Frequent Clinical Assessment Research Articles

Case-Based Review: newly diagnosed glioblastoma.

Glioblastoma (WHO grade IV astrocytoma) is the most common and most aggressive primary brain tumor in adults. Optimal treatment of a patient with glioblastoma requires collaborative care across numerous specialties. The diagnosis of glioblastoma may be suggested by the symptomatic presentation and imaging, but it must be pathologically confirmed via surgery, which can have dual diagnostic and therapeutic roles. Standard of care postsurgical treatment for newly diagnosed patients involves radiation therapy and oral temozolomide chemotherapy. Despite numerous recent trials of novel therapeutic approaches, this standard of care has not changed in over a decade. Treatment options under active investigation include molecularly targeted therapies, immunotherapeutic approaches, and the use of alternating electrical field to disrupt tumor cell division. These trials may be aided by new insights into glioblastoma heterogeneity, allowing for focused evaluation of new treatments in the patient subpopulations most likely to benefit from them. Because glioblastoma is incurable by current therapies, frequent clinical and radiographic assessment is needed after initial treatment to allow for early intervention upon progressive tumor when it occurs.

Spontaneous cerebellar hemorrhage in a patient taking apixaban

Abstract Objectives Atrial fibrillation is closely associated with cardioembolic stroke. Until recently, warfarin has been the gold standard for the treatment of atrial fibrillation. Since 2010 the United States Food and Drug Administration has approved three new agents for anticoagulation in patients with atrial fibrillation. The purpose of this case report is to discuss some of the practical implications for using these agents. Methods A patient taking apixaban presented with a spontaneous cerebellar hemorrhage. While the patient was initially considered a candidate for surgical intervention, the lack of literature addressing surgical intervention in patients on novel anticoagulation clouded the clinical decision-making. The patient was ultimately managed with administration of activated prothrombin complex concentrate, blood pressure control, frequent clinical assessments and airway protection. The patient did not undergo craniotomy for hematoma evacuation. Conclusions Recent FDA approval of several novel oral anticoagulants for use in patients with atrial fibrillation has resulted in a significant number of patients formerly treated with warfarin being switched to these newer agents. There remains a lack of clear guidelines for the management of hemorrhagic complications. This case report describes one management strategy and highlights the paucity of current evidence to support critical clinical decisions.

Push to Avoid Rehospitalization Has Unintended Outcomes

Push to Avoid Rehospitalization Has Unintended Outcomes

Postpartum changes in methadone maintenance dose

The optimal approach to postpartum dosing among women treated with methadone maintenance is unclear. We examined doses among 101 methadone-maintained pregnant women 2, 6 and 12weeks postpartum, and compared the incidence of having doses held for oversedation during pregnancy and postpartum. The average dose at delivery was 83.3mg, and the mean change from delivery to 12weeks postpartum was −3.7mg (95% CI −6.3, −1.1). The incidence of oversedation events per 10,000days was 2.8 among pregnant women and 5.6 for postpartum women (incidence rate ratio [IRR] 2.04, 95% CI 0.66, 6.28). After adjusting for benzodiazepine prescriptions, the IRR of an oversedation event among postpartum women compared to pregnant women was 1.74 (95% CI 0.56, 5.30). In conclusion, postpartum dose changes were small in a methadone clinic using clinical assessments to determine dose. Although the incidence of oversedation events remained low postpartum, the clinically important but not statistically significant increase in events among postpartum women and those prescribed benzodiazepines requires further research. While there are not yet adequate data to support pre-specified postpartum dose reductions, the findings suggest that more frequent clinical assessments continuing as late as 12weeks postpartum may be warranted.

Safety of the breast‐feeding infant after maternal anesthesia

There has been an increase in breast-feeding supported by the recommendations of the American Academy of Pediatrics and the World Health Organization. An anesthesiologist may be presented with a well-motivated breast-feeding mother who wishes to breast-feed her infant in the perioperative period. Administration of anesthesia entails acute administration of drugs with potential for sedation and respiratory effects on the nursing infant. The short-term use of these drugs minimizes the possibility of these effects. The aim should be to minimize the use of narcotics and benzodiazepines, use shorter acting agents, use regional anesthesia where possible and avoid agents with active metabolites. Frequent clinical assessments of the nursing infant are important. Available literature does suggest that although the currently available anesthetic and analgesic drugs are transferred in the breast milk, the amounts transferred are almost always clinically insignificant and pose little or no risk to the nursing infant.

Central nervous system immune reconstitution inflammatory syndrome in AIDS: Experience of a Mexican neurological centre

BackgroundHighly active antiretroviral therapy (HAART) restores the inflammatory immune response in AIDS patients and it may unmask previous subclinical infections or paradoxically exacerbate symptoms of opportunistic infections. Up to 25% of patients receiving HAART develop immune reconstitution inflammatory syndrome (IRIS). We describe six patients with IRIS central nervous system (CNSIRIS) manifestations emphasizing the relevance of CSF cultures and neuroimaging in early diagnosis and management. MethodsPatients with CNSIRIS were identified among hospitalized HIV-infected patients that started HAART from January 2002 through December 2007 at a referral neurological center in Mexico. ResultsOne-hundred and forty-two HIV-infected patients with neurological signs were hospitalized, 64 of which had received HAART, and six (9.3%) developed CNSIRIS. Five patients were male. Two cases of tuberculosis, two of cryptococcosis, one of brain toxoplasmosis, and one possible PML case were found. IRIS onset occurred within 12 weeks of HAART in five patients. Anti-infective therapy was continued. In one case, HAART was temporarily suspended. In long-term follow-up the clinical condition improved in all patients. ConclusionsCNSIRIS associated to opportunistic infections appeared in 9% of patients receiving HAART. Interestingly, no cases of malignancy or neoplasm IRIS-related were found. Frequent clinical assessment and neuroimaging studies supported diagnosis and treatment. Risk factors were similar to those found in other series.

Pediatric rapid fluid resuscitation

Intravenous and enteral fluid resuscitation are frequently used therapies in the management of pediatric patients in emergency departments and critical care settings. Any state of intravascular fluid deficit, ranging from mild dehydration due to gastroenteritis to fulminant septic shock, requires careful assessment and early restoration of hemodynamic stability. Rapid fluid resuscitation has gained increased recognition since the most recent pediatric shock management guidelines. We sought to review the evidence for rapid fluid resuscitation and to outline its clinical indications, implementation, and potential associated risks. Rapid fluid resuscitation benefits pediatric patients with severe dehydration or signs of shock. Studies have proven the modality to be safe and efficacious and to reduce morbidity and mortality. Initial and frequent clinical assessments are key in reducing potential complications of overhydration or clinically significant electrolyte disturbances. Rapid enteral rehydration may be used in the uncomplicated, mildly to moderately dehydrated patient. Antiemetics may facilitate rehydration efforts by limiting further fluid losses. Rapid fluid resuscitation is most commonly used for children with moderate-to-severe dehydration, or for patients in shock to restore circulation. Concerns regarding potential for fluid overload and electrolyte disturbances and regarding the method of rehydration (i.e., enteral versus parenteral) raise some debate about the safety and efficacy of rapid fluid resuscitation in the pediatric patient. Recent studies show that early, aggressive fluid resuscitation of up to 60 ml/kg within 1-2 h may be necessary to replenish circulating intravascular fluid volume. Complications of severe electrolyte disturbances, cerebral edema, or uncontrolled hemorrhage are uncommon and can often be avoided with early clinical assessment and reassessments throughout the resuscitation. In the mildly to moderately dehydrated child, enteral fluid resuscitation with the aid of an antiemetic such as ondansetron can be as effective and efficient as intravenous fluid resuscitation.

Suicide and suicide attempts in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).

The current report describes individuals with bipolar disorder who attempted or completed suicide while participating in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study. Baseline and course features of individuals with suicide events are described. Among the 4360 people with bipolar disorder enrolled, 182 individuals made 270 prospectively observed suicidal acts, including 8 completed suicides. This represents a suicide rate of .014 per 100 person years in STEP-BD, which included frequent clinical visits, evidence based care, and standardized assessment at each patient contact. Approximately 1/3 of those who attempted suicide had more than one attempt during study participation. Those who completed suicide tended to do so early in study participation, and half of them did so on their first attempt. While this study is limited to description of individuals and precipitants of completed suicides and attempts in STEP-BD, further analyses are planned to explore risk factors and potential interventions for prevention of suicidal acts in persons with bipolar disorder. Persons with bipolar disorder are at high risk for suicide. Overall rates of suicide events in STEP-BD were lower than expected, suggesting that the combination of frequent clinical visits (i.e., access to care), standardized assessment, and evidence-based treatment were helpful in this population.

Clinical Outcomes in Household Contacts of Patients with Cholera in Bangladesh

Multiple Vibrio cholerae infections in the same household are common. The objective of this study was to examine the incidence of V. cholerae infection and associated clinical symptoms in household contacts of patients with cholera and to identify risk factors for development of severe dehydration in this cohort. Household contacts of hospitalized patients with cholera were observed with frequent clinical assessments and collection of serum and rectal swab samples for culture for a period of 21 days after presentation of the index case. One-half (460 of 944) of all contacts reported diarrhea during the study period, and symptoms most frequently began 2 days after presentation of the index case. Antibiotics were used by 199 (43%) of 460 contacts with diarrhea. Results of rectal swab cultures for V. cholerae were positive for 202 (21%) of 944 contacts, and 148 (73%) infected contacts experienced diarrhea. Significant dehydration developed in 26 contacts; predictors of dehydration included vomiting, each additional day of diarrhea, and blood group O status. In urban Bangladesh, the burden of diarrheal illness among household contacts of patients with cholera is higher than was previously estimated, and prophylactic intervention is feasible, because the majority of symptomatic cases of V. cholerae infection in contacts begin soon after presentation of the index case. Re-evaluation of targeted chemoprophylaxis for household contacts of patients with cholera may be warranted.

Nephrogenic diabetes insipidus: the key element of paradoxical hyponatremia

Sirs, We have read with great interest the brief report of Boussemart et al. [1] published online first and strongly agree with their recommendation of strict vigilance of the fluid status in young patients with nephrogenic diabetes insipidus (NDI) who begin treatment. In fact, we would also recommend that not only are water balance and frequent clinical assessment, including hemodynamical status when necessary, crucial, but blood and urine sodium determination as well. The authors attribute their patient’s water intoxication to a strong enhanced sodium reabsorption due to the additive effect of hydrochlorothiazide and indomethacin combination therapy together with the lack of any physiological control of water intake secondary to gastric feeding. However, we experienced a water intoxication case in a 2-month-old male infant who only received initial hydrochlorothiazide treatment and was only bottle fed. Our patient was admitted to the hospital for evaluation of prolonged fever. Hypernatremia (Na 158 mEq/l) was revealed on admission, and a repeated medical history from their parents revealed that the infant had experienced polyuria–polydipsia since the first days of life, with a daily oral water intake of 500 ml added to his formula bottles, which they had considered normal. A dehydration test with subsequent 1-desamino-8-D-arginine vasopressin administration confirmed the diagnosis of NDI, and sequence analyses revealed mutation p.Trp200GlyfsX12 in exon 4 of the AVPR2 gene. Hydrochlorothiazide treatment was initiated at 2 mg/kg per day orally twice a day. Six hours after the first dose had been administered, the infant developed transient profuse sweating, paleness and hypothermia. The serum sodium concentration was 141 mEq/l at that time (pretreatment control 153 mEq/l), indicating water intoxication. Consequently, further hydrochlorothiazide treatment was stopped. The infant clinically recovered in the following hours. The treatment was reinitiated the following day at a lower dose, 1 mg/kg per day orally twice a day, which was well tolerated; no serum sodium control was obtained. The third day of treatment, 5 h after receiving the morning dose of hydrochlorothiazide, the patient's clinical condition worsened once again, with sweating, paleness, hypothermia, weakness, lethargy and gasping breathing. The serum sodium level was checked and the patient admitted to the pediatric intensive care unit (PICU). As the serum sodium concentration was 137 mEq/l, we were unable to demonstrate hyponatremia, but we hypothesized that there had probably been a significant serum sodium and subsequent osmolar shift secondary to water intoxication that had led to cerebral swelling. A cranial computerized scan showed no findings at that moment, and the patient recovered spontaneously during the following hours. Polyuria–polydipsia and hypernatremia continued the following days after the withdrawal of treatment. Therefore, 2 days later treatment was once again reinitiated at a lower dose (0.5 mg/kg per day twice a day). This treatment was well tolerated and was progressively increased during the following days (maximum 4 mg/kg per day) until neutral water balances were be achieved. Central venous catheter Pediatr Nephrol (2009) 24:2277–2278 DOI 10.1007/s00467-009-1236-4

Self-management for obesity and cardio-metabolic fitness: Description and evaluation of the lifestyle modification program of a randomised controlled trial

BackgroundSustainable lifestyle modification strategies are needed to address obesity and cardiovascular risk factors. Intensive, individualised programs have been successful, but are limited by time and resources. We have formulated a group-based lifestyle education program based upon national diet and physical activity (PA) recommendations to manage obesity and cardio-metabolic risk factors. This article describes the content and delivery of this program, with information on compliance and acceptability.MethodsOverweight/obese adults (n = 153) with metabolic syndrome were recruited from the community and randomly allocated to intervention (INT) or control (CON). Written copies of Australian national dietary and PA guidelines were provided to all participants. INT took part in a 16-week lifestyle program which provided a curriculum and practical strategies on 1) dietary and PA information based on national guidelines, 2) behavioural self-management tools, 3) food-label reading, supermarkets tour and cooking, 4) exercise sessions, and 5) peer-group support. Compliance was assessed using attendance records and weekly food/PA logs. Participants' motivations, perceived benefits and goals were assessed through facilitated discussion. Program acceptability feedback was collected through structured focus groups.ResultsAlthough completion of weekly food/PA records was poor, attendance at information/education sessions (77% overall) and exercise participation (66% overall) was high, and compared with CON, multiple markers of body composition and cardio-metabolic health improved in INT. Participants reported that the most useful program components included food-label reading, cooking sessions, and learning new and different physical exercises, including home-based options. Participants also reported finding self-management techniques helpful, namely problem solving and short-term goal setting. The use of a group setting and supportive 'peer' leaders were found to be supportive. More frequent clinical assessment was suggested for future programs.ConclusionThis group-based lifestyle program achieved improvements in body composition and cardio-metabolic and physical fitness similar to individualised interventions which are more resource intensive to deliver. It confirmed that active training in lifestyle modification is more effective than passive provision of guidelines. Such programs should include social support and self-management techniques. Continued clinical follow up may be required for long-term maintenance in individuals attempting lifestyle behaviour change. Program facilitation by peers may help and should be further investigated in a community-based model.

Invited commentary

The development of a predictive model to improve risk stratification for patients after resection for lung cancer may improve treatment strategies and outcomes in addition to providing better prognostic estimates for patients, families, and physicians. The effectiveness of the model is influenced by practice patterns for surveillance after resection, the frequency and intensity of radiologic examination, and the aggressiveness of the confirmation of recurrence. In this study [1Williams B.A. Sugimura H. Endo C. et al.Predicting post-recurrence survival among completely resected nonsmall-cell lung cancer patients.Ann Thorac Surg. 2006; 81: 1021-1027Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar], fewer than 25% of the patients identified with recurrence were free of symptoms, and 21% of patients were not analyzed due to inadequate follow-up information. In a setting with more frequent clinical assessment, post-recurrence survival would likely be longer, and other prognostic factors might have been identified as significant. Although the prolonged postrecurrence survival may only represent lead-time bias, the factors identified that relate to the prognostic model may alter clinical practice and improve actual survival.For a prognostic model to influence patient care and outcome, there should be a treatment algorithm associated with the scoring system. Although this model is intriguing, the patients scored at moderate risk or high risk would likely have been accurately identified without this model, as the risk impact of performance status, symptoms, and multiple sites of recurrence are well described. Furthermore, these patients are generally considered poor candidates for therapy, regardless of the predicted length of survival. The ideal model would allow identification and stratification of a larger fraction of patients with early recurrence for which varying therapeutic strategies may be used, including targeted therapy. In addition, stratification would be improved by incorporating tumor-specific factors, such as genetic mutations, protein expression, and treatment sensitivity or resistance analysis. The development of a predictive model to improve risk stratification for patients after resection for lung cancer may improve treatment strategies and outcomes in addition to providing better prognostic estimates for patients, families, and physicians. The effectiveness of the model is influenced by practice patterns for surveillance after resection, the frequency and intensity of radiologic examination, and the aggressiveness of the confirmation of recurrence. In this study [1Williams B.A. Sugimura H. Endo C. et al.Predicting post-recurrence survival among completely resected nonsmall-cell lung cancer patients.Ann Thorac Surg. 2006; 81: 1021-1027Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar], fewer than 25% of the patients identified with recurrence were free of symptoms, and 21% of patients were not analyzed due to inadequate follow-up information. In a setting with more frequent clinical assessment, post-recurrence survival would likely be longer, and other prognostic factors might have been identified as significant. Although the prolonged postrecurrence survival may only represent lead-time bias, the factors identified that relate to the prognostic model may alter clinical practice and improve actual survival. For a prognostic model to influence patient care and outcome, there should be a treatment algorithm associated with the scoring system. Although this model is intriguing, the patients scored at moderate risk or high risk would likely have been accurately identified without this model, as the risk impact of performance status, symptoms, and multiple sites of recurrence are well described. Furthermore, these patients are generally considered poor candidates for therapy, regardless of the predicted length of survival. The ideal model would allow identification and stratification of a larger fraction of patients with early recurrence for which varying therapeutic strategies may be used, including targeted therapy. In addition, stratification would be improved by incorporating tumor-specific factors, such as genetic mutations, protein expression, and treatment sensitivity or resistance analysis.

Practical Guidelines for the Prevention, Diagnosis, and Treatment of Osteonecrosis of the Jaw in Patients With Cancer

This article discusses osteonecrosis of the jaw (ONJ) and offers health care professionals practical guidelines and recommendations for the prevention, diagnosis, and management of ONJ in cancer patients receiving bisphosphonate treatment. A panel of experts representing oral and maxillofacial surgery, oral medicine, endocrinology, and medical oncology was convened to review the literature and clinical evidence, identify risk factors for ONJ, and develop clinical guidelines for the prevention, early diagnosis, and multidisciplinary treatment of ONJ in patients with cancer. The guidelines are based on experience and have not been evaluated within the context of controlled clinical trials. ONJ is a clinical entity with many possible etiologies; historically identified risk factors include corticosteroids, chemotherapy, radiotherapy, trauma, infection, and cancer. With emerging concern for potential development of ONJ in patients receiving bisphosphonates, the panel recommends a dental examination before patients begin therapy with intravenous bisphosphonates. Dental treatments and procedures that require bone healing should be completed before initiating intravenous bisphosphonate therapy. Patients should be instructed on the importance of maintaining good oral hygiene and having regular dental assessments. For patients currently receiving bisphosphonates who require dental procedures, there is no evidence to suggest that interrupting bisphosphonate therapy will prevent or lower the risk of ONJ. Frequent clinical assessments and conservative dental management are suggested for these patients. For treatment of patients who develop ONJ, a conservative, nonsurgical approach is strongly recommended. An increased awareness of the potential risk of ONJ in patients receiving bisphosphonate therapy is needed. Close coordination between the treating physician and oral surgeon and/or a dental specialist is strongly recommended in making treatment decisions.

Practical Guidelines for the Prevention, Diagnosis, and Treatment of Osteonecrosis of the Jaw in Patients With Cancer

Purpose This article discusses osteonecrosis of the jaw (ONJ) and offers health care professionals practical guidelines and recommendations for the prevention, diagnosis, and management of ONJ in cancer patients receiving bisphosphonate treatment. Methods A panel of experts representing oral and maxillofacial surgery, oral medicine, endocrinology, and medical oncology was convened to review the literature and clinical evidence, identify risk factors for ONJ, and develop clinical guidelines for the prevention, early diagnosis, and multidisciplinary treatment of ONJ in patients with cancer. The guidelines are based on experience and have not been evaluated within the context of controlled clinical trials. Results ONJ is a clinical entity with many possible etiologies; historically identified risk factors include corticosteroids, chemotherapy, radiotherapy, trauma, infection, and cancer. With emerging concern for potential development of ONJ in patients receiving bisphosphonates, the panel recommends a dental examination before patients begin therapy with intravenous bisphosphonates. Dental treatments and procedures that require bone healing should be completed before initiating intravenous bisphosphonate therapy. Patients should be instructed on the importance of maintaining good oral hygiene and having regular dental assessments. For patients currently receiving bisphosphonates who require dental procedures, there is no evidence to suggest that interrupting bisphosphonate therapy will prevent or lower the risk of ONJ. Frequent clinical assessments and conservative dental management are suggested for these patients. For treatment of patients who develop ONJ, a conservative, nonsurgical approach is strongly recommended. Conclusion An increased awareness of the potential risk of ONJ in patients receiving bisphosphonate therapy is needed. Close coordination between the treating physician and oral surgeon and/or a dental specialist is strongly recommended in making treatment decisions.

Standards for Specialized Nutrition Support: Home Care Patients

Standards for Specialized Nutrition Support: Home Care Patients

Clinical Management of the Organ Donor

There is a critical mismatch between available organs for transplant and acutely or critically ill patients with end-stage organ disease. Patients who may benefit from organ transplantation far outnumber available organs. The causes for this imbalance are multiple. One cause is family refusal to donate. A second cause is nonrecognition or delay in determination of brain death. A third cause is donor loss due to profound cardiopulmonary and metabolic instability consequent to brain-stem herniation and brain death. Family refusal may be addressed by education, public awareness, as well as close attention to social, cultural and ethical issues, and optimal communication with donor families. Brain death may be consequent to traumatic brain injury, ischemic versus hemorrhagic stroke, as well as massive cerebral anoxia/ischemic following cardiac arrest. Nonrecognition or delay in brain death determination may be addressed by clinician education and frequent clinical assessment to detect early stages of brain-stem herniation refractory to aggressive measures for control of intracranial pressure. Donor loss due to profound cardiopulmonary and metabolic instability may be addressed by aggressive, mechanism-based treatment for clinical instability based on affected body system, as well as measures to support metabolic activity at the cellular and tissue level in the brain-dead organ donor. This article explores cerebral physiology related to impending brain death and catastrophic intracranial pressure elevations. In addition, physiologic consequences of brain death are correlated with affected body systems and mechanism-based therapies to support organ function pending transplantation. Ethical/legal issues are explored as related to patient autonomy and optimal family outcomes. Effective family communication, astute clinical assessment, and optimal clinical management of the organ donor are illustrated using a case study approach, highlighting the role of the advanced practice nurse in donor management.

Salt and the newborn kidney

Renal function differs in term infants from that in adults, with lower glomerular filtration rate (GFR) and reduced proximal tubular reabsorption of sodium (Na) and water: nevertheless, it is adequate for their needs. This is not true of very preterm infants in whom hyponatraemia is common. Animal studies have shown that Na+, K(+)-ATPase and the Na+/K+ exchanger are poorly expressed at birth with rapid postnatal rises. Cell receptors for hormones that influence tubular Na transport are less numerous in the premature infant than later in life: intracellular second messenger systems may also be immature. The low GFR is due to vasoconstriction and may be necessary to prevent water and electrolyte wasting due to tubular overload. The hyponatraemia of prematurity could, in principle, be due either to Na loss or water excess and can be prevented either by giving additional Na or by restricting water intake. Na supplementation causes relative volume expansion (VE), water restriction volume contraction (VC); this is demonstrated by the effect of the two approaches on weight gain and on the levels of vasoactive hormones in the blood. We argue that moderate VE is more physiological than VC, both in attempting to simulate intrauterine conditions and in consideration of the infant's nutritional needs. The much less common complication of hypernatraemia is usually due to abnormal water loss and should be prevented by increasing water intake appropriately. The above applies to well, preterm babies: sick preterm infants are much more variable in their Na and water requirements than well infants of comparable gestation and weight and each needs an individually tailored regimen based on frequent clinical assessment and laboratory measurement.

Abdominal injuries in children : Richardson J. D., Belin R. P. and Griffin W. O. (1972) Blunt abdominal trauma in children. Ann. Surg.176, 213

The problem of abdominal trauma in children is briefly reviewed to show how the etiology, diagnosis and treatment differ from those in adults. Although in many ways management is the same in both groups, certain problems more commonly affect children, and the approach to diagnosis and treatment must be adapted to their needs. The importance of frequent clinical assessment and the rather limited role of peritoneal lavage in children with abdominal trauma are stressed. Experience with splenic injuries in 63 patients treated between 1974 and 1979 is reviewed to provide guidelines for conservative management to assist surgeons who seldom treat children. Since splenectomy in pediatric patients carries a risk of overwhelming infection, distinguishing those whose spleens can be salvaged is extremely important.