Rotary atlanto-axial subluxation with torticollis following central-venous catheter insertion.

Atlanto-axial subluxation with torticollis is an uncommon condition that occurs in children usually as a result of pharyngeal infection, minor trauma, or neck surgery. Passive motion of the head and neck during general anesthesia is probably another etiologic factor. Torticollis is the most common presenting physical finding. Pain may or may not be present, but is commonly present with passive neck motion. Neurologic sequelae are uncommon. Our case illustrates this condition as a complication of central venous catheter (CVC) insertion in a child under general anesthesia. The surgeon should suspect this pathology when a child presents with torticollis following CVC placement. Precautions should be taken in the operating room to avoid aggressive rotation and extension of the child's neck while under general anesthesia whether or not cervical inflammation is present. Special attention to head and neck positioning should be taken in patients with Down's syndrome since they are at increased risk for atlanto-axial subluxation. The prognosis is excellent when diagnosed early. A delay in diagnosis can result in the need for surgical intervention.

Predicting pediatric length of stay and acuity of care in the first ten minutes with artificial neural networks.

OBJECTIVE: To evaluate the efficacy of artificial neural networks in categorizing pediatric trauma patients into four distinct acuity of care groups and in determining the length of stay (LOS) within specific areas of the hospital. DESIGN: Using historical information from >8,000 pediatric trauma patient records, train and evaluate artificial neural networks to predict the injury severity and LOS for each patient in pediatric intensive care units (PICUs), step-down units, and floor units. Each artificial neural network is evaluated for categorization accuracy and mean absolute error difference on the predicted LOS. SUBJECTS: A total of 10,353 patient records from the National Pediatric Trauma registry, representing all pediatric trauma patients treated at affiliated hospitals from April 1994 through December 1996. Records with incomplete information were eliminated from the study, leaving 8,081 usable patient records. MEASUREMENTS: A total of 14 variables are selected from the 81 values present in the National Pediatric Trauma Registry as independent variables for the artificial neural networks. Each neural network produces nine output values: five for categorizing the patient's injury severity, three for the LOS in the PICU, step-down unit, and floor units, and one for the patient's total LOS. RESULTS: A fuzzy ARTMAP neural network accurately categorizes 88% of mortality patients and 58.3% of critical PICU patients. A backpropagation neural network succeeded in predicting the total LOS to within 1 day for 51.4% and the ICU LOS to within 1 day for 70.4% of all evaluated patients. CONCLUSION: Information available in the first 10 mins of a patient's presentation at the emergency room can be used by an artificial neural network to predict injury severity and LOS. Artificial neural networks enable more effective resource planning and patient management.

Vaginal agenesis discovered during repair of high imperforate anus: operative management.

A girl born with laryngeal stenosis, tracheal esophageal fistula and esophageal atresia, imperforate anus, duodenal atresia, and Mayer-Rokitansky-Kuster-Hauser syndrome is presented. An explanation of the abnormalities and the surgical approach are presented.

Blunt cardiac injuries in children: a postmortem study.

We reviewed the records of the Chief Coroner for all pediatric (< 16 years of age) trauma fatalities in Ontario (pediatric population of 2 million) for the period January 1, 1988 through December 31, 1990. Forty-one (14.5%) of 282 patients for which complete autopsy data were available had sustained cardiac injuries. Nineteen patients (46%) died at the scene of the accident, 15 patients (37%) died in an emergency department, and seven patients (17%) died during hospitalization. Rupture of a cardiac chamber occurred in 16 cases; it was the main cause of death in eight cases and a contributing factor in the remainder. Cardiac contusion without chamber rupture was present in 25 cases, but in none of the cases was it the cause of death. Brain injury was the cause of death in 16 (64%) of the cases of cardiac contusion. Cardiac injuries are more common among children who die from blunt trauma than previous reports have suggested. However, because these injuries are often rapidly fatal, many patients die before they reach a hospital. With improvements in emergency medical services and the resulting reduction in transit time, more patients may reach trauma centers alive. A high index of suspicion and rapid diagnosis and treatment of these injuries can save the lives of some of these patients.

Pyloromyotomy: comparison between laparoscopic and open surgical techniques.

Several reports have appeared in the literature recently describing various techniques of performing pyloromyotomy laparoscopically. Although there is no doubt that this is now technically feasible, there are unanswered questions with regard to its safety, efficacy, and potential benefits or otherwise to the patient. In an attempt to resolve some of these issues, we compared the results in 37 infants who underwent open pyloromyotomy with 26 who underwent laparoscopic pyloromyotomy. The two groups were similar in terms of sex, age, weight, and presenting pH, although they could not be randomized. The time from feeding to discharge was less for the laparoscopic group (1.4 days) compared with the open group (1.8 days) (p = 0.04). Postoperative vomiting was not significantly different between the two groups. The operating time was identical for groups, 29 min vs 27 min. There were 3 complications in the open surgical group and 1 in the laparoscopic group. On the criteria measured, our results suggests that laparoscopic pyloromyotomy is at least as good as conventional surgery, and offers the potential benefits of shortened hospital stay and minimal cosmetic deformity.

Percutaneous localization of small pulmonary metastases, enabling limited resection.

An adolescent patient with Ewing's sarcoma, who had undergone three previous thoracotomies for pulmonary metastases, presented with two further left-sided pulmonary metastases, measuring 5 mm and 10 mm in diameter. Chemotherapeutic options were limited, and pulmonary irradiation was inadvisable because of compromised respiratory function. Surgical resection was the favored therapeutic option. A method of accurately localizing the small lesions was devised, using a percutaneous needling technique under computed tomography guidance and the injection of barium and methylene blue. This localization enabled resection of the lesions, with minimal excision and manipulation of the surrounding normal parenchyma. This technique is useful for removal of small impalpable metastases when other modalities of therapy are not appropriate.

Pyloromyotomy: why make an easy operation difficult?

Recently Ohri et al. advocated a modification to the standard pyloromyotomy for pyloric stenosis which they believed reduced postoperative vomiting. Their study had no control group to support their contention. We therefore compared 37 infants with hypertrophic pyloric stenosis who underwent a conventional longitudinal pyloromyotomy with the 37 infants reported by Ohri et al. who underwent a modified Ramstedt's pyloromyotomy. Data were recorded prospectively and the postoperative vomiting was assessed using the same scale as in the previous report. The incidence of vomiting was significantly less in the children undergoing the conventional operation (P = 0.03), suggesting that there is no justification for performing a double V-shaped pyloric incision in pyloric stenosis.

The physical, psychological, and socioeconomic costs of pediatric trauma.

This prospective study examined the physical, psychological, and socioeconomic effects of injuries on children and their immediate families. Ninety-two injured children admitted with minor (ISS less than 16) or major (ISS greater than or equal to 16) injuries were compared with a control group of 59 children admitted during the same period with acute appendicitis. The two populations were similar in mean age, sex ratio, parental age and work status, and number of siblings. The parents of the injured children had a lower level of education than those of the controls. Fifty-four percent of the minor injury patients and 71% of the major injury patients had persistent physical limitations at 12 months in contrast to none of the controls. Thirty-eight percent of minor injury patients had pre-existing behavioral disturbances compared with 14% of major injury patients and 10% of controls. Behavioral disturbances among major trauma patients showed a sharp rise to 41% at 12 months and tended to persist in cases with continuing physical limitations. The major injury patients and those with significant head injuries exhibited a decrease in academic performance; minor injury patients and those without head injury showed no change. Maternal malaise rose sharply to about 40% in both injury groups in contrast to 7% in the controls and was more common in the presence of persistent physical limitations. Only 73% of families in the major injury group had returned to normal family life compared with 87% of the minor injury group and 100% of controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous tracheostomy after trauma and critical illness.

A method of percutaneous tracheostomy (PT) using a tracheostome, which permits insertion of a full-sized cuffed tracheostomy tube, was evaluated in 61 critically ill or injured patients (89% had trauma). Of the 54 trauma patients, 65% had brain injuries, 14% had injuries to the cervical spinal cord, 33% had face or jaw injuries, and 15% had lung injuries. The indications for PT were coma (46%), acute airway obstruction (5%), face or jaw injury (20%), pneumonitis (39%), adult respiratory distress syndrome (12%), and sepsis (21%). Tracheostomy was done in 51% of all cases specifically for managing pulmonary secretions, in 37% for prolonged intubation, and in 25% for neurologic lesions. The tracheostomy was done as an emergency in 5%, as urgent in 28%, and electively in 77%. Percutaneous tracheostomy was successful in 90% of the cases, and in 8% it was converted to a surgical tracheostomy after an initial percutaneous attempt. In 46% it was performed at the bedside, in 46% in the operating room, and in 7% in the emergency suite. A full-sized tracheostomy tube (#6 to #8) was used in all cases and was considered optimal or larger than needed in 87% of cases. With three exceptions the complications of PT were minor, but 30% of the patients died of their primary disease. In one case death occurred because of bronchospasm and cardiac arrest during the PT, but appeared to be independent of the type of tracheostomy. Healing after in-hospital removal (37%) was excellent in 95% of cases and 97% of physicians indicated that they would use the device again.

Blunt trauma during pregnancy: factors affecting fetal outcome.

During a 9 1/2-year period, 76 pregnant women who sustained blunt trauma were admitted to a level-I trauma center. Fetal outcome was ascertained in 59 patients (78%). Successful delivery was noted in 35 patients (46%). Eight patients (11%) elected to undergo abortion for nonmedical reasons. Sixteen patients (21%) sustained fetal loss, and 17 patients (22%) were lost to follow-up. The 51 patients who either delivered successfully or experienced a fetal loss were studied to determine the factors that affected fetal outcome. Variables analyzed included gestational age and maternal age, Glasgow Coma Scale score, serum bicarbonate level, pH, PCO2, PO2, blood pressure, heart rate, Injury Severity Score, and performance of surgery or diagnostic peritoneal lavage. Logistic regression analysis revealed that ISS (p less than 0.01) and admission serum bicarbonate level (p less than 0.02) have the most significant correlation with fetal outcome. No other variable exhibited a statistically significant influence on fetal outcome. This information documents that fetal demise is related to severity of maternal injury as characterized by ISS. A low serum bicarbonate level corresponds to maternal hypoperfusion and hypoxia, which may be otherwise unrecognized because of the normal physiologic changes occurring during pregnancy. Based on these findings, routine serum bicarbonate determination in all pregnant patients being evaluated for trauma is advocated. Performance of DPL and surgery do not have a significant association with fetal loss and therefore should not be withheld when indicated in a pregnant patient.

Field triage--help or hindrance?

Field triage protocols have potential benefits in urban trauma systems, but for optimal effect they must be tailored to local needs and tested in each system for sensitivity and specificity. They should be implemented only by experienced physicians and surgeons who can monitor and adjust the protocol when necessary.

Trauma during pregnancy. A review of 79 cases.

Few studies provide data on pregnant trauma patients that can be used to direct management decisions. Therefore, this retrospective study of 79 pregnant patients who were injured and admitted to a trauma center during a 9-year period was conducted to obtain such information. Maternal mortality for these pregnant patients was 10%, which was not different from that for nonpregnant females. Overall, rate of fetal loss was 34%. Rates of fetal loss were not different in patients with and without evidence of shock and/or hypoxia or in restrained and unrestrained automobile occupants. Diagnostic peritoneal lavage proved to be 95% accurate and safe. Based on these findings, we concluded the following: pregnancy does not increase maternal mortality from trauma. Blood pressure, pulse rate, and PO2 are unreliable indicators of adequate maternal resuscitation and fetal well-being. Assumption of maternal and fetal stability based solely on these usually standard criteria is unwise. Use of seat belts during pregnancy is advisable in the absence of evidence that restraints increase the rate of fetal loss.

Value of CT in determining the need for angiography when findings of mediastinal hemorrhage on chest radiographs are equivocal.

The role of CT in determining the need for angiography in patients with possible thoracic vascular injury resulting from blunt trauma is controversial. During a 24-month period, we prospectively evaluated the results of CT to screen 90 patients with a history of decelerating thoracic trauma for evidence of mediastinal hemorrhage or great vessel abnormality. All patients either had equivocally abnormal mediastinal contours on chest radiographs (64%) or had technically suboptimal chest radiographs owing to body habitus or restriction to the supine projection (36%). Patients with unequivocal signs of mediastinal hemorrhage on chest radiographs underwent immediate arteriography without prior CT. Thoracic CT was interpreted as normal in 63 (77%) patients and no further imaging was performed. Five patients had technically suboptimal CT studies, and CT scans were interpreted as equivocal in six. These 11 patients had normal arteriograms. Sixteen CT scans (18%) demonstrated evidence of mediastinal hemorrhage and/or great vessel contour abnormality. Four (27%) of 15 patients who underwent arteriography had injury to the great vessels. One patient refused to undergo angiography. In 11 patients with CT evidence of mediastinal hemorrhage, major vascular injury was not seen on arteriography. These results suggest a valuable role for CT in determining the need for arteriography to detect potential great vessel injury in patients with blunt decelerating thoracic trauma and equivocally abnormal mediastinal contours on chest radiographs.

Evaluation of blunt abdominal trauma occurring during pregnancy.

Evaluation of abdominal trauma in pregnant patients presents a number of dilemmas. Few series compare the various modalities available in this situation. The present review characterizes various techniques and their results. The charts of all patients with a secondary diagnosis of pregnancy admitted to a Level I trauma center over a 7 1/2-year period were reviewed. Forty were considered to have sustained possible blunt abdominal trauma: 30 were occupants in motor vehicle collisions, five were pedestrians, four sustained falls, and one was riding a motorcycle. Immediate laparotomy for emergency caesarean section or other indications was performed in three cases (7%). In 13 cases (32%) evaluation was accomplished by diagnostic peritoneal lavage (DPL). Three patients (7%) underwent computerized tomography of the abdomen. The remaining 22 patients (55%) were observed with serial physical exams, and hematocrits. The group that was observed had a mean ISS of 5.9. The mean Glasgow Coma Score (GCS) was 14.9. No patients had to undergo exploratory laparotomy for abdominal injury during hospitalization. In the 13 patients undergoing DPL, the mean ISS was 34.6, and the mean GCS was 10.6. Overall accuracy was 92% with no major complications. Pregnant patients sustaining minor injuries and blunt abdominal trauma may be safely observed. Those with major injuries, shock, altered mental status, or neurologic deficit require further studies to rule out intra-abdominal injury. Diagnostic peritoneal lavage proved to be safe and accurate in these patients. Diagnostic peritoneal lavage proved to be safe and accurate in these patients. CT scan and ultrasonography are other modalities which merit further assessment as a primary diagnostic technique in abdominal trauma occurring during pregnancy.

Regulation of fatty acid biosynthesis in rats by physical training.

Physical training in the form of long-term nonexhaustive daily exercise was studied as a means of regulating fatty acid biosynthesis. Male rats were required to swim for periods up to 90 min/day. The exercise was carried out 6 days/wk for approximately 11 wk. Hepatic fatty acid biosynthesis and acetyl-CoA carboxylase [acetyl-CoA: CO2 ligase (EC 6.4.1.2)] activities were compared with nonexercised rats. At the end of the training period the exercised rats had a lower rate of fatty acid biosynthesis activity and a lower rate of acetyl-CoA carboxylase activity. The difference in acetyl-CoA carboxylase activity was due to a change in maximal velocity with no significant change in the Michaelis constant for acetyl-CoA. Untrained rats were subjected to a single bout of exercise. They also exhibited lower rates of fatty acid biosynthesis and acetyl-CoA carboxylase activities compared with nonexercised rats. However, the lower rates of these enzyme activities were sustained longer in the physically trained rats compared with the exercised untrained rats after the cessation of exercise. These results implicate acetyl-CoA carboxylase as a control site in the regulation of hepatic fatty acid biosynthesis by both physical training and acute exercise in rats. Possible inhibitory mechanisms are discussed.

Differences between manganese and magnesium ions with regard to fatty acid biosynthesis, acetyl-coenzyme A carboxylase activity and malonyl-coenzyme A decarboxylation.

Fatty acid-biosynthetic activity in rat liver cytosol fractions is much greater when the bivalent cation in the assay system is Mn(2+) than when it is Mg(2+). This difference between bivalent cations can be abolished if the cytosol fractions are preincubated with isocitrate and the bivalent cation for 30min before assay of fatty acid-biosynthetic activity. In a search for the biochemical basis of this phenomenon, the following differences between Mg(2+) and Mn(2+) were established: (1) Mn(2+) promotes acetyl-CoA carboxylase activity of the protomeric form of the enzyme under conditions in which Mg(2+) does not; (2) Mn(2+)+ATP have little inhibitory effect on the polymerization of acetyl-CoA carboxylase whereas Mg(2+)+ATP are markedly inhibitory; (3) under conditions in which utilization of malonyl-CoA in condensation reactions is prevented, the steady-state concentration of malonyl-CoA formed by a cytosol fraction is much greater with Mn(2+) than with Mg(2+). The role that each of these specific differences between Mn(2+) and Mg(2+) might play in causing liver cytosol preparations to have greater fatty acid-biosynthetic activity in the presence of Mn(2+) is discussed.