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Biomedical subjects

V F Garcia

Publications and source records attributed to V F Garcia.

At least 19 recordsLinked to original sources
PubMed2001

Absent peritoneal fluid on screening trauma ultrasonography in children: a prospective comparison with computed tomography.

BACKGROUND: Although the accuracy of focused abdominal sonography for trauma (FAST) in adults has been demonstrated, results of this technique in children have been conflicting with few comparisons against computed tomography (CT), the imaging gold standard. METHODS: A total of 160 hemodynamically stable pediatric trauma victims referred for abdominal CT initially underwent rapid screening sonography looking for free fluid. Both studies were interpreted in blinded fashion. RESULTS: Forty-four of the 160 patients had an intraabdominal injury on CT, 24 (55%) of which had normal screening sonography. Fifteen of the 44 (34%) had no free fluid on either modality. Accuracy of sonography compared with CT was 76% with a negative predictive value 81%. CONCLUSIONS: Sonography for free fluid alone is not reliable to exclude blunt intraabdominal injury in hemodynamically stable children given the considerable percentage of injured patients without free fluid. J Pediatr Surg 36:565-569.

Abdominal Injuries↗
PubMed2001

Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center.

PURPOSE: Cervical spine (C-spine) injuries occur infrequently in children but may be associated with significant disability and mortality. The purpose of this study was to review the experience of a level 1 pediatric trauma center to determine the epidemiology, risk factors, mechanisms, levels, types of injury, comorbid factors, and outcomes associated with these potentially devastating injuries. METHODS: A retrospective analysis of 103 consecutive C-spine injuries treated at a level 1 pediatric trauma center over a 9(1/2)-year period (January 1991 through August 2000) was performed. RESULTS: The mean age was 10.3 +/- 5.2 years, and the male-to-female ratio was 1.6:1. The most common mechanism of injury was motor vehicle related (52%), followed by sporting injuries (27%). Football injuries accounted for 29% of all sports-related injuries. Sixty-eight percent of all children sustained injuries to C1 to C4; 25% to C5 to C7; and 7% to both. Spinal cord injury without radiographic abnormality (SCIWORA) occurred in 38%. Five patients had complete cord lesions involving the lower C-spine (C4 to C7); 4 of these were motor vehicle related, and all 4 patients died. Isolated C-spine injuries occurred in 43%, whereas 38% had associated closed head injuries (CHI). The overall mortality rate was 18.5%, most commonly motor vehicle related (95%), occurring in younger children (mean and median age 5 years) and associated with upper C-spine injuries (74%) and CHI (89%). C1 dislocations occurred in younger children (mean age, 6.6 years), most often as a result of motor vehicle-related trauma (especially pedestrians) and were associated with the highest injury severity score (ISS), longest length of stay (LOS), most CHIs, and the highest mortality rate (50%). C-spine fractures with or without SCI occurred most commonly as a result of falls and dives. Sporting injuries occurred almost exclusively in adolescent boys (mean age, 13.8 years) and were isolated injuries associated with a relatively low ISS and shorter LOS. Interestingly, 75% of sporting injuries showed SCIWORA, and all infants suffering from child abuse had SCIWORA. CONCLUSIONS: Mechanisms of injury are age related, with younger children sustaining C-spine injuries as a result of motor vehicle-related trauma and older adolescents commonly injured during sporting activities. C-spine injuries in children most commonly involve the upper C-spine, but complete lesions of the cord are associated more frequently with lower C-spine injuries. The type of C-spine injury is related to the mechanism of injury: SCIWORA is associated with sporting activities and child abuse, C-spine dislocations most commonly result from motor vehicle-related trauma (especially among pedestrians), and C-spine fractures occur most commonly as a result of falls and dives. Predictors of mortality include younger age, motor vehicle-related mechanism, C1 dislocations, high ISS greater than 25, and associated CHI. A high index of suspicion for SCIWORA is essential when evaluating adolescents with neck trauma associated with sporting injuries or victims of child abuse.

Accidental Falls↗
PubMed2001

The New Injury Severity Score and the evaluation of pediatric trauma.

BACKGROUND: To compare the effectiveness of the Injury Severity Score (ISS) and New Injury Severity Score (NISS) in predicting mortality in pediatric trauma patients. METHODS: NISS, the sum of the squares of a patient's three highest Abbreviated Injury Scale scores (regardless of body region), were calculated for 9,151 patients treated at four regional pediatric trauma centers and compared with previously calculated ISS values. The power of the two scoring systems to predict mortality was gauged through comparison of misclassification rates, receiver operating characteristic curves, and Hosmer-Lemeshow goodness-of-fit statistics. RESULTS: Although there were significant differences in mean NISS and ISS values for each hospital, differences in the predictive abilities of the two scoring systems were insignificant, even when analysis was restricted to the subgroup of patients with severe or penetrating injuries. CONCLUSION: The significant differences in the predictive abilities of the ISS and NISS reported in studies of adult trauma patients were not seen in this review of pediatric trauma patients.

Child↗
PubMed2001

Delayed diagnosis in pediatric blunt trauma.

OBJECTIVE: Identification of injuries of a traumatized patient is a mandate for the emergency department (ED) and the trauma team. Delayed diagnosis of injury in trauma patients leads to increased morbidity, mortality, dissatisfaction, and risk of litigation. Comparing children admitted for blunt trauma, with and without delay, this study examines risk factors for delayed diagnosis. METHODS: Delays in diagnosis from 1991 to 1996 were identified during prospective collection of trauma registry data. Controls were randomly selected from the trauma registry. Charts from both groups were retrospectively reviewed. RESULTS: Fifty-eight patients had 65 delays in diagnosis. Significant independent delay variables included: female, motor vehicle crash (MVC)-related mechanism, altered consciousness, higher injury severity score, and multiple injuries (P < 0.05). Trauma team activation, documentation of tertiary survey, and length of hospitalization were greater in patients with delay injuries (P < 0.05). Logistic regression identified MVC-related mechanism, female, facial, and extremity injuries as a combination of predictors. CONCLUSIONS: Delays occurred in 1% of patients. Trauma team care itself did not protect all patients from delay. Injury severity at presentation alone is not an adequate predictor of delayed diagnosis in the pediatric patient. A combination of variables was identified as negative predictors of delay. Further study is needed to validate these criteria, and determine if earlier diagnosis would effect quality.

Academic Medical Centers↗
PubMed1999

Splenic injury diagnosed with CT: US follow-up and healing rate in children and adolescents.

PURPOSE: To determine if pediatric splenic injury healing observed during ultrasonography (US) is related to the computed tomographic (CT) grade of injury severity, to review any delayed complications, and to formulate a grade-specific timetable for follow-up imaging. MATERIALS AND METHODS: Sixty-eight children and adolescents with CT-documented blunt splenic injury underwent US at approximate 6-week intervals to document injury healing (normal parenchyma or linear echogenic "scar"). Medical records of those not followed up to complete healing were reviewed. RESULTS: Forty-eight patients were followed up to complete injury healing: 14 of injury grade 1 (mean, 7 weeks; range, 4-12 weeks), 24 of injury grade 2 (mean, 9.5 weeks; range, 6-17 weeks), and 10 of injury grade 3 (mean, 16 weeks; range, 6-29 weeks). The difference in mean time to healing among all grades was significant (P < .02). Only two cysts were found; one decreased in size over time. No complications occurred in the 68 study patients. CONCLUSION: The time course to US-documented healing of blunt pediatric splenic injury is related to injury severity. This information can be used to tailor follow-up imaging and provide cost savings.

Adolescent↗
PubMed1997

Decreased pulmonary compliance is an early indicator of pulmonary oxygen injury.

Pulmonary oxygen injury is classified by the development of tissue and alveolar edema, surfactant dysfunction, lung inflammation, and decreased pulmonary compliance. In neonates prolonged oxygen therapy is associated with the development of bronchopulmonary dysplasia. Recombinant DNA technology makes it possible to experimentally explore the role of specific proteins in the development of pulmonary oxygen injury. However, in vivo experiments require sensitive ways of identifying pulmonary oxygen injury early in its development. We therefore compared the sensitivities of several experimental assays used to assess pulmonary injury. We found that changes in pulmonary compliance were the most sensitive and showed significant differences after 72 hr of exposure to normobaric hyperoxia (FiO2 = 0.95), which correlated with a small change in the histology of the mice lungs. The concentration of protein in the bronchoalveolar lavage fluid was less sensitive and did not differ significantly until after 96 hr of exposure. The survival in hyperoxia also did not worsen until after 96 hr. The lung wet/ dry weight ratios was the least sensitive assay and did not increase until after 5 days of exposure to normobaric hyperoxia. We conclude that a decrease in pulmonary compliance is an early indicator of pulmonary oxygen injury and may be a better way to study the mechanisms and mediators of pulmonary oxygen injury.

Animals↗
PubMed1997

Pancreatic trauma in children: mechanisms of injury.

BACKGROUND: Pancreatic trauma occurs in up to 10% of all cases of blunt pediatric trauma. Here we attempted to identify markers of pancreatic injury in children and to assess our current diagnostic approach to pancreatic injury. METHOD: We performed a retrospective chart review of all patients with a pancreatic injury admitted to a Level I pediatric trauma center between January of 1980 and September of 1994. RESULTS: In all, 26 children were included. All pancreatic injuries were due to blunt trauma. Handlebar injuries were the most common mechanism of injury and resulted in a unique pattern of isolated pancreatic trauma, often complicated by the development of a pseudocyst. Computed tomographic scans, performed with intravenous and oral contrast and done in the acute setting, were 85% sensitive for diagnosing a pancreatic injury. CONCLUSIONS: Double contrast computed tomographic scan is a more sensitive test than ultrasound in diagnosing pancreatic injury. The constellation of abdominal pain, an elevated serum amylase and a handlebar mechanism of injury warrants hospitalization and a double contrast abdominal computed tomographic scan.

Adolescent↗
PubMed1997

Differential effects of hyperoxia on the inducible and constitutive isoforms of nitric oxide synthase in the lung.

Hyperoxia is commonly used in the treatment of newborn respiratory distress. Although essential and life saving, oxygen therapy can result in the development of lung injury. Oxygen toxicity is associated with the production of reactive oxidant species. Nitric oxide (NO) is an oxidant formed by the catalysis of L-arginine when acted upon by the enzyme nitric oxide synthase (NOS). We studied the differential effects of prolonged normobaric hyperoxia (FIO2 = .95, for 3, 4, and 5 days) on the two major NOS enzymes, constitutive endothelial cell NOS (ecNOS) and inducible NOS (iNOS). Hyperoxia led to a significant lung injury, as measured by pulmonary compliance studies. Hyperoxia did not increase serum NO production, measured as the concentration of nitrite and nitrate. However, hyperoxia did result in a small but significant increase in NO production in the bronchoalveolar lavage fluid, as measured by the products of nitrite and nitrate concentration. This increase in NO was not associated with an induction of whole lung iNOS, as measured by the conversion of L-[3H]arginine to L-[3H]citrulline or by Northern blot analysis. Hyperoxia significantly decreased ecNOS activity as measured by the conversion of L-[3H]arginine to L-[3H]citrulline. In addition, administration of the NOS inhibitor NG-nitro-L-arginine methyl ester worsened the injury, as measured by lung compliance and survival. Further studies need to be performed to determine whether this decrease in ecNOS activity during hyperoxia plays a role in the pathogenesis of hyperoxia-related lung injury.

Animals↗
PubMed1997

Animal bites and Pasturella infections.

Although bite wounds are common injuries in the pediatric population, most are minor. Dog bites are the most common animal bite wound. Children are more likely to have head and face injuries and share a disproportionate number of fatal wound injuries. Cat bites have a twofold higher risk of infection than dog wounds, with the most frequent and important pathogen being P multocida. Both cat and dog bite wounds are associated with a wide range of aerobic and anaerobic pathogens. Principles of wound management include copious irrigation, cautious debridement, appropriate antibiotics, elevation, and immobilization. The patient should have follow-up contact and usually a visit within 24 to 48 hours after the initiation of therapy.

Animals↗
PubMed1996

Selective inhibition of the inducible isoform of nitric oxide synthase prevents pulmonary transvascular flux during acute endotoxemia.

The inducible isoform of nitric oxide synthase (iNOS) is expressed in various organs, including the lung, during systemic endotoxemia. Overproduction of nitric oxide (NO) by iNOS contributes significantly to the vascular failure and end-organ damage in endotoxemia. Using selective pharmacological inhibitors of iNOS, the purpose of this study was to define the role of iNOS in a rat model of endotoxin-induced pulmonary transvascular flux (TVF). Lung TVF was assessed by a method of Evans Blue permeability index (PI). Bacterial lipopolysaccharide (LPS) (15 mg/kg intraperitoneally [IP]) significantly increased pulmonary iNOS activity and serum levels of nitrite/nitrate (NO2/NO3). This was accompanied by a significant elevation of the PI 5 hours after injection. Selective iNOS inhibition with either S-methyl isothiourea (SMT; 5 mg/kg IP) or aminoguanidine (AG; 20 mg/kg IP), administered 2 hours after LPS injection, significantly prevented the increase in PI associated with LPS injection. Similarly, inhibition of the induction of iNOS with dexamethasone (10 mg/kg IP), given 3 hours before LPS, also inhibited the increase in PI. All three treatments significantly prevented the increase in both lung iNOS activity and serum NO2/NO3 associated with endotoxemia. In conclusion, the overproduction of NO generated by iNOS during systemic endotoxemia causes a vascular leak in the lung. Thus, it is speculated that selective inhibition of iNOS may be beneficial in preventing the development of acute respiratory failure in sepsis.

Acute Disease↗
PubMed1996

The interval between a septic stimulus and hypoxia/reoxygenation affects cytokine elaboration by murine peritoneal macrophages.

The critically ill patient is commonly exposed to various physiological insults. The authors have previously shown that in vivo hypoxia/reoxygenation (H/R) alters the pattern of cytokines elaborated by murine peritoneal macrophages given a septic stimulus. In this study they sought to determine whether the interval between a septic stimulus and H/R affected the release of inflammatory mediators by macrophages. Adult CBA-strain mice were injected intraperitoneally with 10 micrograms of lipopolysaccharide (LPS). On day 0, 1, 2, 3, 4, or 5 after LPS injection, animals were exposed to 16 hours of hypoxia followed by 2 hours of reoxygenation. Harvested peritoneal macrophages were restimulated in vitro with 2.5 micrograms/mL LPS or left unstimulated. Culture supernatants collected at 2, 4, 6, 8, 10, and 12 hours after LPS injection were assayed for tumor necrosis factor (TNF), prostaglandin E2 (PGE2), and nitric oxide (NO) production. Macrophage-derived mediator production peaked when H/R occurred 3 days following LPS injection (P < .05). These data suggest that the interval between sepsis and subsequent H/R influences the pattern of cytokines elaborated by peritoneal macrophages given a septic stimulus.

Analysis of Variance↗
PubMed1996

Pneumococcal pleural empyemas in children.

Empyema rarely complicates pneumonia. In a 361-bed regional pediatric hospital, 50 pleural empyemas were identified from 1988 through 1994; 17 (34%) occurred in the last 12 months of this period, for which the incidence was 3.3 per 100,000 of the population aged < or = 18 years (P < .05, chi 2 test). A significant seasonal prevalence was observed: 50% of cases occurred in the winter (P < .001, chi 2 test). In contrast with the findings of previous studies, in which empyemas predominantly occurred in infants, the median age of our patients was 7 years; underlying illnesses were present in only 10%, and all had community-acquired disease. Eighty-two percent had chest tubes inserted, 56% required a thoracotomy with pleural decortication, and 2% had a lobectomy. There were no deaths. Streptococcus pneumoniae was isolated in 40% of the cases; specimens in 44% of the cases were sterile. None of the empyemas were associated with Staphylococcus aureus or Haemophilus influenzae type b, and only one was caused by group A streptococcus. Among 13 S. pneumoniae isolates, the rate of resistance to penicillin was 15%; to erythromycin, 15%; to chloramphenicol, 31%; and to cefotaxime, 23%. The penicillin-resistance rate among blood and cerebrospinal fluid pneumococcal isolates was 17% during 1993-1994. Drug-resistant S. pneumoniae is now a recognized cause of pleural empyemas in children.

Adolescent↗
PubMed1996

Spontaneous recanalization of the pancreatic duct: case report and review.

An eight-year-old boy received a grade 3 pancreatic injury as a result of a bicycle handlebar accident. Endoscopic retrograde cholangiopancreatography (ERCP) showed a proximal pancreatic duct transection. At laparotomy, a complete transection of the gland and duct was visualized; however, only debridement and external fistulization were performed. Follow-up ERCP performed 3 months postoperatively showed recanalization of the pancreatic duct without further operative intervention. At 1-year follow-up, the patient is pain free and tolerating a regular diet.

Bicycling↗
PubMed1996

Low-level expression and limited role for the inducible isoform of nitric oxide synthase in the vascular hyporeactivity and mortality associated with cecal ligation and puncture in the rat.

Expression of the inducible isoform of nitric oxide synthase (iNOS) contributes to the hypotension and vascular hyporeactivity in various models of shock induced by bacterial lipopolysaccharide (LPS). However, the role of iNOS in response to shock caused by live bacteria is more controversial. In the present study, we investigated the role of iNOS in a rat model of cecal ligation and puncture (CLP). CLP resulted in increased plasma nitrite/nitrate levels (up to 59 microM at 24 h) and increased pulmonary iNOS activity (up to 71 fmoles/mg/min at 12 h) and caused a significant vascular hyporeactivity at 18 h. The degree of NO production and iNOS induction was approximately 30% of that observed several hours after administration of LPS in the same species, and the degree of vascular hyporeactivity was less than that observed after LPS injection. Selective inhibition of iNOS with mercaptoethylguanidine (MEG) reduced plasma nitrite/nitrate levels, but did not prevent the development of vascular hyporeactivity, and did not improve survival in this model of CLP. Thus, CLP-induced sepsis causes low-level induction of iNOS, but factors other than iNOS are the crucial determinants of the vascular failure and mortality in this model.

Animals↗
PubMed1996

The use of laparoscopy in the management of seat belt trauma in children.

Abdominal wall, hollow viscous, and spinal cord injuries are severe complications of two point seat belt restraints in children. Somatic abdominal wall pain can mask the presence of potentially life-threatening intraperitoneal injuries, false-positive peritoneal lavage can lead to unnecessary celiotomy, and CT scan can miss hollow viscous injury. All of these concerns point to the need for a more effective diagnostic modality. Laparoscopy may have a role in the diagnosis and management of lap belt-related hollow viscous and mesenteric injuries. The presence of either free peritoneal fluid or mesenteric thickening, seen on CT scan, associated with an seat belt-related abdominal wall contusion are criteria for diagnostic laparoscopy. Four patients, age 3 to 15, underwent laparoscopy. Diagnostic laparoscopy employed two additional laterally placed ports and extreme Trendelenburg and reverse Trendelenburg to facilitate the thorough examination of the small bowel. Injuries identified were a severely contused cecum, a contusion of the small bowel with associated mesenteric hematoma, transverse colon contusion and gastric perforation, and a small bowel contusion. No delayed reexplorations were required for missed injuries and there were no complications associated with laparoscopy. This experience suggests that laparoscopy may have a role in the diagnosis and management of seat belt trauma in children.

Abdominal Injuries↗
PubMed1995

Hypoxia/reoxygenation affects endotoxin tolerance.

Pretreatment of animals with sublethal doses of endotoxin renders them tolerant to subsequent endotoxin challenge. Tissue hypoxia following infection may potentiate the immune response to injury. To evaluate the effect of hypoxia/reoxygenation (H/R) on endotoxin tolerance by macrophages, adult CBA mice were pretreated with 10 micrograms/animal of LPS injected intraperitonealy. Five days later, animals were subjected to 16 hr of hypoxia followed by 2 hr of reoxygenation. Harvested peritoneal macrophages were cultured and either stimulated in vitro with LPS or left unstimulated. Culture supernatants collected at 2, 4, and 6 hr were assayed for tumor necrosis factor (TNF), prostaglandin E2 (PGE2), and nitric oxide (NO). Control animals underwent the same procedures, but were maintained in normoxia. H/R resulted in significantly greater TNF production but significantly lower PGE2 and NO production, P < 0.05 by ANOVA. These data suggest that LPS-induced tolerance of macrophages to the same stimulus is abated by H/R.

Animals↗