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Biomedical subjects

Thomas F Tracy

Publications and source records attributed to Thomas F Tracy.

At least 19 recordsLinked to original sources
PubMed2007

Management of common head and neck masses.

Head and neck masses are a common clinical concern in infants, children, and adolescents. The differential diagnosis for a head or neck mass includes congenital, inflammatory, and neoplastic lesions. An orderly and thorough examination of the head and neck with an appropriate directed workup will facilitate the diagnosis. The most common entities occur repeatedly within the various age groups and can be differentiated with a clear understanding of embryology and anatomy of the region, and an understanding of the natural history of a specific lesion. Congenital lesions most commonly found in the pediatric population include the thyroglossal duct cyst and the branchial cleft and arch anomalies. The inflammatory masses are secondary to local or systemic infections. The most common etiology for cervical adenopathy in children is reactive lymphadenopathy following a viral or bacterial illness. Persistent adenopathy raises more concerns, especially enlarged lymph nodes within the posterior triangle or supraclavicular space, nodes that are painless, firm, and not mobile, or a single dominant node that persists for more than 6 weeks should all heighten concern for malignancy. In this review, we discuss the current principles of surgical management of the most common head and neck masses that present to pediatricians and pediatric surgeons.

Adolescent↗
PubMed2006

Isolated computed tomography diagnosis of pulmonary contusion does not correlate with increased morbidity.

BACKGROUND: Increased utilization of computed tomography (CT) has led to a rise in the diagnosis of pulmonary contusion. Its clinical significance, in the absence of findings on chest radiograph (CXR), has not been defined. This study examines the clinical course of patients with CT-only diagnosis of pulmonary contusion and compares it with that of patients with CXR-proven pulmonary contusion. METHODS: The trauma database identified all children undergoing chest CT for blunt thoracic trauma during a 3-year period. Records were reviewed for age, mechanism of injury, Injury Severity Score (ISS), length of hospital stay (LOS), need for intensive care unit admission, and need for endotracheal intubation. A pediatric radiologist reviewed all films in a blinded fashion. Statistical analysis was performed using analysis of variance and Fisher's Exact test for 2 x 3 tables. RESULTS: Eighty-two patients were identified. There were no CXR-positive, CT-negative cases. A CT diagnosis of pulmonary contusion was made in 46 patients. Of these, 31 had a contusion on CXR as well (CXR+ group) and 15 had a normal CXR (CT+ only group). Mean ISS score did not differ significantly between the two groups (27 +/- 12.3 and 22 +/- 10.3, respectively). Thirty-six patients had a normal CT (control). Mean LOS was significantly longer in the CXR+ group (13 +/- 12.0 days) than in the CT+ only and control groups (5 +/- 3.6 and 9 +/- 9.5 days, respectively; P < .01). The percentages of children requiring intensive care unit admission and intubation were also significantly higher in the CXR+ group. CONCLUSION: The finding of pulmonary contusion by CT alone does not increase patient morbidity and appears to be of limited clinical significance.

Adolescent↗
PubMed2006

Perinatal management of congenital cystic lung lesions in the age of minimally invasive surgery.

BACKGROUND: Most congenital cystic lung lesions (CCLLs) do not require in utero or perinatal intervention. The management of asymptomatic lesions is controversial: the theoretical risk of infection and malignancy is offset by whether thoracotomy in asymptomatic children is justified. We examined our recent experience and the role of minimally invasive surgery. METHODS: We analyzed the pre-, peri-, and postnatal findings of all consecutive CCLLs diagnosed between 1997 and 2005. We reviewed records for pre-, and postnatal imaging, management, and outcome. RESULTS: Thirty-five CCLL were diagnosed prenatally. Since 2000, all asymptomatic lesions were removed endoscopically at 6 to 18 months (thoracoscopy for 6 extralobar sequestrations, 3 intralobar sequestrations/congenital cystic adenomatoid malformations, 5 bronchogenic cysts, and retroperitoneal laparoscopy for 2 intraabdominal sequestrations). Congenital cystic adenomatoid malformation elements were present in more than 70%. Two abdominal lesions have regressed, and 2 patients are awaiting intervention. One symptomatic infant underwent thoracotomy for congenital lobar emphysema. CONCLUSIONS: It has been argued that the risks associated with congenital lung lesions (infection and malignancy) justify intervention in the asymptomatic patient. In our experience, all these lesions could be safely removed using endosurgical techniques. Counseling of (future) parents should be updated to include minimally invasive surgery in the management algorithm.

Cystic Adenomatoid Malformation of Lung, Congenita↗
PubMed2006

Port insertion and removal techniques to minimize premature rupture of the membranes in endoscopic fetal surgery.

BACKGROUND: Premature rupture of membranes (PROM) remains a significant complication of fetal surgery. Rates of 40% to 100% have been reported after both open and endoscopic fetal surgery. We describe a technique of endoscopic port insertion and removal that minimizes trauma to the membranes. METHODS: Twenty-seven consecutive patients undergoing endoscopic laser ablation for twin-to-twin transfusion syndrome were reviewed. In each case, a minilaparotomy was performed, and the amniotic cavity was entered under direct vision of the uterus using a Seldinger technique. The entry site was carefully dilated to accommodate a 4.0-mm-diameter cannula. A gelatin sponge plug was placed at port removal. Postoperative management and outcome were evaluated. RESULTS: Median gestational age at operation was 21.3 weeks. Median operating time was 60 minutes. One patient delivered intraoperatively because of fetal distress. Seventeen (65.4%) patients required postoperative tocolysis (median duration, 12 hours). Median postoperative gestation was 6.5 weeks (range, 1-20 weeks). Only 1 (4.2%) of 24 patients with successful gelatin sponge placement developed PROM. CONCLUSIONS: Meticulous technique and atraumatic insertion and removal of ports help minimize the risk of postoperative amniotic leak after endoscopic fetal surgery. Our PROM rate of 4.2% contrasts sharply with previously reported rates after similar operations.

Adolescent↗
PubMed2006

Kupffer cells abrogate cholestatic liver injury in mice.

BACKGROUND & AIMS: Biliary obstruction and cholestasis can cause hepatocellular apoptosis and necrosis. Ligation of the common bile duct in mice provides an excellent model in which to study the underlying mechanisms. Kupffer cells play a key role in modulating the inflammatory response observed in most animal models of liver injury. This study was performed to determine the role of Kupffer cells in the injury attending cholestasis. METHODS: Mice were not treated or were rendered Kupffer cell-depleted by intravenous inoculation of multilamellar liposome-encapsulated dichloromethylene diphosphonate, the common bile duct was ligated and divided; sham-operated animals served as controls. Similarly, interleukin-6 (IL-6)-deficient and tumor necrosis factor-receptor-deficient mice underwent bile duct ligation (BDL) or sham operations. RESULTS: Serum alanine transaminase levels were increased in all BDL mice at 3 days after surgery, but were significantly higher in IL-6-deficient mice or mice rendered Kupffer cell-depleted before ligation. Histologic examination of BDL livers showed portal inflammation, neutrophil infiltration, bile duct proliferation, and hepatocellular necrosis. Photoimage analyses confirmed more necrosis in the livers of Kupffer cell-depleted and IL-6-deficient animals. Purified Kupffer cells derived from BDL animals produced more IL-6 in culture. Similarly, Kupffer cells obtained by laser capture microdissection from the livers of BDL mice expressed increased levels of IL-6 messenger RNA. Recombinant mouse IL-6 administered 1 hour before BDL completely reversed the increased liver damage assessed otherwise in Kupffer cell-depleted mice. CONCLUSIONS: These findings indicate that Kupffer cells abrogate cholestatic liver injury by cytokine-dependent mechanisms that include the production of IL-6.

Animals↗
PubMed2005

Is there a role for routine preoperative endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in children?

HYPOTHESIS: Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used preoperatively in adult patients with suspected choledocholithiasis. Cholelithiasis occurs much less often in children, and the indications for ERCP are not established. We hypothesized that the natural history of choledocholithiasis in children is spontaneous passage of stones through the papilla and that these children can be managed without routine preoperative ERCP. DESIGN: Retrospective analysis of patients treated over a 10-year period. SETTING: Tertiary care children's hospital. PATIENTS: All patients with cholecystectomy for biliary disease. INTERVENTIONS: Cholecystectomy; intraoperative cholangiography for suspected choledocholithiasis: hyperbilirubinemia, gallstone pancreatitis, and ultrasonographic evidence of common bile duct dilation or common bile duct stones; and postoperative ERCP for symptomatic choledocholithiasis: pain and jaundice. MAIN OUTCOME MEASURES: Incidence and complications of choledocholithiasis and frequency of ERCP. RESULTS: One hundred patients (63 females) were studied. Indications included acute cholecystitis (10%), chronic cholecystitis (59%), gallstone pancreatitis (26%), and choledocholithiasis (5%). An intraoperative cholangiography was performed in 45 patients, and common bile duct stones were identified in 13. Expectant management of asymptomatic common bile duct stones was associated with sonographic resolution within 1 week. One patient with intraoperative cholangiography-proven choledocholithiasis required ERCP for symptoms 24 hours after operation. One additional patient, who did not undergo intraoperative cholangiography, developed symptomatic choledocholithiasis and required ERCP. There were no choledocholithiasis- or ERCP-related complications. CONCLUSIONS: This study suggests that choledocholithiasis occurs frequently in children and that spontaneous passage of common bile duct stones is common. This could explain the relatively high incidence of gallstone pancreatitis. Conservative management of choledocholithiasis is successful in the majority of patients. Routine preoperative or postoperative ERCP is usually not indicated.

Adolescent↗
PubMed2005

Pulmonary embolism: which pediatric trauma patients are at risk?

BACKGROUND/PURPOSE: Deep vein thrombosis and pulmonary embolism (DVT/PE) are rare in pediatric trauma patients, and guidelines for prophylaxis are scarce. The authors sought to identify subgroups of patients who may be at higher risk of developing DVT/PE. METHODS: Case-control study of pediatric trauma patients with DVT/PE. Odds ratios (ORs) and confidence intervals (CIs) were calculated for known risk factors of PE using matched trauma controls (chi2 analysis). RESULTS: A total of 3637 pediatric trauma patients was admitted over the last 7 years. Three patients developed DVT/PE (overall incidence, 0.08%). There were 2 girls and 1 boy, aged 15, 15, and 9 years, respectively. All 3 had an Injury Severity Score (ISS) > or =25 and an initial Glasgow Coma Score (GCS) < or =8. None of the known and potential risk factors significantly increased the OR for developing DVT/PE: age 9 years or older (OR, 3.6; CI, 0.4-26), presence of head injury (OR, 2.9; CI, 0.3-22), female sex (OR, 1.2; CI, 0.15-9.1), GCS < or =8 (OR, 9.2; CI, 0.9-230), except ISS > or =25 (OR, 82; CI, 7.6-2058). The OR for a combination of age and GCS was 106, and the OR for the 3 risk factors (age, ISS, GCS) common to all 3 patients was 114 (CI, 10-5000; P < .001). CONCLUSIONS: The overall incidence of DVT/PE in pediatric trauma patients is <0.1% and routine prophylaxis is not recommended. Children aged 9 years or older with an initial GCS < or =8 and patients with an estimated ISS > or =25 may constitute a high-risk group in which prophylaxis could be considered.

Adolescent↗
PubMed2005

Pediatric trauma patients with isolated airway compromise or Glasgow Coma Scale less than 8: does immediate attending surgeon's presence upon arrival make a difference?

BACKGROUND/PURPOSE: Optimal trauma care requires an attending pediatric surgeon to head a trauma team for the most severely injured patients. Recently, the American College of Surgeons-Committee on Trauma has added "Glasgow Coma Scale (GCS) <8" and "airway compromise" to the existing anatomical and physiological criteria for immediate attending presence. This report analyzes the outcome of children who met these isolated criteria and were treated before the change in guidelines was made. METHODS: The trauma registry of this level I trauma center was queried for all pediatric patients with GCS <8 or airway compromise. Age, sex, initial GCS, Revised Trauma Score, Injury Severity Score, outcome, and probability of survival (TRISS methodology) were recorded. The subgroup of patients for whom an attending surgeon was not immediately present was further analyzed. RESULTS: Over a 5-year period, 2895 trauma patients (aged 0-16 years) were admitted. One hundred fifteen patients had a GCS <8 and/or airway compromise. In 61 cases, an attending surgeon was not present upon patient arrival. Of these patients, 24 died (group D), 15 were discharged to a rehabilitation facility (group R), and 22 were discharged home (group H). Ten patients with a probability of survival of lower than 0.5 survived. Only 4 of the 24 patients who died had a probability of survival of >0.5 (mean, 0.697). All 4 had an Injury Severity Score >25 and a GCS < or =4. All deaths were reviewed through a quality improvement program and were deemed nonpreventable by objective reviewers. Patient outcome was not affected by the presence or absence of an attending surgeon upon patient arrival. CONCLUSIONS: Outcome of severely injured children with GCS <8 or airway compromise met and, in some cases, exceeded expectations of survival according to the TRISS methodology. The lack of immediate attending surgeon's presence does not appear to have negatively influenced the outcome in these children. Based on this series, there is no evidence to justify mandatory immediate presence of an attending surgeon for these 2 criteria alone.

Adolescent↗
PubMed2005

What--and why--the pediatric surgeon should know about twin-to-twin transfusion syndrome.

Abstract Endoscopic laser ablation of placental vessels is the most commonly performed fetal operation today. Herein, we review the pathophysiology of twin-to-twin transfusion syndrome and the challenges of its treatment. Pediatric surgeons, with their knowledge of fetal and congenital pathology, and their technical expertise with minimally invasive surgery, can be of great benefit to the patient and the medical team.

Amniotic Fluid↗
PubMed2005

Repair after cholestatic liver injury correlates with neutrophil infiltration and matrix metalloproteinase 8 activity.

BACKGROUND: Although timely surgical treatment of liver disease can interrupt inflammation and reduce fibrosis, the mechanisms of repair are unknown. We questioned whether these mechanisms of repair include changes in the inflammatory infiltrate and associated biological activity of matrix metalloproteinases (MMPs) 8 and 2. METHODS: Rats (n >or= 3) underwent biliary ductal suspension for 7 days followed by decompression. Livers were collected after 7 days of obstruction (d0) and after 2, 5, and 7 days of repair (d2, d5, d7, respectively), and assessed morphometrically for collagen, polymorphonuclear cells (PMNs), Kupffer cells (KCs), and inflammatory mononuclear phagocytes (MNPs). In situ zymography was performed by using fluorogenic substrates for MMP-8 and MMP-2 to spatially localize enzymatic activity. RESULTS: Cholestatic injury resulted in significantly elevated (P <or= .001) collagen deposition (3-fold), and elevated numbers of MNPs (10-fold), KCs (5-fold), and PMNs (4-fold), compared with shams. PMNs remained elevated through d7, while collagen deposition, KCs, and MNPs returned to sham levels by d2. In situ zymography showed no significant changes in MMP-2 activity after cholestatic injury and repair. MMP-8 activity was significantly (P <or= .05) elevated only during repair. Activity was localized to fibrotic portal triads containing PMNs. CONCLUSIONS: Cholestatic injury results in increased fibrosis, MNPs, KCs, and PMNs but no MMP-2 or MMP-8 activity. Biliary decompression results in increased MMP-8 activity co-localized to areas of portal fibrosis and PMN accumulation. We conclude that secretion of MMP-8 by neutrophils may play a critical role in resolving the fibrotic scar generated during cholestasis.

Animals↗
PubMed2005

Use of cholecystokinin-octapeptide for the prevention of parenteral nutrition-associated cholestasis.

OBJECTIVE: To determine whether cholecystokinin-octapeptide (CCK-OP) would prevent or ameliorate parenteral nutrition-associated cholestasis (PNAC) among high-risk neonates treated with total parenteral nutrition. STUDY DESIGN: This was a multicenter, double-blind, randomized, controlled trial conducted between 1996 and 2001. PATIENTS: Neonates at risk for the development of PNAC included very low birth weight neonates and those with major surgical conditions involving the gastrointestinal tract. SETTING: Tertiary care hospitals. INTERVENTION: Patients were randomized to receive CCK-OP (0.04 mug/kg per dose, twice daily) or placebo. Eligible infants were all <30 days of age. Patients were enrolled within 2 weeks after birth or within 7 days after surgery. OUTCOME MEASURES: The primary outcome measure was conjugated bilirubin (CB) levels, which were measured weekly. Secondary outcome measures included incidence of sepsis, times to achieve 50% and 100% of energy intake through the enteral route, number of ICU and hospital days, mortality rate, and incidences of biliary sludge and cholelithiasis. RESULTS: A total of 243 neonates were enrolled in the study. CCK-OP administration did not significantly affect CB levels (1.76 +/- 3.14 and 1.93 +/- 3.31 mg/dL for CCK-OP and placebo groups, respectively; mean +/- SD). Secondary outcome measures also were not significantly affected by the study drug. CONCLUSIONS: Use of CCK-OP failed to reduce significantly the incidence of PNAC or levels of CB. CCK-OP had no effect on other secondary measures and should not be recommended for the prevention of PNAC.

Bilirubin↗
PubMed2004

Legal prosecution of alcohol-impaired drivers admitted to a level I trauma center in Rhode Island.

BACKGROUND: Despite harsh legislation, driving under the influence of alcohol (DUI) is exceedingly common, and alcohol-related motor vehicle crashes (MVCs) account for significant morbidity, mortality, and economic loss. Legal sanctions can keep offenders off the road (protecting other drivers and pedestrians) and ensure compliance with treatment programs (reducing recidivism). However, even with clear evidence of a transgression, the law seems to be inconsistently enforced among trauma patients. The purpose of this study was to measure the rate of legal prosecution among impaired drivers admitted to a trauma center after MVCs, and to determine the recidivism rate among these individuals. METHODS: Our trauma registry was queried to identify intoxicated drivers admitted during an 18-month period. Court records identified patients who had been charged with traffic offenses, including prior (2 years) and subsequent (1 year) charges. RESULTS: Blood alcohol concentration (BAC) was measured in 387 (74%) of 525 drivers, of whom 137 (35%) had BAC > or =100 mg/dL. Of 113 state residents, 22 (19%) were charged with an offense related to the MVC. Of 12 charged with DUI, 10 were convicted, for an overall DUI conviction rate of just 9%. Seven (32%) of those who were charged had prior or subsequent charges. Of 91 patients not charged for the index event, 31 (34%) had prior or subsequent charges. CONCLUSION: Alcohol is involved in a large percentage of MVCs in our region. The infrequency of prosecution for DUI despite property damage and/or personal injury, and the high recidivism rate, are significant social concerns. These data suggest the need for processes to facilitate legal prosecution--possibly including revision of legislation involving reporting of BACs.

Accidents, Traffic↗
PubMed2003

In-line image projection accelerates task performance in laparoscopic appendectomy.

BACKGROUND: In laparoscopy, the monitor usually is placed at or above eye level across from the operating surgeon. Position of the endoscopic image at hand level has been shown in a laboratory model to facilitate task performance. The authors tested the hypothesis that in-line image projection reduced operating time for a standardized procedure. METHODS: Children undergoing laparoscopic appendectomy were assigned randomly according to video image position: (1) at the top of the laparoscopy tower in front of the surgeon ("overhead") or (2) on a screen placed on the patient's abdomen ("in-line"). Operating time was recorded for each operation, and patients were stratified according to severity of appendicitis and training level of the operating surgeon. Statistical analysis was performed using Student's t, chi2 tests, and analysis of variance with post-hoc Fisher test (P <.05. significant). RESULTS: One hundred eight children, aged 2 to 17 years, underwent a laparoscopic appendectomy during a 26-month period. Fifty-four were assigned to the in-line projection screen and 54 to the overhead monitor. Operating time was significantly shorter (P =.013) when in-line projection was used (46.8 +/- 10.2 v. 52.2 +/- 15.1 minutes with overhead monitor). By analysis of variance (ANOVA) the only factors that significantly affected operating time were use of in-line projection (P =.030), severity of appendicitis (P =.002), and training level of the operating surgeon (P =.047). CONCLUSIONS: Placing the endoscopic image in the same field as the surgeon's hands decreases operating time by 10%, even for procedures that, like appendectomy, do not require complex suturing skills. This decrease in operating time occurs independently of the surgeon's level of proficiency or the degree of difficulty of the operation.

Adolescent↗
PubMed2003

Small bowel obstruction in an adolescent with pelvic inflammatory disease due to Chlamydia trachomatis.

A 19-yr-old adolescent, who was hospitalized because of pelvic inflammatory disease (PID) due to Chlamydia trachomatis, developed bile-stained emesis. A mild amount of free fluid in the pelvis was found on abdominal ultrasound but there was no sonographic evidence of a pelvic mass or of a tubo-ovarian abscess. Plain radiography and computer tomography (with contrast) of the abdomen revealed a high-grade partial small bowel obstruction. Conservative treatment, which included intravenous fluids and antibiotics together with continuous bowel decompression via nasogastric tube, led to resolution of the small bowel obstruction within 2 days and to resumption of oral feeding within 4 days of treatment. Follow-up for 6 months after this episode was uneventful. The present case calls for inclusion of plain radiography of the abdomen in the evaluation of PID associated with emesis. It also suggests that, in a clinically stable patient diagnosed with small bowel obstruction associated with PID, conservative treatment could be attempted before any operative intervention is considered.

Adult↗
PubMed2002

Benefits of term delivery in infants with antenatally diagnosed gastroschisis.

OBJECTIVE: To test the hypothesis that term gestation offers the best outcome. The relationship between gestational age and the extent of bowel injury in fetuses with gastroschisis is a matter of debate. Early delivery and cesarean delivery have been recommended to limit intestinal damage, but their benefits are unclear. METHODS: Data on all patients with gastroschisis seen at our institution from 1991 through 2001 were included. Patients were compared based on gestational age: less than 35 weeks, 35-37 weeks, and term (more than 37 weeks) with regard to age at definitive closure, age at first and full feedings, and hospital stay. Statistical significance (P <.05) was determined by analysis of variance and chi(2) analysis. RESULTS: Of the 57 patients, 19.3%, 43.8%, and 36.9% were born at less than 35 weeks, 35-37 weeks, and more than 37 weeks, respectively. Age at definitive closure was significantly higher at 35-37 weeks (5.9 +/- 4.6 days) than at more than 37 weeks (1.5 +/- 2.3 days) and less than 35 weeks (2.6 +/- 2.5 days) (P <.05). A prosthetic pouch (silo) was used more often at 35-37 weeks than at more than 37 weeks or less than 35 weeks (P =.03, chi(2)). Age at first (P =.04) and full feedings (P <.01) and length of hospitalization (P <.01) were all significantly higher at 35-37 weeks than at more than 37 weeks. CONCLUSION: Based on a homogeneous cohort of patients in whom gastroschisis was diagnosed antenatally, term delivery results in earlier closure of the defect and shorter time to full feedings. The benefit of early delivery postulated by others cannot be substantiated.

Delivery, Obstetric↗
PubMedDate not supplied

Limited prognostic value of a staging system for twin-to-twin transfusion syndrome.

OBJECTIVE: Severe twin-to-twin transfusion syndrome (TTTS) is usually classified according to a staging system (I-V) based on ultrasonographic findings of polyhydramnios in the recipient, oligohydramnios in the donor, the presence or absence of the donor's bladder, Doppler waveform changes and (impending) hydrops. Stage correlates with the severity of disease, and it is assumed that, without intervention, severe TTTS will evolve in succession from stage I to stage V (fetal demise). However, this progression has not been validated in longitudinal studies. Herein, we report on the natural progression of severe TTTS in a cohort of patients from a regional Fetal Treatment Program. METHODS: Eighteen patients with severe TTTS, diagnosed between 15 and 25 weeks of gestation, were managed over a 28-month period. Data were collected until delivery, endoscopic surgical intervention or dual fetal demise. Patients were evaluated at least once a week. Stage, estimated fetal weight, percent recipient/donor body weight discordance and survival were recorded. RESULTS: The present study represents a total follow-up of 108 patient-weeks. Of 90 week-to-week evaluations, 65 showed no change in stage; 11 showed downstaging (by more than 1 stage in 3, or 27%), and 13 showed upstaging (by more than 1 stage in 8, or 62%). Nine patients (all stage II or above) underwent endoscopic laser ablation. Overall survival was 67%, and survival of at least 1 twin occurred in 78% of pregnancies. Weight discordance between the donor and recipient did not predict outcome. CONCLUSION: The current staging system for severe TTTS may not be helpful in predicting the direction, degree or speed of progression of the condition. Indications for intervention should remain stage-related, and not based on projected progression.

Cohort Studies↗