Biomedical subjects

J L Meller

Publications and source records attributed to J L Meller.

At least 19 recordsLinked to original sources

PubMed1998

Cryptococcal rib osteomyelitis in a pediatric patient.

A case of cryptococcal rib osteomyelitis in a pediatric patient is described. Isolated cryptococcal osteomyelitis in pediatric patients is a rare entity, and only 10 cases have been reported in the literature. The radiological findings are reviewed to include chest films, nuclear bone scan, and computed tomographic imaging scan. Because of its rarity, the management of isolated cryptococcal osteomyelitis is controversial. Although antifungal antibiotics and surgery are the two therapeutic options, the treatment of cryptococcal osteomyelitis has not been standardized yet. This patient was treated successfully with limited resection of the involved rib and antifungal chemotherapy. This article describes the second case in the literature of cryptococcal rib osteomyelitis in a pediatric patient, reviews the literature of similar cases, and evaluates the current role of surgery in its treatment.

Adolescent↗

PubMed1996

The outcome for children with blunt trauma is best at a pediatric trauma center.

PURPOSE: The mortality rate for pediatric trauma patients cared for in adult trauma centers has been shown, by means of TRISS methodology, not to differ significantly from that of the Major Trauma Outcome Study (MTOS). The question remains, however, whether the outcome of injured children is better in a designated pediatric trauma center (DPTC). The authors' hypothesis is that outcome is better at a DPTC. METHODS: The records of 1,797 children (0 to 15 years of age) admitted to a DPTC between 1987 and 1993 were reviewed. TRISS methodology was used to calculate probability of survival for outcome comparison with the MTOS. The data also was compared with outcome in relation to the admitting Glasgow Coma Score (GCS) reported in the National Pediatric Trauma Registry (NPTR). RESULTS: The outcome of all children at this DPTC had a Z score of +1.4199 (P > .1). The Z score of children admitted because of penetrating trauma (PT, n = 460) did not differ significantly from that of the MTOS. However, the children admitted because of blunt trauma (BT, n = 1,337) had a Z score of +3.3501 (M score = .90), which is significantly better than that of the MTOS (P < .001). The BT population with an ISS of > or = 9 (n = 149) had a Z score of +2.8686 (P < .005) (M = .95). By GCS comparison, the BT group had a outcome similar to that reported in the NPTR. Head injury was the cause of death for 26 (84%) of the 31 PT deaths and 20 (83%) of the 24 BT deaths (three of the remaining four had associated severe head injury). Only 1 of 24 (4%) BT liver injuries and 5 (21%) of 24 BT splenic injuries required surgical intervention. This low incidence of liver and splenic surgical invention is similar to that reported by other DPTCs, but for children treated at adult centers the rates are 37% to 58% and 43% to 53% for liver & splenic surgical intervention, respectively. CONCLUSION: Children with BT have a significantly better outcome at a DPTC; the outcome for children with PT does not differ. Successful nonoperative treatment of blunt abdominal injuries is more likely to occur at a DPTC than at adult trauma centers "with pediatric committment." Thus, children with blunt injuries should be taken to a DPTC, when available.

Adolescent↗

PubMed1995

The new epidemic in children: penetrating injuries.

OBJECTIVE: It is our hypothesis that there has been a dramatic increase in penetrating injuries in children. The purpose of this study is to verify this "new" epidemic in children and to note some of its characteristics. METHODS: We performed a 7-year retrospective review of the trauma registry at our urban pediatric (< 16 years of age) trauma center (UPTC). RESULTS: The percentage of admissions due to penetrating injuries at our UPTC has gradually risen over the past 7 years primarily due to gunshot wounds. In 1992 and 1993, compared to 1987 and 1988, the incidence of penetrating injuries has increased from 20 to 36% in all children and from 45 to 66% in the 12-to-15-year-old age group. CONCLUSION: Injuries due to penetrating trauma have, indeed, increased to epidemic proportions.

Adolescent↗

PubMed1994

Arteriography in the evaluation of penetrating pediatric extremity injuries.

The routine use of arteriography for evaluating penetrating extremity injuries is undergoing reevaluation in the adult literature. Its role in children is less clear. Eighty-seven children treated for penetrating extremity trauma over a 5-year period were studied retrospectively to define the usefulness of arteriography. The ages ranged from 2 to 16 years. Twenty-four arteriograms were performed. Twelve were for patients who exhibited physical signs of vascular injury (diminished pulse, distal ischemia, expanding hematoma, or bruits/thrills over the wound). The other 12 were performed on asymptomatic children with wounds in proximity to major vessels. Two other patients with ongoing hemorrhage were taken directly to the operating room. Of the 12 arteriograms performed for abnormal physical signs, eight (67%) showed vascular injuries. None of the studies performed for proximity alone had abnormal results (P < .01). Ten of 10 patients with vascular injuries had abnormal physical findings, whereas only four of 77 patients without vascular injuries had abnormal findings (sensitivity 100%, specificity 95%). Eighty-five percent of patients have had follow-up in the pediatric surgery clinic, and no missed injuries or complications have been discovered. Timely diagnosis and repair is the cornerstone for successful management of vascular injuries. While the arteriogram is an important adjunct in patients who have abnormal physical findings, proximity to major vessels alone fails to identify patients at risk for significant injuries. Angiography may not be warranted in patients whose physical examination results are normal. Noninvasive modalities such as B-mode ultrasound and Doppler may have future application in the evaluation of these cases.

Adolescent↗

PubMed1994

Surgical and genetic aspects of persistent müllerian duct syndrome.

Persistent müllerian duct syndrome (PMDS) is characterized by the presence of a uterus, cervix, and fallopian tubes in an otherwise normally differentiated 46.XY male. During embryogenesis, regression of müllerian structures in normal males is mediated by antimüllerian hormone (AMH), also called müllerian inhibiting substance (MIS), produced by fetal Sertoli's cells. PMDS has been attributed to deficient AMH activity or to abnormalities in the AMH receptor. The authors report on two patients with PMDS in whom the abnormalities were discovered during surgery for inguinal hernia and cryptorchidism. During the initial operations in each case, testicular biopsies were obtained, and the gonads and müllerian elements were replaced in the pelvis. A second operative procedure, performed several months later, included proximal salpingectomies with dissection of the vasa deferentia on pedicles of myometrium. This permitted excision of the vestigial uterine corpus, leaving a tiny remnant of cervix with the vasa deferentia. The testes were further mobilized so that bilateral orchidopexies could be completed. In the first case, a molecular abnormality was present at position 377 of the first exon of the AMH gene. Thymine replaced cytosine, which altered a CGG arginine codon to a TGG tryptophan codon, rendering the AMH molecule unstable. The molecular abnormality in the first case differs from the first abnormality in AMH reported by Knebelmann et al, thus indicating heterogeneity in this condition. The molecular basis for deficient AMH activity in the second patient has not yet been defined. No molecular abnormalities were found in the exons of this patient's AMH gene.

Anti-Mullerian Hormone↗

PubMed1993

Traumatic death in urban children, revisited.

OBJECTIVE: Trauma is the leading cause of death in children older than 1 year in the United States. We performed an analysis of the causes of death due to trauma in children in a large urban community to suggest means of prevention in such communities. We also examined data obtained before and after the designation of pediatric trauma centers to determine whether this has made a difference. DATA SOURCES: Records of the Medical Examiner, Cook County, Illinois, from 1983 through 1988. STUDY SELECTION: The admitting log was reviewed for all children before their 16th birthday. During the 6-year study period, 3121 autopsies were performed on children, 36.1% of whom died due to traumatic injuries. We reviewed the records of those children who died secondary to these injuries. DATA EXTRACTION: Record review on pediatric trauma deaths as to cause of death, time of death, age, sex, and any other pertinent information. RESULTS: Of all trauma deaths, fire was the most common cause of death, followed by motor vehicle-related injuries, homicides, drownings, and falls. These findings differ from national statistics. Improvement in outcome was seen following the designation of general trauma centers, with further improvement seen following the designation of specific pediatric trauma centers. CONCLUSIONS: Identification of causes of pediatric trauma death enables us to suggest methods of prevention. The centralized care of seriously injured children through the establishment of trauma centers and, specifically, pediatric trauma centers might help to prevent these deaths. Further study of pediatric trauma deaths, including hospital and ambulance records, is needed to improve medical care.

Accidents↗

PubMed1993

Massive osteolysis of the chest in children: an unusual cause of respiratory distress.

Massive osteolysis, also called Gorham's disease, is an uncommon disease in which bone virtually disintegrates and is replaced by vascular fibrous connective tissue. The authors treated two children with massive osteolysis of the chest. Both conditions responded well to radiation therapy; one even showed evidence of reossification. Massive osteolysis should be considered in children who have spontaneous hemothorax. The bony structures should be examined for evidence of lytic lesions.

Adolescent↗

PubMed1991

Penetrating zone-II neck injuries in children.

Over a 4-year period, 1,237 children under 16 years of age were managed at our level-I pediatric trauma center, of which 24 (1.9%) had zone-II penetrating neck injuries. Six of these 24 children (25%) were explored surgically with positive findings in four and negative findings in two neck explorations; five children (21%) underwent radiologic or endoscopic studies and were observed; 13 (54%) were observed only and did not require studies or exploration. Nonoperative observation of penetrating zone-II neck injuries is safe and the procedure of choice if active observation can be performed and the facilities for immediate operative intervention are available.

Adolescent↗

PubMed1991

One-drug versus two-drug antibiotic therapy in pediatric perforated appendicitis: a prospective randomized study.

A prospective randomized study was undertaken to compare the use of the combination of gentamicin and clindamycin with single agent, cefoxitin, in the treatment of perforated appendicitis in the pediatric patient. In a 3-year period from 1986 to 1989, 56 patients with perforated appendicitis were randomized. Twenty-nine patients received cefoxitin, and 27 patients received gentamicin and clindamycin. Antibiotics were started before operation and continued for a minimum of 6 days after operation. Skin and subcutaneous tissues were left open at surgery and closed secondarily after day 3, if they appeared to be clean. Wounds were considered infected if they developed increased purulence with positive wound cultures. Age range was similar in both groups, with a mean of 9 years (range, 1 to 17 years); 28 were boys and 28 were girls. No changes in antibiotics were required for reasons of susceptibility. No adverse drug reactions occurred in either group. The most common organisms were Escherichia coli in 35 cases (62%) and Bacteroides species in 26 cases (46%). No difference was noted in infection complications in the two groups nor in length of hospital stay. Therefore, no difference is evident in the use of cefoxitin versus gentamicin and clindamycin in the treatment of perforated appendicitis in terms of disease or drug-related complications.

Adolescent↗

PubMed1989

Ideal treatment for total colonic Hirschsprung's disease.

Five children were treated for total colonic Hirschsprung's disease between 1982 and 1986. Three girls and two boys underwent total colectomy and straight ileoanal endorectal pull-through, with creation of a suprapelvic side-to-side anastomosis of 10 cm of cecum and ascending colon to ileum (Boley procedure). All patients have been followed for periods of greater than 1 year, and they have been free of any postoperative complication. Stool frequency on an unrestricted diet has been between one and five semiformed per day. Their growth and development have been excellent. An advantage of this procedure is excellent water absorption without the risks of mechanical problems encountered with a variety of pelvic pouch creations in the young growing child.

Anal Canal↗

PubMed1989

A variant of the split notochord syndrome.

Split notochord syndrome has been described in several previous case reports; however, we recently treated a patient with a previously undescribed variant of this syndrome. A 2.5-g baby girl was admitted to the neonatal intensive care unit with a skin-covered mass on the back, and a portion of intestine, with meconium being passed, attached to it. The legs were equino varus, and the anus was anteriorly displaced. Radiographs were consistent with a lumbar split notochord, and the patient was taken to the operating room for closure. During surgery, the skin-covered mass was opened and found to contain loops of small intestine leading to an intussuscepted cecum and an open ended duplication of the cecum attached to the end of the spinal cord. The small intestinal loops exited the abdomen from a peritoneal-lined opening to the back. The loops were returned to the abdomen after releasing the duplication from the cord. The peritoneal connection was closed with a purse string suture, and the abdomen was opened. The duplication of the cecum was partially amputated and the rest was used to create a chimney-type stoma. The intraabdominal exploration was significant for nonrotation as well as a normal rectum. The postoperative course was uneventful. This case is unique because most cases of split notochord only involve a fistula to the rectum. In this case, a major part of the small bowel had herniated. Moreover, there was an open duplication similar to that found in extrophy. In approaching such a situation, it is also important to have the neurosurgeon available to provide adequate closure of the back similar to a myelomeningocele.

Abnormalities, Multiple↗

PubMed1989

The mortality of childhood falls.

Falls accounted for 5.9% of the childhood deaths due to trauma in a review of the medical examiner's files in a large urban county. Falls represented the seventh leading cause of traumatic death in all children 15 years of age or younger, but the third leading cause of death in children 1 to 4 years old. The mean age of those with accidental falls was 2.3 years, which is markedly younger than that seen in hospital admission series, suggesting that infants are much more likely to die from a fall than older children. Forty-one per cent of the deaths occurred from "minor" falls such as falls from furniture or while playing; 50% were falls from a height of one story or greater; the remainder were falls down stairs. Of children falling from less than five stories, death was due to a lethal head injury in 86%. Additionally, 61.3% of the children with head injuries had mass lesions which would have required acute neurosurgical intervention. The need for an organized pediatric trauma system is demonstrated as more than one third of the children were transferred to another hospital, with more than half of these deteriorating during the delay. Of the patients with "minor" falls, 38% had parental delay in seeking medical attention, with deterioration of all. The trauma system must also incorporate the education of parents and medical personnel to the potential lethality of "minor" falls in infants and must legislate injury prevention programs.

Accidental Falls↗

PubMed1989

Gastroschisis and omphalocele.

The etiology, presentation, and treatment of the abdominal wall defects of omphalocele and gastroschisis are discussed, based on a ten-year clinical experience in an urban medical center.

Abdominal Muscles↗

PubMed1989

Circle of Willis blood velocity and flow direction after common carotid artery ligation for neonatal extracorporeal membrane oxygenation.

The velocity and direction of blood flow in the circle of Willis arteries were measured in three infants who underwent right common carotid artery ligation for extracorporeal membrane oxygenation treatment. Within 15 minutes of common carotid artery ligation, blood flow was detected in one infant's right middle cerebral artery; however, the velocity was reduced to 50% of the preextracorporeal membrane oxygenation level. The velocity remained 50% to 70% lower than normal during the 88 hours of extracorporeal membrane oxygenation therapy. In the other two infants, the velocity changes were less severe. By 2 to 10 weeks after weaning from extracorporeal membrane oxygenation, the velocities in the left cerebral arteries were increased to 116% to 217% of the corresponding right cerebral vessels. Following common carotid artery ligation, a retrograde direction of flow was noted in the first (A1) segment of the right anterior cerebral artery and in the right posterior communicating artery, whereas the direction of flow was normal in the corresponding vessels on the left. After common carotid artery ligation, the vertebrobasilar and the contralateral internal carotid systems appear to be the main sources of reperfusion of the right cerebral hemisphere via the circle of Willis. Furthermore, because of the known variants of the circle anatomy, a noninvasive pulsed Doppler method could be used to evaluate the flow patterns in the circle of Willis arteries, both before and after common carotid artery ligation for extracorporeal membrane oxygenation.

Arteriovenous Shunt, Surgical↗

PubMed1989

Management of esophageal atresia and tracheoesophageal fistula.

We can draw several conclusions from an analysis of our series: 1. Although prematurity remains to be an important factor in the survival of infants with major surgical or medical disease, the more important risk factor in esophageal atresia and tracheoesophageal fistula concerns: a. Severity of associated anomalies that are uncorrectable and fatal b. Associated complication from the disease or surgery (especially in infants less than 1500 gm). Complications such as tracheal perforation and gastric perforation are not tolerated well and can be fatal (the case in two of our patients). 2. Premature infants weighing even less than 1500 gm tolerate a major thoracotomy well with correction of an esophageal anomaly. In this series, the smallest weighed 1220 gm. This infant had an uneventful recovery with a good outcome. 3. Simultaneous correction of associated anomalies also is well tolerated by these patients. Judgment, however, should be exercised as to the extent and length of operative procedures performed. 4. Staged reconstruction is still an excellent alternative when one is dealing with a premature infant with concomitant surgical procedures, although lengthening operations with primary anastomosis for the most part have replaced the need for staging esophageal reconstruction. 5. Radiographs indicating a high upper pouch lesion also require bronchoscopic identification of the fistula prior to operative intervention to provide a guide to the proper surgical approach to the lesion. 6. Acute anastomotic leaks should be treated aggressively by antibiotics and immediate thoracotomy, with cervical esophagostomy, closure of the distal esophagus, drainage of the mediastinum, and gastrostomy placement. immediate intervention will result in better survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Esophageal Atresia↗

PubMed1989

Neonatal intestinal obstruction.

Our experience in the management of 138 infants with various causes of intestinal obstruction has provided us with important principles of diagnosis and treatments that we adhere to in the course of our practice. 1. The overall mortality of neonates suffering from intestinal obstruction should be fewer than 5 per cent. The high survival rate is accounted for by improved care these patients receive in specialized units. 2. Prematurity did not appear to play a significant factor in the outcome of these infants with intestinal obstruction. Our experience shows that premature infants tolerate operative procedures well, even in those instances in which an associated surgically correctable lesion is simultaneously repaired. 3. The major risk factor in any neonate with intestinal obstruction is the delay in diagnosis and operative intervention, especially in infants diagnosed to have midgut volvulus. The additional second risk factor is the association of chromosome abnormality. 4. Traditional diagnostic studies such as plain films of the abdomen supplemented by either an upper GI or lower GI contrast study for specific indications have been very effective in obtaining an accurate diagnosis of intestinal bowel obstruction. 5. Hirschsprung's disease can be diagnosed in the neonatal period if the index of suspicion for this is high. 6. Special surgical techniques as described should be used whenever indicated to minimize morbidity. 7. The traditional Wangensteen-Rice evaluation of a patient with imperforate anus is accurate, and specialized studies should be deferred for the postoperative period. Collaborative care provided by the neonatologist, pediatric anesthesiologist, and pediatric surgeon for these patients is the key to a favorable outcome.

Abnormalities, Multiple↗

PubMed1987

Falls in urban children. A problem revisited.

Falls in urban setting are a common cause for emergency room visits in children and adolescents. In a retrospective review, the charts of 48 patients admitted between 1980 and 1985 with a history of a vertical fall from a height were examined. In comparison, a previous review from the same institution disclosed that 66 patients were admitted because of a vertical fall from a height between 1965 and 1974, suggesting an increase of 37.5%. Most children fell from heights of 12 ft or less, although an increasing proportion of children in our series (33%) fell from heights of 36 ft or less. Sites included windows, walls, and roofs. The peak age of incidence has increased from 2 to 6 years; however, the mean age of children in whom significant injury occurred was 7.5 years, with only 27% of children under 3 years of age suffering a documented injury, as opposed to 67% of children over 3 years of age. Children are more apt to suffer a fracture than any other injury, most likely a fracture of the ulna and/or radius. Although hospital costs are high, mortality rates (2%) and the incidence of long-term sequelae (4%) are low. In conclusion, falls in the urban setting continue to be a significant public health problem, particularly in the 6- to 7-year age group.

Accidental Falls↗

PubMed1987

Transduodenal feedings: a superior route of enteral nutrition.

Our recent study comparing gastric with jejunal feedings in neonatal piglets demonstrated better weight gain, less diarrhea, and less fat malabsorption in animals fed gastrically. These differences were postulated to be due either to loss of duodenal osmoregulation and absorption, and/or to loss of the combined effects of salivary enzymes, gastric emptying, and gastric secretions on jejunal feedings. The objective of this investigation was to determine the relative contributions of gastric and duodenal function to the differences between gastric and jejunal feedings. Seven piglets (3 to 5 days old, 1.5 to 2.0 kg) underwent operative transgastric insertion of a duodenostomy tube placed just distal to the pylorus. Intravenous fluids and antibiotics were administered for two days postoperatively, then Premature Enfamil Formula (24 kcal/oz; Mead Johnson, Evansville, IN) was administered continuously through the feeding tube. The animals were maintained on 115 kcal/kg/d as in the previous study. Weight, fecal fat analysis, and stool characteristics were determined throughout the 2-week period. The resulting data were compared with data from our previous study comparing gastric with jejunal feedings. These data suggest the vital importance of gastroduodenal contributions of absorption, osmoregulation, and regulation of nutrient concentrations in improving the nutritional status of experimental animals. Duodenal feedings may be preferred to either gastric or jejunal feedings because they provide equivalent nutritional support without the gastroesophageal reflux and aspiration reported with gastric feedings in the neonatal population.

Animals↗