Biomedical subjects
Publications and source records attributed to J E Allen.
The in vitro activity of aztreonam and 10 other antibiotics was determined for clinical isolates of Pseudomonas aeruginosa from 18 cystic fibrosis patients obtained before, at the end of, and 7-14 days after the completion of therapy with aztreonam. The percent of isolates susceptible to aztreonam at each sampling period were 79%, 78%, and 81% respectively.
Visceral ischemia secondary to increased intraabdominal pressure (IAP) following closure of abdominal wall defects presents a serious postoperative problem. Currently, the method of closure and postoperative management are determined by clinical impressions rather than measurement of IAP. In this study various methods of indirectly measuring IAP were compared in 17 rabbits in which IAP was sequentially increased with an intraabdominal balloon. Vesical and inferior vena caval (IVC) pressures were found to have good statistical correlation with IAP. Other methods tested were gastric, rectal, superior vena caval, femoral and brachial artery, and rectus compartment pressures. All were found to be poor indicators of actual IAP. In nine of the rabbits, radiolabeled microspheres were used to assess cardiac output and visceral blood flow. Renal blood flow was very sensitive to increased IAP with dramatic impairment at IAP above 10 to 15 mmHg. Small intestinal flow was less sensitive and did not become significantly diminished until IAP exceeded 25 to 30 mmHg. Our studies suggest that vesical and IVC pressure monitoring should be used to evaluate IAP in the clinical setting. If IAP is in excess of 10 to 15 mmHg surgical intervention is indicated to prevent the development of renal ischemia.
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The outlook for the child with neuroblastoma remains dismal. The tumor has been known to undergo spontaneous resolution, and this phenomenon has led to increased interest and research in possible immune mechanisms that may be involved. Treatment often involves the use of surgery, radiation, and chemotherapy, frequently producing a short-term response, but a cure of the disease in an advanced stage can rarely be attributed to any of these treatment modalities. The present staging and treatment method used by the authors is that of the Pediatric Oncology Group (POG) #8104. As far as the immunological therapeutic approach is concerned, promising results have been obtained in animal studies with monoclonal antibodies and immunocellular components. Cumulative data from various pediatric centers have showed that the patient's age strongly influences the prognosis in all stages of the disease.
Before 1969, 58 patients with Wilms' tumors treated at Children's Hospital of Buffalo had an all-stage survival of 57%. From 1970 to 1983, following the National Wilms' Tumor Study protocols, this survival rate has improved to 79% in the last 47 patients. With continued attention toward early diagnosis, accurate and complete staging, refinement of radiation and chemotherapy protocols, and absolute follow-up of all patients, the relapse-free survival rate will continue to improve.
Rhabdomyosarcoma is the most common soft tissue sarcoma in children under 15 years of age. Several decades ago it was associated with an 80% mortality rate. Recent advances with combined modality therapy have improved the 5-year survival rate to almost 70%. The focus for the improvement in treatment regimens is now shifting to concerns regarding the preservation of body function and the treatment of far advanced disease. Regardless of age, histology, stage, or site of primary tumor, there has been no group where chemotherapy has not been proven beneficial. The current recommendations used by the Intergroup Rhabdomyosarcoma Study, with regard to chemotherapy, are summarized. Radiation therapy adjunctive to surgery has a useful place in the treatment of rhabdomyosarcoma, but prophylactic nodal irradiation is not recommended. Involved nodes should, however, be treated. Since the potentially adverse side effects of chemotherapy and radiation are accentuated when combined, radiation therapy is no longer recommended in patients with group I rhabdomyosarcoma. Prognostic factors and future considerations from the operative standpoint are presented.
Leiomyoma of the omentum is a rare tumor. This is a report of the first known case of such a tumor presenting in childhood.
During a five-year period from 1979 to 1985, 100 consecutive children with perforated appendicitis were managed at our institution. These patients were divided into two groups, which were determined by length of illness and physical findings. Group A consisted of 88 children with signs and symptoms of peritonitis from appendiceal perforation. They were treated with fluid resuscitation, antipyretics, and triple antibiotics (ampicillin, gentamicin, clindamycin), and appendectomy within a few hours of hospitalization. Saline lavage was used. Group B was composed of 12 patients with a periappendiceal mass without generalized peritonitis who had symptoms of 6 to 12 days duration. They were treated nonoperatively with triple antibiotics and underwent interval appendectomy 4 to 6 weeks later. The complication rate for Group A was 6.8%. This included three wound infections (3.4%), one intra-abdominal abscess (1.1%), one patient with pneumonia and ileus (1.1%), and a small bowel obstruction (1.1%). These results are equivalent to the lowest complication rate reported in the literature, in which the treatment included transperitoneal drainage, antibiotic lavage, and parenteral antibiotics. Group B patients had a 16.7% complication rate, which included one small bowel obstruction and one recurrent intra-abdominal abscess. Our method of management resulted in the lowest complication rate reported to date in children with perforated appendicitis. Transperitoneal drainage, delayed wound closure, and antibiotic lavage were not used. Subcuticular incisional closure resulted in minimal wound care and excellent cosmetic results. The experience demonstrates that with proper timing of surgery and appropriate use of contemporary antibiotics, the morbidity of perforated appendicitis can be limited and excesses of treatment can be avoided.
A six-year experience using computed tomography (CT) in the diagnosis of blunt abdominal trauma was reviewed to assess the impact of CT scanning on a patient with renal injury. Three questions were evaluated: Does the increased sensitivity of the CT scan alter the indications for surgery? Does the CT scan help predict the course and eventual outcome of nonoperative therapy? Are there circumstances when the CT scan is not the most efficient and cost effective method of diagnosis? One hundred seventy six consecutive patients with suspected renal trauma were reviewed. One hundred thirty eight were evaluated by CT scan and IVP, the other 38 by excretory urogram alone. Forty four renal injuries were identified. Four of these patients required urgent surgery and four others required later operation for unsuspected congenital anomalies. The injuries sustained by the other 36 cases resolved without surgery. Each patient has been followed for 1 to 5 years following their trauma, and their status assessed by questionnaire and physical examination. The CT technique provides better definition of the injury upon which to base the decision to operate or to enter the patient into nonoperative management. The extravasation seen on CT scan is frequently exaggerated and should not be an absolute indication for exploration. The scan provides improved follow-up data as to completeness of healing and allows directions to be given to the parents concerning resumption of full physical activities. The patients with asymptomatic posttraumatic hematuria, have in our experience, a very low incidence of intraperitoneal or retroperitoneal injuries. Therefore, these patients do not require the advantages of CT scan and may be screened by the less expensive intravenous pyelogram.
Although Scheuermann's disease (juvenile dorsal kyphosis) is a common problem of late childhood and adolescence, its potential for neurological complications is not widely appreciated. In rare instances, spinal cord compression appears to be produced by the kyphotic protrusion alone, and we present an example of this unusual problem. Although the results of surgical treatment in this situation cannot be substantiated, anterior spondylotomy and decompression followed by posterior fixation appear to offer the best mechanical relief. Spinal cord compression can also be produced by extradural cysts, with which Scheuermann's disease is frequently associated. Scheuermann's disease also is reported to occur in combination with thoracic disc protrusion, but the coincidence here may be random. Pertinent literature is reviewed.
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A small, round cell tumor of the left scapula was found in a 3-month-old female Caucasian child. The histology was consistent with Ewing's sarcoma. Subsequently, a solitary pulmonary metastasis was excised. Thirty-one months after diagnosis, the child presented with leukokoria and a solitary pleural metastasis. The histology of both was identical to that of the original scapular tumor. G-banded karyotypes of the pulmonary metastasis and the ocular tumor revealed the presence of a balanced translocation, 46,XX, t(11;22)(q24;q12), which supported the original diagnosis of Ewing's sarcoma.
During the past 53 years, 105 patients with Wilms' Tumor have been treated at the Children's Hospital of Buffalo. Prospective and retrospective staging of these cases has allowed comparison with other reported series. All-stage survival improved from 37% with operation alone to 46% with operation and planned radiotherapy. During the past 22 years, with the addition of adjunctive chemotherapy, all-stage survival is now 80% with lesser stage survival approaching 100%. Participation in the cooperative National Wilms' Tumor Study has brought the most effective proven treatment to the patient in the shortest period of time.
Previous studies have identified a reliable relation between the quantity of food ingested and ruminating in profoundly retarded individuals and have established some parametric characteristics of this relation. The present study investigated three different properties of food that may influence this relation. Experiment 1 examined the role of stomach distention produced by including in the subject's diet wheat bran in amounts equivalent to and exceeding the calculated amount of crude fiber in the starch-satiation diet reported by Rast, Johnston, Drum, and Conrin (1981) and Rast, Johnston, and Drum (1984). There was a decrease in ruminating, although this decrease was smaller and more gradual than in the starch-satiation condition. Experiment 2 showed that increasing calories without increasing food volume resulted in a gradual and moderate decrease in ruminating. Experiment 3 replicated and extended the first two experiments by varying both caloric intake and stomach distention as well as oropharyngeal and esophageal stimulation in a different sequence of conditions. All variables exerted some control over responding. However, the large and immediate effects of the starch-satiation procedure occurred only when subjects were permitted to consume unlimited quantities.
Forty-eight patients over 60 years of age who had sustained blunt chest trauma were evaluated by injury, treatment, survival, and return to preinjury function. The patients ranged in age from 60-92 years (mean 72). The cause of injury was a fall in 25 (52.1%) and motor vehicle accident in 20 (41.7%). Twenty-three (47.9%) patients had major extrathoracic injuries. The average Injury Severity Score was 18 (range 5-41). Seven (14.6%) patients were treated with ventilation; six of these patients had flail chests, and four (57.1%) intubated patients developed pulmonary complications. Nonventilatory therapy was utilized in 41 (85.4%) patients; there were two (4.9%) treatment failures who required subsequent intubation. Six of 41 (14.6%) developed pneumonia. There was one death overall, yielding a mortality rate of 2.1%. Forty-three (89.6%) patients were discharged home: 39 (81.3%) to an independent life and four (8.3%) requiring partial assistance. Four (8.3%) required long term nursing home care. Severe chest trauma alone does not forecast a poor outcome in the elderly. Most elderly patients who sustain blunt chest trauma will be able to return to an independent life. Nonventilatory therapy, where indicated, is preferred to reduce severe pulmonary complications. Antecedent nutritional depletion may indicate the need for ventilatory therapy in the elderly chest trauma patient.
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Four children with yolk sac tumor were treated with an aggressive combination chemotherapy program. Three children had presacral primary tumors, one having pulmonary metastases, and one had a testicular primary tumor with pulmonary metastases. Three children were treated when they had measurable disease, and one had no measurable disease. The chemotherapy program consisted of a 6-wk induction period with vincristine (VCR), cis-diamminedichloroplatinum (DDP), and bleomycin. Maintenance therapy consisted of VCR, actinomycin D, and cyclophosphamide (cytoxan) every 3-4 wk as tolerated. Treatment was discontinued after 12 mo of complete remission. All three patients with evaluable disease had a partial response (PR) to induction therapy. Two underwent surgical exploration following induction therapy, one a laparotomy and the other a thoracotomy, and were found to have only scar tissue at the sites of presumed residual disease. The third child with measurable disease progressed to a clinical complete response (CR) during maintenance therapy. Two patients have had no evidence of disease (NED) for 42+ and 41+ mo since starting therapy (28+ and 27+ mo since completing treatment). Two patients are NED 11+ and 7+ mo since starting therapy and remain on treatment. We have encountered no significant renal or pulmonary toxicity, and there have been only two hospitalizations during maintenance therapy for fever and neutropenia. These preliminary results employing different induction and maintenance chemotherapy programs and planned second-look surgical intervention appear encouraging.
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