Biomedical subjects

Marion C W Henry

Publications and source records attributed to Marion C W Henry.

10 recordsLinked to original sources

PubMed2007

Matched analysis of nonoperative management vs immediate appendectomy for perforated appendicitis.

BACKGROUND: The role of nonoperative therapy vs immediate appendectomy in the management of children with perforated appendicitis remains undefined. The objective of this study was to rigorously compare these management options in groups of patients with matched clinical characteristics. METHODS: Multicenter case-control study was conducted from 1998 to 2003. We compared patients treated nonoperatively vs those undergoing appendectomy to identify differences in 12 clinical parameters. We then generated a second control group of patients matched for these variables and compared the following outcomes in these clinically similar groups: complication rate, abscess rate, and length of stay (LOS). Analysis was performed according to intention-to-treat principles, using chi2, Fisher exact, and Student t tests. RESULTS: The only significant difference between patients treated nonoperatively and those treated by appendectomy was the duration of pain on presentation (6.8 vs 3.1 days of pain). We created a second control group of patients undergoing immediate appendectomy matched on duration of pain on presentation to patients treated nonoperatively. These groups continued to be clinically comparable for the other 11 parameters. Compared to this matched control group, the nonoperative group had fewer complications (19% vs 43%, P < .01), fewer abscesses (4% vs 24%, P < .01), and a trend for shorter LOS (6.5 +/- 5.7 vs 8.8 +/- 6.7 days, P = .08). CONCLUSIONS: When nonoperative management for perforated appendicitis was studied using appropriately matched clinical controls, we found that it resulted in a lower complication rate and shorter LOS in the subset of patients presenting with a long duration of pain. Our data suggest that nonoperative management should be prospectively evaluated in children with perforated appendicitis presenting with a history of pain exceeding 5 days.

Adolescent↗

PubMed2006

The appendix sign: a radiographic marker for irreducible intussusception.

PURPOSE: Radiographic reduction (hydrostatic or pneumatic) of intussusception has become the standard of care in the pediatric population with success rates of more than 80%. Identification of those patients who are likely to fail nonoperative management could lead to earlier operation, a reduction in radiation exposure, and a decreased risk for complications after repeated attempts at enema reduction. During successful radiographic reduction, the small bowel is almost always visualized before the appendix. Visualization of the appendix before visualization of the small bowel during a successful reduction of an intussusception is a rare event. We report a new radiographic sign that we have termed the appendix sign (radiographic visualization of the appendix without reflux of air or contrast into the small intestine), which we hypothesize may have association with failure of nonoperative management. METHOD: We performed a retrospective review of the last 12 years of irreducible intussusception. The associated studies were then reviewed to examine the incidence, sensitivity, and specificity of this radiographic finding. RESULTS: Ninety-one cases of intussusception were identified and had films available for review. Seventy-seven (76%) of the studies included the appropriate image. The appendix sign was visualized in 14 studies for an incidence of 18%. Of 14 patients, 10 failed enema reduction (positive predictive value, 71%). The sensitivity of the appendix sign is 43%. The specificity of the sign is 93%. CONCLUSIONS: Our experience suggests that the presence of an appendix sign is associated with failing enema reduction of an intussusception and may be useful as a marker for determining the end point for further attempts at radiographic reduction.

Appendix↗

PubMed2005

Primary versus delayed wound closure in complicated appendicitis: an international systematic review and meta-analysis.

The purpose of this study was to determine, by means of a systematic review, whether the method of wound closure in complicated appendicitis affects the incidence of wound infection. A comprehensive literature search of multiple databases including MEDLINE (1980-2003), was performed, using the Cochrane search strategy, for articles on wound closure and complicated appendicitis. Clinical trials examining the method of wound closure were selected for systematic review and all quasi-randomized and randomized trials underwent meta-analysis. Failure to close the wound as planned in delayed closure (DC) was considered indicative of a wound infection. Purulent drainage requiring wound opening indicated an infection in the wounds closed primarily. Six randomized trials were considered adequate for meta-analysis. None independently showed a statistically significant difference in the risk of developing a wound infection with primary closure (PC). When pooled data were subjected to meta-analysis, PC achieved a statistically significant reduction in the relative risk of treatment failure and did not lead to an increase in wound infections. Primary closure does not increase the risk of developing a wound infection after operation for perforated appendicitis. Given the lack of benefit of DC, and the less traumatic, less painful, and less costly nature of PC; primary closure is a safe and practical treatment option.

Appendicitis↗

PubMed2005

The impact of the 80-hour workweek on pediatric surgical training: an Association of Pediatric Surgery Program Directors-sponsored study.

BACKGROUND/PURPOSE: The aim of this study was to determine the preliminary impact of work hour regulations on pediatric surgical training. METHODS: An anonymous survey was sent to all program directors (PDs) and fellows to identify changes in pediatric surgery fellowship programs. RESULTS: Ninety-three percent of programs and 87% of PDs responded. Thirty programs hired additional personnel, including nurse practitioners, physician assistants, and fellows outside the training program. Thirteen programs reported increased attending coverage. The daily composition of the surgical team has changed, with postcall fellows and residents leaving in the morning. Residents and fellows also take call less frequently. More than 50% of PDs felt that quality of care had declined and three quarters of respondents felt that continuity of care was worse. Half of the respondents feared missed educational opportunities. However, half of the fellows felt more rested, 61% reported more family time, and 22% reported increased social time. In contrast, no PDs perceived life-style improvements. CONCLUSIONS: The work hour regulations have resulted in fundamental changes in pediatric surgical training. Ongoing assessment is needed to prioritize quality of care, improve continuity of care, and track changes in operative, clinical, and didactic experiences of the trainees. The added impact of these changes on the time spent available for commitment to teaching by the faculty should be assessed.

Attitude of Health Personnel↗

PubMed2005

Postoperative paraplegia secondary to the use of oxidized cellulose (Surgicel).

Iatrogenic paraplegia after thoracic surgery is a devastating complication. In this report, the authors present a case of paraplegia in a toddler after the resection of a mediastinal neuroblastoma. In this case, the paraplegia was caused by spinal cord compression after migration of oxidized cellulose into the spinal canal.

Cellulose, Oxidized↗

PubMed2005

Surgical therapy for necrotizing enterocolitis: bringing evidence to the bedside.

Necrotizing enterocolitis is the most common surgical emergency in the neonatal intensive care unit. Despite decades of research that have led to a growing knowledge base about this disease, NEC continues to challenge the pediatric surgeon. In this review, we will examine the development of surgical therapy for NEC in the context of the supportive evidence, or lack thereof, for treatment approaches. We will discuss issues of indications for surgical intervention, primary peritoneal drainage versus laparotomy, enterostomy versus primary anastamosis and issues surrounding NEC totalis.

Anastomosis, Surgical↗

PubMed2005

Neuroblastoma update.

PURPOSE OF REVIEW: The purpose of this paper is to review the most recent medical literature pertaining to neuroblastoma. Clinically, progress continues to be made on the refinement of radiographic staging and risk stratification-based treatment. RECENT FINDINGS: Meanwhile, experimental efforts focus on the continued search for biologic prognostic markers and the development of novel therapies including second-generation retinoids, tumor vaccines, and new modes of drug delivery with improved safety and efficacy. SUMMARY: Review of the recent neuroblastoma literature demonstrates continued progress in our ability to understand and treat this enigmatic tumor.

Biomarkers, Tumor↗

PubMed2004

Current issues in the management of necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) is the most common surgical emergency in the neonatal intensive care unit and remains a major cause of death in neonates. Although the pathophysiology of NEC has not been completely elucidated, progress has been made in the characterization of the molecular events which may take place during an episode of ischemia. This possible initiating event is followed by a complex cascade of inflammatory mediators active in NEC: epidermal growth factor, platelet-activating factor, and, nitric oxide. Additionally, unique characteristics of the premature gut are thought to be crucial to the development of NEC. The diagnosis of NEC continues to be based on clinical and radiographic features. Several new laboratory tests are under investigation for the purposes of earlier diagnosis, but none have prevailed at this time. Both exploratory laparotomy, with intestinal resection and peritoneal drainage are widely practiced. Mortality rates remain high and have improved little over the last couple of decades. Therefore, prevention remains crucial in order to decrease the incidence of NEC. Cautious feeding regimens, the use of maternal breast milk, passive immunization, and the use of probiotics have all been suggested but not proven as possible preventive methods. Although many advances have been made, significant opportunity remains to improve our understanding of the disease process and to develop better strategies for prevention and treatment.

Enterocolitis, Necrotizing↗

PubMed2003

Critical analysis of clinical research reporting in pediatric surgery: justifying the need for a new standard.

BACKGROUND/PURPOSE: Clinical practice in surgery relies heavily on observational data in which accurate and nonbiased reporting is critical. This study aims to assess the adequacy of clinical research reporting in pediatric surgery and to develop a means to raise the standard of such reporting. METHODS: The authors analyzed all observational studies published in The Journal of Pediatric Surgery from 1997 to 2002 (n = 300). Studies were assessed for 16 baseline criteria essential for the nonbiased reporting of clinical data (details regarding surgeons, cases, interventions, and statistical methods). Seven additional criteria pertaining to comparison methods were assessed in studies using controls. RESULTS: Ninety-five percent of all studies were retrospective, and only 25% utilized a control group. Most studies met less than half of the essential reporting criteria (mean, 7.6 of 16 baseline criteria; 3.3 of 7 comparison criteria). Reporting deficiencies were found in all major aspects of study design and statistical analysis. CONCLUSIONS: More rigorous reporting of clinical data in pediatric surgery could increase the clinical utility of published results. The authors have identified the fundamental elements essential to nonbiased reporting of clinical research data in surgery. Implementation of mandatory peer-review guidelines based on these principles could set a new standard for clinical reporting in surgery.

Bibliometrics↗

PubMed2003

Small evidence for small incisions: pediatric laparoscopy and the need for more rigorous evaluation of novel surgical therapies.

BACKGROUND/PURPOSE: Laparoscopic surgery has been widely adopted for many pediatric surgical diseases for its potential to reduce morbidity and hospital stay. To date, no study has examined the qualitative state of evidence supporting the use of these techniques in children. The authors present a systematic and objective review of this evidence. METHODS: The authors identified all clinical reports during the last 10 years for the 3 most common pediatric surgical diseases managed laparoscopically (appendicitis, gastroesophageal reflux, and conditions requiring splenectomy). Standardized and previously validated quality assessment instruments were used to examine individual studies in 4 areas: (1) clinical relevance, (2) generalizability to clinical practice, (3) reporting methodology, and (4) strength of conclusions. RESULTS: The authors evaluated a total of 131 clinical reports (39 to 48 per disease). Ninety-three percent of all studies were retrospective, with single institution case reports accounting for the majority of evidence. Only 23% of studies used a control group of any kind. Randomized trials comprised 3% of all evidence (4 studies). Forty-five percent of nonrandomized studies were found to be of poor quality, and 55% were of fair quality by epidemiologic standards. The distribution of quality scores was not significantly different between the 3 operative indications examined (analysis of variance P =0.10). Randomized studies also were found to be of poor methodologic quality by standardized assessment criteria. CONCLUSIONS: The current body of evidence is of insufficient quality to justify the widespread adoption of laparoscopic techniques into accepted standards of care. Wider use of prospective studies such as multicenter databases and randomized trials are needed to clarify the indications and outcomes for these innovative techniques. Significant improvement in the quality of published observational studies is also warranted, and this may be facilitated by the adoption of standardized reporting guidelines specific to nonrandomized data.

Appendectomy↗