Biomedical subjects
Publications and source records attributed to M A Hoffman.
Packing the abdomen can be lifesaving when severe hepatic trauma is complicated by refractory hypothermia, coagulopathy, and continuing hemorrhage requiring large-volume transfusion. This report describes the successful use of abdominal packs and a modified silo in a child following blunt liver injury.
This short-term longitudinal study assessed the degree to which the frequency of fathers' visits with their preterm infants in the hospital was associated with the quality of ongoing and long-term fathering and infant development. Data on fathering and infant development were collected during the hospital stay, at discharge, at 8 months of age, and at 18 months of age, using both questionnaires and observational schedules. The frequency of visits was significantly correlated with more extensive and positive patterns of fathering at discharge and later periods. It was also associated with more positive perceptions of the infant, as well as with weight gain during hospitalization and psychosocial aspects of later infant development during the first 18 months. The discussion emphasized possible ways in which early paternal contact in the hospital might influence fathers, mothers, and infants. The frequency of paternal visits was high-lighted as a variable useful in predicting high-risk parenting.
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Biliary atresia is the most common indication for liver transplantation in infants and children, despite the advent of the Kasai operation. Coexisting anomalies, which have been noted in up to 27% of patients with biliary atresia, may form an association known as the "polysplenia syndrome," which includes (1) polysplenia, (2) midgut malrotation, (3) preduodenal portal vein, (4) absent prerenal inferior vena cava with azygos continuation, (5) situs inversus, (6) symmetric liver, (7) hepatic arterial anomalies, and (8) bilobed right lung with hyparterial bronchus. Two of 31 patients undergoing orthotopic liver transplantation for biliary atresia following failed portoenterostomy over the past 11 years manifested the polysplenia syndrome with absent prerenal inferior vena cava. The clinical course of these patients, constellation of anomalies, and technical adjustments required to perform liver transplantation are described. We do not believe that these complex congenital anomalies preclude liver transplantation.
The combined anomalies of pulmonary agenesis with esophageal atresia and distal tracheoesopahgeal fistula are an exceedingly rare and highly lethal association. The longest survivor in the literature is 10 months. We describe two neonates with this association who underwent primary repair shortly after birth and who are alive and well at 24 and 18 months. One of these neonates also demonstrated duodenal atresia. The prime goal in the management of these patients is early protection and preservation of respiratory units. This goal is best accomplished by primary repair of the tracheoesophageal lesion, when feasible, rather than by more complex procedures.
Over a 20-month period, we prospectively studied 41 children with blunt thoracic trauma (BTT) to determine the incidence and morbidity of cardiac injury in this population. Four patients died, and the data were incomplete in 10, leaving 27 for analysis. Serial electrocardiograms (ECG) were abnormal in 36% of the patients studied, serial creatine phosphokinase isoenzyme (CK-MB) ratios were elevated in 31%, echocardiogram showed septal dysfunction in 14%, and pyrophosphate scan showed grade 1 uptake in 14%. There was poor correlation among tests, since only four patients had more than one abnormal test. There was no significant difference in Injury Severity Score or Thoracic Abbreviated Injury Scale between patients with and without abnormal investigations. No patient in the study developed arrhythmias or cardiac failure. In 13 trauma-related deaths undergoing autopsy over the same period, including the four with thoracic trauma, none had evidence of cardiac injury. These results indicate a striking lack of consistency in the diagnosis of posttraumatic cardiac injury in children using standard investigations. The absence of adverse cardiac events in surviving patients and the lack of autopsy evidence of cardiac injury in the trauma deaths suggest that the actual incidence and clinical significance of these lesions in children is lower than generally reported. Children with BTT should be followed clinically, and reliance on screening tests should be avoided.
A 14-year-old boy sustained severe blunt, multisystem trauma. On presentation, vital signs were present but disappeared despite maximal resuscitation. Emergency department thoracotomy (EDT) resulted in return of vital signs and transfer to the operating room for a definitive procedure. Ultimately, the child survived with normal neurologic function and quality of life. This case illustrates the potential value of EDT in selected patients who present with detectable vital signs and deteriorate in the face of maximal conventional therapy.
A technique of central venous line (CVL) placement using ECG guidance is described. The method utilizes equipment found in most operating room departments, is easily learned and taught, and obviates the need for x-rays. CVL placement in 50 consecutive infants and children was performed over a 4-month period by the ECG-guided method, with catheter tip position subsequently determined by x-ray study. The technique demonstrated a 96% success and 100% accuracy rate. The two technical failures were both preventable. Equipment malfunction was responsible for one failure. The second failure was secondary to a preexisting supraventricular arrhythmia, and patients with arrhythmias or pacemakers are not suitable candidates for this technique of central venous catheterization. Radiologic methods of CVL placement were necessary in these two patients.
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Louis H. Bauer, M.D., 1888-1964, founded the Aero Medical Association of the United States, which has become the Aerospace Medical Association. He founded the Association's journal and was its editor for 25 years. The accompanying short article highlights some of his accomplishments.
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Unilateral agenesis of ribs with a "lung hernia," may cause severe respiratory distress in a neonate. Our experience with the use of a temporary external chest splint for stabilization of the congenital flail chest in one patient is presented. The device facilitated extubation and allowed the infant to grow prior to future surgical reconstruction.
Injury patterns and use of passenger restraints were studied in 91 children injured while riding in motor vehicles and admitted to The Hospital for Sick Children, Toronto, from June 1984 through December 1985. Of theses, 44 had used restraints and 38 had not. Nine were excluded from the study because restraint use could not be determined. Age and sex distributions were closely matched in both study groups. The no-restraint group had more massive head injuries, thoracic injuries, and liver and spleen injuries than the restraint group. Classic "seatbelt syndrome" injuries were seen in the seatbelt group. The overall Injury Severity Scores were not significantly different between the groups. Despite mandatory legislation, many children do not use restraints, and many who do still suffer severe or fatal injuries. We conclude that better compliance with existing passenger restraint laws and more effective restraint systems are needed.
In patients who present with TIA, RIND, or CVA, the cranial CT scan can rule out other etiologies for neurologic symptoms. In addition to the clinical presentation, the CT scan allows further stratification of patients being considered for carotid endarterectomy. We propose that patients be classified as TIA (+), TIA (-), RIND (+), or CVA (-). The CT scan has defined a new subgroup of patients, TIA (+) and RIND (+)--the Silent Cerebral Infarction. Patients who are categorized as TIA (+), RIND (+), and CVA (+) (cerebral infarction on CT or by history) are at increased risk for intraoperative ischemia and postoperative neurologic deficit. As such, they should be selectively shunted based on intraoperative EEG monitoring or routinely shunted. There is a strong association between ulcerative plaque at the carotid bifurcation and cerebral infarction on CT. The CT scan is a critical diagnostic procedure in evaluating the patient with an acute neurologic event. Patients with negative CT scans are candidates for early operation. Carotid endarterectomy should generally be delayed for 4 to 6 weeks in patients with positive CT scans.
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A bacterial lipopolysaccharide (LPS) extracted from a rough strain of Salmonella minnesota ( Re595 ) containing primarily lipid A was used to study tissue distribution following its intravenous injection in rabbits. For this purpose, the Re595 was either labelled with 125iodine (125I) and localization quantitated by gamma radiation spectrometry and radioautography of different tissues or a fluorescein labelled antibody to Re595 was employed. Localization of [125I]- Re595 or LPS was looked for at 30 min and 2 hr after intravenous injection. [131I]-albumin was employed either to measure intravascular protein or total tissue protein and, in some studies, [131I]-albumin and [125I]-fibrinogen were used to measure protein after unlabelled Re595 . Both fractions of isotopes injected and estimates of tissue-bound Re595 were made in the whole eye, liver, spleen, kidney and lung and in isolated iris-ciliary processes, aqueous, lens, vitreous, and posterior segment (retina, choroid, and sclera). Aqueous and iris-ciliary processes, but no other tissues, showed a marked extravazation of [131I]-albumin and [125I]-fibrinogen. [125I]- Re595 was found to localize primarily in liver and spleen. At 30 min, [125I]- Re595 was found in nanogram quantities within the eye and at 2 h greater amounts of LPS were found in iris-ciliary processes and aqueous than in the posterior segment. Neither radioautography nor fluorescein-labelled antibody to Re595 showed evidence of histologic localization of LPS in the iris-ciliary processes. These results indicate that although LPS does not localize preferentially in the eye, it does accumulate in quantities sufficient to have an effect locally.
Antibodies specific to thymic tissue were detected in normal human serum by means of an indirect immunofluorescent technique. Approximately 50-88% of the total sera (33) showed positive staining, which was confined to the medullary zone primarily associated with the surface membranes of epithelial cells including Hassall's corpuscles. These observations point to the recognition by the immune-self of antigen(s) of the thymic epithelium in health, and presumably in disease.