Biomedical subjects
Publications and source records attributed to Robert F Tamburro.
We present the radiological and clinical aspects of a patient with advanced-stage Burkitt lymphoma who presented with an acute abdomen complicated by abdominal compartment syndrome.
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When anesthetizing a patient with an anterior mediastinal mass, sudden hypoxaemia and cardiovascular collapse may result from compression of a large airway or vascular structure in the mediastinum. We report the case of a pediatric cancer patient with an anterior mediastinal mass, who developed sudden and fatal hypoxaemia and cardiovascular collapse in the hours following sedation. A massive pulmonary thromboembolism was diagnosed at autopsy. We suggest that pulmonary embolism should be considered in the differential diagnosis when a patient with a mediastinal mass develops perioperative hypoxaemia, cardiovascular collapse, or both.
OBJECTIVE: To describe survival to intensive care unit (ICU) discharge and 6-month survival in a large cohort of pediatric oncology patients with severe sepsis. DESIGN: Retrospective analysis. SETTING: The ICU of a single pediatric oncology center. PATIENTS: Patients with cancer admitted to the ICU of St. Jude Children's Research Hospital between January 1, 1990, and December 31, 2002, who met the following criteria: 1) severe sepsis by ACCP/SCCM (American College of Chest Physicians/Society of Critical Care Medicine) Consensus Conference criteria and 2) receipt of fluid boluses of > or =30 mL/kg to correct hypoperfusion or receipt of a dopamine infusion of >5 microg.kg.min for inotropic support. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data evaluated were demographic variables, oncologic diagnosis and time from diagnosis to ICU admission, Pediatric Risk of Mortality III score and absolute neutrophil count at admission, use of inotropes or pressors, use of mechanical ventilation, maximum organ system failure score, blood culture results, survival to ICU discharge, and 6-month survival. We identified 446 ICU admissions of 359 eligible patients. Overall ICU mortality was 76 of 446 (17%): 40 of 132 (30%) in post-bone marrow transplant (BMT) admissions and 36 of 314 (12%) in non-BMT admissions (p < .0001). In the 106 admissions requiring both mechanical ventilation and inotropic support, ICU mortality was 68 of 106 (64%). Regarding individual patients, 6-month survival was 170 of 248 (69%) among non-BMT patients vs. 43 of 111 (39%) for BMT patients (p < .001). When the 38 patients who survived to ICU discharge after requiring both mechanical ventilation and inotropic/vasopressor support are considered, 27 (71%) were alive 6 months after ICU discharge (22 of 27 [81%] non-BMT vs. 5 of 27 BMT [19%; p < .001]). ICU mortality varied by causative pathogen, from 63% for fungal sepsis (12 of 19) to 9% (5 of 53) for Gram-negative sepsis. Logistic regression analysis of factors significantly associated with ICU mortality in admissions requiring both mechanical ventilation and inotropic support identified four variables: BMT (odds ratio, 2.9; 95% confidence interval, 1.1-7.4; p = .03); fungal sepsis (odds ratio, 10.7; 95% confidence interval, 1.2-94.4; p = .03); use of multiple inotropes (odds ratio, 4.1; 95% confidence interval, 1.4-11.8; p = .01); and Pediatric Risk of Mortality III score (odds ratio, 1.1; 95% confidence interval, 1.0-1.2; p = .04). CONCLUSIONS: In a large series of pediatric oncology patients with severe sepsis, ICU mortality was only 17% overall, although mortality remained quite high in the higher acuity patients. Mortality among the higher acuity patients was significantly associated with only a small number of variables. The number of patients alive at 6 months and the encouraging ICU survival rate further justifies the use of aggressive ICU interventions in this population.
INTRODUCTION: Some children treated for cancer become critically ill because of immune suppression and sepsis requiring prolonged intensive care support and assisted ventilation. METHODS: Over a 3-year-period, we have identified six children (four with brain tumors) who developed a generalized movement disorder during a protracted intensive care unit stay. Median age was 2 years (range 1-6 years). Movement disorder developed while receiving multiple medications. RESULTS: Sedation was achieved with midazolam and opioid infusions. Dystonic posturing of limbs, jaw movements, tongue thrusting, and intermittent eye deviations were present in all. Movements increased if the child was stimulated and an electroencephalogram performed in five children excluded seizures. CONCLUSIONS: This movement disorder should be differentiated from seizures to prevent inappropriate treatment. Exacerbation with stimulation is a clinical clue to the correct diagnosis and an electroencephalogram can help differentiate this movement disorder from seizures.
Malignant infantile osteopetrosis (MIOP), a rare genetic disorder of the osteoclast, is fatal without hematopoietic stem cell transplantation. Primary pulmonary hypertension (PPH), a rare progressive disorder of the pulmonary circulation, is predominantly fatal in the absence of successful therapy. A clinical association between these two disorders has not been recognized and a pathophysiologic link between osteoclast function and pulmonary vascular pressure as a rationale for such an association is not readily apparent. Here, we report five infants with MIOP, without cardiac abnormalities, who were found to have PPH after undergoing stem cell transplantation. We suggest that PPH may be linked to a specific variant of MIOP and recognizing the potential for pulmonary hypertension in children with MIOP may lead to a more rapid diagnosis and life-saving intervention.
OBJECTIVE: To determine whether a unit specific nursing acuity score is useful for assessing patients with cancer admitted to the pediatric intensive care unit. DESIGN: Prospective, cohort analysis. SETTING: The intensive care unit of a tertiary-care pediatric oncology hospital. PATIENTS: A total of 219 patients admitted to the pediatric intensive care unit with a diagnosis of cancer or after hematopoietic stem cell transplantation. INTERVENTIONS: The nursing acuity scores obtained during the second shift after admission were recorded and compared with rates of mortality. These nursing acuity scores were also compared with the Pediatric Risk of Mortality (PRISM III) and Therapeutic Intervention Scoring System (TISS-28) scores recorded during the first day of intensive care unit admission. MAIN RESULTS: Mortality differed across the nursing acuity categories (0%, 7.5%, 20.8%, and 47.4%; p=.0002). TISS-28 and PRISM III scores progressively increased with each increase in the categorical nursing score and differed significantly among these levels (TISS-28, p=.0078; PRISM III, p=.0327). The Spearman correlation coefficients between the nursing score and TISS-28 and PRISM III were 0.432 and 0.285, respectively (p<.0001). CONCLUSIONS: The nursing acuity score accurately predicts survival in pediatric patients with cancer, correlates with established indexes of severity of illness and predictors of mortality, and identifies different mortalities across the nursing acuity categories. Although its predictive value may have been enhanced by the use of a second shift score, these findings suggest that it may be a useful tool in this patient population and affirms the insight of the bedside nurse in assessing severity of illness.
OBJECTIVE: To determine whether heme oxygenase-1 messenger RNA expression in peripheral blood mononuclear cells is induced in pediatric cancer patients with the systemic inflammatory response syndrome (SIRS) and whether this expression correlates with the heme oxygenase-1 products, bilirubin and carboxyhemoglobin. DESIGN: Prospective, controlled study. SETTING: A tertiary care pediatric oncology hospital. PATIENTS: Fourteen patients admitted to the intensive care unit with a diagnosis of SIRS by American College of Chest Physicians/Society for Critical Care Medicine consensus criteria and 17 control patients (off therapy, no acute illness). INTERVENTIONS: Blood for bilirubin, carboxyhemoglobin, and heme oxygenase-1 messenger RNA expression was collected at study entry. SIRS patients continued to have samples collected every 12 hrs for 1 wk or until intensive care unit discharge. Heme oxygenase-1, bilirubin, and carboxyhemoglobin levels of SIRS patients were compared with controls, and correlation between heme oxygenase-1 and products was assessed. MEASUREMENTS AND MAIN RESULTS: Within 48 hrs of study entry, maximum heme oxygenase-1 expression for all SIRS patients compared with controls was 5.5 +/- 1.0 vs. 1.1 +/- 0.1 (p < .0006). Maximum expression was > or =2.3-fold in 13 of 14 SIRS patients. Maximum heme oxygenase-1 expression also differed from minimum (5.5 +/- 1.0 vs. 1.6 +/- 0.3, p < .003). Maximum bilirubin and carboxyhemoglobin levels within 48 hrs of study entry differed between SIRS patients and controls (3.0 +/- 0.8 vs. 0.3 +/- 0.1, p = .006; and 1.2 +/- 0.2 vs. 0.6 +/- 0.1, p = .001, respectively). Bilirubin, but not carboxyhemoglobin, correlated with heme oxygenase-1 expression (p = .0013). CONCLUSIONS: Heme oxygenase-1 messenger RNA, bilirubin, and carboxyhemoglobin levels were increased within 48 hrs of admission in pediatric cancer patients with SIRS. Heme oxygenase-1 expression correlated with serum bilirubin levels. The increase in heme oxygenase-1 expression may add to the understanding of the increase in serum bilirubin observed in patients with SIRS/sepsis. These findings support a role for heme oxygenase-1 in the physiologic response to inflammatory stress.
OBJECTIVE: Injuries are the leading cause of death in children, and media exposure seems to increase children's risk-taking behavior. Televised sports are commonly viewed by children. The objective of this study was to determine the proportion of commercials that depict violence or other unsafe behavior during major televised sporting events that are aired before 9:00 pm. METHODS: We obtained a list of the 50 sports programs that were most highly rated by Nielsen Media Research and that were televised between September 1, 2001, and September 1, 2002. These 50 programs included Winter Olympics events (n = 15), National Football League (NFL) regular season games (n = 14), NFL playoff games (n = 10), Major League Baseball World Series and playoff games (n = 7), the NFL Super Bowl (n = 1), the National Basketball Association Western Conference Final Game (n = 1), the College Football Rose Bowl (n = 1), and the National Collegiate Athletic Association Basketball Championship game (n = 1). Two other events were reviewed as well: the final round of the Masters Golf Championship, because it was the only sporting event rated in the top 50 of the previous year that was not represented by a similar sporting event in the study year, and the Daytona 500 National Association for Stock Car Auto Racing race, because it was the only event rated among the top 75 of the study year that was not represented by a similar event (ie, there were no other golfing or auto racing events reviewed). These events were included because different sporting events may attract different viewers and different advertisements; thus, their inclusion provides a more comprehensive evaluation of the topic. For sporting events with >3 programs in the top 50 (NFL regular season games, NFL playoff games, Winter Olympic events, and Major League Baseball World Series), representative samples of events were assessed. Surrogate events were analyzed for programs that were aired after 9:00 PM (Eastern Time) to control for the reduced likelihood of viewing by children after 9:00 PM. For example, afternoon telecasts of the National Collegiate Athletic Association Regional Final and National Semifinal games were assessed in place of the Championship game, which started after 9:00 PM. Weekend afternoon telecasts of the Winter Olympics (3 successive weekends) were assessed as surrogates for all Olympics telecasts. For the World Series, the Super Bowl, and the National Basketball Association Conference Championship games, which began before 9:00 PM but ended after that time, we evaluated only commercials that aired before 9:00 PM. All commercials that were aired during these programs were reviewed at standard speed for unsafe behavior or violence. Commercials that were aired during pregame, postgame, or halftime periods were not assessed. Commercials were categorized according to the product being advertised. Unsafe behavior was simply defined as any action that could have harmful consequences or that contravened the injury prevention recommendations of national organizations. Violence was defined as any intentional physical contact by an aggressor that had the potential to inflict injury or harm or the legitimate threat of such action. All commercials were reviewed by at least 2 investigators; when the 2 could not agree on the findings, a third investigator was used to resolve differences. The percentage of commercials and of commercial breaks that portrayed violent or unsafe behavior was determined for each category of event and advertised product. A commercial break was defined as a series of commercials shown during a single break from the sporting event. chi2 analysis was used for all analyses, and relative risks with 95% confidence intervals were determined. The proportion of commercials that depicted unsafe behavior and/or violence during each sporting event was compared with the proportion of such commercials that were observed during the Masters Golf Tournament (which had the lowest proportion of commercials depicting such behavior). The proportion of commercials that contained violent/unsafe behavior for each advertised product was compared with the proportion of such commercials that advertised food or nonalcoholic beverages. Food and nonalcoholic beverage commercials were selected as the reference because they are a well-defined, common category of commercial. RESULTS: Of the 1185 commercials assessed, 14% (n = 165) displayed unsafe behavior and 6% (n = 66) depicted violence. Of the 322 commercial breaks, 158 (49%) contained at least 1 commercial showing unsafe behavior or violence. Sixty-three commercials required review by a third investigator to adjudicate violence or unsafe behavior; 20 of 52 were ultimately judged to portray unsafe behavior, and 4 of 11 were ultimately judged to portray violence. Sporting events differed in the proportion of commercials that showed violence or unsafe behavior. The Super Bowl had the highest proportion of such commercials, and the Masters Golf Tournament had the least (relative risk: 4.3; 95% confidence interval: 1.4-12.5). The Masters Golf Tournament was noteworthy for the complete absence of violent commercials. Only 18% of reviewed commercials advertised movies or television programs, yet these commercials accounted for 86% of all violent commercials. Forty-eight percent of commercials that contained violence were for movies, and an additional 38% were for television programs. Nearly two thirds of all commercials for movies contained violence, whereas 15% of all commercials for television programs contained violence, a rate that increased to 22% when commercials for other sporting events were excluded. Several categories of commercials portrayed unsafe behaviors; commercials for automobiles accounted for the most. In 8 different categories, 10% or more of the commercials depicted unsafe behavior, and 7 were significantly more likely to depict such behavior than a food or beverage commercial. CONCLUSIONS: Children who watch televised sports view a significant amount of violent and unsafe behavior. In accordance with American Academy of Pediatrics recommendations for television viewing, parents should both limit and directly supervise children's viewing of these events. Our findings suggest that parents should remain present during commercials or should consider implementing commercial-skipping technology. In addition, efforts should be made to regulate the content of commercials that promote television programs and movies on the basis of the hour at which the sporting event is aired. Moreover, the sports, movie, and television industries should be encouraged to adopt models of advertising that limit or eliminate such content. These efforts could help to ensure that the viewing of televised sporting events is a safe and positive experience for children.
A 17-year-old with acute myeloid leukemia M4 and hyperleukocytosis developed fulminant hypoxemic respiratory failure at presentation. After failing to respond to conventional mechanical ventilation and leukapheresis, he was started on inhaled nitric oxide (iNO) with dramatic improvement in oxygenation. Following graduated chemotherapy, his pulmonary status again deteriorated coincident with tumor lysis. After failing to respond to increases in iNO, he was placed in prone position with immediate improvement. The patient was successfully extubated. Patients with myelomonocytic leukemias are at risk for early death due to pulmonary complications. The use of adjuvant therapies directed by specific pathophysiology might decrease this risk.
OBJECTIVE: To determine whether analysis of the pulse-oximetry waveform can be useful in detecting the pulsus paradoxus associated with large pericardial effusions in pediatric patients. METHODS: A retrospective review of charts of 8 pediatric patients (age range: 5-19 years) who had echocardiographic evidence of large pericardial effusion, subsequently underwent pericardiocentesis, and had pulse-oximetry waveform tracings obtained before and after pericardiocentesis within an 18-month period was conducted in 2 tertiary-care pediatric intensive care units. We analyzed the pulse-oximetry waveform tracings for the presence of a pulsus paradoxus. Other abstracted data included clinical evidence of tamponade, echocardiographic findings, and the volume of pericardial fluid aspirated. RESULTS: Before pericardiocentesis, a decrease in the highest value of the upper plethysmographic peak of the pulse-oximetry waveform was observed during inspiration in each patient. Echocardiographic evidence of large pericardial effusion with compromised cardiac filling was also present in each patient. Only 6 of these patients had clinical evidence of cardiac tamponade at that time, 4 with a documented pulsus paradoxus using standard methods of blood pressure analysis. After pericardiocentesis, the inspiratory fall in the highest value of the upper plethysmographic peak of the pulse-oximetry waveform lessened in every patient. Echocardiography documented a decrease in the size of the effusion and resolution of the compromised cardiac filling in every patient. CONCLUSIONS: Analysis of pulse-oximetry waveforms may be a widely available, easily interpretable, and reliable method of detecting the pulsus paradoxus associated with large pericardial effusions in pediatric patients.
The purpose of this project was to assess if the presence of a mediastinal mass adversely influences peripherally inserted central catheter (PICC) positioning. A retrospective review of all PICC placements over an 18-month period in a pediatric oncology hospital was conducted in which patients were categorized by the presence or absence of a mediastinal mass. A much higher proportion of patients with a mediastinal mass (8 of 13) had a malpositioned catheter than those without a mass (3 of 38; P = .0002). A significant proportion of the malpositioned catheters in patients with a mediastinal mass terminated in the right heart chambers. These findings show that clinicians must be vigilant about checking for PICC malpositioning in this patient population.