longitudinal RCCT

Cancer is the leading cause of disease-related death for adolescents and young adults (AYAs) in the United States. Parents of AYAs with life-threatening illnesses have expressed the desire to talk to their children about end of life (EOL) care, yet, like caregivers of adult patients, struggle to initiate this conversation. Building Evidence for Effective Palliative/End of Life Care for Teens with Cancer is a longitudinal, randomized, controlled, single-blinded clinical trial aimed at evaluating the efficacy of FAmily CEntered disease-specific advance care planning (ACP) for teens with cancer (FACE-TC). A total of 130 dyads (260 subjects) composed of AYAs 14–20years old with cancer and their family decision maker (≥18years old) will be recruited from pediatric oncology programs at Akron Children's Hospital and St. Jude Children's Research Hospital. Dyads will be randomized to either the FACE-TC intervention or Treatment as Usual (TAU) control. FACE-TC intervention dyads will complete three 60-minute ACP sessions held at weekly intervals. Follow-up data will be collected at 3, 6, 12, and 18months post-intervention by a blinded research assistant (RA). The effects of FACE-TC on patient-family congruence in treatment preferences, quality of life (QOL), and advance directive completion will be analyzed. FACE-TC is an evidenced-based and patient-centered intervention that considers QOL and EOL care according to the AYA's representation of illness. The family is involved in the ACP process to facilitate shared decision making, increase understanding of the AYA's preferences, and make a commitment to honor the AYA's wishes.

Hydroxyurea to Treat Pediatric Sickle Cell Disease in Haiti - a Preliminary Report

Introduction. Haiti is the poorest nation in the Western Hemisphere, and the prevalence of sickle cell disease (SCD) in thatnation is twice that among African-Americans in the United States. Patients with SCD in Haiti have limited access to preventative care and disease management measures due to scarce healthcare resources. Hydroxyurea (HU) is a compelling option for the amelioration of complications of SCD in Haiti due to its relatively low cost, proven safety, and well-documented efficacy. Hydroxyurea programs have been implemented in India and in several African settings, however little data existto demonstrate the acceptability or feasibility of such an effort in Haiti.Study Design/Objectives. This is an open label, single arm pilot study with the primary objective of examining the acceptability and feasibility of the use of HU to treat children with SCD in an existing pediatric SCD program in Port-au-Prince, Haiti. Acceptability was defined as enrollment of a minimum of two-thirds of patients who are offered participation in the study. Feasibility was defined as two thirds of the enrolled patients being compliant with a defined minimum number of mandated study visits, lab draws, and HU doses. Secondary objectives include documenting the effect of HU on renal, hepatic, and bone marrow function as well as describing the incidence of clinical events in Haitian sickle cell patients taking HU.Methods. Patients with HbSS disease, age 2-15 years, who met minimum hematologic, renal, and hepatic parameters, were eligible for the study. Patients were approached for inclusion into the study consecutively during three separate enrollment periods from November 2015 through June 2016. The starting dose of Hydroxyurea (capsule and suspension form were available) was 20mg/kg which was increased to a maximum dose of 25mg/kg. Study visits occurred every 4 to 8 weeks at which point laboratory and clinical efficacy parameters, as well as potential adverse effects history were collected and dose modifications occurred. The study period for each patient will last 1 year. Akron Children's Hospital (ACH) IRB and the Haitian National Ethics Board approved the study. Funding for this project is provided through grants from the American Academy of Pediatrics and the ACH Foundation.Results. The study is ongoing with the enrollment period being closed as of June 2016. Forty-three patients have been enrolled, with a mean length of participation of 17.6 weeks (range 0-32 weeks).Forty-seven patients were offered participation in the study and 45 signed consent and underwent the screening process, generating an acceptability measure of 95.7%. Two out of the 45 screened patients were excluded based on results from screening labs (1 non-HbSS on confirmatory electrophoresis, 1 severe anemia) resulting in the final enrollment of 43 patients (23M:20F, mean age 9 years). Feasibility is being actively assessed.There have been no serious adverse events and no deaths. Three out of 43 enrolled patients were lost to follow-up and removed from the study due to missing 3 consecutive study visits (see figure 1). Compliance with mandated study visits was high among the enrolled patients with an attendance of 92.9% of the visits. Percent attainment of mandated laboratory tests is shown in table 1. No patients have had HU dose interruptions based on abnormal lab tests. Sixteen study patients have 6 month hematologic laboratory data available at this time: mean Hemoglobin and MCV have increased from 7.1 to 7.9g/dL and 90.6 to 107.1fL, respectively, and mean WBC and platelet count have decreased from 18.0 to 12.4(10^9/mL) and 557 to 413(10^9/mL), respectively.Conclusion. Results suggest that HU isan acceptable option for treating children with sickle cell disease in Haiti. Our preliminary data show that HU is feasible, safe, and effective in this setting. Challenges exist in ensuring reliable laboratory follow-up and will likely have to be addressed on an individual clinic and laboratory basis. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

25th Anniversary State-of-the-Art Expert Discussion With Todd A. Ponsky, MD, FACS, on the Advances of Surgical Practice in Pediatric Hernia Repair.

Dr. Todd A. Ponsky is currently Associate Professor of Surgery and Pediatrics at Northeast Ohio Medical University and a Pediatric Surgeon at Akron Children's Hospital. He attended medical school at Case Western Reserve University in Cleveland, OH, from 1995 to 1999, Residency in General Surgery at The George Washington University in Washington, DC, from 1999 to 2005, Pediatric Surgery Fellowship at Children's National Medical Center in Washington, DC, from 2005 to 2007, and an Advanced Minimally Invasive Pediatric Surgery Fellowship at The Rocky Mountain Hospital for Children in Denver, CO, from 2007 to 2008. Dr. Ponsky has a particular interest in minimally invasive pediatric surgery. He has trained over 200 surgeons in single-port and needlescopic surgery. He has written over 60 manuscripts and almost 20 book chapters. He has a strong focus on surgical education and virtual education and has directed over 20 national/international courses. He has won numerous teaching awards, including “The Faculty Teaching Award” at Case Western Reserve University's Department of Surgery in his first year as a faculty member. He is a reviewer for over 15 medical journals and is on four editorial boards. He is on the leadership of four national societies and has been Program Chair and is currently serving as Secretary on the Executive Committee of The International Pediatric Endosurgery Group (IPEG). He is involved in both outcomes and animal research with a focus on inguinal hernia physiology, foregut motility, and gastric stimulation, as well as endoscopic repair techniques for pure esophageal atresia. He has a wife, Diana, and three daughters, Sasha, Josie, and Ella.

Discordant circulating fetal DNA and subsequent cytogenetics reveal false negative, placental mosaic, and fetal mosaic cfDNA genotypes.

BackgroundThe American College of Obstetrics and Gynecology (ACOG) and Maternal Fetal Medicine (MFM) Societies recommended that abnormal cfDNA fetal results should be confirmed by amniocentesis and karyotyping. Our results demonstrate that normal cfDNA results inconsistent with high-resolution abnormal ultrasounds should be confirmed by karyotyping following a substantial frequency of incorrect cfDNA results.MethodsHistorical review of our ~4,000 signed prenatal karyotypes found ~24% of reported abnormalities would not have been detected by cfDNA. Akron Children’s Hospital Cytogenetics Laboratory has completed 28 abnormal cfDNA cases among the 112 amniocenteses karyotyped.ResultsFollowing abnormal cfDNA results our karyotypes confirmed only 60% of the cfDNA results were consistent. Our cases found a normal cfDNA test result followed by a 20 weeks anatomical ultrasound detected a false negative trisomy 18 cfDNA result. One cfDNA result that reported trisomy 21 in the fetus was confirmed by karyotyping which also added an originally undetected balanced reciprocal translocation. Another reported karyotyped case followed by a repeated microarray of pure fetal DNA, together revealed one phenotypically normal newborn with a complex mosaic karyotype substantially decreasing the newborn’s eventual reproductive fitness. This second case establishes the importance of karyotyping the placenta and cord or peripheral blood when inconsistent or mosaic results are identified following an abnormal cfDNA result with a normal newborn phenotype without a prenatal karyotype.ConclusionsThese Maternal Fetal Medicine referrals demonstrate that positive NIPT results identify an increased abnormal karyotypic frequency as well as a substantial proportion of discordant fetal results. Our results found: (1) a normal NIPT test result followed by a 20 week anatomical ultrasound detected a false negative trisomy 18 NIPT result, (2) a substantial proportion of abnormal NIPT tests identify chromosomal mosaicism that may or may not be confined to the placenta, (3) follow up karyotyping should be completed on the newborn placenta and peripheral blood when the amniocyte karyotype does not confirm the NIPT reported abnormality in order to identify ongoing risk of developing mosaic symptoms, and (4) karyotyping all high risk fetuses tested by amniocentesis defines the 24% of chromosome abnormalities not currently screened by NIPT.Electronic supplementary materialThe online version of this article (doi:10.1186/s12967-015-0569-y) contains supplementary material, which is available to authorized users.

Intravitreal bevacizumab for retinopathy of prematurity (ROP): the Akron Children's Hospital (ACH) experience

Intravitreal bevacizumab for retinopathy of prematurity (ROP): the Akron Children's Hospital (ACH) experience

Eradication of factor viii inhibitors in patients with mild and moderate hemophilia A

In hemophilia A, up to 25% of new antifactor VIII (FVIII) inhibitory antibodies (inhibitors) occur in patients with mild or moderate disease. Once the inhibitor develops, options for management include observation, immune modulation, and immune tolerance induction (ITI). Currently, there is little data to guide a clinician's management decisions. In a case series, eight of the 26 subjects with mild or moderate hemophilia complicated by an inhibitor underwent ITI; two were successful, two were unsuccessful, and four were partially successful. In a systematic review of the literature, 12 of the 16 patients with mild or moderate hemophilia responded to rituximab for treatment to eradicate the inhibitor. To increase our understanding of treatment options for inhibitor eradication in patients with mild or moderate hemophilia A complicated by an inhibitor, a secondary analysis of clinical and treatment characteristics in a cohort of 36 patients with mild or moderate hemophilia A and inhibitor was undertaken. In multivariate analyses, rituximab alone (n = 6) and other immune-modulating treatments alone (n = 2) were significantly associated with an increased likelihood of inhibitor clearance [hazard ratio (HR) = 4.4 (95% CI = 1.06–20.03) and 10.21 (95% CI = 1.17–78.28), respectively], whereas ITI alone (n = 9) was not [HR = 1.35 (95% CI = 0.44–4.07)].

ORAL PRESENTATION

ORAL PRESENTATION

Improving Care at Cystic Fibrosis Centers through Quality Improvement

Quality improvement (QI) using a clinical microsystems approach provides cystic fibrosis (CF) centers the opportunity to make a significant positive impact on the health of their patients. The availability of center-specific outcomes data and the support of the Cystic Fibrosis Foundation are important advantages for these quality improvement efforts. This article illustrates how the clinical microsystems methodology can improve care delivery and outcomes by describing the gradual application of quality improvement principles over the past 5 years by the CF team at the Lewis Walker Cystic Fibrosis Center at Akron Children's Hospital in Akron, Ohio. Using the example of a project to improve the pulmonary function of the pediatric patients at our center as a framework, we describe the QI process from the initial team-building phase, through the assessment of care processes, standardization of care, and developing a culture of continuous improvement. We outline how enthusiastic commitment from physician leadership, clinical managers and central administration, the availability of coaches, and an appreciation of the importance of measurement, patient involvement, communication, and standardization are critical components for successful process improvement.

Pediatric Urolithiasis: Clinical Predictors in the Emergency Department

The objective of this study was to identify factors that predict the presence of urolithiasis detected with unenhanced computed tomography (UCT) in children. A retrospective study of all subjects <21 years of age who presented to the emergency department at Akron Children's Hospital and underwent UCT of the abdomen between January 2002 and December 2005 was performed. Demographic, clinical, diagnostic, treatment, and disposition data were abstracted by using a standardized form. Univariate and logistic regression analyses of factors associated with urolithiasis were performed. A total of 339 eligible patients were identified, with 110 cases of urolithiasis detected with UCT for 95 individual patients. The mean age of the study patients was 14.4 years; 72 patients (66%) were female. In 17 cases (15%) of urolithiasis, initial urinalysis results were negative for blood. Fifty-seven stones (51.8%) were ureteral, 26 (23.6%) were renal, and 4 (3.6%) were in the bladder. Among children who did not have a stone identified through UCT, 23 cases (10%) of potentially significant, alternative diagnoses were identified. A history of urolithiasis, a history of nausea and vomiting, the presence of flank pain on examination, and >2 red blood cells per high-power field in urine microscopy were positively associated with urolithiasis. A history of fever or dysuria and costovertebral angle tenderness on physical examination were inversely associated with urolithiasis on UCT scans. UCT plays an important role in the diagnostic evaluation of children with flank pain. Approximately 15% of children with urolithiasis do not have hematuria.

Gastroschisis: An 18-Year Review

From 1972 to 1990, 69 cases of gastroschisis were treated at Akron Children's Hospital Medical Center. Eighty-one percent of these patients underwent primary closure of their abdominal wall defect. Thirteen of 69 patients (19%) required Silastic silos with final closure in an average of 7.8 days. There was no sex predilection, the average birth weight was 2,473 g, and the mean gestational age was 36.3 weeks. Twenty-six percent had associated anomalies, the majority were intestinal atresia, volvulus, and/or undescended testicles. Seventy-seven percent of the infants were delivered vaginally. Fourteen children were delivered via cesarean section. Seven cesarean sections were done solely for prenatal ultrasonic identification of an abdominal wall defect. There was no improvement in hospital stay, complications, days until enteral feeds were tolerated, days intubated, or number of surgical procedures in this group. In 14 patients, mesh sheeting (Marlex, Silastic) was used in the final closure. Sixty-four percent of these incurred wound breakdown necessitating removal of the mesh. This compares with a 3.2% wound breakdown in the nonmesh group. The average hospital stay was 43.9 days and the average time to enteral feeds 20.2 days. Sixty-four percent of the patients required postoperative intubation for an average of 5.5 days. The overall mortality rate was 4.3%. The present data do not support gastroschisis alone as an indication for cesarean section. The data indicate that mesh be avoided in the final closure if possible and support a favorable prognosis for most babies.

Standardized residuals as a means for detection of growth alteration in the pathologic human fetus.

This paper introduces and discusses the use of standardized residuals as a technique for comparing the growth of normal and pathologic human fetuses. Anthropometric measures, radiographic measures, and organ weights were regressed on known gestational age of second- and third-trimester fetuses. Standardized residuals were calculated for a group of potentially growth-impaired fetuses. Use of residuals aids in identification of patterns of growth alteration in specific pathologies. Most important, studying the response of developing organ systems to a variety of insults may elucidate mechanisms of growth regulation in the fetus. We emphasize the special quality of the multivariate measures of the core sample of fetuses from the Akron Children's Hospital collection.

Congenital Dislocation of the Hip Associated with Congenital Muscular Torticollis

Four recently identified cases of congenital dislocation of the hip associated with congenital muscular torticollis out of 49 consecutive cases of frank dislocation of the hip suggest that: the coexistence of congenital muscular torticollis and congenital dislocation of the hip occurs more commonly than is generally appreciated; the presence of either abnormality should initiate a careful appraisal for the presence of the other; although both conditions are seen more commonly in children delivered by breech extraction, a direct causal relationship has not yet been established although the abnormal uterine position is definitely related to each condition.