Radiological case of the month. Orange seed aspiration.
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Citrus↗
Biomedical subjects
C M Cosentino
Publications and source records attributed to C M Cosentino.
A 25-year experience with renal tumors of childhood.
A retrospective analysis of the medical records of 234 children with renal tumors managed over a 25-year period at the Children's Memorial Medical Center was undertaken to evaluate long-term morbidity and mortality. There was a significant increase in survival over the years of the study. The 5-year survival for patients treated during the period 1985 to 1989 was 94% versus 68% for the period 1965 to 1969. Thirty-three children have died, 15 with known disease progression. Long-term morbidity included scoliosis (39), cardiorespiratory insufficiency (13), hypertension (7), renal insufficiency (7), small bowel obstruction (10), chest wall deformity (3), amenorrhea (1), leg length discrepancy (1), and 1 patient with an esophageal stricture. One patient with cardiomyopathy secondary to adriamycin has recently undergone cardiac transplantation. Five patients with renal insufficiency have required dialysis. Of these five, one patient has had two renal transplants. The presence of distant metastases and positive hilar or regional lymph nodes were the only findings at operation that were associated with an increased mortality (P = .005). There was a significantly increased mortality in those children operated on by general surgeons or urologists at other hospitals (11/43) versus those operated upon at our hospital (22/191) (P = .033). There was no statistical difference in the staging or histology among these children. We feel that the careful and systematic approach of a radical nephrectomy assures accurate staging of the tumor removing gross and microscopic disease in the abdomen.
Cause of Death↗
Early hepatobiliary dysfunction during total parenteral nutrition: an experimental study.
The etiology and pathophysiology of the liver disease associated with total parenteral nutrition (TPN) are unknown. In this study, we have attempted to define the early changes in hepatobiliary function during TPN in young rabbits nourished totally by the intravenous route for 3, 5, and 15 days, with age-matched rabbits on lab chow serving as controls. A decrease in basal bile flow along with elevations of serum bile acids and cholesterol was seen. The capacity for biliary secretion of sulfobromophthalein and of ursodeoxycholic acid was measured at the end of each diet regimen. Early impairment of biliary sulfobromophthalein (BSP) secretion was seen after 5 days of TPN, with no further deterioration after 15 days. Maximal bile acid secretory rate and bile flow, in response to the ursodeoxycholic acid load, were decreased after 15 days of TPN. Furthermore, after 15 days of TPN, both the volume of gallbladder bile and its bile acid content increased. The combined effects of the enteral fast and the intravenous administration of all nutrients were bile acid sequestration in an adynamic gallbladder with interruption of the enterohepatic circulation. In the parenterally fed rabbit, we have demonstrated bile secretory failure and gallbladder sludge, the two common complications of clinical TPN. These may be the early events that subsequently lead to cholestasis and liver damage in neonates maintained on prolonged TPN.
Animals↗
Choledochal duct cyst: resection with physiologic reconstruction.
BACKGROUND: The accepted surgical treatment of choledochal duct cyst is complete excision and enteric drainage through an intestinal conduit. Peptic ulceration and fat malabsorption have been reported after Roux-en-Y reconstruction. Such long-term complications may be avoided by a technique that simulates normal physiology. METHODS: Twenty-one patients have undergone resection of a choledochal duct cyst in the past 12 1/2 years. The pathologic duct is resected to the level of normal mucosa. A short segment of jejunum with a intussusception valve (1.5 to 2 cm) is interposed between the common hepatic duct and the duodenum. The medical records and all radiographs of each patient were reviewed. Eighteen children were reexamined or the parents were contacted by phone. RESULTS: Twenty of 21 patients recovered without major perioperative complications. Twelve of them are well and have no symptoms at 3 to 12+ years (mean, 6 years) after operation. Four children are currently well 6 to 19 months after operation. Three children were well when lost to follow-up. Two patients have radiographic evidence of incompetence of the interposition valve. One of these, who initially underwent operation at 9 months of age, was reexplored at 10 months and at 10 years for a stricture at the hepaticojejunal anastomosis. The other, a 7-year-old girl who was admitted with jaundice and pancreatitis, has had episodic abdominal pain for 7 years after operation but is well. CONCLUSIONS: The valved jejunal interposition hepaticoduodenostomy offers superior biliary reconstruction after excision of a choledochal duct cyst. Normal physiology is simulated, with bile draining directly into the duodenum. A short conduit prevents stasis, and biliary reflux is minimized with the addition of an intussusception valve.
Child↗
The impact of level 1 pediatric trauma center designation on demographics and financial reimbursement.
A retrospective analysis of medical and financial records of trauma patients admitted over a 4-year period was undertaken to determine the impact of level 1 pediatric trauma center designation on demographics and financial reimbursement. Three hundred fifty-four patients were admitted from November 1, 1985, to October 31, 1986 (Prelevel 1 designation [PREL1]). Five hundred seven patients were admitted from November 1, 1986, to October 31, 1987 (Postlevel 1 designation [PostL1]) (P less than .005). Mechanisms of injury were similar in both groups, with falls being most prevelant (PreL1, 50.8%; PostL1, 43.4%). The magnitude of injuries in the PostL1 period, as expressed by Pediatric Trauma Scores and Injury Severity Scores, did not change significantly. The types of injuries, as indicated by organ systems involved, did not change. The exception was thoracic injuries, which increased from 1.7% to 4.5% (P = .037). Total hospital charges per patient increased ($5,820 PreL1; $7,691 PostL1) (P = .034). Collection rates did not change (77.6% PreL1; 76.4% PostL1). The institution incurred a financial loss per patient of $1,149 PreL1 and $1,795 PostL1 (P = .055). Years 2 and 3 PostL1 designation were analyzed to identify trends (year 2 PostL1: November 1, 1987 to October 31, 1988 [488 patients]; year 3 PostL1: November 1, 1988 to October 31, 1989 [459 patients]). The distribution of Pediatric Trauma Scores and Injury Severity Scores did not change. Total hospital charges per patient remained fairly constant ($8,082 year 2 PostL1; $7,276 year 3 PostL1). Unreimbursed costs increased significantly compared with losses during the PostL1 period ($4,262 year 2 PostL1, P less than .005; $2,799 year 3 PostL1, P = .04).(ABSTRACT TRUNCATED AT 250 WORDS)
Chicago↗
Pericardial patch tracheoplasty for severe tracheal stenosis in children: intermediate results.
Between 1982 and 1990, 15 children have undergone pericardial patch tracheoplasty, 13 for complete tracheal rings and 2 for acquired tracheal stenosis. Eleven had complete tracheal rings from the thoracic inlet or the cricoid to the carina. Diagnosis was by bronchoscopy (15), computed tomography (10), and magnetic resonance imaging (3). As first described by Idriss in 1984, the surgical technique uses a median sternotomy approach, extracorporeal circulation, bronchoscopic guidance, and the use of pericardium as a tracheal patch. There was one perioperative death of mediastinitis (operative survival, 93%). There were two late deaths caused by complications of tracheostomy (1) and direct laryngoscopy and bronchoscopy (DLB) (1). Follow-up is complete in 12 intermediate-term survivors and ranges from 0.4 to 8.2 years (mean, 4.2 +/- 2.9 years). Five children required multiple DLBs with dilation and excision of granulation tissue; one of these patients underwent tracheoplasty revision 5 months after the initial procedure for residual tracheal rings, and four of these children have had tracheostomies, two temporary and two currently (4 months, 7 years). Seven children had widely patent tracheas observed at follow-up DLB with little or no residual stenosis after tracheoplasty. All survivors are currently asymptomatic, except for the two children with tracheostomies. Pericardial patch tracheoplasty offers effective therapy with relatively low operative mortality for infants and children with severe long segment tracheal stenosis. On intermediate-term follow-up, nearly all survivors are essentially free of symptoms of residual tracheal stenosis.
Child, Preschool↗
Transfusion requirements in conservative nonoperative management of blunt splenic and hepatic injuries during childhood.
Nonoperative management of splenic and hepatic injuries in children is safe, and the majority of those with isolated injuries do not require blood transfusion. Thirty-seven children were treated for blunt splenic or hepatic trauma from November 1983 to September 1989. There was one death in a patient with a lethal head injury. No operations were performed on those with isolated splenic or hepatic injuries. Three of those with multiple injuries underwent delayed laparotomy. Two had perirenal and retroperitoneal hematomas without active bleeding, and one had a bowel obstruction secondary to an intramural jejunal hematoma. There were no late complications related to the splenic or hepatic injuries. Eight children (22%) required surgery for other injuries. Twelve children were not transfused, including the majority (8/11) of those with isolated splenic or hepatic injury. The hematocrit of four of these children fell to below 28% and this anemia was well-tolerated. Two children with bleeding disorders (factor VIII [antihemophilic factor] and factor XII [Hageman factor] deficiency) did not require packed red blood cells transfusion. Two clinically distinct groups of children received blood transfusions: (1) eight patients with multiple injuries were transfused during initial resuscitation when unstable or during early operation for other system trauma (mean, 62.0 mL blood/kg body weight); and (2) three hemodynamically stable patients with isolated injuries and 14 stable patients with multiple injuries were transfused empirically after initial resuscitation solely because of decreasing blood counts. They received an average of 16.5 and 21.1 mL blood/kg body weight, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)
Accidental Falls↗
Hepatic organic anion transport kinetics and bile flow during short-term total parenteral nutrition in the rabbit.
Plasma disappearance of sulfobromophthalein (BSP) after an intravenous bolus (5 mg/kg) was determined in six lab chow-fed (LCF) rabbits and in six rabbits maintained on total parenteral nutrition (TPN) for 5 days. A common bile duct cannula enabled measurements of bile flow and biliary BSP excretion. Compartmental analysis of the biexponential plasma disappearance curve yielded three fractional transfer rates, plasma to liver (hepatic uptake), liver to plasma (reflux), and liver to bile (canalicular excretion). The transfer rates for hepatic uptake were 0.253 +/- 0.061/min for LCF and 0.147 +/- 0.040/min for TPN (P less than 0.01) and for the canalicular excretion of BSP were 0.038 +/- 0.019/min for LCF and 0.019 +/- 0.002/min for TPN (P less than 0.05). Model-computed rates for BSP excretion in bile over 60 min were lower with TPN (61%) than with LCF (80%); the measured excretory rates were 53% for TPN rabbits and 75% of injected dose for LCF animals. Basal biliary flow was reduced by 50% in the TPN group. With a two-compartmental model, assuming two pools and three transfer rates, we have demonstrated for the first time significant decreases in hepatic uptake and canalicular excretion of the organic anion BSP during TPN. A decrease in hepatic blood flow due to the enteral fast of TPN could have contributed in part to the decreased hepatic uptake. But, because the second exponent of the biexponential curve is independent of hepatic blood flow, the decrease in liver to bile transfer rate is a true approximation of a diminished canalicular excretory capacity during TPN. It is concluded that the movement of organic anions along the hepatic BSP/bilirubin transport system is impaired early during TPN.
Animals↗
Giant cranial hemangiopericytoma: MR and angiographic findings.
The authors detail the MR and angiographic findings of a very large hemangiopericytoma in the skull of a 63-year-old woman. Angiography showed a marked tumor blush with early draining veins; MR showed heterogeneously increased T2 signal intensity and enhancement with gadolinium secondary to the richly vascularized tumor.
Angiography↗