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Biomedical subjects

D W Vane

Publications and source records attributed to D W Vane.

At least 37 records · Page 2Linked to original sources
PubMed1995

Management of pediatric blunt splenic injury: comparison of pediatric and adult trauma surgeons.

The majority of injured children requiring hospitalization in the United States are cared for by nonpediatric surgeons. To determine whether there are differences in the management strategies (frequency of operative intervention) of pediatric and nonpediatric surgeons caring for children with blunt splenic injury, the data for children with this injury from the entire state of Vermont and the National Pediatric Trauma Registry were compared. From January 1, 1985 through December 31, 1991, 817 children (aged < 19 years) were entered into the study. There was operative intervention for splenic injury in 21% of the children managed by pediatric surgeons and in 52% of those managed by "adult" trauma surgeons (P < .05). This significance was maintained when operative rates were analyzed with control for injury severity score and age. The overall splenectomy rate was higher among cases treated by nonpediatric surgeons (24% v 13%; P < .05). In addition, previously reported factors (transfusion requirements, length of stay, hospital costs) used by opponents to nonoperative management were studied to determine management influence. Both transfusion requirement and hospital cost were lower for patients managed nonoperatively (P < .05). Length of hospital stay did not differ between the groups. Acute mortality rates were similar. The management of children with splenic injury must take into consideration the long-term morbidity associated with splenectomy as well as the acute operative morbidity. Today, adult trauma surgeons appear to manage children with blunt splenic injury with practice standards more appropriate for adult patients. Outcome analysis must include methods of care and their long- and short-term consequences to be considered valid.

Adolescent↗
PubMed1995

Nonoperative treatment of a major hepatic injury in a hemophiliac.

Selective nonoperative management of hepatic injuries from blunt trauma has become an accepted practice over the past 10 years. A case of nonoperative management of a major hepatic injury in a person with Hemophilia A is reported. Treatment with aggressive blood component therapy resulted in a successful outcome.

Blood Component Transfusion↗
PubMed1995

Epidemiology of rural traumatic death in children: a population-based study.

To determine the epidemiology of traumatic death in pediatric patients in a rural state, we reviewed all deaths caused by injury in victims < 19 years old between 1985 and 1990. We hypothesized that mortality would be higher than equivalent populations in urban areas. During the study period, 5,322 children were hospitalized for trauma (14% of total admissions for children in the state) and 36 died (0.67%). For this subgroup, head injury was the most common cause of death (72%). When compared with data from the National Pediatric Trauma Registry from urban centers, the mortality rate for hospitalized children in this rural state was lower (0.67% vs. 2.7%, p < 0.001). On review of the population-based statistics for the entire state, we found that these numbers were deceivingly low. In all, 731 children died during the study period, of which 283 were determined by autopsy or coroner's report to have died of trauma (38.7%). Eighty-seven percent of children who died never reached the hospital. Mortality (age-adjusted) was highest in the 15- to 18-year-olds (68.5 of 100,000), then < 1-year-old (26.8 of 100,000), 1- to 5-year-olds (15.6 of 100,000), and 5- to 14-year-olds (11.8 of 100,000), which significantly exceeds the predicted national averages for these age groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Spinal anesthesia for primary repair of gastroschisis: a new and safe technique for selected patients.

Spinal anesthesia has been described for infants and premature babies undergoing minor operative procedures. The advantages of shorter operating time, avoidance of intubation, and shorter hospital stay have made this the gold standard for premature and other high-risk infants requiring minor procedures. However, little is known about this technique for major interventions in newborns and preterm infants. Recently, four infants born with gastroschisis underwent repair under spinal anesthesia. Two had accompanying intestinal atresia (one with a prenatal perforation and pan-hypopituitarism), and two had intact gastrointestinal systems. The gestational ages were 39, 33, 36, and 36 weeks, respectively. All had primary closure of the defect; one had no repair of the atresia because the bowel was thick and matted with a significant peel, and the defect was not identified. In the second case with atresia, necrosis and perforation of a localized segment of intestine was identified proximal to the intestinal atresia, and was exteriorized with the primary repair. When they arrived in the operating room, all four infants were breathing spontaneously, on room air, after appropriate fluid resuscitation. All underwent spinal anesthesia, which was the only agent used for the operation. The operative time was 45, 25, 30, and 25 minutes, respectively (mean, 31.25 minutes). The duration of anesthesia was 170 to 230 minutes (mean, 205 minutes). All infants were returned to the neonatal intensive care unit on room air and breathing spontaneously. One was given morphine postoperatively and suffered significant respiratory depression, requiring intubation. It appears that spinal anesthesia is safe and effective for major operative procedures in high-risk infants. (ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Muscles↗
PubMed1994

Prompt fixation of isolated femur fractures in a rural trauma center: a study examining the timing of fixation and resource allocation.

Early fixation is defined by most authors as fracture fixation within 24 hours of admission. This definition of early is arbitrary and may not be achievable in a rural environment where interhospital transfer is often required and operating room resources are constrained. A review of isolated femur fractures was performed to determine if prompt fixation (24-72 hours, Early) was more effective than late fixation (> 72 hours, Late) and similar to immediate fixation (< 24 hours, Immediate) with regard to complications, mortality, and resource utilization. Between October 1, 1987 and December 31, 1990, 67 patients were admitted and stratified into one of the three groups based on the timing of fixation. The number of emergency operations was significantly greater in the Immediate group and the surgery took significantly longer to perform than in either the Early or Late groups (p < 0.004; ANOVA). There were significantly fewer pulmonary and infectious complications in the Immediate and Early groups compared with the Late group (p < 0.05, chi 2). Fixation of isolated femur fractures after 24 hours but before 72 hours had morbidity similar to fixation within the first 24 hours, but utilized operating room resources more efficiently.

Adult↗
PubMed1994

Pulmonary embolism in pediatric trauma patients.

Recent articles in the literature on adults have recommended prophylaxis for pulmonary embolism (PE) in selected trauma patients; however, to date no information is available regarding pediatric patients. We decided to investigate whether the incidence of PE in pediatric trauma patients is as high as that reported in adults, and identify those children who might be at high risk and benefit from prophylactic treatment. Utilizing the data from the National Pediatric Trauma Registry (NPTR), records were reviewed of all pediatric trauma patients (age < 19 years) admitted to the participating institutions between December 1987 and February 1993. Patients with documented PE were identified as well as those having associated risk factors as identified in adult trauma patients (deep venous thrombosis, extremity injury, spinal cord injury, and head injury). A total of 28,692 pediatric trauma patients were reviewed from the NPTR. The mean age was 9 years and the mean Injury Severity Score for the group was 11. Two thousand one children (7%) had serious head injuries (Glasgow Coma Scale score < 8), over 5700 (20%) had an isolated extremity injury, 290 had an identified spinal cord injury (108 with associated paralysis), and deep venous thrombosis was identified in 6 patients. Pulmonary embolism occurred in only two of the children in this series. Both patients with PE had spinal cord injuries with associated paraplegia, significant pulmonary injury, and high ISSs (25 and 27). The overall incidence of PE in the group was 0.000069%, and for those children with paralysis from spinal cord injury 1.85%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1993

The effect of hypotension and hypoxia on children with severe head injuries.

Survival of children (< 17 years) with severe head injuries (Glascow Coma Scale [GCS] score < 8) has been shown to be better than that of adults. The addition of hypotension (HT) or hypoxia (H) has a deleterious effect on outcome in adults but no information is currently available about their effects in children. Over a 5-year period, 58 children with GCS scores < 8 were admitted and prospectively evaluated at this institution. Patients were divided into two groups on the basis of systolic blood pressure (SBP) and arterial blood gasses. Patients exhibiting HT, defined as a SBP < 90 mm Hg, and patients demonstrating H with a PaO2 < 60 mm Hg were compared with normoxic, normotensive children. Survival was increased fourfold in patients with neither H nor HT as compared with children with either H or HT (P < .001). To validate these observations we reviewed the data from the National Pediatric Trauma Registry for similar patients and included our cohort in the analysis. In total, 509 children had sufficient data for analysis and were studied. Hypoxia alone was not associated with increased mortality in normotensive patients (P = .34). Hypotension significantly increased mortality in these children even without concomitant H (P < .00001). If both HT and H were found together, mortality was only slightly increased over those children with HT alone (P = .056). These data confirm that HT with or without H causes significantly increased mortality in head-injured children to those levels normally found in adults (P = .9), alleviating any age-related protective mechanisms normally afforded.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1993

Regional anesthesia in pediatric surgery: complications and postoperative comfort level in 174 children.

Postoperative pain control (PPC) in children is a difficult management problem. Systemic narcotics often result in respiratory depression, while nonnarcotic analgesics are associated with inconsistent PPC. This report reviews a 29-month (January 1989 through July 1991) experience with 174 children (aged < 18 years) who received regional PPC through indwelling catheters. There were 105 males and 69 females. Patient age ranged from 1 day to 17 years 10 months (mean age, 97 months). All catheters were placed using introduction needles ranging from 24 to 16 gauge. Agents were delivered as either continuous infusion (151 patients, 87%) or bolus injections (23 patients, 13%). Analgesics were age- and weight-determined dosages of bupivacaine with or without narcotic supplementation. All patients had surgical procedures except two who had catheters placed for pain control after trauma and one who had a catheter for intractable abdominal pain of unknown etiology. Twenty-five (15%) children had thoracic incisions, 76 (43%) abdominal, 16 (9%) flank, and 54 (31%) extremity. Catheter placement included 40 thoracic epidurals (23%), 100 lumbar (57%), 27 caudal (16%), and 7 pleural (4%). Catheters were utilized for a duration of 0.5 to 8 days (mean, 2.1 +/- 1.2 days). One hundred forty-four children required no additional pain medications (83%). Thirty (17%) patients required supplemental medications. Acetaminophen was used in 6 (3%), acetaminophen with codeine in 4(2%), morphine in 18 (10%), and Percocet in 1(1%). Minor complications occurred 21 times in 16 children (9%).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1993

The epidemiology of injury in a rural state: 5,322 cases over 6 years.

Presently, descriptions of rural trauma are complications of national sample statistics and local data from states projected to rural areas. This study reviews all hospital discharges (36,866) for children (aged 0 to 18 years) from January 1985 through December 1990 in an entirely rural state. Fourteen percent of admissions (5,322) were due to traumatic injury and 63% of these occurred in boys. Injury rates were age dependent with children 15 to 18 years experiencing an incidence of 110/10,000; 10 to 14 years 55/10,000; 5 to 9 years 39/10,000; 1 to 4 years 35/10,000; and < 1 year 39.5/10,000. Mean age for the entire population was 11.4 +/- 5.7 years. Thirty-five percent of children had more than one major site of injury. Sixty-three percent of admissions were for blunt trauma and only 4.8% were penetrating. The remainder were due to burns, hanging, ingestion, and other toxic agents. Falls constituted the most prevalent cause of injury in this population occurring in 25.9%, motor vehicle accidents 22.9%, struck by an object 9.6%, suicide attempts 8.5%, poisoning 4.7%, fire 1.2%, drowning 0.7%, and farm machinery 0.3%. The vast majority of motor vehicle accidents involved the child as an operator or occupant of the vehicle. Less than 10% involved a pedestrian being struck and less than 5% involved a child being struck while on a bicycle. Less than 6% of all injuries involved a bicycle. Child maltreatment was recorded in less than 2% of this population. Only 3.3% of injured children required transfer to another acute care facility (1/3 because of a motor vehicle accident and 1/4 because of a fall).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1992

Improved outcome utilizing spinal anesthesia in high-risk infants.

The development of apnea following general anesthesia in high-risk infants (less than 60 weeks postconceptual age) has been reported up to 37%, prompting the routine admission of these children following minor surgical procedures. One hundred forty high-risk infants (American Society of Anesthesiologists category greater than or equal to 2) were prospectively evaluated after undergoing surgical procedures normally performed as outpatients in low-risk babies. All patients had spinal anesthesia for their operations. The mean gestational age for these infants was 30.8 +/- 3.7 weeks (minimum, 24 weeks) with a mean birth weight of 1,466.0 +/- 638.8 g. The mean postconceptual age and weight at the time of surgery were 44.8 +/- 7.8 weeks and 3,336 +/- 1,242 g, respectively. Difficulty in administering the spinal anesthetic occurred in 6 cases (4.2%). Postoperative complications occurred in 5 children (3.8%). They were: postoperative fever (2), transient bradycardia (2), and apnea (1). The four cases of postoperative fever and bradycardia were insignificant and required no medical intervention. The single case of apnea occurred in a premature infant who received a supplemental dose of intravenous midazolam. Length of operation in these cases ranged from 15 minutes to 95 minutes (mean, 53 minutes), with two incidents of inadequate anesthesia occurring in this cohort. Mean duration of anesthesia was 146 minutes (range, 50 to 240 minutes) and was directly dependent on dosage administration of the agents. These data indicate that the use of spinal anesthesia in high-risk infants is safe and effective for surgical procedures generally performed as outpatients (3.0% minor complication rate, 0.8% major complication rate).(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulatory Surgical Procedures↗
PubMed1991

Inguinal hernia in children: factors affecting recurrence in 62 cases.

This report analyzes factors associated with 71 recurrent inguinal hernias in 62 children treated between 1976 and 1988. Cases were evaluated for sex, age, type of initial repair, interval to recurrence, the presence of comorbid conditions, and type of reoperation. There were 57 boys and 5 girls. Sixty percent of patients were less than 6 months old and 72% were less than 1 year of age at the time of the initial repair. Recurrence was on the right in 74%, left in 24%, and bilateral in 2%. Recurrence was noted by 6 months in 50%, by 2 years in 76%, and by 5 years in 96%. Comorbid conditions were present in 60% of cases, including increased intraabdominal pressure (ventriculoperitoneal [VP] shunts), growth failure, prematurity, chronic pulmonary disease, bladder exstrophy, connective tissue disorders, cryptorchism, seizure disorder, and malnutrition. Incarceration was a factor in four of the 62 cases. Seven patients had multiple recurrences. Fifty-one recurrences were indirect, whereas 20 were direct inguinal hernias. Inadequate high ligation (three with chromic catgut), wound infection, and groin hematoma were other findings. The direct hernias may be related to injury to the floor of the canal during initial repair. Recurrent repair included high ligation of the sac alone (20), high ligation plus snugging of a large internal ring (11), and high ligation with repair of the iliopubic tract in patients with VP shunts, connective tissue disorder, or weak floor (20). All direct hernias had a Cooper's ligament (McVay) repair. Two direct hernias recurred again and were successfully repaired using a preperitoneal approach.(ABSTRACT TRUNCATED AT 250 WORDS)

Child↗
PubMed1990

Failure of percutaneous drainage in children with traumatic pancreatic pseudocysts.

Recent reports have documented the successful use of percutaneous drainage (PD) in the management of traumatic pancreatic pseudocysts in children. This study presents four cases of pancreatic pseudocyst in which percutaneous catheter drainage was performed. In one instance, no operative therapy was required. However, in the other three cases PD failed to resolve the problem and distal pancreatectomy with splenic salvage was performed when contrast studies (endoscopic retrograde cholangiopancreatography or catheter injection) demonstrated disruption of the main pancreatic duct. This report suggests that children with pancreatic pseudocysts unresponsive to PD require prompt investigation of ductal anatomy to rule out transection or other major injury.

Abdominal Injuries↗
PubMed1990

Pulmonary hypertension in neonatal cystic lung disease: survival following lobectomy and ECMO in two cases.

Extracorporeal membrane oxygenation (ECMO) is an accepted form of therapy in the treatment of neonates with otherwise lethal persistent pulmonary hypertension related to meconium aspiration, congenital diaphragmatic hernia, and sepsis. This report concerns two neonates with congenital cystic lesions of the lung who developed severe pulmonary hypertension and were salvaged with lobectomy and ECMO. These cases present an additional group of patients in whom ECMO may be a life-saving measure.

Cystic Adenomatoid Malformation of Lung, Congenita↗
PubMed1990

Pancreatic tumors in childhood: analysis of 13 cases.

Pancreatic tumors are rare in children. Over a 20-year period we have treated 13 children with pancreatic neoplasms. There were eight boys and five girls (age range, 4 months to 12 years). Seven tumors were benign, including five insulinomas, and two cystadenomas. Six lesions were malignant (rhabdomyosarcoma, 2; pancreatic carcinoma, 4). Children with insulinoma presented with hypoglycemia and irrational behavior. Three had abnormal insulin:glucose ratios ( greater than 1.0). The tumor was detected by computed tomography scan in three cases, at the time of surgery in one, and with intraoperative ultrasound in one. Surgical treatment included tumor enucleation in four cases and 80% pancreatectomy in one. Mucinous cystadenomas were observed in two patients, ages 4 months and 10 months. Tha latter infant underwent cyst excision alone, resulting in malignant recurrence at 18 months of age and death. The 4-month-old child had a distal pancreatectomy and is alive at 6 years. Two of the four children with pancreatic cancer had unresectable tumors at diagnosis, and were treated by biopsy (ductal adenocarcinoma), irradiation, and chemotherapy. Length of survival was 6 months and 9 months. Two others (ages 4 and 12 years) underwent 85% distal pancreatic resection for pancreatoblastoma and a pancreatoduodenectomy for papillary carcinoma, respectively. The latter is alive and tumor-free at 20 years of follow-up. The former underwent hepatic lobectomy for a 3.0 x 3.0 cm solitary liver metastases and is alive at 6 years with no evidence of disease. One child with rhabdomyosarcoma died of progressive disease, the other is alive with residual disease despite resection and chemotherapy. Most insulinomas can be treated by enucleation.(ABSTRACT TRUNCATED AT 250 WORDS)

Child↗
PubMed1990

The effect of chloroquine and hyperthermia on murine neuroblastoma.

A number of reports suggest that hyperthermia is an effective adjunctive treatment modality in management of neural crest tumors. Recent studies have demonstrated a synergistic effect of induced hyperthermia when coupled with chloroquine in an in vitro model. This study examines the effect of chloroquine and hyperthermia in an in vivo murine neuroblastoma model. Forty-seven Ajax white mice (weighing 20 to 30 g) received a subaxillary tumor burden (C-1300 murine neuroblastoma) per trochar (1.25 x 10(6) cells). The tumor was then incubated for 9 days. Mice were then divided into four groups: group 1, controls (n = 15); group 2, hyperthermia (n = 12); group 3, chloroquine (n = 10); and group 4, chloroquine with hyperthermia (n = 10). Hyperthermia was induced with 40 to 69 mW/cm2 at 2,450 MHz microwave radiation for 4 minutes to achieve a temperature of 41.5 degrees C for 10 of 14 treatment days. Chloroquine was administered intraperitoneally at a dose of 40 mg/kg body weight for 10 of 14 treatment days. Mice were weighed and tumor size was determined daily. Animals were killed on day 21 and postmortem examination was performed, with tumors graded histologically. Animal weight, tumor weight, and tumor size were similar for all groups (P greater than .05). Mortality was 6% in group 1, 25% in group 2, 50% in group 3, and 40% in group 4 (P less than .05). Rate of tumor metastases was also statistically different from controls: group 1, 0%; group 2, 60%; group 3, 90%; and group 4, 90% (P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1990

Delayed onset of intestinal obstruction in children after unrecognized seat belt injury.

The increased use of child safety seats and seat belt restraints has significantly reduced the incidence of severe head injuries associated with motor vehicular accidents. However, an increase in the number of both acutely recognized intestinal perforations and delayed obstructions due to ischemic strictures has been noted. This report describes two children with delayed onset of intestinal obstruction related to the "seat belt syndrome" who presented with bilious emesis 3 to 6 weeks following an unrecognized lap belt injury. At laparotomy, a volvulus around an omental band adherent to a resolving traumatic mesenteric hematoma was the basis of the obstruction in both cases. The volvulus resulted in a stricture in each instance that required resection and end-to-end anastomosis. The diagnosis of posttraumatic intestinal obstruction should be suspected in children who develop nausea and bilious emesis following motor vehicular accidents in which they were wearing lap belts.

Abdominal Injuries↗
PubMed1990

Acquired aganglionosis: a rare occurrence following pull-through procedures for Hirschsprung's disease.

Hirschsprung's disease (HD) is a neurogenic form of intestinal obstruction characterized by a congenital absence of ganglion cells in the submucosal and myenteric plexuses. Acquired aganglionosis (AAG) is a rare condition that may occur following various pull-through procedures for HD. This report describes five boys with acquired aganglionosis. In all cases, the presence of normal ganglion cells was confirmed on review of biopsies of the pull-through segments at the initial operation. The original pull-through procedure included Soave (2), Duhamel (2), and Swenson (1) operations. Three procedures were initially performed at other institutions. Recurrent symptoms including abdominal distention, obstipation, enterocolitis, and failure to thrive developed 7, 11, 12, 18, and 30 months postoperatively (mean, 15.6 months). The diagnosis of AAG was delayed 1.5 to 9 years after the onset of recurrent symptoms. Full column barium enema studies revealed a transition zone or narrow area in the rectosigmoid or descending colon in four children. Repeat full thickness rectal biopsies at 3.0 cm above the anal verge in the pull-through segment confirmed the absence of ganglion cells in each case. Two children (post Swenson and Duhamel) were successfully revised with a Swenson procedure. Two additional children (post Soave and Duhamel) were successfully treated with extended posterior anomyomectomy procedures. The remaining boy now has a preliminary colostomy and is awaiting a second procedure. Vascular compromise of the distal bowel segment at the time of the initial pull-through procedure may contribute to the selective loss of ganglion cells postoperatively as neural tissues are most sensitive to hypoxia.(ABSTRACT TRUNCATED AT 250 WORDS)

Colon↗