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Biomedical subjects

R M Filler

Publications and source records attributed to R M Filler.

At least 91 records · Page 5Linked to original sources
PubMed1987

Long-term functional results of prosthetic airway splinting in tracheomalacia and bronchomalacia.

The long-term functional results of splinting a collapsing major airway with a silastic Marlex mesh prosthesis were assessed. Six patients in whom follow-up has been longer than 4 years (mean 5.3 years) were studied. The prosthetic semirigid splints had been implanted in five children with tracheomalacia and one with bronchomalacia. Mean age at the time of airway splinting was 4 years (range 6 months to 8 years). At their last clinical evaluation, all six children were leading normal active lives. Three had mild respiratory symptoms not related to the splinting. The only long-term complication was a serous effusion that developed around the splint and compressed the trachea in one child 2 years postoperatively. Tracheal fluoroscopy, barium swallow, and computed tomography scans of the trachea in five patients demonstrated satisfactory tracheal caliber without airway collapse during expiration and coughing. Pulmonary function testing showed a mild increase in airway resistance in one child who had had a tracheostomy. These results demonstrate that the application of composite synthetic graft to a segment of a malacic airway in young patients can provide long-term relief from airway collapse without compromising airway growth.

Airway Obstruction↗
PubMed1987

Injury severity, whole body protein turnover, and energy expenditure in pediatric trauma.

The purpose of this study was to quantify the changes in energy expenditure and protein turnover imposed by blunt trauma in children and to correlate them with the Injury Severity Score (ISS). We studied 19 children (mean age 10 +/- 1 year, mean ISS 20 +/- 2). Basal metabolic rate (BMR) was measured in the postabsorptive state by open-circuit indirect calorimetry. Whole body protein turnover (Q) and synthesis (S) were determined by the 15N enrichment of urinary ammonia in a 12-hour collection following a single dose of 15N glycine. Twelve-hour total urinary nitrogen excretion (E) was also determined. Because nitrogen intake was 0 during the study period, Q was equivalent to protein breakdown (B). Eleven patients were restudied at 3- to 5-day intervals during hospitalization and eight were restudied after discharge (mean 34 +/- 6 days post injury). There was a significant increase in BMR, Q, S, and E following injury, when compared with post injury baseline values. However, while BMR increased by 14%, there were 93% and 82% increases in Q (B) and S, respectively. Negative nitrogen balance resulted from the fact that protein breakdown increased more than protein synthesis. The initial increase in BMR varied directly with the severity of injury, as reflected in the ISS (r = 0.56, P less than .02). There was no significant correlation between ISS and any of the parameters of protein metabolism. These results suggest that the metabolic response of pediatric patients to multiple trauma may differ from that of adults. In addition, they imply that the ISS may not be a reliable indicator of the severity of tissue injury.

Adolescent↗
PubMed1987

Changes in the body composition of the surgical infant in the early postoperative period.

The purpose of this study was to evaluate the effects of postoperative nutritional management on the body composition of infants after major surgery. We studied 13 full-term surgical infants (mean initial weight 2.88 +/- 0.19 kg; mean days postsurgery 5.0 +/- 0.5). Ten infants were receiving total parenteral nutrition and three were orally fed (mean caloric intake 84 +/- 4 kcal/kg/d; mean fluid intake 145 +/- 4 mL/kg/d). Total body water (TBW) was measured by isotope dilution using heavy oxygen (18O) labeled water (H2(18)O). Total body fat (TBF) was estimated from anthropometric data. Lean body mass (LBM) was calculated as follows: LBM = weight--TBF. Protein, fat, and carbohydrate accretion were determined by energy and macronutrient balance in conjunction with open-circuit indirect calorimetry. Body composition was reevaluated after an interval of seven days. Body weight increased from 2.88 +/- 0.19 to 3.00 +/- 0.19 kg, representing a mean growth velocity of 5.9 g/kg/d. Increments were observed in all body compartments but only the increase in TBF reached statistic significance (12.9 v 14% of body weight, P less than .05). TBW ranged from an initial value of 76.2 +/- 1.4% to a value of 75.5 +/- 1.4% at the end of the study. Protein, fat, and carbohydrate accretion (g/kg/d) during the seven-day study period were 1.62 +/- 0.13; 1.44 +/- 0.41, and 0.96 +/- 0.70, respectively. These data indicate that in the early postoperative period, the weight gain is secondary to both water and solid tissue accretion. Fat represents the major form of energy storage in the new tissues synthesized.(ABSTRACT TRUNCATED AT 250 WORDS)

Body Composition↗
PubMed1987

Neonatal pharyngoesophageal perforation mimicking esophageal atresia: clues to diagnosis.

Perforation of the newborn child's esophagus or pharynx can mimic esophageal atresia clinically. Fourteen cases of newborn hypopharyngeal or esophageal perforation are presented. In nine cases, esophageal atresia was the initial diagnosis entertained; seven of these on the first day of life. In four others, the diagnosis of a perforated pharynx or esophagus was evident on plain x-ray. Six patients had esophagograms. Two newborns underwent thoracotomies for repair of their initially diagnosed esophageal atresia. Subsequently, esophageal perforation was diagnosed intraoperatively on each and suture repair was undertaken. The 12 remaining neonates were treated nonoperatively. There were four deaths, all in the nonoperative group and three weighing less than 1,000 g. None of the deaths were directly attributable to the perforations. In retrospect, each child presented with one or more early clues to the diagnosis of pharyngoesophageal perforation, which included a history of difficult tracheal or nasogastric intubation, blood in the nasogastric tube, length and course of nasogastric tube inserted, and subtle chest x-ray changes. In these cases, nonoperative treatment is usually successful.

Diagnosis, Differential↗
PubMed1987

Blunt injury to the pancreas in children: selective management based on ultrasound.

Twenty-one children with blunt injuries to the pancreas were treated over a 5-year period. Group I consisted of 12 patients brought to our hospital within 24 hours of injury. Group II included nine patients who were referred to us more than 24 hours after injury following initial treatment at another hospital. Two group I patients died within four hours of admission from other causes. Three had early laparotomy for other injuries. Of these, two had a contusion and one had a complete transection of the pancreas. All recovered uneventfully after appropriate surgical treatment. The remaining seven were all treated nonoperatively. Two had obstructive pancreatitis secondary to duodenal hematomas, three had pancreatic contusions, and two developed pancreatic pseudocysts. All seven recovered completely without operation. In group II, three patients had undergone laparotomy elsewhere. All three had pancreatic contusions. However, only one had appropriate drainage of the injured pancreas; he recovered uneventfully. Two, who were not drained, developed pseudocysts and one of these required surgical drainage by cystgastrostomy. The other six patients in group II presented to our hospital with established pseudocysts. Three of these resolved with nonoperative treatment but three required drainage. Overall, six of ten posttraumatic pancreatic pseudocysts resolved without surgical treatment. The single most useful diagnostic test in the management of these patients was abdominal ultrasound (US). US revealed specific anatomic lesions of the pancreas--contusion, obstructive pancreatitis, or pseudocyst--and provided an objective guide to management. Surgical intervention is not necessary in all cases of pancreatic trauma.

Adolescent↗
PubMed1987

Validation of doubly labeled water for assessing energy expenditure in infants.

Previous studies show that the doubly labeled water method is accurate for measuring energy expenditure in the adult human. To validate this method in infants, carbon dioxide production rate and energy expenditure were measured for 5 to 6 days by doubly labeled water (DLW) and periodic open circuit respiratory gas exchange (RGE) in 10 blinded studies in nine infants following abdominal surgery. Infants were maintained on consistent oral or parenteral nutrition prior to and during study. This avoided diet-related changes in baseline isotopic enrichment of body water which could theoretically contribute to significant errors in calculation of carbon dioxide production rate. For DLW, insensible water loss was assumed to be proportional to respiratory volume and body surface area, where the former was predicted from carbon dioxide production rate. Insensible water loss thus calculated averaged 18% of water turnover. Rates of carbon dioxide production measured by DLW were not significantly different from that of RGE (10.4 +/- 1.1 and 10.5 +/- 0.9 l/kg/day, mean +/- SD, respectively). Energy expenditure was calculated using respiratory quotients from dietary intake (DLW:DIET) and RGE (DLW:RGE) data. There was no significant difference between energy expenditure determined by DLW (DLW:DIET and DLW:RGE) and that measured by RGE (58.5 +/- 6.1, 56.8 +/- 6.1, and 57.3 +/- 5.1 kcal/kg/day, mean +/- SD, respectively). Rate of carbon dioxide production, DLW:diet, and DLW:RGE calculated by DLW differed from corresponding RGE values by -0.9 +/- 6.2, -1.1 +/- 6.1, and 1.6 +/- 6.2%, mean +/- SD, respectively. These findings demonstrate the validity of the doubly labeled water method for determining energy expenditure in infants without concurrent water balance studies.

Absorption↗
PubMed1987

The pediatric passenger: trends in seatbelt use and injury patterns.

Injury patterns and use of passenger restraints were studied in 91 children injured while riding in motor vehicles and admitted to The Hospital for Sick Children, Toronto, from June 1984 through December 1985. Of theses, 44 had used restraints and 38 had not. Nine were excluded from the study because restraint use could not be determined. Age and sex distributions were closely matched in both study groups. The no-restraint group had more massive head injuries, thoracic injuries, and liver and spleen injuries than the restraint group. Classic "seatbelt syndrome" injuries were seen in the seatbelt group. The overall Injury Severity Scores were not significantly different between the groups. Despite mandatory legislation, many children do not use restraints, and many who do still suffer severe or fatal injuries. We conclude that better compliance with existing passenger restraint laws and more effective restraint systems are needed.

Accidents, Traffic↗
PubMed1986

Growth and development in patients operated on for islet cell dysplasia.

Neonatal hypoglycemia caused by islet cell dysplasia (ICD), sometimes called nesidioblastosis, may lead to psychomotor retardation and neurologic dysfunction in up to 50% of patients who are not given early aggressive treatment. In 1979, we adopted a more aggressive protocol for treating this condition that consists of the following steps: immediate insertion of a silastic central venous line for reliable venous access; continuous intravenous infusion of glucose and glucagon to maintain euglycemia; oral diazoxide; and near total pancreatectomy if the first steps fail to overcome the hypoglycemia or the patient cannot be weaned off intravenous therapy. Twelve consecutive patients who underwent pancreatectomy for control of hypoglycemia between 1979 and 1984 were recalled and evaluated for growth delay, neurologic dysfunction, and psychomotor retardation using the Revised Yale Developmental Schedules, the Peabody Picture Vocabulary, and the Draw a Man Test. Follow-up ages ranged from 1.2 to 6.0 years with a median of 3.6 years. No significant growth abnormalities were identified. No patient exhibited focal neurologic dysfunction, although some demonstrated soft neurologic signs, which did not appear to be related to their earlier hypoglycemia. Psychomotor function for the group as a whole was normal, with a mean developmental quotient (DQ) of 99.2. The DQ was average for five patients and above average for four; no patient had a DQ in the frankly subnormal range. Psychomotor development correlated better with the family's socioeconomic and educational status than with the neonatal hypoglycemia. These children are developmentally and neurologically normal despite severe neonatal hypoglycemia. Continued follow-up will be necessary to detect any late sequelae.(ABSTRACT TRUNCATED AT 250 WORDS)

Body Height↗
PubMed1986

Intra-abdominal tissue expansion: an adjunct in the separation of conjoined twins.

Intra-abdominal tissue expansion routinely occurs physiologically with pregnancy and may be seen in a variety of pathologic states. There are a number of situations where additional abdominal wall would be helpful. We encountered such a situation in a set of ischiopagus conjoined twins. In effect, separation would result in an abdominal wall deficit of approximately 50%. As an alternative to intraperitoneal air, we inserted two 1,000 mL tissue expanders through a subcostal incision at 6 months of age. Over the ensuing 7 weeks, each expander was gradually inflated to greater than capacity (1,250 mL each). Except for initial ileus, there was no difficulty in expanding the abdomen to enormous proportions. At the time of surgical separation, the expanders were removed and the available abdominal wall tissue almost closed directly on both children. Closure was complete in one baby, whereas a small upper abdominal wall defect was left in the other, necessitating Marlex reinforcement. There has been a recent explosion in the use of tissue expanders in reconstructive surgery. From head to toe, soft tissue can be expanded to be used as flaps, to close donor defects, or both. With this report, its use intra-abdominally is described. Future application is limited only by our ingenuity and imagination.

Abdominal Muscles↗
PubMed1986

Traumatic duodenal hematoma in the pediatric patient.

Twenty children with duodenal hematomas secondary to blunt trauma were treated between 1953 and 1983. The duodenal injury was isolated in ten cases and associated with intra-abdominal injuries in the others. In ten, the duodenal injury was suspected on admission and the diagnosis was confirmed within 24 hours by radiographic contrast studies. All ten were managed successfully with nasogastric suction and intravenous fluids. Ten patients underwent laparotomy for increasing abdominal tenderness and guarding. An isolated duodenal hematoma was found in four and treated by evacuation and/or gastroenterostomy. In five of the remaining six surgical patients, all of whom had multiple intra-abdominal injuries, the duodenum was left untouched. Three of these patients had postoperative contrast studies that showed early resolution of the duodenal hematoma. No duodenal stricture or leak developed in any patient. The children with isolated duodenal hematomas who were treated conservatively had a mean hospital stay of six days, whereas those treated surgically had a mean stay of 17 days. The ten patients with multiple intra-abdominal injuries had a mean hospital stay of 32 days. In this group, eight required total parenteral nutrition or nasojejunal feeds for nutritional support. In these patients, an isolated duodenal hematoma resulted in minimal morbidity and nonoperative management was usually successful. The presence of associated intra-abdominal injuries was responsible for the prolonged hospitalization and delayed return of normal intestinal function in some patients.

Abdominal Injuries↗
PubMed1986

Treatment of tracheomalacia: eight years' experience.

Between 1978 and 1985, 21 patients were treated for tracheomalacia, (group I) and 4 for tracheobronchomalacia (group II). The median age at treatment was 7 months (range 1 to 96 months). Indications for surgery in group I were, "dying spells" (n = 12), recurrent pneumonia (n = 4), intermittent respiratory obstruction (n = 3) and inability to extubate airway (n = 2). 18 had esophageal atresia repair. Treatment in group I was aortopexy (n = 19), three of whom also required an external airway splint; two had an airway splint only. Airway obstruction was relieved in all. Group II patients required surgery because they could not be extubated; none had esophageal atresia. Aortopexy in all and splinting in one failed in 3 of 4 patients. Aortopexy is the primary treatment of tracheomalacia. External airway splinting may be used where aortopexy is inadequate. A satisfactory treatment for tracheobronchomalacia has not yet been devised.

Aorta↗
PubMed1986

Intussusception due to lymphoma.

Over 1,200 infants and children with an intussusception were treated at our hospital over the last 40 years and from this group, only 11 were found to have a lymphoma as a leading point for the intussusception. This number represents 17% of the 65 pathologic lesions that have caused an intussusception. Three children were under 41/2 years of age. All the children except two were chronically ill with pain for at least 1 week and usually for several months; weight loss and an abdominal mass in many instances provided the suspicion of a possible malignancy. When barium studies were done, there was almost always an ileocolic intussusception present with some obstruction. Reduction of the intussusception was accomplished with hydrostatic barium enema in 10 of the 11 patients; the one reduction, however, had a residual filling defect. Surgery confirmed the above findings and a resection of the leading point lymphoma was carried out in all of the children. In spite of all forms of treatment, death followed in all but three, usually within several months. One of these three survivors was treated with radiotherapy and steroids (after surgical excision) and is alive after 30 years; the second was also given chemotherapy and is alive and well after 6 years, and the third has not had radiotherapy and is alive after 10 months.

Child↗
PubMed1986

Incisionless gastrostomy for nutritional support.

A technique of percutaneous endoscopic gastrostomy was evaluated in 51 children and young adults aged 4 months to 26 years (mean, 9.7 years). Indications for gastrostomy included malnutrition secondary to cystic fibrosis, severe CNS disease, and others. The procedure was performed in 26 patients using local and topical anesthesia. General anesthesia was employed in children under 8 years of age. Duration of operative procedure ranged from 20 to 60 min. The average time for maintenance of feeding gastrostomy was 5.6 months. No procedure-related deaths were observed. Significant complications occurred less frequently than with traditional gastrostomy. We conclude that this procedure is technically simpler than, and at least as safe as, other methods of gastrostomy. It is especially useful in children for whom general anesthesia is best avoided.

Adolescent↗
PubMed1986

A new model of tracheal stenosis and its repair with free periosteal grafts.

Stenosis of 50% to 80% of the cervical or thoracic tracheal lumen was created in 17 piglets by encircling the trachea with silicone rubber sheet for 3 to 19 days (median 14 days). In 13 animals thoracic tracheal stenosis was repaired by longitudinal incision and insertion of a free tibial periosteal graft into the defect. An omental pedicle graft was applied to the surface of the free periosteal graft to augment its blood supply in three of these animals. An endotracheal silicone rubber splint was left in place for 2 to 3 weeks after the operations. Four animals served as untreated controls. In 12 of 13 piglets respiratory obstruction was relieved. One repair failed because of graft necrosis. In two animals put to death 1 month and 2 months later, stenosis was absent and the grafts showed variable ossification. The luminal surface had epithelialized. In nine of 10 animals put to death 3 months after the operation, tracheal cross-sectional areas had doubled, stenosis and granulation tissue were absent, and all the grafts had ossified and epithelialized. A mild stenosis (24%) developed over a 2 mm length in one animal and the graft had not ossified. The omental pedicle graft did not improve vascularization of the free periosteal graft. These studies describe a model of tracheal stenosis that can be used to assess various methods of repair. The results indicate that tracheal stenosis can be successfully treated by incision and insertion of a free periosteal graft into the defect.

Animals↗
PubMed1985

The successful reconstruction of thoracic tracheal defects with free periosteal grafts.

A defect was created in the thoracic trachea in nine piglets (10 kg) by excising a segment from the entire thoracic trachea proximal to the right upper lobe bronchus (3 to 3.5 cm in length) and 30% of the circumference in width (1 to 1.5 cm). The defect was repaired with a free tibial periosteal graft (FPG) and in four piglets an omental pedicle graft (OPG) was applied to the surface of the FPG. An internal tracheal splint was inserted for 12 to 16 days to support the repair and prevent air leak. The splints were removed bronchoscopically. None of the pigs developed signs of airway obstruction at any stage following the repair. Eight were killed 3 months postoperatively when four to six times their original weight. One pig died on the 18th postoperative day of unknown cause. The tracheas were removed, x-rayed, and examined grossly and histologically. The results demonstrated normal tracheal growth with absence of either stenosis, collapse, or granulation tissue. All grafts were viable, bone formation was present, and the lumenal surfaces were lined with columnar and respiratory epithelium. The OPG did not improve vascularization of the FPG. This model suggests that tracheal stenosis in children may be surgically corrected by simply incising the stenotic segment longitudinally and enlarging the tracheal diameter by inserting a FPG into the defect.

Animals↗