Biomedical subjects
Publications and source records attributed to J D Burrington.
Children are naturally active and enjoy many forms of physical activity. Each community, family, and physician owes the children in his care the opportunity to exercise and compete to the limits of their ability under supervised programs that will encourage a life-long participation.
Severe neonatal hypoglycemia with pathologic findings of diffuse nesidoblastosis of the pancreas is described in five children of both sexes from two families with unaffected parents. This appears to represent an autosomal recessive disorder of pancreatic development. Despite extensive testing, the diagnosis of hyperinsulinism was difficult in the index case of each family and delayed definitive treatment. Medical therapy with steroids and diazoxide was unsuccessful; pancreatectomy was required to treat persistent hypoglycemia. An abnormality of circulating glucagon found in one child with this disorder suggested that hyperinsulinism may not be the sole hormonal imbalance present, but rather that this disease is one of generalized disturbance of islet cell function. The history of severe, persistent neonatal hypoglycemia in an older sibling should lead the physician to investigate subsequent children for the presence of asymptomatic hypoglycemia.
This is a report of the gray scale ultrasound findings of pancreatic carcinoma occurring in a child. Although this tumor is rare, the preoperative diagnosis can be made if the physician is aware of this possibility. 99 mTc sulfur colloid radionuclide scan, liver spleen scan, gallium scan, and ultrasound examinations are helpful in distinguishing the site of origin of upper abdominal masses.
A study was designed and carried out to determine if the canine model of hypertrophic pyloric stenosis is applicable to other species and to demonstrate the transplacental passage of gastrin. Results of the study show that (1) pentagastrin does not induce hypertrophic pyloric stenosis in the rabbit; (2) human gastrin does not cross the canine placenta, and (3) gastrin has no documented and little inferred role in the etiology of CHPS.
The following conditions were surgically created in fetal lambs at the gestational ages of 80 to 90 days: (1) preductal coarctation, (2) postductal coarctation, (3) pulmonic stenosis, and (4) constriction of the ductus arteriosus. Studies performed at the time of delivery showed the following: Preductal coarctation and postductal coarctation often are associated with a dilated ductus arteriosus that remains patent. Pulmonic stenosis often results in prestenotic and poststenotic dilatation that may include the ductus arteriosus. The fetal ventricles become hypertrophied in response to the increased pressure work imposed by the distal stenoses.
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This report outlines principles of management for extensive corrosive esophageal burns in children complicated by formation of a tracheoesophageal fistula (TEF). Direct operative attack on the fistula usually is unsuccessful, since the tracheal tissues are so damaged that they will not hold sutures. On the basis of experiences with six children, we suggest the following plan of management: (1) early investigation of suspected TEF with thin barium or Dionosil; (2) early tracheostomy using a short, plastic tube; (3) end cervical esophagostomy with closure of the distal stump of the cervical esophagus; (4) gastrotomy; (5) complete disconnection of the intra-abdominal esophagus from the stomach. This can be completed in a single operation and leaves the thoracic esophagus containing the fistula completely isolated so that the trachea is protected from contamination by saliva and gastric juice. The esophageal mucosa in all cases has been destroyed so extensively by the corrosive material that the esophagus heals as a band of muscle and scar. If protected from continuous contamination by saliva, the trachea heals itself with little long-term defect. The esophagus is replaced with colon or a gastric tube 6 to 12 months later when the child is in good health. All four children treated by this regimen have survived and are able to eat normally.
Studies of tracheal growth in the rat, puppy, and human being indicate that there is a linear relationship between body weight and tracheal cross-sectional area. Each tracheal cartilage grows continuously, and there appear to be no growth centers. Each cartilage enlarges by proliferation of chondrocytes on the convex surface and resorption of cartilage on the concave surface. Vertical incisions in the trachea heal by fibrous union without interruption of growth. These studies indicate that there is no optimal age for surgical repair of subglottic stenosis, since growth is constant and is not interrupted by vertical incisions in the tracheal rings.
Ten consecutive children with clinical evidence of splenic rupture underwent surgical exploration. In eight patients, all or part of the spleen could be preserved. The two patients requiring splenectomy had associated injury to the tail of the pancreas. Surgical techniques employed to preserve the injured spleen were those in common use to repair equivalent hepatic or renal injuries. There was no morbidity or mortality associated with the procedure. Splenic salvage protects the child from increased susceptibility to sepsis associated with splenectomy.
The technique and scoring system of 24-hr pH esophageal monitoring has been modified to evaluate gastroesophageal reflux in infants and children. The data from two pediatric controls and five clinical cases are presented and compared to normal adult values. This test has better objectivity, precision, sensitivity, and reliability than contrast studies, endoscopy, esophageal biopsy, acid perfusion, or acid reflux tests. The 24-hr pH monitoring assists the evaluation of sphincter maturation, pulmonary disease, and the significance of body position. With more experience, this technique could identify children at risk fo developing severe complications of reflux esophagitis and aid in the selection of candidates for surgical intervention.
Treatment of lye ingestions by antidotes recommended on product labels includes the use of acid neutralizers. The possibility that heat produced by this exothermic reaction increased tissue damage was examined in vitro. Although Drano produced heat with all diluents including water and milk, acid antidotes prolonged the duration of high temperature. Clinitest tablets neutralized with milk produced no temperatures above 40 degrees C. The ready availability of milk or water, their acceptance by the child, and lack of toxic side effects make them diluents of choice for alkaline corrosive agents.
Fasting serum gastrin concentrations were determined by radioimmunoassay for 124 infants and children free of gastrointestinal disease. Values for the entire group ranged from 1.1 to 167.9 pg/ml (mean, 32.3 pg/ml). Mean serum gastrin levels for children who fasted eight or more hours were 22.5+/-23.9 pg/ml while the mean serum gastrin levels for children who fasted four to eight hours ranged from 42.4+/-33.9 pg/ml to 59.2+/-49.6 pg/ml. The mean serum gastrin levels varied inversely with body surface area among children who fasted the same length of time.
In a 3 1/2- year period, seven children have been treated for complications of ingestion or aspiration of pull tabs from aluminum beverage cans. One child died from a fistula between the esophagus and a branch of the aortic arch, and two children suffered esophageal perforation with local abscess formation. Since aluminum absorbs x-rays poorly, the pull tabs cannot be seen in frontal projection if they overlie vertebral bodies. Any toddler with unexplained alteration of feeding habits or persistent respiratory symptoms requires evaluation for an aspirated or ingested foreign body.
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Forty-five patients, of whom most were children, underwent extensive exposure of the thoracolumbar spine to correct serious orthopedic abnormalities. The spine was exposed through a combined thoracotomy and retroperitoneal approach that gave excellent access with minimal morbidity. The diaphragm was opened circumferentially after the peritoneum had been dissected from its muscular portion. This permitted repair of the diaphragm with no detectable loss of function. Although this approach was developed for exposure of the spine, it can also be utilized to expose the entire aorta, both kidneys and their blood supply, and the retroperitoneal area for possible excision of large tumors.
Examination of the records of 378 children with intussusception at our institution revealed that 29 cases were caused by an identifiable intestinal lesion. A Meckel's diverticulum was the causative agent in 21 children, all of whom were under 2 yr of age. A previously undiagnosed ileal lymphosarcoma produced the intussusception in six other children, all between 6 1/2 and 9 yr of age. Our experience indicates that any child over 6 yr of age with the clinical findings of colicky abdominal pain, bloody stools, and a palpable mass plus the radiographic evidence of intussusception must be considered to have ileal lymphosarcoma until proven otherwise. Hydrostatic reduction of the intussusception must be accompanied by extensive small bowel reflux of barium in order to effectively rule out a small intestinal lesion. If this is not accomplished, surgery should be planned with the suspicion that a malignancy may be present. If this suspicion is confirmed by frozen section, the operation procedure should include wide surgical excision of the lesion along with the regional lymph nodes.
Based on this series of six patients with aganglionosis of the entire colon we conclude: (1) Radiographic findings of a shortened colon of normal caliber or the presence of "jejunalization" of the colon suggest total colonic aganglionosis in patients with a suggestive history. (2) All infants with persistent obstipation, distention, and poor weight gain should have a punch biopsy of the rectum even if the barium enema is normal. (3) The Martin modification of Duhamel's operation gives functional results comparable to those achievable in children with short-segment Hirschsprung's disease. (4) The use of a stapling device to divide the septum between aganglionic colon and pulled-through ileum is less satisfactory than using crushing clamps.