Biomedical subjects
Publications and source records attributed to A G Coran.
Until recently, concern over the care of the trauma victim has largely involved the adult population; although 7% of emergency calls are for the pediatric patient, insufficient attention has been paid to the care of these children. This article concentrates on those unique problems encountered in the management of pediatric trauma in prehospital and hospital settings.
Seven children who sustained splenic trauma were scanned by ultrasound and computed tomography (CT) or ultrasound and nuclear liver/spleen scan. All patients were managed conservatively and did not need abdominal surgery. On the initial sonogram, the majority of children had multiple areas of both increased and decreased echogenicity. Hematomas were followed to resolution in five of seven children and were usually multiple and hypoechoic prior to complete disappearance. On contrast-enhanced CT scans, areas of splenic hemorrhage appeared as low attenuation. Our small patient population demonstrates that, following an initial CT scan, sonography is helpful for sequential splenic imaging to show when the appearance of the spleen returns to normal. When correlated with the clinical information, such data are helpful to the clinician in determining when a child who has sustained splenic trauma may resume normal activity.
Explore the source record for details and available documents.
beta-Oxidation, an important pathway in the metabolism of free fatty acids, occurs within the mitochondria in mammals. L-Carnitine is an essential cofactor in the transfer of long-chain fatty acids across the inner mitochondrial membrane. Maintenance of normal carnitine concentrations in whole blood and tissues, either through diet or biosynthesis, would appear necessary for adequate utilization of fat as an energy source. Infants, especially premature ones, without an exogenous dietary source of carnitine, have decreased plasma carnitine levels compared with infants receiving carnitine-supplemented feedings. To determine the importance of carnitine supplementation in a total parenteral nutrition program in infants in which a fat emulsion serves as a major calorie source, the following study was undertaken. Twelve infants receiving total parenteral nutrition (TPN) with fat for seven days were divided into two treatment groups. Group 1 was orally supplemented for seven days with carnitine (70 mumol/l/kg/24 h in 24 mL of 5% dextrose), while the second group received seven days of placebo supplementation (dextrose 5%, 24 cc/24 h). Plasma carnitine levels in the carnitine-supplemented group were significantly higher (29 +/- 8 nmol/mL) than in the control group (12.4 +/- 3.5 nmol/mL) after seven days of treatment. However, clearance of serum triglycerides and free fatty acids was not significantly different between the two groups. Baseline triglyceride levels in the carnitine-supplemented group were 96 +/- 42 mg/dL, increased to 242 +/- 101 mg/dL after the lipid challenge and decreased to 121 +/- 47 mg/dL two hours after the lipid infusion.(ABSTRACT TRUNCATED AT 250 WORDS)
Total intraperitoneal nutrition (IPN) for patients in whom enteral nutrition is impossible would utilize the access techniques of peritoneal dialysis and avoid long-term central venous cannulation. We previously demonstrated that a lipid emulsion was quantitatively absorbed from the dog's peritoneal cavity over four hours. We have now investigated the efficacy of total IPN in dogs over periods up to four weeks. A solution of 1.25% amino acids, 1% glucose, 77 mEq/L Na, 4 mEq/L K, and 81 mEq/L Cl (AGE) was administered IP at 65 mL/kg every 12 hours in combination with 25 mL/kg of 20% lipid emulsion to five dogs allowed free access to food and water for ten days. Sixty percent of administered fluid was absorbed. When AGE and lipid were administered separately every 12 hours to six dogs, 90% was absorbed. In five dogs kept strictly NPO for two weeks while receiving alternating AGE and lipid, absorption averaged 60%. Removing the amino acids allowed absorption to remain at 70% for two weeks, although it dropped to 40% by four weeks. Nine dogs were maintained for a mean of 3.5 weeks while strictly NPO using a solution of 1% glucose and electrolytes at 120 mL/kg every 12 hours with 50 mL/kg of 20% lipid given at a third separate infusion. During the fourth week, they absorbed 118 mL/kg/24 hours of fluid and 26 calories/kg/24 hours. Body weight decreased to 75% of control over four weeks. Complete blood cell count (CBC), Na, K, Cl, total protein (TP), SGOT, and alkaline phosphatase (AP) remained unchanged during this time.(ABSTRACT TRUNCATED AT 250 WORDS)
Although rare in children, achalasia can be the cause of debilitating symptoms and growth retardation. During a 4-year period, six patients (mean age 9.9 years) underwent a modified Heller operation (anterior esophageal myotomy) without complication. A concomitant modified Belsey fundoplication was performed in three patients who were judged at the time of operation to be at high risk for postoperative gastroesophageal reflux. Preoperative symptoms of dysphagia, postprandial vomiting, retrosternal pain, and pulmonary complications were eliminated in all patients. Follow-up interviews seven to 48 months (mean 23 months) following operation revealed normal diet and normal growth in all six children, with no recurrence of preoperative symptoms or evidence of gastroesophageal reflux. Technical details which we believe contribute to success in the operative management of pediatric achalasia include the transthoracic approach and the selective performance of complementary anti-reflux procedures.
From July 1974 through November 1984, 92 patients with Hirschsprung's disease (congenital aganglionosis) have been treated at the University of Michigan-Mott Children's Hospital. This series includes 67 consecutive modified endorectal pull-through (ERPT) procedures in children. Fifty-one of these 67 patients had standard rectosigmoid disease and underwent a successful ERPT with only two major complications. One of these 51 children underwent a successful ERPT but died in the late postoperative period from severe congenital heart disease. Eighteen of the 92 patients suffered from total aganglionosis or long-segment disease. Sixteen of these have undergone an ERPT with no mortality or operative morbidity. The follow-up ranges from 6 months to 10 years. All of the children who have reached 3 years of age are continent. Of the remaining 23 patients, 12 were referred following an unsuccessful pull-through at another hospital. The 12 operations included five Swenson pull-throughs, five Duhamel procedures, one ERPT, and one subtotal colectomy. It was possible to redo or revise the pull-through procedures successfully in all but one patient, who required a permanent colostomy. Finally, 11 children were referred for management of a variety of complications following pull-through procedures performed at other institutions. None of these 11 patients required a reperformance of their pull-through, and all were successfully treated with lesser surgical procedures or with medical management. The excellent functional results and the low morbidity and zero operative mortality are attributed to the technical ease of performing the modified ERPT.
The mortality of infants with gastroschisis has been reduced markedly in the last decade with the application of new surgical techniques, improved metabolic monitoring, and total parenteral nutrition. The late complications of repaired gastroschisis are now emerging. In this series of 30 infants with gastroschisis (20% mortality) significant gastroesophageal reflux was identified in seven of 10 infants with the appropriate barium study. The clinical symptom complexes of dysmotility, a recognized problem in gastroschisis, and gastroesophageal reflux can be easily confused. In addition, 11 episodes of necrotizing enterocolitis were identified in seven infants, four with perforations. The children with necrotizing enterocolitis had a deceptively benign clinical presentation, which was easily misinterpreted in these ill infants. Awareness of these two significant gastrointestinal complications and close cooperation of clinicians and radiologists to detect them should insure better survival in the infant with gastroschisis.
A malignant cystic neoplasm in the liver of a 6-month-old girl is reported. The neoplasm has unique clinical and morphological features, and despite ultrastructural and immunohistochemical studies, the tumor could not be clearly classified as any known primary hepatic neoplasm of infancy. A differentiated cystic component of the neoplasm had features of cystic peritoneal mesothelioma. Alpha-1-antitrypsin and alpha-fetoprotein were demonstrated in solid, anaplastic portions of the recurrent tumor by immunohistochemistry. The neoplasm recurred after surgical resection and proved fatal 11 months following diagnosis, despite multiple courses of chemotherapy.
A patient with hematochezia and a false negative Meckel's scan is presented. A Meckel's diverticulum was subsequently diagnosed on barium small bowel follow-through. Meckel's diverticulum is discussed with emphasis on the relationship of barium and radionuclide studies.
Explore the source record for details and available documents.
A case of a 4-year old child with a hepatic artery aneurysm after the mucocutaneous lymph node syndrome is reported. The child had obstructive jaundice and preoperative evaluation did not lead to the correct diagnosis. The aneurysm was resected and the postoperative course was unremarkable. The literature on this entity is reviewed.
Pheochromocytomas in the same anatomic site, the right renal hilum, occurred in a family over three successive generations. For two patients in the latter two generations, scintigraphy with iodine 131-tagged metaiodobenzylguanidine (MIBG) showed tumors only in the region of the right renal hilum, thus indicating that they were primary lesions. At surgery, except for lymph node metastases noted microscopically in one patient, tumors were found only near the right renal hilum. The adrenal glands seemed normal on inspection, palpation, and computed tomography. In another family, a mother and son had primary pheochromocytomas arising from the urinary bladder. We suggest that primary extra-adrenal pheochromocytoma is a syndrome in which specific genetic abnormalities determine sites of tumor development.
Factors that influence recurrence and survival following thoracotomy for metastatic osteogenic sarcoma are not well defined. We examined the clinical and pathological material from 51 patients who had no metastases at the time of operative treatment of osteogenic sarcoma at the University of Michigan from 1962 to 1982. Ages ranged from 2 to 30 years (mean, 15 years). Metastases developed in 37 patients (72.5%) at a mean of 8 months after initial operation. Thirteen patients were treated with chemotherapy only; 12 of them died after a mean survival of 7 months. Twenty-four patients were treated with chemotherapy and 45 thoracotomies (mean, 1.9 per patient; range, 1 to 5) during which 120 wedge resections or lobectomies were performed. Follow-up is available on 22 of these 24 patients, 11 (50%) of whom are alive (9, tumor free) at a mean of 51 months after thoracotomy. Eleven patients died after a mean survival of 27 months (p less than or equal to 0.001 compared with the group having chemotherapy only). Microfoci of tumor (tumor cells separate from the gross tumor nodule) were found in resection specimens in 12 patients at the first thoracotomy; in 11 of these 12 patients, new metastases subsequently developed resulting in 10 reoperations. Twelve patients had no microfoci at the first operation; new metastases developed in 5; 3 underwent reoperation. Overall, microfoci were found at 29 operations; in patients with this finding, new metastases developed twenty-seven times (93%).(ABSTRACT TRUNCATED AT 250 WORDS)
Hirschsprung's disease has become a more common cause of newborn intestinal obstruction in the past 30 years. In a group of 137 newborns with intestinal obstruction the most common diagnosis was necrotizing enterocolitis. The second most common cause, however, was Hirschsprung's disease. We have reviewed 26 infants with aganglionosis who presented at 32 days of age or less between 1972 and 1978. The average age at presentation was 8.3 days. There were 21 males and five females. Five infants had long-segment or total colonic disease. There was only one premature infant (34 weeks, 1840 g). The mean birthweight in the series was 3.6 kg. Six children had a family history of a congenital anomaly (23%). Three of these had a family history of Hirschsprung's disease (12%). Nine infants (35%) had associated congenital anomalies. Four of these newborns had Down's syndrome, and all four had a cardiac anomaly as well. Fifteen newborns presented with emesis (58%) which was bilious in nine (35%) cases. Seventeen babies (65%) had abdominal distension at the time of presentation. Eleven infants passed a meconium stool by 24 hours of age (42%), and 15 had passed meconium by 48 hours (58%). Twenty-two of 24 (92%) barium enema examinations available prior to diagnosis were diagnostic of Hirschsprung's disease. All of the 23 suction rectal biopsies were positive. All 26 patients underwent a colostomy or ileostomy following diagnosis. There was no enterocolitis and no mortality. All 26 patients have had an endorectal pullthrough performed at a mean age of 11.8 months without major complications.(ABSTRACT TRUNCATED AT 250 WORDS)
The nature of weight gain seen in infants receiving total parenteral nutrition continues to be controversial. The debate centers around whether or not the weight gain represents an increase in body mass or water retention. The following study was carried out to answer this question. Eighteen infants receiving peripheral or central intravenous nutrition following major surgery were studied for periods ranging from 1 to 17 weeks. The following studies were carried out after receiving informed consent from the parents and in accordance with the standards established by the Human Use Committee. Total body water was measured using the nonradioactive isotope, deuterium oxide; extracellular fluid volume was assayed using the nonradioactive isotope, sodium bromide. Both body fluid compartments were calculated using the Fick principle of dye dilution. Following double vacuum distillation, serum deuterium oxide was assayed using the falling drop technique. Serum bromide was measured by a technique developed in our laboratory that involves the complexing of bromide with gold chloride and the measurement of this chemical complex colorimetrically. Weight gain was observed in all patients. Total body water percent body weight was 82% +/- 15% prior to the initiation of intravenous nutrition; it decreased within the first week to 71% +/- 12% and then stabilized for the remainder of the study period at 75% +/- 7%. The extracellular fluid volume percent body weight was 56% +/- 15% prior to the start of intravenous nutrition; it fell to 47% +/- 10% during the first week of parenteral nutrition, and then stabilized at 40% +/- 9%.(ABSTRACT TRUNCATED AT 250 WORDS)
A barium colon examination is recommended for the diagnosis and reduction of intussusception in children, except when bowel perforation is evident either radiographically or clinically. In our experience and contrary to recent reports neither radiographic evidence of bowel obstruction nor an age of less than six months is a contraindication. We reviewed 40 patients diagnosed as having had intussusception and found five children aged more than six months with perforations discovered at operation. Three of the five children had plain radiographic findings of small bowel obstruction as did nine other children. In four of the 12 children with evidence of small bowel obstruction a successful hydrostatic reduction of the intussusception was carried out. Barium studies were performed for diagnosis and therapy in eight children with ileo-colic intussusception aged six months or less, four of whom had evidence of small bowel obstruction. In five, including two with obstruction, reduction of the intussusception was successful. The major contraindication to barium examination is radiographic or clinical evidence of perforation.
Explore the source record for details and available documents.