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Biomedical subjects

R D Spicer

Publications and source records attributed to R D Spicer.

At least 19 recordsLinked to original sources
PubMed2004

Surgical risk factors for Hickman catheter sepsis: a prospective study.

Catheter-related sepsis (CRS) is a major cause of morbidity in patients receiving chemotherapy and prolonged parenteral nutrition. To determine whether avoiding emergency insertions by using a planned elective list and adopting a 'no-touch' technique has a role in reducing CRS, all cuffed central venous catheters inserted by the open method between 1999 and 2000 were prospectively followed for a total duration of 12 months. The incidence of early sepsis (within 30 catheter days) that could be attributed to surgical factors was studied. CRS was defined as the presence of any two of the following: (1) signs of clinical sepsis without an obvious focus; (2) positive cultures in blood obtained from the catheter; and (3) clinical improvement following removal. A total of 146 catheters were inserted in 130 patients; 15 had a second and 1 had a third catheter inserted. Early CRS was encountered in 13 cases (9%); 95 catheters were inserted on an elective list and 51 on an emergency basis. The distributions of age, sex, number of lumens, neutrophil count, and underlying diagnosis were similar between the groups. There was no significant difference (P = 1) between elective (9/95) and emergency (4/51) insertions. A total of 47 catheters were inserted by the 'no-touch' technique and 48 by the manual technique. There was no significant difference in early sepsis (P = 0.7) between the two techniques (6/47 vs 3/48). Thus avoiding emergency insertion or adopting a 'no-touch' technique does not reduce early CRS. Larger prospective studies are warranted to identify surgical risk factors.

Catheterization, Central Venous↗
PubMed2002

Perianal abscess in childhood.

Perianal abscess (PA) is a common condition encountered in childhood, but its optimal primary treatment is uncertain. Treatment of PA by incision and drainage (I & D) alone is associated with an unacceptably high recurrence rate, either as fistula-in-ano (FIA) or as PA. To identify possible causes of recurrence and assess the value of concomitant laying open of a fistulous tract at the time of primary incision and drainage, the case notes of all children who presented to our institution with a PA between January 1992 and January 1997 were reviewed retrospectively. Thirty-three cases were identified (29 boys and 4 girls). A fistulous tract was identified and laid open at the time of primary drainage in 20 cases, whilst 13 were treated by I & D alone. Following primary drainage, there were 7 recurrences (21.2%) (FIA 5 and PA 2). All recurrences had been primarily treated by drainage alone, whilst there were no recurrences in patients who had also undergone fistulotomy at the time of primary drainage. Thus the primary treatment of PA in childhood should involve a careful search for a coexisting fistula and treatment of this by fistulotomy.

Abscess↗
PubMed2002

Implanted vascular access devices (ports) in children: complications and their prevention.

Implanted vascular access devices (ports) play a major role in the management of children with cystic fibrosis (CF) and many haematological conditions. With the expanding use of ports, new and more frequent complications are being encountered. To retrospectively review the complications associated with ports, the case notes of all patients who underwent insertion of a port between 1997 and 2000 were analysed. Details of the underlying disorder, type of vascular device, nature of use, and complications were recorded; 55 ports were inserted in 41 patients (a second port was required in 12, a third port in 2) during this period. Their underlying diagnoses were CF (11), haemophilia (4), haemolytic anaemias (2), immunological disorders (6), solid neoplasms (8), and leukaemia (10). Thirteen ports (24%) were removed and replaced for various complications: infection (2), blockage (4), leak (2), dislodgement (2), and malposition (3). Including four port-related problems managed conservatively (3 access problems managed by change in access technique; 1 blockage managed by urokinase), the over all complication rate was 31%. Ports thus have a high complication rate with long-term use. Selecting the right port system, proper installation of the port chamber, and efficient handling and maintenance by trained staff could prevent the vast majority of port-related complications.

Adolescent↗
PubMed2001

"Cuff-stitch" to prevent inadvertent dislodgement of central venous catheters.

The insertion of central venous catheters (CVCs) is an established practice in the management of children who need long-term total parenteral nutrition or chemotherapy. Inadvertent falling out of CVCs before the cuff becomes incorporated in the tissues is a commonly encountered problem. The technique described involves inserting a circular stitch in the subcutaneous plane before the catheter is placed. Once the CVC is pulled into position, the "cuff-stitch" lays around the catheter distal to the cuff, narrows the tunnel, and prevents accidental dislodgement.

Catheterization, Central Venous↗
PubMed2001

Pneumatic dilatation for childhood achalasia.

Treatment of achalasia by pneumatic balloon dilatation (PBD) is well established in adults. Due to limited experience and the rarity of the condition in children, there are relatively few reports in the paediatric literature. Although PBD has been reported as a primary method of treatment, there are no reports of secondary PBD for childhood achalasia. Between 1995 and 1999, five patients underwent treatment for achalasia (age: 9-14 years, M:F = 4:1). The presenting symptoms were dysphagia (5). vomiting episodes (2), aspiration (1), food-bolus obstruction (1), and failure to thrive (1). In all patients a barium swallow and manometry were used to confirm the diagnosis. Three underwent primary PBD. Two who had previously undergone surgical myotomy underwent secondary PBD for recurrence of symptoms. Dilatation was performed using a 35-mm balloon with the child under general anaesthesia. Technical success was defined as demonstration of a waist under screening at lower pressures followed by abolition of the waist at higher pressures. In addition to reviewing our results, a systematic review of the literature was performed (Medline, Cochrane Library, Pubmed, Embase). Three patients (primary dilatation) showed excellent improvement after a single dilatation. In two cases (secondary dilatation) three and five attempts were required. No complications were encountered. The mean follow-up period was 2 years (1-3.5 years) and four patients remained asymptomatic, an overall success rate of 80%. The literature review revealed similar good results in most of the recent reports. Thus, PBD as a primary treatment for childhood achalasia has a success rate of 70%-90% with minimal side effects, short hospital stay, and good patient acceptability over an operation. We have also established the usefulness of this method as a secondary treatment when symptoms recur after surgery.

Adolescent↗
PubMed2001

Mixed foregut cyst associated with esophageal atresia.

The authors report an unusual case of a thoracoabdominal foregut malformation with components of bronchogenic, esophageal duplication, and pancreatic enterogenous cysts, that presented in a child with esophageal atresia. J Pediatr Surg 36:939-940.

Abnormalities, Multiple↗
PubMed2001

Ecthyma gangraenosum--a trap for the unwary.

Neutropaenic patients are at particular risk of developing a pseudomonal fasciitis known as ecthyma gangraenosum. Despite the similarities with necrotising fasciitis, Fournier's gangrene has a very different aetiology and management.

Child, Preschool↗
PubMed2000

Mucin gene expression in Barrett's oesophagus: an in situ hybridisation and immunohistochemical study.

BACKGROUND AND AIMS: Mucin genes are expressed in a site specific manner throughout the gastrointestinal tract. Little is known about the expression pattern in the oesophagus. In this study we have investigated MUC gene expression in both the normal oesophagus and specialised intestinal metaplasia (Barrett's oesophagus). PATIENTS: Archived paraffin embedded material from eight specimens of normal oesophagus, 18 Barrett's oesophagus, eight gastric metaplasia, six high grade dysplasia, and six cases of adenocarcinoma were examined for expression of the mucin genes MUC1-6. METHODS: Mucin mRNA was detected by in situ hybridisation using [(35)S] dATP labelled oligonucleotide probes. Mucin core protein was detected by immunohistochemistry. RESULTS: Normal oesophagus expressed MUC5B in the submucosal glands and MUC1 and MUC4 in the stratified squamous epithelium. Barrett's oesophagus strongly expressed MUC5AC and MUC3 in the superficial columnar epithelium, MUC2 in the goblet cells, and MUC6 in the glands. In high grade dysplasia and adenocarcinoma there was downregulation of MUC2, MUC3, MUC5AC, and MUC6, but upregulation of MUC1 and MUC4 in half of the specimens examined. CONCLUSIONS: Normal oesophagus and Barrett's oesophagus have a novel pattern of mucin gene expression. Barrett's oesophagus expressed the mucins associated with normal gastric epithelium and normal intestinal epithelium. While most mucin genes were downregulated in severely dysplastic and neoplastic tissues, there was upregulation of the membrane bound mucins MUC1 and MUC4. This may prove useful in detecting early signs of progression to adenocarcinoma of the oesophagus.

Adult↗
PubMed1999

Role of surgical biopsies in the management of bone marrow transplant patients.

BACKGROUND: Bone marrow transplantation (BMT) patients frequently develop life-threatening problems that have similar clinical presentations but differing aetiologies. Despite intensive investigation by haematological, biochemical, and microbiological means, accurate diagnosis is not always possible. Histological and microbiological examination of biopsies from the affected organ may be indicated to enable an accurate diagnosis to be made in these patients. Here we assess the indications, findings, and outcomes in patients who have required surgical biopsy after BMT. PROCEDURE: We retrospectively reviewed all BMT patients who had surgical biopsies between February 1994 and January 1997. Twenty-six patients (1-46 years, median age 10 years) underwent 40 biopsies from the upper and lower GI tract, lung, or liver. Indications for BMT were: relapsed leukaemia = 18; other types of leukaemia = 3; aplastic anaemia=3; other diseases = 2. Type of BMT: matched related donor = 3, unrelated T-cell depleted donor = 23. RESULTS: Eleven (42%) cases had a change in management; 4 (16%) patients avoided further aggressive therapy because of poor prognosis. Unexpected diagnoses were found in 7 biopsies: 1 acute colitis, 1 duodenal ulcer, 1 liver aspergilloma, 2 transfusion siderosis, 1 radiation fibrosis of the lung, and 1 cytomegalovirus infection of the lung. Three patients were noted to have complications after their procedure. CONCLUSIONS: Surgical biopsies for undiagnosed problems can be of benefit in the management of very sick patients who have received bone marrow transplantations. Despite the fact that these patients are so unwell, there is a low rate of complications related to surgery and anaesthesia.

Adolescent↗
PubMed1999

Histochemical and genetic analysis of colonic mucin glycoproteins in Hirschsprung's disease.

BACKGROUND/PURPOSE: Mucin glycoproteins (mucins) recently have been shown to be deficient in the colonic mucosa of patients with Hirschsprung's disease (HD). The authors performed a detailed histo- and immunohistochemical analysis of mucins in the colonic mucosa and studied the expression of mucin genes to characterize histologically mucin quality and gene expression in HD compared with controls. METHODS: Paraffin-embedded 4-microm thick sections from patients with HD (n = 11 ganglionic, 10 aganglionic) and controls (n = 19) were taken. Slides were stained with mild periodic acid Schiff with and without saponification with KOH (reacts with O-actylated mucins), high iron diamine/alcian blue (differentiates sulphated v nonsulphated mucins), the monoclonal antimucin antibodies, PR3A5 (against di- and tri-O-acetylated sialic acids) and 91.9H (against sulphated mucins). O-acetylation and sulphation both confer an increased resistance of mucins to bacterial degradation and are thought to be important in the defensive function of the colonic mucus gel layer. In situ hybridization was used to study expression of the mucin genes MUC 1, 2, 3, 4, 5AC, 5B, 6, 7, and 8. [35S]-sulphate-labelled antisense oligonucleotide 48mer probes designed to the known tandem repeat domains of MUC genes were used. After hybridization and washing the slides were opposed to Hyperfilm MP for 7 days. The autoradiographs were scored by three independent observers for differences in expression and by image analysis. Those with positive findings were dipped in photographic emulsion, developed, and counterstained for photomicrographs. RESULTS: There were different patterns of staining dependent on the region of the colon and especially the age of the patient with three reagents. No significant differences in the histological staining pattern was detected between HD patients and controls. The colonic mucins in HD were found to be primarily O-acetylated and sulphated. The MUC gene expression was similar in patients and controls. MUC2 and 4 were strongly expressed, MUC1, 3, and 5B had moderate to weak expression, and MUC 5AB, 6, 7, and 8 had baseline expression. CONCLUSIONS: The mucin glycoproteins in children with HD, although quantitatively deficient, show no qualitative differences on histo- and immunohistochemical staining from normal controls. The expression of all the known mucin genes, the genetic control of mucin secretion, and the quality of mucins, is similar to normal controls.

Age Factors↗
PubMed1999

Conservative treatment for girls with nonmetastatic rhabdomyosarcoma of the genital tract: A report from the Study Committee of the International Society of Pediatric Oncology.

PURPOSE: To report the results of a conservative multimodal approach in girls with nonmetastatic rhabdomyosarcoma (RMS) of the genital tract, treated in International Society of Pediatric Oncology (SIOP) Malignant Mesenchymal Tumors 84 and 89 protocols. PATIENTS AND METHODS: From 1984 to 1994, 38 girls with RMS of the genital tract (vulva, vagina, uterus) were treated in SIOP protocols. With the exception of patients with rare small tumors, which were resected at the start of the studies, all patients received initial chemotherapy (CHT) (ifosfamide, vincristine, and actinomycin D). Local treatment including surgery, brachytherapy (BT), and external-beam radiotherapy (ERT) was given only to girls who did not achieve complete remission (CR) with CHT or who subsequently relapsed. RESULTS: The primary tumor originated in the vulva or vagina in 27 girls and in the uterus in 11. The overall survival rate (+/- SE) was 91% +/- 6% at 5 years, and the event-free survival rate was 78% +/- 7%. At a median follow-up of 5 years, 30 girls were alive and in first CR and five were alive and in second CR. Four patients treated with complete resection of the tumor at diagnosis received less CHT. Thirteen patients were treated with CHT alone. In 17 patients, local treatment was necessary to achieve complete local control, for a residual mass after initial CHT (10 patients), for viable tumor on biopsy (three patients), or for local relapse (four patients). The local treatment used was radiotherapy (RT) (ERT in three patients, BT in seven), radical surgery with uterine ablation (three patients), RT and radical surgery (three patients), and conservative surgery with RT (one patient). CONCLUSION: Girls with nonmetastatic RMS of the genital tract have an excellent prognosis. We found no difference in outcome between uterine and vulvovaginal RMS. Local treatment does not seem necessary in patients who have a complete response to CHT. When a local treatment is needed, BT may be an alternative to radical surgery or ERT.

Adolescent↗
PubMed1998

The role of magnetic resonance imaging in the preoperative assessment of anorectal anomalies.

The role of magnetic resonance imaging (MRI) compared to other investigations in providing information relevant to and affecting surgical management in patients with anorectal anomalies (ARA) was studied in two groups of patients. In group 1 a pilot study was done in 9 patients with colostomy for high ARA awaiting posterior sagittal anorectoplasty. These patients had MRI, plain radiographs, a distal loopogram through the mucous fistula, ultrasound scans of the spinal cord and urinary tract, and a micturating cystourethrogram. The level of bowel and spinal-cord termination was correctly determined in all patients by MRI and conventional investigations. The presence or absence of a fistula, urological abnormalities, and bony abnormalities of the pelvis and spine were better visualized by conventional investigations than with MRI. The striated-muscle complex (SMC) was well-visualized by MRI, the thickness accurately graded, and the findings confirmed at operation. The information on muscle thickness and the presence or absence of a fistula was interesting, but played no part in decisions made about surgical management, and the operative technique was not altered. In group 2 the patients were much older and had MRI for persistent problems, mainly soiling; 6 had low lesions and 6 had high lesions. Three patients with low lesions were found to have intraspinal abnormalities on MRI; 4 were found to have malpositioned bowel in the SMC, which was again accurately visualized and graded. Therefore, in 7/12 patients of this group a surgically correctable abnormality was found. We conclude that MRI has no role as a primary investigation in patients with high ARA, but it is useful if there are suspected spinal-cord problems or persistent problems after definitive surgery.

Anal Canal↗
PubMed1998

Turnover of radioactive mucin precursors in the colon of patients with Hirschsprung's disease correlates with the development of enterocolitis.

BACKGROUND/PURPOSE: Mucin glycoproteins (mucins) in the colonic mucus gel layer interact with pathogens performing protective functions by a variety of mechanisms. It is recognised that patients with Hirschsprung's disease (HD) are prone to episodes of enterocolitis even after corrective surgery, the aetiology of which is poorly understood. The authors correlated the turnover of radioactive mucin precursors in organ culture of the proximal ganglionated colon at the time of pull-through with the development of postoperative enterocolitis. METHODS: The colonic mucins in the retained proximal ganglionated colon of nine HD patients at the time of pull-through were studied. Organ culture of intact mucosa was performed with radioactive mucin precursors 35S-sulphate and 3H-glucosamine. Mucins in the secretions and epithelial cells were then purified by gel filtration. Turnover of the isotopes was determined by relating radioactivity to tissue DNA content. These patients were followed up prospectively for a mean duration of 30.8 months. The patients were assigned to one of two groups according to the criteria of requiring hospital admission for enterocolitis during this period. There were five patients in the group that remained well after corrective surgery and four in the group that developed entercolitis. The turnover values of both radioisotopes were analysed for differences in the two groups of patients. RESULTS: Patients in the enterocolitis group had a median value for turnover of 331 dpm/microg DNA, and the group that was well had a median value of 2044 dpm/microg DNA. These differences were statistically significant (Mann-Whitney, P = .037). CONCLUSIONS: A reduced turnover of mucins as shown by incorporation of radioactive precursors will give rise to a defective colonic mucus-defensive barrier. It can be inferred that the lower the turnover, the more prone a patient is to postoperative enterocolitis. It is therefore possible that organ culture with radioactive mucin precursors of the proximal ganglionated mucosa performed at the time of pull-through has a predictive value in the development of postoperative enterocolitis.

Colon↗