Biomedical subjects

Rebeccah L Brown

Publications and source records attributed to Rebeccah L Brown.

13 recordsLinked to original sources

PubMed2007

The epidemiology of infant injuries and alarming health disparities.

PURPOSE: Injury epidemiology is the underappreciated foundation of injury prevention and control strategies. Given the substantial disparity of infant injury-related mortality between African Americans (AA) and whites in our region, we sought to better understand the epidemiology of infant injury-related mortality rates. METHODS: Our trauma database was reviewed for all infant injuries over a 10-year period. The mortality rates were analyzed based on race, mechanism, and health insurance type. RESULTS: From 1995 to 2004, 1270 infants were identified. Sixty-nine percent were white, 26% AA, and 5% were other. Overall mortality was 4.8%. There were significant disparities in mortality comparing AA to whites: overall, 9.6% vs 2.8%*; abuse, 15% vs 4%*; suffocation, 100% vs 55%* (*P < .05). Although 75% of AA vs 40% of whites were insured by Medicaid, when separated by insurance type, the disparity in mortality rates between races remained significant. CONCLUSIONS: African-American infants have 3.5 times increased risk of death from preventable injuries compared to white infants. This disparity persists despite controlling for type of health insurance, a surrogate for socioeconomic status. Understanding these disparities and developing injury-prevention programs targeting high-risk mechanisms of injury such as abuse and suffocation among AA is critical toward eventually eliminating these preventable deaths.

Black or African American↗

PubMed2006

Laparotomy versus peritoneal drainage for necrotizing enterocolitis and perforation.

BACKGROUND: Perforated necrotizing enterocolitis is a major cause of morbidity and mortality in premature infants, and the optimal treatment is uncertain. We designed this multicenter randomized trial to compare outcomes of primary peritoneal drainage with laparotomy and bowel resection in preterm infants with perforated necrotizing enterocolitis. METHODS: We randomly assigned 117 preterm infants (delivered before 34 weeks of gestation) with birth weights less than 1500 g and perforated necrotizing enterocolitis at 15 pediatric centers to undergo primary peritoneal drainage or laparotomy with bowel resection. Postoperative care was standardized. The primary outcome was survival at 90 days postoperatively. Secondary outcomes included dependence on parenteral nutrition 90 days postoperatively and length of hospital stay. RESULTS: At 90 days postoperatively, 19 of 55 infants assigned to primary peritoneal drainage had died (34.5 percent), as compared with 22 of 62 infants assigned to laparotomy (35.5 percent, P=0.92). The percentages of infants who depended on total parenteral nutrition were 17 of 36 (47.2 percent) in the peritoneal-drainage group and 16 of 40 (40.0 percent) in the laparotomy group (P=0.53). The mean (+/-SD) length of hospitalization for the 76 infants who were alive 90 days after operation was similar in the primary peritoneal-drainage and laparotomy groups (126+/-58 days and 116+/-56 days, respectively; P=0.43). Subgroup analyses stratified according to the presence or absence of radiographic evidence of extensive necrotizing enterocolitis (pneumatosis intestinalis), gestational age of less than 25 weeks, and serum pH less than 7.30 at presentation showed no significant advantage of either treatment in any group. CONCLUSIONS: The type of operation performed for perforated necrotizing enterocolitis does not influence survival or other clinically important early outcomes in preterm infants. (ClinicalTrials.gov number, NCT00252681.).

Birth Weight↗

PubMed2006

Pediatric trauma nurse practitioners provide excellent care with superior patient satisfaction for injured children.

PURPOSE: Work hour restrictions for house staff have forced a reevaluation of the traditional roles of all health care providers. In 2001, our level I pediatric trauma center augmented the role of our trauma pediatric nurse practitioners (PNPs) to include in-patient management. We hypothesized that a PNP can provide injured children a level of care commensurate with a resident (RES). METHODS: All children between 2 months and 17 years old admitted to the Trauma Service were considered for the study. Patients were randomized to PNP or RES care groups. Types of injuries, injury severity score, missed injuries, readmissions, hospital length of stay (LOS), and cost were recorded. Satisfaction surveys were administered to all families. RESULTS: A total of 76 children were enrolled. During the study period, there were no missed injuries or readmissions. The PNP group had a significantly shorter LOS and received significantly higher satisfaction survey scores with regard to information on injuries, tests and treatment, and frequency of visits provided to the patient/family. CONCLUSIONS: PNPs provide equivalent care for injured children with significantly shorter LOS and higher patient satisfaction than RESs. In-patient trauma nurse practitioners provide added value to the care of the injured child in the era of reduced RES work hours.

Adolescent↗

PubMed2006

The effect of a right-sided aortic arch on outcome in children with esophageal atresia and tracheoesophageal fistula.

UNLABELLED: During repair of an esophageal atresia with tracheoesophageal fistula (EA/TEF), a right-sided aortic arch (RAA) presents a technical challenge. We reviewed our experience with EA/TEF focusing on the impact of RAA. METHODS: A retrospective review of patients with EA/TEF at our institution from 1990 to 2004 was performed. Of 61 patients, 53 had a left aortic arch (LAA) and 8 had RAA. RESULTS: The mean gestational age and birth weight were similar between patients with LAA and RAA. There were more vascular rings in patients with RAA than with LAA (37.5% vs 3.8%, P = .009). A preoperative echocardiogram correctly identified the location of the arch in all with LAA but only 62.5% of those with RAA. Operative complications occurred in 25% of patients with RAA and 11% of patients with LAA. CONCLUSIONS: Management of a child with RAA and EA/TEF is technically challenging. Preoperative identification of the great vessel anomalies may impact operative decision making. Therefore, careful diagnostic evaluation of a patient with an aortic arch that cannot be easily defined by ECHO should be considered before definitive repair.

Aorta, Thoracic↗

PubMed2006

Nonoperative management of pectus carinatum.

BACKGROUND: Although surgery has been the mainstay of treatment of chondrogladiolar pectus carinatum (PC), several authors have advocated the benefits of nonoperative approaches to induce chest wall remodeling. Based on our initial success with compression bracing, we have integrated this modality into our treatment algorithm. METHOD: We reviewed the charts of all patients treated for PC at our pediatric hospital between 1997 and 2004. Patients were managed with observation, operative repair, and orthotic bracing that provides continuous anteroposterior sternal compression. The brace was worn for 14 to 16 hours per day until linear growth was complete or for a minimum of 2 years. RESULTS: One hundred patients were diagnosed with PC. Fifty-seven patients had no treatment and were monitored. Twenty-nine patients were fitted with a brace. Of these 29 patients, 3 were noncompliant, resulting in a compliance rate of 90%. Of the remaining brace patients, all have had positive outcomes with no observed complications. Seventeen patients underwent surgical repair. Their outcomes were also positive with no major complications. CONCLUSION: Our findings clearly demonstrate that compression bracing is a safe and effective treatment for children with chondrogladiolar PC. We currently offer this approach as a first-line treatment, reserving surgery for patients who are noncompliant and those who fail the nonoperative modality.

Adolescent↗

PubMed2006

A case report of severe tracheal obstruction requiring extracorporeal membrane oxygenation.

The authors describe the case of a near-fatal airway obstruction requiring extracorporeal membrane oxygenation. The patient presented with severe respiratory distress owing to a bean impacted in the distal trachea. The foreign body could not be removed by bronchoscopy because of instability of the patient. The patient was placed on extracorporeal membrane oxygenation for temporary pulmonary support, and the foreign body was removed using a rigid bronchoscope. The patient had a full recovery and suffered no neurologic sequelae.

Airway Obstruction↗

PubMed2006

Complications of nonoperative management of pediatric blunt hepatic injury: Diagnosis, management, and outcomes.

BACKGROUND: Nonoperative management (NOM) of blunt hepatic injury is the standard of care in the hemodynamically stable pediatric patient, but it is not without pitfalls. The purpose of this study is to assess the incidence and types of complications associated with NOM in terms of diagnosis, management, and outcomes. METHODS: A retrospective study of pediatric patients with blunt hepatic injuries admitted from 1991 through 1997 to a Level I pediatric trauma center was conducted. All stable patients were initially managed nonoperatively according to the Isolated Liver Laceration Critical Pathway. Surveillance was performed by physical examination and tracking of hematocrit and liver function test (LFT) results. Follow-up ultrasound (US) or computed tomography (CT) were performed as clinically indicated. RESULTS: In all, 185 patients with nonoperatively managed blunt hepatic injuries were identified during a 7-year period. Over 90% (168/185) were successfully managed nonoperatively without adverse sequelae. Ten patients (5.4%) died: seven as a result of head injury; three as a result of multisystem organ failure; none directly attributable to their hepatic injuries. Complications occurred in seven patients (3.8%) with Grades III or IV right lobe liver lacerations and included biloma (5), hepatic artery pseudoaneurysm with hemobilia (1), and necrotic gallbladder (1). All seven patients (100%) had fever, persistent or worsening right upper quadrant pain, feeding intolerance, and persistently elevated LFTs. Complications were diagnosed by CT or US. Nonoperative treatment of complications was successful in four of the seven patients (57.1%) and consisted of percutaneous drain placement only (1), percutaneous drain placement and endoscopic retrograde cholangiopancreatography (ERCP)-guided stent placement (2) and angioembolization (1). Three patients (42.9%) required laparotomy, one for management of a concomitant pancreatic pseudocyst. CONCLUSION: Complications of NOM of pediatric blunt hepatic injury are rare, but may include biloma, hepatic artery pseudoaneurysm, and necrotic gallbladder. Complications occur only with Grade III or greater injuries and are accompanied by fever, right upper quadrant pain, feeding intolerance, and persistently elevated LFTs. The clinician must maintain a high index of suspicion for the development of complications and have a low threshold for obtaining a CT or US for diagnosis. Interventional radiology techniques, angiography, and ERCP are useful adjuncts to nonoperative management, but some patients may still require laparotomy for management of complications.

Adolescent↗

PubMed2005

Postoperative outcomes of extremely low birth-weight infants with necrotizing enterocolitis or isolated intestinal perforation: a prospective cohort study by the NICHD Neonatal Research Network.

OBJECTIVE: Purposes of this study were: 1) to compare mortality and postoperative morbidities (intra-abdominal abscess, wound dehiscence, and intestinal stricture) in extremely low birth weight (ELBW) infants who underwent initial laparotomy or drainage for necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP); 2) to determine the ability to distinguish NEC from IP preoperatively and the importance of this distinction on outcome measures; and 3) to evaluate the association between extent of intestinal disease determined at operation and outcome measures. BACKGROUND: ELBW infants who undergo operation for NEC or IP have a postoperative, in-hospital mortality rate of approximately 50%. Whether to perform laparotomy or drainage initially is controversial. Also unknown is the importance of distinguishing NEC from IP and the current ability to make this distinction based on objective data available prior to operation. METHODS: A prospective, multicenter cohort study of 156 ELBW infants at 16 neonatal intensive care units (NICU) within the NICHD Neonatal Research Network. RESULTS: Among the 156 enrolled infants, 80 underwent initial peritoneal drainage and 76 initial laparotomy. Mortality rate was 49% (76 of 156). Ninety-six patients had a preoperative diagnosis of NEC and 60 had presumed IP. There was a high level of agreement between the presumed preoperative diagnosis and intraoperative diagnosis in patients undergoing initial laparotomy (kappa = 0.85). The relative risk for death with a preoperative diagnosis of NEC (versus IP) was 1.4 (95% confidence interval, 0.99-2.1, P = 0.052). The overall incidence of postoperative intestinal stricture was 10.3%, wound dehiscence 4.4%, and intra-abdominal abscess 5.8%, and did not significantly differ between groups undergoing initial laparotomy versus initial drainage. CONCLUSIONS: Survival to hospital discharge after operation for NEC or IP in ELBW neonates remains poor (51%). Patients with a preoperative diagnosis of NEC have a relative risk for death of 1.4 compared with those with a preoperative diagnosis of IP. A distinction can be made preoperatively between NEC and IP based on abdominal radiographic findings and the patient's age at operation. Future randomized trials that compare laparotomy versus drainage would likely benefit from stratification of treatment assignment based on preoperative diagnosis.

Drainage↗

PubMed2005

The failure of nonoperative management in pediatric solid organ injury: a multi-institutional experience.

BACKGROUND: Nonoperative management (NOM) is the accepted treatment of most pediatric solid organ injuries (SOI) and, is typically successful. We sought to elucidate predictors of, and the time course to, failure in the subset of children suffering SOI who required operative intervention. METHODS: A retrospective analysis was performed from January 1997 through December 2002 of all pediatric patients (age 0-20 years) with a SOI (liver, spleen, kidney, pancreas) from the trauma registries of seven designated, level I pediatric trauma centers. Failure of NOM was defined as the need for intra-abdominal operative intervention. Data reviewed included demographics, injury mechanism, injury severity (ISS, AIS, SOI grade, and GCS), and outcome. For the failures of NOM, time to operation and relevant clinical variables were also abstracted. A summary AIS (sAIS) was calculated for each patient by summing the AIS values for each SOI, to account for multiple SOI in the same patient. Univariate and multivariate analyses were employed, and significance was set at p < 0.05. RESULTS: A total of 1,880 children were identified. Of these, 62 sustained nonsurvivable head injuries that precluded assessment of NOM outcome and were thus excluded. The remaining 1,818 patients comprised the overall study population. There were 1,729 successful NOM patients (controls -- C) and 89 failures (F), for an overall NOM failure rate of 5%. For isolated organ injuries, the failure rates were: kidney 3%, liver 3%, spleen 4%, and pancreas 18%. There were 14 deaths in the failure group from nonsalvageable injuries (mean ISS = 54 +/- 15). The two groups did not differ with respect to mean age or gender. An MVC was the most common injury mechanism in both groups. Only bicycle crashes were associated with a significantly increased risk of failing NOM (RR = 1.76, 95% CI = 1.02-3.04, p < 0.05). Injury severity and organ specific injuries were associated with NOM failure. When controlling for ISS and GCS, multivariate regression analysis confirmed that a sAIS > or = 4, isolated pancreatic injury, and >1 organ injured were significantly associated with NOM failure (p < 0.01). The median time to failure was 3 hours (range, 0.5-144 hours) with 38% having failed by 2 hours, 59% by 4 hours, and 76% by 12 hours. CONCLUSIONS: Failure of NOM is un common (5%) and typically occurs within the first 12 hours after injury. Failure is associated with injury severity and multiplicity, as well as isolated pancreatic injuries.

Adolescent↗

PubMed2003

Pediatric trauma: beyond the brain.

In pediatric trauma care, many long-held tenets of management have been revised. This article reviews the latest advances in pediatric trauma care, particularly in the areas of resuscitation and management of thoracic and abdominal injuries. The final topic is a discussion of what the intensivist and surgeon must know when caring for the pediatric victim of terrorist attacks.

Critical Care↗

PubMed2002

All-terrain vehicle and bicycle crashes in children: epidemiology and comparison of injury severity.

BACKGROUND/PURPOSE: Despite statements by the American Academy of Pediatrics (AAP) and the US Consumer Product Safety Commission (CPSC) against the use of all-terrain vehicles (ATVs) by children under the age of 16 years, nearly half of ATV-related injuries and over 35% of all ATV-related deaths continue to occur in this age group. Because ATV and bicycle crashes have been associated with serious injury in children, the authors compared the demographics, mechanism of injury, injury severity, and outcome of children with ATV- and bicycle-related injuries. Further, the authors sought to identify whether ATV-related injuries elicited changes in risk-taking behavior. METHODS: A retrospective, comparative analysis of 109 children admitted for ATV-related injuries and 994 children admitted for bicycle-related injuries to a level 1 pediatric trauma center between January 1991 and June 2000 was performed. A phone survey was conducted to determine self-reported changes in safety behaviors or use patterns after ATV injury. RESULTS: Mean age was 11.1 plus minus 3.5 years (range, 2 to 18 years) for ATV crashes versus 9.4 plus minus 3.3 years (range, 1 to 17 years) for bicycle crashes (P <.05). Ninety-three percent of ATV crashes occurred in children less than 16 years of age; 31% in children less-than-or-equal10 years of age; and 7% in children less-than-or-equal5 years of age. Male-to-female ratio was about 3:1 for both groups. White race accounted for 97% of ATV injuries compared with 79% of bicycle injuries (P <.05). Falls from ATVs or bicycles were the most common mechanism of injury (41% v 59%, respectively). Collisions with motor vehicles were more common for bicyclists (32% v 10%), whereas collisions with stationary objects were more common among ATV riders (27% v 9%). Sixteen percent of ATV crashes were caused by a roll-over mechanism. Mean injury severity score (ISS) were significantly higher for victims of ATV crashes (8.3 ATV v 6.7 bicycle; P <.05). ATV-related trauma was associated with multiple injuries, more operative interventions, and longer hospital stays. Location and distribution of injuries were similar for both groups. Helmet use was low in both groups but higher for ATV riders (23% v 8%; P <.5). Mortality rate was similar for both groups (0.9% for ATV riders v 0.7% for bicyclists). There was a 39% response for the phone survey post-ATV injury. Twenty-three of 43 (53%) respondents owned the ATV, and 70% of these received safety information at the time of purchase. However, only 14% of injured riders received any formal training before riding ATVs. Postinjury, 60% of children continued to ride, although 42% reported decreased riding time. Fifty-four percent of children reportedly wore helmets preinjury, and there were no changes in helmet usage postinjury. There were no differences in pre- and postinjury parental supervision (61% v 65%). CONCLUSIONS: Both ATV and bicycle-related injuries occur predominantly in boys, but ATV victims are older and almost all are white. Almost all ATV injuries occurred in children under the age of 16 years. Although both ATV and bicycle crashes cause severe injuries in children, injury severity is higher for ATV crashes in terms of multiple injuries, need for operative intervention, and longer length of stay. Despite severe injuries, the majority of children injured by ATVs continue to ride, albeit fewer hours per day, and safety behaviors are unaltered. These data reinforce the current AAP stance that legislation prohibiting the use of ATVs in children under the age of 16 years without a valid driver's license should be pursued and enforced aggressively.

Accidents, Traffic↗

PubMedDate not supplied

Pediatric trauma nurse practitioners increase bedside nurses' satisfaction with pediatric trauma patient care.

PURPOSE: Our Level I Pediatric Trauma Center employs pediatric nurse practitioners (PNP) to manage inpatients. We hypothesized that the involvement of a PNP would lead to increased nursing staff satisfaction with patient care. METHODS: Children admitted to the trauma service were randomized to PNP or resident care groups. Nurses caring for these children were asked to fill out a satisfaction survey regarding the care that the child received. FINDINGS: Sixty-five nurses participated. Nurses scored the PNP group significantly higher in human qualities, information given about the tests, management of the child's pain, and response time to pages/questions. CONCLUSIONS: Involvement of the PNP leads to higher nursing satisfaction scores compared with residents while providing equivalent care for injured children.

Attitude of Health Personnel↗

PubMedDate not supplied

Effect of safety education on classmates of injured children: a prospective clinical trial.

We hypothesized that using the teachable moment associated with an injured classmate, school-aged children would demonstrate improved retention of injury prevention education. The injured child's class and one control with presentation class received an injury prevention presentation. Prospective evaluation was performed using pre, immediate post, and 1-month posttesting. Immediately following the presentation, 83% of classes in both groups demonstrated significant improvement in test scores. At 1 month, 100% of the injured child's and only 66% of control with presentation classrooms maintained significant improvements. This unique program results not only in immediate but also in long-term retention of injury prevention information.

Academic Medical Centers↗