Biomedical subjects
Publications and source records attributed to S Emil.
A 2-year-old boy presented with bowel obstruction 5 days after repair of a recurrent epigastric hernia. Pre-operative imaging implicated intussusception as a cause of the obstruction. At operation a gangrenous transverse colocolic intussusception was resected en masse. No clear lead point was seen. Recovery was uneventful.
PURPOSE: Abdominal sonography has gained popularity in establishing the diagnosis of appendicitis in children with equivocal clinical presentations. However, no clear outcome benefits have been demonstrated to date. The authors conducted a retrospective study to compare the characteristics and outcomes of patients undergoing appendectomy after clinical evaluation only with those undergoing the procedure after sonography. METHODS: The charts of 454 consecutive patients undergoing appendectomy for acute appendicitis between January 1, 1998 and December 4, 1999 were reviewed. Patients operated on after clinical evaluation only were compared with patients operated on after abdominal sonography. RESULTS: Forty-two percent of patients (n = 191) constituted the sonography group. When compared with the clinical group, these patients had higher prevalence of female gender (52% v 38%; P =.004), longer symptom duration (2.2 +/- 2.5 v 1.6 +/- 1.6 days; P =.003), higher incidence of preoperative in-patient observation (19% v 4%; P <.001), longer duration between evaluation and operation (8.0 +/- 3.9 v 4.9 +/- 2.9 hours; P <.001), higher incidence of normal appendices on pathologic examination (13% v 6%; P =.006), and higher incidence of postoperative abscesses or phlegmons (4.4% v 1.2%; P =.04). The groups did not differ significantly in age, hospital stay, incidence of complicated appendicitis, or incidence of wound infection. CONCLUSIONS: Patients undergoing sonography before appendectomy have a longer delay before operation, a higher rate of misdiagnosis, and more postoperative complications. Limiting sonography to truly equivocal cases and using it early in the diagnostic workup may improve outcomes in this group of patients.
Retroperitoneal epidermoid cysts are rare. The authors report a case of an 11-year-old boy with an asymptomatic subdiaphragmatic cyst, which was found incidentally during an investigation for hypertension. At laparoscopy, the cyst was densely adherent to the diaphragm, resulting in a pneumothorax during dissection. Nevertheless, the excision and the diaphragmatic repair could be completed laparoscopically without complication. Microscopic examination showed an epidermoid cyst. No similar case has been reported in the literature.
PURPOSE: Renal vein thrombosis (RVT) is a rare cause for pediatric surgical consultation. The purpose of this study is to review the Montreal experience in the 1990s with RVT. METHODS: A retrospective chart review was conducted from 1990 through 1999. RESULTS: Twenty-three cases were identified by Duplex ultrasound scan. Mean length of follow-up was 42 months. Eighty-three percent (83%) of cases were diagnosed within the first month of life. In utero thrombosis was suspected in 22% and was associated with caval thrombosis and factor V Leiden. Known risk factors were present in 87%. The "diagnostic triad" of flank mass, gross hematuria, and thrombocytopenia was present in only 13% at the time of diagnosis. Long-term renal function impairment was detected in 100% of those who did not receive heparin, and in 33% of those who did receive heparin. No patient required dialysis. One patient required nephrectomy for recurrent pyelonephritis. CONCLUSIONS: RVT occurs more commonly than anticipated. Because the "classic" triad of signs usually is absent at presentation, the presence of either a flank mass, hematuria, or thrombocytopenia in a patient with risk factors should prompt investigation for RVT. Factor V Leiden is a risk factor for in utero RVT. Anticoagulation improves renal outcome. Patients with RVT require long-term follow-up.
OBJECTIVE: To investigate whether inhaled nitric oxide (INO) can prevent platelet activating factor (PAF)-induced pulmonary hypertension and shock. DESIGN: Randomized controlled animal trial. SETTING: Laboratory. SUBJECTS: Yorkshire swine. INTERVENTIONS: Animals received general anesthesia and invasive hemodynamic monitoring, then PAF only, 2.5 micrograms/kg intravenously over 45 minutes (PAF group, n = 9) or PAF in addition to INO, 20 ppm (PAF-INO group, n = 6). MAIN OUTCOME: Vascular pressures (mean arterial and mean pulmonary), vascular resistance indexes (systemic and pulmonary), cardiac indexes, and oxygen delivery and oxygen consumption. RESULTS: Mean arterial pressures, cardiac indexes, and oxygen delivery and consumption were significantly higher in the PAF-INO group. Mean pulmonary arterial pressures and systemic and pulmonary vascular resistance indexes were significantly lower in the PAF-INO group. There were 4 deaths (44%) in the PAF group vs none (0%) in the PAF-INO group (P = 10). CONCLUSIONS: The use of INO prevents pulmonary hypertension, circulatory failure, and death during PAF-induced shock.
Adequate absorptive function of transplanted small intestine is essential for success of this procedure. This study compared water transport under basal and meal stimulated conditions in the transplanted swine jejunum to native jejunum. Six female adolescent Yorkshire swine were randomized to undergo construction of either a 25-cm native proximal jejunal Thiry-Vella Fistula (TVF), n=3, or a 25-cm proximal jejunal allograft TVF, n=3. Immunosuppression in the transplanted animals was accomplished with intravenous methylprednisolone, azathioprine, and cyclosporin. Jejunal absorption studies, each 4 hr long, were performed utilizing 14C-polyethylene glycol to calculate net water flux. Each animal underwent at least three fasting and three postprandial studies. New water flux was negative, i.e., secretory, in both the native and transplanted proximal swine jejunum. In the basal state, integrated hourly water transport was more secretory in the native bowel vs the transplanted bowel during the 2nd, 3rd, and 4th experimental hr (-4.6 +/- .8 vs -2.1 +/- .7 cc, P = 0.034; -4.4 +/- .7 vs -1.8 +/- .6 cc, P = 0.012; and -4.7 vs 1.3 +/- .5 cc, P < 0.005), respectively. In native jejunum, integrated hourly water transport was less secretory 2 and 3 hr postprandially compared to basal (-1.9 +/- .5 vs -4.4 +/- .7 cc, P = 0.016; and -2.0 +/- .5 vs -4.7 +/- .7 cc, P = 0.021), respectively. This postprandial proabsorptive response did not occur in the transplanted jejunum. Native and transplanted jejunal water flux in the postprandial state did not differ significantly. We conclude that there is higher secretion in native vs transplanted jejunum during fasting. The postprandial proabsorptive response of the proximal porcine jejunum is abolished by transplantation.
It has been shown that pulmonary vasodilation is sustained after discontinuation of inhaled nitric oxide (INO) during moderate hypoxic pulmonary hypertension (HPH) in swine. The present investigations demonstrated how INO dose, hypoxia duration, and endogenous NO production influence this important phenomenon. Fifteen adolescent Yorkshire swine were randomly assigned to three groups (n = 5 each) and underwent the following phasic experimental protocol: (I) Baseline ventilation (FIO2 = .3); (II) Initiating HPH (FIO2 = .16 to .18, PaO2 = 45 to 55 mm Hg); (III) INO at 10 ppm; (IV) Posttreatment observation; (V) INO of 80 ppm; and (VI) Posttreatment observation. Phase II (pretreatment hypoxia) lasted 30 minutes in group A (short hypoxia) and 120 minutes in group B (long hypoxia). N-nitro-L-arginine methyl ester (NAME) was used to inhibit nitric oxide synthase (NOS) throughout the experiment in group C (short hypoxia + NAME). Hemodynamics and blood gases were monitored by systemic and pulmonary artery catheters placed by femoral cutdown. Analysis of variance with post-hoc adjustment was used to compare groups at each phase, and the paired t test was used for comparisons within a group. With respect to baseline mean pulmonary artery pressure (MPAP) and pulmonary vascular resistance (PVR), there were no significant differences among the three groups. MPAP and PVR were significantly higher in group C than in group A during phase II, (MPAP, 76% +/- 8% v 33% +/- 2%; PVR, 197% +/- 19% v 78% +/- 10%; P < .05). There were no significant differences in MPAP or PVR during phases III through VI. When MPAP was expressed as percent dilation, 80 ppm caused significantly more dilation than did 10 ppm in all three groups. Groups A and C had significantly higher sustained pulmonary artery dilation after 80 ppm than after 10 ppm (A, 82% +/- 31% v 17% +/- 11%; C, 68% +/- 10% v 42% +/- 12%; both P < .05), but group B did not (43% +/- 15% v 30% +/- 9%; P = .25). High dose results in stronger vasodilation than low dose during and after INO for moderate HPH of short duration. Long hypoxia blunts this high-dose advantage. Endogenous NO inhibition augments HPH but does not decrease pulmonary vasodilation during or after INO.
We studied the effects of systemic endotoxemia on small intestinal absorption in an in vivo animal model. Seven adolescent Yorkshire swine underwent creation of 25 cm distal ileal Thiry-Vella fistulae. After 1 week recovery, the fistulae were perfused with a solution of glucose and electrolytes labeled with 14C-PEG, and net absorption of water, Na+, Cl-, and glucose was calculated. Animals were studied under three different conditions: (1) Basal fasting state, (2) immediately after intravenous injection of E. coli lipopolysaccharide (LPS; 250 micrograms/kg), and (3) 24 hours after LPS. Water, Na+, and Cl- absorption was significantly reduced 2 hours after LPS, but recovered to baseline values by the third hour after LPS. Twenty-four hours after LPS water, Na+, and Cl- absorption was significantly decreased below baseline values. Glucose absorption after LPS paralleled that of water and electrolytes, except that the transient early recovery was not observed. Histological studies of the ileum after LPS showed marked epithelial inflammation at 6 hours, villous atrophy at 24 hours, and signs of recovery at 7 days. Intestinal absorption of water, electrolytes, and glucose is adversely affected in the immediate and early periods after an endotoxemic episode, but the histological epithelial injury secondary to endotoxemia is reversible.
Although inhaled nitric oxide (NO) has been variably successful in resolving pulmonary hypertension in neonates, children, and adults, no parameters predictive of response to this therapy have been elucidated. We conducted an animal study to determine if severity of hypoxia can predict magnitude and sustenance of response to inhaled NO therapy. Seven Yorkshire swine weighing 11 to 20 kg underwent 16 experiments, each consisting of four phases: Phase 1: Control period of ventilation on FIO2 .3; phase 2: Hypoxic period on FIO2 .10 to .15, establishing pulmonary hypertension; phase 3: Treatment period with NO starting at five parts per million (ppm), doubling dose every 10 min to 80 ppm; phase 4: Posttreatment observation period after discontinuation of NO while maintaining hypoxia for 1 hour or until circulatory failure or pulmonary hypertension of pre-NO magnitude developed. Each animal underwent a maximum of three experiments in random order of hypoxia severity before sacrifice with pentobarbital overdose. Continuous hemodynamic parameters, intermittent cardiac output and pulmonary capillary wedge pressure, and intermittent arterial blood gas analyses were obtained through pulmonary and systemic artery catheters placed by femoral cutdown. Pulmonary and systemic vascular resistances (PVR and SVR) were calculated by standard formulas. Experiments were divided into two groups (n = 8 in each): group 1 with severe hypoxia (PaO2, 25 to 35) and group 2 with moderate hypoxia (PaO2, 36 to 65). Data for all hemodynamic parameters were expressed as mean percentage change from baseline (phase 1) +/- SEM under each set of conditions, and the two groups were compared by two-way analysis of variance and covariance adjusted for order of experimentation.(ABSTRACT TRUNCATED AT 250 WORDS)
Laparoscopic operative procedures are gaining wider acceptance in pediatric patients. Although laparoscopic splenectomy is being performed more frequently, no studies to date have compared this procedure with the standard open technique with respect to operative outcomes. We performed a case control study of seven laparoscopic splenectomies and 14 open splenectomies. Two-tailed t test was used to compare the two groups for mean operative time, mean hospital stay, mean interval before tolerating a regular diet, and total parenteral narcotic dose in morphine equivalents. Operative time was significantly longer in the laparoscopic group (221 minutes vs 59 minutes, P < 0.001). Hospital stay, interval before tolerating a regular diet, and postoperative narcotic dose did not differ significantly between the two groups. In the laparoscopic group, one operation was converted to an open procedure secondary to bleeding complications. Three patients required mini-laparotomies for removal of extremely large spleens after completion of the dissection. Pediatric laparoscopic splenectomy does not appear to have advantages over the traditional method with regard to operative time, hospital stay, postoperative ileus, or postoperative pain. Larger studies, including cost analysis, are needed before major proposed advantages of laparoscopic splenectomy can be accepted.
Thirty-six cocaine abusers in treatment and 16 non-using controls were exposed to visual cocaine cues; measurements included changes in skin conductance and a rating of psychological arousal (persisting cocaine thoughts and images during the 24 h following the experiment). The GSI score of the HSCL-58 was used as an indicator of psychological distress. Probands showed arousal responses significantly higher than the controls. Skin conductance readings correlated positively with HSCL-58 scores and with severity of craving in the week prior to the trial. Unexpectedly, they correlated negatively with duration of cocaine use and did not vary as a function of the severity of cocaine addiction or the duration of cocaine abstinence prior to the test. Neither cocaine addiction measurements nor arousal responses were found to predict cessation of use (a minimum of 3 months of sustained abstinence) 1 year after the test.
After exposure of growing chicks to different concentrations of dietary chromium (Cr) as potassium chromate (K2CrO4) for a period of 3 w, the Cr uptake by different internal organs was determined. More Cr was accumulated in the kidney, liver, pancreas and spleen than in the blood, muscle, heart and lung. A very small amount was found in the brains of the birds given different concentrations of Cr.
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We report the first case of hemolytic uremic syndrome in a patient with burns. An unusual case of the syndrome developed in a 1-year-old black girl hospitalized after second-degree burns to 33% of her total body surface area. Acute abdominal distention, hemolytic anemia, hematuria, and oliguric renal failure developed 1 week after admission to the burn unit. Blood cultures grew Escherichia coli O157:H7. She received supportive care and antibiotics, in addition to low-dose dopamine, which promptly reversed the oliguria. Dialysis was not required, and the child made a complete recovery.