Confronting a tempest. Acute leukemia.
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Acute Disease↗
Biomedical subjects
C L Snyder
Publications and source records attributed to C L Snyder.
Thal fundoplication in neurologically impaired children.
Children with neurological impairment (NI) frequently require feeding gastrostomy, and this often aggravates or produces gastroesophageal reflux (GER). From 1976 to 1994, 141 children with severe NI underwent Thal fundoplication and gastrostomy (GT). GER was evident in 80%; in the rest, fundoplication was an adjunct to GT. Ph results were positive in 38 cases, and 57 children had reflux according to the barium studies. There were no major intraoperative complications. Disruption of the repair and/or recurrent GER was noted in 14 cases (10%); 8 were redone as Thals, and 6 were converted to Nissen procedures. Pyloroplasty was done later in 9 children (6%). Bowel obstruction was seen in 4 patients (3%). Clinical follow-up (mean, 54 months) showed improvement in 96%; only 5 of the 141 (3.2%) have residual symptoms. Of the patients with an intact Thal, 67% could burp or vomit. The ability to vomit may protect the Thal fundoplication and avoid disruption of the repair.
Adolescent↗
Esophageal duplication cyst with esophageal web and tracheoesophageal fistula.
The authors report the case of lower cervical/upper thoracic esophageal duplication associated with an obstructing esophageal web. This presented in the newborn period as an esophageal atresia. Initial resection of the web and closure of the fistula were performed. The duplication was excised electively at 2 months of age. Persistent symptomatic tracheomalacia required aortopexy, after which the child recovered uneventfully. There are only three other reports (four cases) in the literature of esophageal atresia (or variants) associated with esophageal duplication.
Aorta↗
Significance of chest trauma in children.
Chest trauma in children is a marker of injury severity and is associated with a high mortality rate. This retrospective study of 1,356 trauma patients from a private pediatric hospital over a 2.5-year period identified 82 patients with chest injuries and a mortality rate of 22%. Results of Injury Severity Score, Glasgow Coma Scale, and Revised Trauma Score all indicated that children with chest injuries sustained more severe injuries. The presence of any extrathoracic injury was associated with a higher mortality (29%) than chest injury alone (4.3%). The type of extrathoracic injury was important, with head and neck injuries resulting in the highest mortality. Specific chest injuries, such as rib fractures and pulmonary contusions, were not related to increased mortality unless there was an associated extrathoracic injury. Many reports have shown a high mortality associated with chest trauma. This study suggests that it is the associated extrathoracic injury, rather than the chest injury itself, that is the real cause of the high mortality.
Abdominal Injuries↗
A simplified method for mucosal proctectomy in children.
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Adenomatous Polyposis Coli↗
Axon terminals immunolabeled for dopamine or tyrosine hydroxylase synapse on GABA-immunoreactive dendrites in rat and monkey cortex.
Dopamine afferents to the cortex regulate the excitability of pyramidal neurons via a direct synaptic input. However, it has not been established whether dopamine also modulates pyramidal cell activity indirectly through synapses on gamma-aminobutyric acid (GABA) interneurons, and whether such inputs differ across cortical regions and species. We sought to address these issues by an immunocytochemical electron microscopic approach that combined peroxidase staining for dopamine or tyrosine hydroxylase (TH) with a pre-embedding gold-silver marker for GABA. In the deep layers of the rat prefrontal cortex and in the superficial layers of the monkey prefrontal and primary motor cortices, terminal varicosities immunoreactive for dopamine or TH formed primarily thin, symmetric synapses on distal dendrites. Both GABA-immunoreactive dendrites as well as unlabeled spines and dendrites were contacted by dopamine- or TH-immunoreactive terminals. Synaptic specializations were detected at some, but not all of these contacts. The relative frequency of these appositional and synaptic contacts did not appear to differ between the rat and monkey prefrontal cortex, or between the monkey prefrontal and motor cortices. Across regions and species, labeled and unlabeled targets of dopamine- or TH-positive terminals received additional synaptic input from unlabeled, and occasionally GABA-immunoreactive terminals. Close appositions between dopamine- or TH-immunoreactive and GABA-positive terminals were observed only rarely. These findings indicate that dopamine afferents provide direct synaptic inputs to GABA local circuit neurons in a consistent fashion across cortical regions and species. Thus, dopamine's cellular actions involve direct as well as modulatory effects on both GABA interneurons and pyramidal projection neurons.
Animals↗
Cellular and subcellular localization of syntaxin-like immunoreactivity in the rat striatum and cortex.
Syntaxin is a synapse-specific protein previously localized to the plasma membrane of axon terminals. Biochemical and molecular biological studies indicate a prominent role for syntaxin 1A and 1B in synaptic vesicle docking and/or fusion, suggesting that these proteins are localized to active zone regions of most terminal varicosities in the central nervous system. We sought to test this hypothesis by examining the cellular and subcellular immunocytochemical localization of syntaxin 1 proteins in the striatum and frontal cortex of rats. Using either a polyclonal anti-syntaxin antibody, or a monoclonal antibody directed against the identical protein, HPC-1, immunoperoxidase reaction product was localized to preterminal axons and terminal varicosities that made almost exclusively Type I (asymmetric) synapses on dendritic spines or distal shafts. Immunoreactive terminals forming Type II (symmetric) synapses were observed rarely and only in tissue that was pretreated by rapid freeze-thaw to enhance antibody penetration. From a semi-quantitative analysis, it was estimated that at least 48-62% of all vesicle-filled varicosities and 67-69% of all terminals forming Type I synapses were immunoreactive for syntaxin or HPC-1, respectively. Using a pre-embedding immunogold-silver technique to provide a non-diffusible marker for subcellular localization, gold-silver particles for syntaxin or HPC-1 were localized to the cytoplasmic surface of non-synaptic portions of the plasma membrane of preterminal axons and terminal varicosities. Enrichment of presynaptic active zone regions was not observed with immunogold-silver staining. These findings suggest that syntaxin is primarily contained in a subpopulation of terminals that are associated with excitatory amino acid transmitters, but appears not to be ubiquitously expressed in all terminal classes. The results further indicate that syntaxin is localized to non-synaptic regions of axon and terminal membranes, but may not be enriched in presynaptic active zones. The apparent inconsistency between the subcellular localization of syntaxin and its proposed role in vesicle exocytosis is discussed in terms of possible technical limitations and alternative functions for syntaxin.
Animals↗
Central venous catheter change over a guide wire: a simple technique.
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Catheterization, Central Venous↗
A combined hospital experience with fundoplication and gastric emptying procedure for gastroesophageal reflux in children.
BACKGROUND: Operative treatment of symptomatic gastroesophageal reflux (GER), often together with neurologic feeding disorders, is very common in infancy and childhood. Delayed gastric emptying (DGE) has been observed frequently in association with GER in children. STUDY DESIGN: A retrospective review was performed on 1,200 consecutive patients 18 years of age and younger operated upon for symptomatic GER or neurologic feeding disorders, or both, at two pediatric surgery centers in widely separated geographic areas in the United States of America, to compare the results after fundoplication with or without a gastric emptying procedure (GEP). RESULTS: Operations included gastroesophageal fundoplication (GEF) alone (871 patients), GEF plus GEP (286 patients), reoperative GEF plus GEP (30 patients), and GEP alone (13 patients). Thus, 27 percent of the total and 40 percent of the last 494 children with reflux had a GEP. Delayed gastric emptying with retention of more than 60 percent of an isotope meal appropriate for age at 90 minutes was present in 241 of the 451 children with reflux studied. Major neurologic disorders were present in 219 (25 percent) of 871 children who underwent GEF alone and in 247 (75 percent) of 329 children who had a GEP. All patients operated upon from both hospitals were relieved of recurrent emesis, and those with failure to thrive showed significant weight gain; pulmonary symptoms were relieved in 94 percent. Recurrent GER developed in 47 (5.2 percent) of 901 children who had GEF alone, but in only four (1.2 percent) of 329 patients who had a GEP. CONCLUSIONS: The excellent clinical results with low morbidity in this largest reported clinical experience with GEP in childhood suggest that a GEP should be combined with GEF for symptomatic children who have both GER and DGE. Minimal investigative studies are necessary for most neurologically impaired children who require a feeding gastrostomy.
Adolescent↗
An absent right and persistent left superior vena cava in an infant requiring extracorporeal membrane oxygenation therapy.
A persistent left superior vena cava (PLSVC) is the most common anomaly of the major veins. However, an absent right superior vena cava and PLSVC is much less common; fewer than 100 cases have been reported in the world literature in patients with situs solitus. This rare variation was encountered in a newborn requiring extracorporeal membrane oxygenation (ECMO) for meconium aspiration and interfered with venous cannulation. The anomaly was not suspected before an unusual cannula position was observed on the chest radiograph, and it was confirmed by bedside venography. Adequate venous cannulation was obtained through the anomalous vessel using a flexible catheter, allowing for an uneventful ECMO course. The epidemiology and embryology of this incidental anomaly are reviewed, and the methods used to circumvent the difficulties it presented in this case are described.
Congenital Abnormalities↗
Aggressive metastasectomy for pulmonic sarcomatous metastases: a follow-up study.
Pulmonary metastases are the primary cause of death due to bone and soft tissue sarcomas. We have previously shown that an aggressive approach and a new technique of multiple pulmonary metastasectomies have resulted in improved survival for patients with pulmonary metastases. In this follow-up study, an expanded database of patients was retrospectively analyzed to determine survivability as well as to evaluate potential prognostic indicators. Forty-nine patients, 26 of whom had osteogenic sarcoma (OGS), were evaluated. A number of patients had been referred from other institutions where their disease had been considered inoperable because it was extensive or recurrent. Using lateral thoracotomies exclusively, employment of a laser technique, and excision of minimal pulmonary parenchymal tissue, we performed aggressive metastasectomy. A mean of 3.0 thoracotomies was performed, in which an average of 10.2 nodules per thoracotomy were excised. Operative morbidity and mortality were minimal. The disease-free interval, the number of nodules resected, the number of thoracotomies performed, and the size of the nodules were evaluated as potential prognostic indicators. Statistically significant correlation could be established only for the size of the nodules resected. The 5-year survival rate for all patients was 39%; it was 24% for patients with OGS and 71% for those without OGS. Aggressive surgical resection of pulmonary metastases from bone and soft tissue sarcoma should be considered when there is control of local disease, no evidence of extrapulmonary metastasis, and adequate post-resection pulmonary reserve. The presence of bilateral, extensive, or recurrent disease is not a contraindication to thoracotomy. Aggressive resection of multiple nodules and improved chemotherapy appear to prolong survival of these patients when compared with survival rates of historical control subjects.
Adolescent↗
Decreased incidence of intracranial hemorrhage using cephalic jugular venous drainage during neonatal extracorporeal membrane oxygenation.
Intracranial hemorrhage (ICH) remains one of the more common serious complications of extracorporeal membrane oxygenation (ECMO) in neonates. In 1990 this center began routine use of cephalic jugular venous drainage during neonatal ECMO to augment blood return to the ECMO pump and potentially decrease the incidence of ICH by decreasing cerebral venous pressure. Thirty-four ECMO cases utilizing cephalic jugular venous drainage were compared with the previous 34 ECMO cases. The incidence of ICH decreased from 35% (12/34) to 6% (2/34) when neonates without cephalic jugular venous drainage are compared with those being subject to this technique (P < .01). No differences were found between the two groups in gestational age, birth weight, duration of ECMO, survival, platelet counts, activated clotting times, or incidence of other bleeding complications. Cephalic jugular venous drainage during neonatal ECMO appears to be safe and may decrease the incidence of ICH.
Catheterization, Central Venous↗
A new approach to the resection of pulmonary osteosarcoma metastases. Results of aggressive metastasectomy.
Pulmonary metastases are the primary cause of death from bone and soft-tissue sarcoma. Recognition that even multiple resections of metastases can improve survival has led to a more aggressive surgical approach to these patients. The authors instituted an aggressive approach and a new technique and retrospectively analyzed the results of multiple, pulmonary metastasectomies for pulmonary metastases in 34 patients, 21 of whom had osteogenic sarcoma (OGS). A number of cases were referred from other institutions, where they had been considered inoperable because of extensive or recurrent disease. Using lateral thoracotomies, laser technique with minimal parenchymal excision, and thin gloves for palpation, aggressive metastectomy was carried out. A mean of 3.1 thoracotomies were performed, with an average of 10.6 nodules resected per thoracotomy. Operative morbidity and mortality were minimal. Evaluation of potential prognostic factors revealed no statistically significant survival difference on the basis of disease-free interval (DFI), number of nodules resected, number of thoracotomies, or size of largest nodule resected. There was a clear trend toward decreased survival of patients with larger nodules (greater than 2 cm), but because of the small number of patients in this group, no firm conclusions can be drawn. Five-year survival was 49% for the study group as a whole, and 39% for the OGS patients. Aggressive surgical resection of pulmonary metastases from bone and soft-tissue sarcoma should be considered when there is control of local disease, no evidence of extrapulmonary metastasis, and adequate postresection pulmonary reserve. The presence of bilateral, extensive, or recurrent disease is not a contraindication to thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
A simple technique for assessing the viability of stomas of the intestines.
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Enterostomy↗
Diagnostic open-lung biopsy after bone marrow transplantation.
The development of pulmonary infiltrates is an ominous sign in the immunocompromised host (ICH). Selection of the best diagnostic and therapeutic approach is often difficult, and in part depends on the risk-to-benefit ratio of various diagnostic modalities, such as bronchoscopy, bronchioalveolar lavage, percutaneous needle biopsy, and open-lung biopsy (OLB). We reviewed our experience with OLB and bronchoscopy in a predominantly pediatric bone marrow transplantation population, and attempted to assess the frequency with which OLB results directed a therapeutic change, as well as the clinical results of any such therapeutic alteration. A retrospective chart review was conducted of 87 bone marrow transplantation recipients undergoing diagnostic OLB from 1975 to 1986. Bronchoscopic and OLB cultures, histopathologic studies, serological data, and autopsy results were all carefully examined. An assessment of therapeutic alteration as a result of OLB was made, and clinical changes attributable to an OLB-directed therapeutic alteration were sought. Ninety-four OLBs and 37 bronchoscopic examinations were performed in 87 patients. All patients had undergone bone marrow transplantation, most often for leukemia (58/87) or aplastic anemia (13/87). The mean interval from bone marrow transplantation to OLB was 106 days. There were no intraoperative complications, but minor postoperative surgical complications were frequent (incidence, 21%). Postoperative mortality, defined as a death occurring within 30 days of surgery, was 45% (39/87). Seventy-four percent of the patients (64/87) died during the course of the study, at a mean of 43 days after OLB. Most OLBs (60%) yielded a specific diagnosis, defined as the establishment of a precise cause for the infiltrate.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Peripheral venous monitoring with acute blood volume alteration: cuff-occluded rate of rise of peripheral venous pressure.
We investigated the use of a new peripheral hemodynamic monitoring technique, the cuff-occluded rate of rise of peripheral venous pressure (CORRP), in the assessment of volume status in fluid overload. Seven adult mongrel dogs were given a general anesthetic, and monitoring lines were inserted. The animals were then subjected to an incremental volume overload of approximately 13% of estimated initial blood volume at 5-min intervals until a total volume infusion nearly equal to the animal's initial blood volume was reached. Comparison of the various monitoring techniques (e.g., cardiac output, CVP, systemic BP, pulmonary wedge pressure) demonstrated that the peripheral measurement of CORRP had better correlation with known administered volume (r = .96) than any of the other variables. The sensitivity of each of the variables in assessing small amounts of volume overload was also studied. The volume of crystalloid infusion necessary to cause a clinically significant change (defined as greater than 2 SD above the baseline mean) was compared for each of the monitoring variables. CORRP was equivalent to the other variables in sensing early volume overload. In summary, in the anesthetized animal model CORRP appears to be a sensitive, minimally invasive method of assessing volume status in acute volume overload. The efficacy of CORRP in a canine hemorrhagic shock and reperfusion model had previously been demonstrated. This technique could be clinically applicable in situations such as trauma with hemorrhagic shock, intraoperative volume changes, and in the assessment of intravascular volume after resuscitation.
Animals↗
Blunt trauma in adults and children: a comparative analysis.
Trauma remains the major cause of death in children and young adults. Adult and pediatric patients differ significantly in both mechanism of and physiologic response to injury. We reviewed the records of all consecutive adult and pediatric blunt trauma patients admitted to a major metropolitan trauma center for a 10-year period. An extensive computerized database has been maintained for all patients since 1977. A comparative statistical analysis of mechanism of injury, specific organ injury, and clinical outcome was performed. Altogether, 1,722 adults and 289 children were treated during the study period. Blunt trauma accounted for 82.8% of adult and 94.3% of pediatric injury (p = 0.00005), and only these patients were considered for analysis. Diagnostic peritoneal lavage was performed in 249 children and 1,464 adults, with a respective accuracy of 99.6% and 97.2%. Mechanism of injury was comparable for both groups, although children were far more likely to be injured by falls, bicycle accidents, or struck by an automobile. Comparative analysis of specific injuries demonstrated significantly fewer pediatric chest (p = 0.001), spine (p = 0.03), and pelvic (p = 0.003) injuries. Central nervous system (CNS) injury in children was a strong determinant of outcome: serious pediatric CNS trauma was associated with a tenfold increase in mortality. Mortality for children in the absence of CNS injury was less than 3%. Spinal injury also appeared to be a predictor of poor outcome in the pediatric population, with an associated mortality of greater than 50%. Overall, survival was age independent (82.5% of adults and 85.8% of children were survivors.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Spontaneous perforation of the extrahepatic biliary tree in infancy. A case report.
Spontaneous perforation of the bile duct in infancy is rare, with less than 55 cases described in the literature to date. The authors report the case of a 30-day-old neonate who presented with a 2-week history of progressive abdominal distension and intermittent jaundice. Disofenin technicium 99m sequential scintiscanning provided a preoperative noninvasive confirmation of the diagnosis of biliary ascites secondary to spontaneous perforation of the extrahepatic biliary tract. Distal common bile duct atresia was identified intraoperatively, and end-to-side Roux-en-Y hepaticojejunostomy was performed, with an uneventful postoperative recovery. The etiology, diagnosis, and treatment of spontaneous neonatal biliary perforation is discussed.
Ascites↗