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Joseph H Piatt

Publications and source records attributed to Joseph H Piatt.

At least 19 recordsLinked to original sources
PubMed2006

Intrathecal baclofen overdose and withdrawal.

Intrathecal baclofen (ITB) therapy is being used increasingly to treat medically intractable spasticity in children with cerebral palsy and spinal cord injuries. Baclofen overdose and withdrawal are potentially life-threatening complications of pump and spinal catheter system malfunction. We report a case of a 12-year-old boy, on long-term ITB therapy, who presents to our emergency department with an overdose of ITB, which is followed by withdrawal symptoms. The patient initially presented obtunded and in respiratory arrest. His symptoms of respiratory arrest, obtundation, fixed pupils, and hypotension mimicked other diagnoses, such as head trauma. The history obtained from the family about the pump reservoir being refilled just before the onset of symptoms led to the diagnosis. During hospitalization, as the patient recovered from the overdose, he began to experience symptoms of baclofen withdrawal, including hypertension, hyperthermia, and hallucinations. The pump was found to be disconnected and was revised. The patient was discharged home without permanent sequelae. With increased use of ITB, emergency medicine physicians must be aware of the mechanics of these pumps and the management of baclofen toxicity and withdrawal.

Baclofen↗
PubMed2006

Application of computer-assisted design in craniofacial reconstructive surgery using a commercial image guidance system. Technical note.

The technology of digital image guidance systems has transformed many aspects of neurosurgery, including intracranial tumor surgery, functional neurosurgery, and spinal surgery. Despite the central role of imaging studies in diagnosis and treatment planning, intraoperative image guidance has so far had very limited application to the surgical correction of craniofacial deformities, particularly those associated with craniosynostosis. The authors report an example of the marriage of computer-assisted design methods to a commercially available neurosurgical image-guidance system in the treatment of a case of anterior plagiocephaly due to unilateral coronal synostosis. They discuss the steps that must yet be taken to make this technology applicable to the management of craniosynostosis in infants.

Child↗
PubMed2006

Dorsal rhizotomy.

Explore the source record for details and available documents.

Cerebral Palsy↗
PubMed2006

Detected and overlooked cervical spine injury in comatose victims of trauma: report from the Pennsylvania Trauma Outcomes Study.

OBJECT: This study was undertaken to determine whether a clinically useful rule could be formulated for identifying the presence of traumatic brain injury (TBI) in patients who are at exceptionally low risk of cervical spine injury. METHODS: The Pennsylvania Trauma Outcomes Study database was searched for cases of TBI in which the admission Glasgow Coma Scale (GCS) score was less than or equal to 8. Cases of cervical injury were identified based on diagnostic codes. Associations between cervical injury and various clinical variables were tested using chi-square analysis. The probability of cervical injury was modeled using logistic regression. Decision tree models were constructed. Statistical determinants of overlooked cervical injury were examined. The prevalence of cervical injury among 41,142 cases of TBI was 8%. Mechanism of injury, thoracolumbosacral (TLS) fracture, age, limb fracture, admission GCS score, hypotension, and facial fracture were associated with cervical injury and were incorporated into the following logistic regression model: probability = 1/(1 + exp[4.248 - 0.417 X mechanism -0.264 X age - 0.678 X TLS - 0.299 X limb - 0.218 X GCS - 0.231 X hypotension - 0.157 X facial]). The results of applying this model provided a rule for cervical spine clearance applicable to 28% of the cases with a negative predictive value (NPV) of 97.0%. Decision tree analysis yielded a rule applicable to 24% of the cases with an NPV of 98.2%. The prevalence of overlooked cervical injury in all individuals with severe TBI was 0.3%; the prevalence of overlooked cervical injury in patients with cervical injury was 3.9%. Overlooked cervical injury was less common in patients with associated TLS fractures (odds ratio 0.453, 95% confidence interval 0.245-0.837). CONCLUSIONS: This analysis identified no acceptable rule to justify relaxing vigilance in the search for cervical injury in patients with severe TBI. Provider vigilance and consequent rates of overlooked cervical injury can be affected by environmental cues and presumably by other behavioral and organizational factors.

Adolescent↗
PubMed2005

Detected and overlooked cervical spine injury among comatose trauma patients: from the Pennsylvania Trauma Outcomes Study.

OBJECT: A rule for identifying patients with traumatic brain injury (TBI) who are at exceptionally low risk of cervical spine injury might be clinically useful. The goal in this study was to research case records to determine whether such a rule would be practicable. METHODS: The Pennsylvania Trauma Outcomes Study database was used to find patients with TBI in whom Glasgow Coma Scale (GCS) scores at admission were 8 or less. Cases of cervical spine injury were identified from diagnostic codes. Associations between these injuries and a variety of clinical variables were tested using chi-square analysis. The probability of a cervical spine injury in these patients was modeled by logistic regression. Decision tree models were constructed and statistical determinants of overlooked cervical spine injury were examined. The prevalence of cervical spine injury among 41,142 cases of TBI was 8%. The mechanism of injury, presence of thoracolumbosacral (TLS) spinal, limb and/or facial fracture, patient age, GCS score at admission, and the presence of hypotension were all factors associated with cervical spine injury. These were incorporated into the following logistic regression model: probability of cervical spine injury = 1/(1 + exp[4.030 - 0.417*mechanism - 0.264*age - 0.678*TLS - 0.299*limb + 0.218*GCS score - 0.231*hypotension - 0.157*facial]). This model yielded a rule for clearance of 28% of cases, with a negative predictive value (NPV) of 97%. Decision tree analysis yielded an easily stated rule for clearance of 24% of cases, with an NPV of 98.2%. The prevalence of overlooked cervical spine injury among all patients with severe TBI was 0.3%; the prevalence of overlooked cervical spine injury among patients in whom it was later diagnosed was 3.9%. Overlooked cervical spine injury was less common among patients with associated TLS fractures (odds ratio 0.453, 95% confidence interval 0.245-0.837). CONCLUSIONS: No acceptable rule for relaxation of vigilance in the search for cervical spine injury among patients with severe TBI has been identified. Levels of provider vigilance and consequent rates of overlooked cervical spine injury can be affected by environmental cues and presumably by other behavioral and organizational factors.

Adolescent↗
PubMed2005

Birth injuries of the brachial plexus.

Birth injuries of the brachial plexus are fairly common, but the majority of affected newborns make quick recoveries without any specific intervention. A minority suffer more severe injuries that lead to varying degrees of life-long disability. Happily, modern microsurgical techniques permit reconstruction of certain plexus injuries and, in carefully selected patients, can restore voluntary activity to target muscle groups. To what degree reanimation of paralyzed muscles improves function and quality of life for these children is a more important matter that has not yet been addressed at the level of modern standards of evidence. Brachial plexus reconstruction is only a first step in the multidisciplinary process needed to optimize long-term functional outcomes for severely affected infants.

Birth Injuries↗
PubMed2005

Intrathecal baclofen overdose followed by withdrawal: clinical and EEG features.

Intrathecal baclofen therapy is increasingly used to alleviate medically intractable spasticity in children with cerebral palsy, spinal cord injuries, and generalized dystonia. Complications like overdose or withdrawal can occur and could be the result of pump malfunction (device-related) or refilling and programming mistakes (human errors). This report describes a case, with emphasis on electroencephalographic changes, of a 12-year old male on long-term intrathecal baclofen therapy who had sequential occurrence of both acute inadvertent baclofen overdose followed by withdrawal symptoms. During baclofen intoxication, electroencephalography documented periodic generalized epileptiform discharges, occasionally followed by intermittent electro-decremental responses on a background of diffuse delta slowing (1-2 Hz). During withdrawal, mild generalized slowing during wakefulness was observed along with the appearance of high-amplitude, sharply contoured delta activity resembling frontal intermittent rhythmic delta activity in sleep. To our knowledge, this temporal profile of electroencephalographic features during baclofen intoxication followed by withdrawal has not been described before in pediatric patients. It is important for treating physicians to recognize the evolution of this electroencephalographic pattern in order to avoid misinterpretation of diagnosis and prognosis.

Baclofen↗
PubMed2005

Progressive syringomyelia controlled by treatment of associated hydrocephalus in an infant with birth injury. Case report.

The author's aim in reporting this case is to extend awareness of the importance of management of associated hydrocephalus among patients with syringomyelia to the posttraumatic state. A full-term infant was delivered by cesarean section because of transverse lie. In the 2nd week of life, hypotonia affecting the lower limbs and the left upper limb was recognized. On MR imaging, posterior fossa subdural hemorrhage and spinal cord injury at the T-1 and T-2 levels were evident. Sequential imaging studies demonstrated progressive myelomalacic changes in the cervical spinal cord and eventual development of syrinx cavities as far cephalad as C-3. Hydrocephalus developed simultaneously as well. A ventriculoperitoneal cerebrospinal fluid shunt was inserted at 22 months of age. Six months after shunt insertion, MR imaging demonstrated regression of the posttraumatic syringomyelia. The patient was stable from an imaging standpoint at 16 months after shunt insertion, and she has continued to make developmental progress. The importance of treatment of associated hydrocephalus is widely recognized in the management of syringomyelia associated with the Chiari malformations. It should be considered in the management of posttraumatic syringomyelia as well.

Birth Injuries↗
PubMed2004

Selective dorsal rhizotomy versus orthopedic surgery: a multidimensional assessment of outcome efficacy.

OBJECTIVE: To compare the efficacy of selective dorsal rhizotomy (SDR) and orthopedic surgery using multidimensional (National Center for Medical Rehabilitation Research disablement framework) outcome measures. DESIGN: Prospective outcome study. SETTING: Pediatric orthopedic hospital. PARTICIPANTS: Twenty-five children with spastic diplegia. Eighteen participants (mean age, 71.3 mo) chose SDR. Seven participants (mean age, 78.6 mo) chose orthopedic surgery. INTERVENTIONS: Children were evaluated 2 days before surgical intervention and at 6 months, 1 year, and 2 years postsurgically. MAIN OUTCOME MEASURES: The Gross Motor Performance Measure, the Gross Motor Function Measure, and the Pediatric Evaluation of Disability Inventory. RESULTS: The SDR group improved significantly in quality of movement attributes 6 months postsurgically; however, gross motor skills (standing; walking, running, and jumping) gains were seen 2 years postsurgically. The orthopedic group improved significantly in select quality of movement attributes 6 months postsurgically and in standing skills within the first postsurgical year. Self-care skills, mobility, and social function gains were seen earlier and with greater frequency in the SDR group. CONCLUSIONS: Both surgical interventions demonstrated multidimensional benefits for ambulatory children with spastic diplegia. The results suggest that qualitative changes in movement, achieved by spasticity reduction, have a greater effect on the enhancement of functional skill proficiency, thus independence, than recognized.

Cerebral Palsy↗
PubMed2004

Hydrocephalus.

Hydrocephalus is not an exotic condition in general pediatric practice. A general pediatrician might expect to serve two to five children with CSF shunts. This article reviews posthemorrhagic hydrocephalus in detail.

Cerebrospinal Fluid Shunts↗
PubMed2004

Birth injuries of the brachial plexus.

Birth injuries of the brachial plexus are fairly common, but most affected newborns make quick recoveries without any specific intervention. A minority suffer more severe injuries that lead to varying degrees of life-long disability. Modem microsurgical techniques permit reconstruction of certain plexus injuries and, in carefully selected patients, can restore voluntary activity to target muscle groups. The degree to which reanimation of paralyzed muscles improves function and quality of life for these children is a more important matter that has not yet been addressed using modern standards of evidence. Brachial plexus reconstruction is only a first step in the multidisciplinary process needed to optimize long-term functional outcomes for severely affected infants.

Birth Injuries↗
PubMed2004

Recognizing neurosurgical conditions in the pediatrician's office.

Clinical problems with potential neurosurgical ramifications, such as headache and abnormalities of head size and shape, arise often in general pediatric practice. Other neurosurgical issues may manifest themselves less frequently and more insidiously. In either case the pediatrician who is alert to spectrum of the presentations of neurosurgical conditions will direct investigations and referrals efficiently and inspire the confidence of the patient and the family.

Brain Diseases↗
PubMed2004

Unexpected findings on brain and spine imaging in children.

In the office practice of pediatrics, the clinical threshold for order-ing imaging studies of the brain and spine has fallen in recent years, and requests have multiplied for consultation .o assess the meaning of unexpected imaging findings. Familiarity with the most common entities that precipitate such requests allows the pediatrician to allay parental anxieties with informed preliminary counseling and to set appropriate priorities for subsequent referrals and investigations.

Arachnoid Cysts↗
PubMed2004

A 2-year follow-up of outcomes following orthopedic surgery or selective dorsal rhizotomy in children with spastic diplegia.

The purpose of this study was to prospectively compare the effect of orthopedic surgery (OS) and selective dorsal rhizotomy (SDR) on muscle tone, range of motion, gait and energy efficiency in ambulatory children with spastic diplegia. Twenty-five children with a diagnosis of spastic diplegia, with a mean age of 73 months, were evaluated prior to surgery and 1 and 2 years postoperatively; however, only the preoperative and 2-year postoperative data are reported here. Eighteen children received SDR and seven received OS. Children were evaluated with the Ashworth scale for muscle tone, passive range of motion (PROM), gait analysis and oxygen consumption for energy cost. Significant improvements were seen in PROM, muscle tone, gait kinematics and oxygen cost regardless of surgical intervention. Although OS and SDR interventions influence motor function through different mechanisms, the gait and energy outcomes 2 years following OS or SDR are similar.

Cerebral Palsy↗
PubMed2004

Syringomyelia complicating myelomeningocele: review of the evidence.

Syringomyelia is frequently found in association with myelomeningocele. Although often asymptomatic, it can, in exceptional cases, cause severe morbidity. The author performed a structured literature review to address the following aspects of this clinical problem. What is the natural history? There are data concerning the imaging prevalence, the autopsy prevalence, and the prevalence of clinically active syringomyelia among patients with myelomeningocele, but literature provides no description of the course of this condition over time. What is the clinical significance? That correlations among symptoms, signs, treatments, and imaging findings are poorly described is no surprise in view of the large fraction of patients with syringomyelia who are asymptomatic. There is, however, an impressive mass of anecdotal evidence associating progressive syringomyelia with untreated (or inadequately treated) hydrocephalus. How to make the diagnosis? There is no disagreement that magnetic resonance imaging is the diagnostic modality of choice, but the literature provides very little guidance about who should undergo this investigation. There is no analysis of the costs and benefits of screening or periodic surveillance. What is the best treatment? Many surgical procedures have been reported to be useful as components of complex algorithms relating clinical factors and imaging data to treatment recommendations. There have been no controlled studies. There have been no prospective studies. There have been no multiinstitutional studies. No studies in which outcomes have been evaluated using objective, validated instruments. No studies in which the robustness of treatment effects over time have been documented. The complexity of treatment selection in contemporary practice makes syringomyelia unsuitable for randomized controlled trials of different therapies. Prospective cohort studies are feasible, however, and hold the potential to address many important questions about natural history and patient outcomes.

Adolescent↗