Biomedical subjects

David A Partrick

Publications and source records attributed to David A Partrick.

At least 19 recordsLinked to original sources

PubMed2006

Resection of neurogenic tumors in children: is thoracoscopy superior to thoracotomy?

BACKGROUND: Minimally invasive resection of solid tumors is controversial because of concerns of inadequate resection and local recurrence. Thoracoscopy has been used in the diagnosis of mediastinal tumors in children, but its role in resection is unproved. The purpose of this study was to compare thoracoscopic and open approaches to the resection of thoracic neurogenic tumors in children. STUDY DESIGN: The tumor registry of a regional children's hospital was queried to identify patients who underwent resection of neurogenic tumors over a 6-year period. Thoracoscopic and open groups were compared for demographic, operative, oncologic, and outcomes characteristics. RESULTS: Seventeen children underwent resection of mediastinal neurogenic tumors (10 thoracoscopic resections, 7 open resections). Mean age was 4.7 years (range 6 months to 12 years). The thoracoscopic and open groups showed no difference in operative time or blood loss. Tumors in the two groups were comparable in size (5.2+/-2.2 cm versus 5.7+/-2.6 cm), histology, surgical margin, and stage. Hospital stay was shorter after thoracoscopic resection (1.9+/-0.7 days versus 4.1+/-2.5 days, p<0.05). There were no regional recurrences. Distant metastases developed in one patient in each group. Eight of 10 children with malignant tumors remain disease-free at an average of 25 months of followup (range 3 to 80 months). CONCLUSIONS: Thoracoscopic resection of neurogenic tumors achieved similar local control and disease-free survival when compared with open resection in this preliminary series. These results were accompanied by a shorter hospital stay. These findings suggest that thoracoscopic resection of neurogenic tumors in children may offer advantages to open resection and should be studied in the context of a large, cooperative trial.

Child↗

PubMed2006

Prospective evaluation of a primary laparoscopic approach for children presenting with simple or complicated appendicitis.

BACKGROUND: Previous studies have suggested laparoscopy leads to an increased risk of postoperative intra-abdominal abscess formation in complicated appendicitis. The purpose of this study is to prospectively evaluate a standardized laparoscopic approach applied by a single surgeon for all children who present with appendicitis and to determine the postoperative outcome. METHODS: Over a 5-year period (2001-2005), all children presenting to the author with simple or complicated appendicitis were approached laparoscopically and their preoperative workup, intraoperative findings, and postoperative outcomes recorded. RESULTS: One hundred seventy-five consecutive laparoscopic appendectomies were performed with no open conversions. Mean patient age was 9 years. Sixty-seven patients (38%) presented with complicated appendicitis. The overall complication rate was 6% (9 children developed a postoperative intra-abdominal abscess or phlegmon and 2 had umbilical wound infections). CONCLUSIONS: When laparoscopic appendectomy is used as the primary technique, only 6% of patients experience infectious complications. Therefore, a laparoscopic approach to all children presenting with appendicitis does not lead to an increased complication rate.

Abdominal Pain↗

PubMed2006

Nonaccidental trauma is a major cause of morbidity and mortality among patients at a regional level 1 pediatric trauma center.

BACKGROUND: Traumatic injuries are a major cause of morbidity and mortality in children. The purpose of the present study was to determine the incidence of nonaccidental trauma (NAT) and to compare the outcomes of accidental trauma (AT) patients with NAT patients at a large pediatric trauma center. METHODS: A retrospective chart review of 6186 trauma patients younger than 18 years evaluated during the period of 1996 to 2004. RESULTS: During the period of study, NAT accounted for 7.3% (n = 453) of trauma evaluations (n = 6186). Compared to AT, the NAT patient was younger, 12 vs 76 months (P < .05); were more severely injured, injury severity score 18 vs 9 (P < .05); and required both longer intensive care unit stay, 2 vs 1 day (P < .05), and overall hospital stay, 6 vs 3 days (P < .05). Craniotomy was required in 4.4% of NAT patients compared with 2.7 % of AT patients (P < .05). Abdominal exploration was necessary in 3.5% of NAT patients compared to 1.6% of AT patients. The mortality rate for NAT was 9.7% compared to 2.2% for AT (P < .05). CONCLUSIONS: The surgeon caring for children must appreciate the high incidence of NAT with its increased morbidity and mortality relative to AT patients. A surgical evaluation should be performed promptly in NAT patients because of their frequent need for emergent intervention.

Child↗

PubMed2005

Visceral injuries in nonaccidental trauma: spectrum of injury and outcomes.

BACKGROUND: Nonaccidental trauma (NAT) causes significant morbidity and mortality in children. The purpose of this study was to characterize visceral injuries associated with NAT and the management and outcomes of children with these injuries. METHODS: During a 7-year period, children admitted to our regional pediatric trauma center with a diagnosis of NAT were identified and their injuries characterized. RESULTS: NAT accounted for 7% (n = 265 of 3705) of all trauma admissions during the period of study. Visceral injuries were diagnosed in 9% (n = 24 of 265) of NAT patients. Compared with the remaining NAT population, children with visceral injuries were similar in age and sex but had higher injury severity scores (21 vs. 17, P < .05). There was a high coincidence of thoracic trauma and nonburn integumental injuries in abdominally injured NAT patients. Children with visceral injuries were more likely to undergo emergent operations (46% [11 of 24] vs. 5% [15 of 241], P < .0001) than those without. However, there was no difference in Intensive Care Unit stay, hospital stay, or overall mortality for children with visceral injuries compared with those without. CONCLUSIONS: Visceral injuries are not uncommon in NAT, and these injuries often require emergent operative intervention. Thus, prompt evaluation and treatment by a surgeon remains a critical step in the management of children with NAT.

Abdominal Injuries↗

PubMed2005

Sentinel lymph node biopsy for melanoma and other melanocytic tumors in adolescents.

BACKGROUND/PURPOSE: Melanoma is rare, accounting for only 1% of all pediatric malignancies. The management of pediatric melanoma is controversial but largely parallels that of an adult occurrence. Sentinel lymph node biopsy (SLNBX) has become a standard of care for adults with melanoma, but the role of this procedure in the staging of pediatric patients remains to be established. The goal of this study was to determine outcomes and complications of children and adolescent patients undergoing SLNBX at the authors' institution. METHODS: A retrospective review of patients younger than 21 years (N = 20) undergoing SLNBX for melanoma or other melanocytic skin lesions at the University of Colorado Health Science Center between 1996 and 2003 was conducted. RESULTS: Sentinel lymph node biopsy was successful in all 20 patients, and 8 patients (40%) were found to have metastases within the sentinel node. As in adults, the sentinel node status correlates with primary tumor depth. No complications occurred in patients undergoing SLNBX, but 4 clinically significant complications (57%) occurred in the 7 patients undergoing a completion lymph node dissection. At 33 months median follow-up, all patients were disease free. CONCLUSIONS: Sentinel lymph node biopsy can be successfully and safely performed in pediatric patients for melanoma and atypical nevi. However, the prognostic information and therapeutic implications of SLNBX results for children and adolescents remain unclear. Completion lymph node dissection for microscopic disease is a morbid procedure with uncertain benefit to pediatric or adult patients with a positive SLNBX result. Long-term follow-up data are needed before SLNBX can become a standard of care in pediatric melanoma or as a diagnostic tool to distinguish the atypical Spitz nevus from melanoma.

Adolescent↗

PubMed2005

Survival in sentinel lymph node-positive pediatric melanoma.

BACKGROUND: Sentinel lymph node (SLN) status is the strongest predictor of survival in adult melanoma. However, the prognostic value of SLN status in children and adolescents with melanoma is unknown. METHODS: Records of 327 patients aged 12 to 86 years undergoing SLN biopsy for melanoma or other melanocytic lesions were reviewed. A literature search identified additional patients younger than 21 years undergoing SLN biopsy for the same indications and these patients were combined with our series for meta-analysis. RESULTS: Sentinel lymph node metastases were found in 8 (40%) of 20 patients aged 12 to 20 years compared with 55 (18%) of 307 adults (P < .05). Median follow-up was 35 and 17 months for the groups, respectively. Sentinel lymph node-positive pediatric patients did not recur, whereas 14 (25%) adults recurred within this period. Of the 55 adults, 5 (9.1%) have died of disease. Of the combined SLN-positive children and adolescents from the literature (total n = 25), only a single (4%) child recurred at 6 months. The difference in survival for adult and pediatric patients was significant. CONCLUSION: Pediatric patients have a higher incidence of SLN metastases than adults yet have a lower incidence of recurrence. Sentinel lymph node status does not predict early recurrence in pediatric patients with melanoma or atypical Spitz nevi.

Adolescent↗

PubMed2005

Efficacy of left thoracoscopy and blunt mediastinal dissection during the Nuss procedure for pectus excavatum.

BACKGROUND/PURPOSE: The minimally invasive Nuss procedure is emerging as the preferred technique for repair of pectus excavatum. Original methods of pectus bar placement have been modified to improve safety and efficacy and avoid cardiothoracic complications. The currently reported modifications to facilitate retrosternal pectus bar placement include routine use of right thoracoscopy or a subxiphoid incision. The purpose of this article is to describe additional modifications of the Nuss procedure to improve safety and efficacy. METHODS: A retrospective analysis was performed on 51 patients who have had a thoracoscopic-assisted Nuss procedure at The Children's Hospital, Denver, Colo, between 1999 and 2002. Technical modifications included patient positioning, routine use of left thoracoscopy, and an Endo-kittner. RESULTS: Fifty-one patients have successfully undergone the Nuss procedure using the new modifications. Surgical time ranged from 45 to 120 minutes. There have been no intraoperative or postoperative bleeding complications. There have been 2 large pneumothoraces requiring needle thoracenteses in the operating room before extubation. No chest tubes were required postoperatively. Subjectively, all patients have been satisfied with their surgical correction. Average length of hospital stay was 4 to 6 days. CONCLUSIONS: By using left chest thoracoscopy and Endo-kittner dissectors, the risk of cardiothoracic injury can be eliminated. Moreover, other methods to ensure safe substernal dissection are unnecessary.

Adolescent↗

PubMed2005

Delayed near-fatal hemorrhage after Nuss bar displacement.

A novel case of Nuss bar displacement with near-fatal hemorrhage 3 months after insertion and 3 weeks after unreported bar movement is presented. Salient features of presentation, evaluation, and treatment are described including how to divide the bar from an intrathoracic approach.

Adolescent↗

PubMed2004

IL-1beta induces an exaggerated pro- and anti-inflammatory response in peritoneal macrophages of children compared with adults.

Children have a lower incidence of acute lung injury (ALI) compared with adults. Because ALI appears to be the end result of systemic hyperinflammation, children may either have 1) an attenuated pro-inflammatory response or 2) an augmented anti-inflammatory response compared with adults. The purpose of this study was to determine the IL-1-induced pro- and anti-inflammatory response of pediatric vs. adult peritoneal macrophages (PMs). We hypothesized that pediatric PMs would have an enhanced anti-inflammatory response compared with adult PMs. Human PMs were collected during elective laparoscopic procedures, cultured, and stimulated with IL-1beta. IL-6, IL-8, IL-10, and TNFalpha production were determined by ELISA. Statistical analyses were by ANOVA; a P <0.05 was significant. Our results showed that IL-1beta induced an 11-fold increase in IL-10 production in pediatric PMs (659+/-103 vs. 60+/-25 control, P <0.05). There was no IL-10 production in IL-1beta-stimulated adult PMs. IL-1beta-induced TNF production was greater in children compared with adults (2152+/-166 vs. 592+/-188, P <0.05). Similarly, IL-1beta-induced IL-6 production was greater in pediatric PMs compared with adults (532+/-3 vs. 444+/-52, P <0.05). There was no difference in IL-1beta-induced IL-8 production in children compared with adults. The IL-10:TNFalpha ratio after IL-1beta stimulation was 0.306+/-0.056 in pediatric macrophages and 0.020+/-0.015 in adult macrophages ( P<0.01). In conclusion, IL-1beta-induced IL-6 and TNFalpha production were greater in pediatric than adult PMs. Furthermore, pediatric PMs had an 11-fold increase in IL-1beta-induced IL-10 production, while adult PMs did not produce IL-10. Therefore, IL-1beta induces both a pro- and an anti-inflammatory response in pediatric PMs, whereas adult PMs produce only pro-inflammatory cytokines in response to IL-1beta. The exaggerated anti-inflammatory IL-10 response in children may be an important factor in the observed differences in ALI between children and adults.

Adult↗

PubMed2004

Endotoxin induces an exaggerated interleukin-10 response in peritoneal macrophages of children compared with adults.

BACKGROUND: Children have a lower incidence of postinjury multiple organ failure (MOF) compared with adults with equivalent injury severity. Because MOF appears to be the end result of systemic hyperinflammation, children may have either an attenuated proinflammatory response or an augmented antiinflammatory response compared with adults. The purpose of this study was to determine the lipopolysaccharide (LPS)-induced pro- and antiinflammatory cytokine response of pediatric versus adult peritoneal macrophages (PM). The authors hypothesized that pediatric PMs would have an enhanced antiinflammatory response compared with adults. METHODS: Human PMs were collected during elective laparoscopic procedures and stimulated with LPS. (Pediatric cohort: n = 9 [mean, 5.4 years], adult cohort: n = 8 [mean, 41.6 years]). P less than.05 was accepted as significant. RESULTS: LPS-induced a 50-fold increase in interleukin-10 (IL-10) antiinflammatory cytokine production in pediatric versus adult PMs. LPS-induced tumor necrosis factor-alpha (TNF-alpha) production was also increased in pediatric versus adult PMs. The anti-proinflammatory cytokine ratio (IL-10 to TNF-alpha) was 20-fold higher in pediatric versus adult PMs. CONCLUSIONS: LPS-induced macrophage production of both IL-10 and TNF-alpha was increased in children. The anti-proinflammatory cytokine ratio (IL-10 to TNF-alpha) was strikingly higher in pediatric versus adult PMs. These data suggest that the age-related balance of anti- and proinflammatory cytokines in resident macrophages is different in children compared with adults.

Adult↗

PubMed2004

Blunt diaphragmatic rupture in children.

BACKGROUND: Although several series of blunt diaphragmatic rupture in adults have been published, this injury remains largely uncharacterized in the pediatric population. METHODS: We queried our trauma registry for all children admitted with blunt diaphragmatic rupture over a 10-year period at a Level I pediatric trauma center. RESULTS: Six children (aged 2-15 years; mean, 7 years) were identified with blunt diaphragmatic rupture (three right, two left, one bilateral), representing 0.4% of admissions. All of the children had associated injuries (4.5 per child), with a mean Injury Severity Score of 32. Four diaphragmatic injuries were identified during the initial evaluation. The two missed injuries were diagnosed at postinjury days 5 and 8. There were no deaths and all children were eventually discharged without sequelae. CONCLUSION: Blunt diaphragmatic rupture occurs in children with a frequency and severity commensurate with that observed in adults. Our data suggest improved survival compared with adults with this injury.

Adolescent↗

PubMed2003

On-pump coronary artery bypass surgery activates human myocardial NF-kappaB and increases TNF-alpha in the heart.

PURPOSE: Myocardial tumor necrosis factor alpha (TNF) production and nuclear factor kappa B (NF-kappaB) activation has been demonstrated in chronic heart failure and experimental models of acute ischemia-reperfusion injury. Further, a cause and effect relationship has been established between these events and cardiomyocyte apoptosis following such conditions. It remains unknown, however, whether the myocardial injury associated with coronary artery bypass surgery (CAB) results in myocardial NF-kappaB activation and TNF production. We hypothesized that CAB with cardiopulmonary bypass ("on-pump") activates human myocardial NF-kappaB and increases TNF in the heart. METHODS: Patients, 18 to 65 years of age, scheduled for elective cardiac surgery but without other preexisting disease were considered eligible for the study. Biopsies of human myocardium were obtained before and after cardiopulmonary bypass and myocardial TNF levels were determined by ELISA and cytotoxicity assay, and NF-kappaB activation was determined by electrophoretic mobility shift assay (n = 6 patients). NF-kappaB activation was quantitated with gel densitometry. RESULTS: The clinical characteristics of the study patients were as follows (means +/- SEM): mean age (y) 50.0 +/- 5.7, male 6 (100%), cardiopulmonary bypass time (min) 107 +/- 37.7, cross-clamp time (min) 68 +/- 17.6, number of CAB 3.0 +/- 1.1, and length of hospital stay (d) 4.8 +/- 0.9. Before CAB, myocardial TNF-alpha levels were 251 +/- 22 pg/g and 33 +/- 9 U/g, as determined by ELISA and cytotoxicity assay, respectively. Following CAB, human myocardial TNF-alpha levels increased to 892 +/- 71 pg/g (P = 0.0008) and 141 +/- 11 U/g (P = 0.0042), as determined by ELISA and cytotoxicity assay, respectively. Before CAB, the ratio of bound to unbound NF-kappaB DNA was 0.009 +/- 0.0007 and after CAB the ratio was 0.24 +/- 0.01 (P < 0.0001). CONCLUSIONS: This study represents the initial demonstration that coronary artery bypass grafting results in an activation of NF-kappaB and an increase of TNF in the heart.

Cardiopulmonary Bypass↗

PubMed2003

Increased CT scan utilization does not improve the diagnostic accuracy of appendicitis in children.

BACKGROUND/PURPOSE: Appendicitis continues to present a diagnostic dilemma in children of all ages leading to increased utilization of radiographic studies. Focused computed tomography (CT) scanning has become the diagnostic test of choice in many hospitals. The purpose of this study was to critically evaluate the use of radiographic studies for the evaluation of acute appendicitis in children and to determine if diagnostic accuracy has improved. METHODS: Children undergoing appendectomy for acute appendicitis were reviewed from 1997 to 2001. Diagnostic workup (CT scan, ultrasound [US], or no radiographic study) was recorded as were the final pathology results. RESULTS: Six hundred sixteen appendectomies were performed. Mean age was 10.4 +/- 4.1 years, and 60% were boys. Overall, 184 children (30%) underwent CT scanning, 104 (17%) had US performed, and 310 (50%) had no radiographic study (18 patients had both CT and US performed). A pathologically normal appendix was removed in 7% (14 of 202) of CT patients, 11% (14 of 122) of US patients, and 8% (26 of 310) of patients without a study. The frequency of CT scanning increased from 1.3% of all children in 1997 to 58% in 2001, whereas utilization of US decreased from 40% to 7%. Over the same period, the overall negative appendectomy rate did not change significantly from 8% to 7%. CONCLUSIONS: With increased utilization of focused CT scanning, the negative appendectomy rate has remained unchanged. History and physical examination by an experienced surgeon is as accurate as CT in correctly diagnosing acute appendicitis in children.

Adolescent↗

PubMed2003

Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access?

PURPOSE: The aim of this study was to determine in a pediatric population whether a routine chest x-ray after central venous access is necessary when the central venous catheter is placed with intraoperative fluoroscopy. METHODS: This was a retrospective review of the charts of all patients at Children's Hospital in Denver, Colorado who underwent subclavian or internal jugular central venous catheter placement from January 1, 1998 through December 31, 2001. Age, sex, primary reason for access, access site, number of venipuncture attempts, type of catheter, intraoperative fluoroscopy results, chest x-ray results, location of the tip of the catheter, and complications were analyzed. RESULTS: There were 1,039 central venous catheters placed in 824 patients, 92.6% in the subclavian vein and 7.4% in the internal jugular vein. There were 604 (58.1%) children who had both fluoroscopy and a postprocedure chest x-ray, there were 308 (29.6%) who had only fluoroscopy, there were 117 (11.3%) who had only a postprocedure chest x-ray, and there were 10 (1.0%) who had neither fluoroscopy nor chest x-ray. On completion of the procedure, there were 12 (1.1%) children with misplaced central venous catheters, only 1 (0.1%) when intraoperative fluoroscopy was used. There were 17 (1.6%) complications; 9 (0.9%) were pulmonary (pneumothorax, hemothorax, or an effusion). All children with pulmonary complications experienced clinical signs and symptoms suggestive of the complication after their central venous catheter insertion but before their postprocedure chest x-ray. CONCLUSIONS: The number of complications encountered in children who had central venous access of the subclavian vein or internal jugular central vein with intraoperative fluoroscopy was infrequent, the number of misplaced catheters was minimized with intraoperative fluoroscopy, and all children with pulmonary complications showed clinical signs suggestive of pulmonary complications before postoperative chest x-ray. Therefore, children who have had central venous access of the subclavian and internal jugular vein with intraoperative fluoroscopy do not appear to require a routine chest x-ray after catheter placement unless clinical suspicion of a complication exists.

Adolescent↗

PubMed2003

Management of giant omphalocele in a premature low-birth-weight neonate utilizing a bedside sequential clamping technique without prosthesis.

Management of giant omphalocele in a full-term neonate is a challenging clinical situation. Even more challenging is giant omphalocele in a premature low-birth-weight infant. The authors describe a successful staged noninvasive technique for the management of giant omphalocele in a premature, low-birth-weight neonate without the use of prosthetic material until delayed primary closure could be attempted.

Female↗

PubMed2003

Spectrum of anorectal anomalies in pygopagus twins.

BACKGROUND/PURPOSE: The literature lacks a concise description of the anorectal anomalies encountered in pygopagus twins. METHODS: This is a retrospective literature review of 34 pygopagus twins highlighting their anorectal malformations. RESULTS: Overall pygopagus twins represent 17% of all conjoined twins. Live-birth pygopagus twins are more commonly female (86%), whereas stillborns are commonly male (80%). Half of the twins had nonfused rectums, and half had fused rectums. The nonfused had 2 rectums (80%) or one rectum and one rectovaginal fistula (20%). The fused had high (46%) or low (54%) rectal junctions. All reported living male pygopagus twins have had nonfused rectums. All can be managed applying the principles of posterior sagittal anorectoplasty. CONCLUSIONS: In general, live-born male pygopagus twins are likely to survive with a nonfused rectum and good bowel function, whereas live-born female pygopagus twins have a good chance of surviving with a fused rectum (high or low), which requires appropriate operative reconstruction.

Abnormalities, Multiple↗

PubMed2003

Alteration of the postinjury hyperinflammatory response by means of resuscitation with a red cell substitute.

BACKGROUND: Transfusion of stored packed red blood cells (PRBCs) has unintended effects beyond the desired results of increased oxygen delivery. A particular concern is the potential for lipid and cytokine mediators present in PRBCs to augment the postinjury inflammatory response that sometimes culminates in multiple organ failure. Through the use of a polymerized human hemoglobin (PolyHeme), we have been able to measure the inflammatory response in patients resuscitated with minimal exposure to banked components in the early postinjury period. METHODS: Critically injured patients requiring urgent transfusion were resuscitated with either PRBCs or PolyHeme in the early postinjury period. Proinflammatory cytokines (interleukin [IL]-8 and IL-6), counterregulatory cytokines (IL-10 and IL-11), and markers of endothelial injury (soluble intercellular adhesion molecule and soluble E-selectin) were serially measured. RESULTS: Increases in IL-8, IL-6, and IL-10 were greater in patients resuscitated with PRBCs. IL-11 plasma levels were largely below the level of detection of the assay. There was no difference in markers of endothelial injury. CONCLUSION: Consistent with concerns about the immunoinflammatory response to transfusion of PRBCs, we observed exaggerated levels of three markers associated with adverse outcome. The clinical significance of these findings with respect to the development of multiple organ failure awaits further study.

Adult↗

PubMed2003

The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children.

BACKGROUND: Rib fractures have a strong association with nonaccidental trauma (NAT) and severe trauma. The purposes of this study were to evaluate rib fractures in children to determine (1) the positive predictive value of a rib fracture in defining NAT and (2) the frequency of rib fractures as the only skeletal manifestation of NAT. METHODS: We reviewed the medical records and imaging of all children with rib fractures over a 6-year period. NAT was determined by the Child Advocacy and Protection team. RESULTS: In children younger than 3 years of age, the positive predictive value (PPV) of a rib fracture as an indicator of NAT was 95%. The positive predictive value increased to 100% once historical and clinical circumstance excluded all other causes for rib fractures. CONCLUSION: In this study, rib fracture(s) were the only skeletal manifestation of NAT in 29% of the children.

Adolescent↗