Effects of tracheostomies on infection and airway complications in pediatric burn patients

Considerable controversy exists as to whether tracheostomy is ever indicated in burn patients. New advents in the treatment of inhalation injury have improved survival, making the use of tracheostomy more usual. The purpose of this study was to analyze the outcome of tracheostomies, and the effect of time on complications. Patients requiring ventilatory support and tracheostomies were studied. Demographic data, hospital course, ventilatory parameters and complications were analyzed. Two hundred ninety patients required ventilation and 36 tracheostomy. Mean percentage of TBSA burned was 59%+/-4. Ninety percent of these patients presented with inhalation injury. Mortality in tracheostomy patients was 25 and 16% in all ventilated patients. Thirty-five percent of the patients developed late complications. Patients who had their airway converted to tracheostomy before day 10 postinjury had a significantly lower incidence of subglottic stenosis. and patients who required airway pressures over 50 cm H2O for more than 10 days had a significantly higher incidence of tracheomalacia. Pneumonia occurred at similar incidence in ventilated and tracheostomy patients. The mortality and late complications of pediatric burn patients with tracheostomy has decreased over the last decade. They do not present with higher incidence of pneumonia. Maintenance of airway pressures below 50 cm H2O and conversion of the artificial airway to tracheostomy before day 10 postinjury may be advisable in patients requiring long term ventilation to prevent late complications.     

Contents Volume 32 No. 1 (2000) Section One: International Urology and Nephrology

Table of Contents

Contents Volume 32 No. 1 (2000) Section One: International Urology and Nephrology     

Percutaneous nephrolithotripsy in ectopic kidneys

BACKGROUND: Percutaneous nephrolithotomy (PCNL), although an accepted treatment modality in anatomically normal kidneys, is still not universally performed for calculi in pelvic ectopic kidneys. Fear of injury to abdominal viscera makes it a technically challenging procedure. PATIENTS AND METHODS: We have performed PCNL in nine patients with calculi in pelvic ectopic kidneys. Technical factors which made this procedure safe include ultrasound-guided puncture, use of a mature tract or an Amplatz sheath, routine postoperative double-J stenting, and nephrostogram prior to nephrostomy tube removal. RESULTS: Complete stone clearance was achieved in all cases. Six patients were treated in a single stage, while three patients required two stages. Seven patients needed only one tract, and two needed two tracts. No notable complications were encountered. The average hospital stay was 5.2 days. CONCLUSION: With proper precautions and meticulous technique, PCNL is a safe and effective modality to treat calculi in pelvic ectopic kidney.     

Unusual massive neurinoma in the suboccipital region--case report

An 8-year-old boy with no evidence of von Recklinghausen's disease presented with an unusual neurinoma manifesting as a gradually progressive swelling in the suboccipital region over 2 years. The lesion was massive and had widely eroded the posterior aspects of the atlas, axis, and suboccipital bone. The tumor had involved the dura of the sigmoid and transverse sinuses, was highly vascular, and had encased the ipsilateral vertebral artery. The tumor was almost completely resected although with considerable loss of blood through a large rent in the right sigmoid sinus. This unusual benign neurinoma most probably arose from the second cervical ganglion.     

Basaloid squamous cell cancer arising in Barrett’s esophagus

Basaloid squamous cell carcinoma (BSCC) is a rare form of cancer that arises primarily in the upper aerodigestive tract. Esophageal BSCC is extremely rare, accounting for less than 2% of primary esophageal malignancies. It is histopathologically distinct from squamous cell carcinoma and has an aggressive biological behavior with poor survival outcomes. There is no known association of Barrett’s esophagus with esophageal BSCC. Here, we report what we believe is the first such case of esophageal BSCC occurring in the setting of Barrett’s esophagus.     

Comparative mouse skin tumorigenicity and induction of Ha-ras mutations by bay region diol epoxides of 5-methylchrysene and 5,6- dimethylchrysene

We compared the tumor-initiating activities toward mouse skin of two structurally related polycyclic aromatic hydrocarbon diol epoxides: racemic anti-1,2,3,4-tetrahydro-5,6-dimethylchrysene-1,2-diol-3,4- epoxide (5,6-diMeCDE) and racemic anti-1,2,3,4-tetrahydro-5- methylchrysene-1,2-diol-3,4-epoxide (5-MeCDE). Tumors induced by these diol epoxides were analysed for mutations in the Ha-ras gene. 5,6- diMeCDE is derived from the non-planar parent compound 5,6- dimethylchrysene, and reacts to approximately equal extents with dA and dG in DNA, whereas 5-MeCDE is derived from a nearly planar parent compound, 5-methylchrysene, and reacts mainly with dG in DNA. 5,6- diMeCDE, at initiating doses of 33, 100 or 400 nmol per mouse, induced 1.2, 2.2 and 6.2 skin tumors per mouse, respectively. It was significantly less tumorigenic than 5-MeCDE which induced 3.1, 7.5 and 9.1 skin tumors per mouse at the same doses. Tumors induced by 5,6- diMeCDE had a large number of CAA-->CTA mutations in codon 61 of the Ha- ras gene: 50, 55 and 75% of the tumors analysed had this mutation at the 33, 100 and 400 nmol doses. No mutations were found in codons 12 and 13 in the tumors induced by 5,6-diMeCDE. In contrast, CAA-->CTA mutations in codon 61 were rarely seen in tumors induced by 5-MeCDE. At the highest dose of 5-MeCDE, 20% of the tumors analysed had mutations at G of codons 12 and 13. The results of this comparative study support the hypothesis that mutations in the Ha-ras gene in mouse skin tumors induced by PAH diol epoxides occur as a result of their direct reaction with the gene. However, pathways other than the commonly observed Ha- ras codon 61 mutations are clearly important in mouse skin tumorigenesis by these diol epoxides.      

Gradient correction and classification of CT lung images for the automated quantification of mosaic attenuation pattern

PURPOSE: The detection of density differences, or "mosaic attenuation pattern," on CT images may be difficult when the regional inhomogeneity of the density of the lung parenchyma is subtle. The purpose of this work was to develop a fully automated method for the reproducible quantification of the underattenuated areas of the lung parenchyma. This technique may be useful in increasing the precision of investigation of structure/function relationships. METHOD: Anatomical segmentation was achieved by a structure-filtering operator based on mathematical morphology. To compensate for the density gradient visible on lung CT scans, a model-based iterative deconvolution filter and an adaptive clustering algorithm were developed. Validation was performed with CT images from a lung phantom, 15 patients with constrictive obliterative bronchiolitis, and 8 normal subjects. RESULTS: The accuracy of the estimate of the density gradient on phantom studies was 93.3%. The automated quantification of the areas of decreased attenuation on scans of constrictive obliterative bronchiolitis was within 8.2% from the average scoring of two experienced observers. CONCLUSION: The proposed technique is fully automated and can accurately correct for density gradient and classify areas of decreased attenuation on lung CT images.     

Glutamatergic dysfunction in OCD.

The role of glutamatergic dysfunction in the pathophysiology of OCD has hardly been explored despite recent reports implicating glutamatergic dysfunction in OCD. We decided to investigate CSF glutamate levels in adult OCD probands compared to psychiatrically normal controls. In total, 21 consenting psychotropic drug-na?ve adult OCD patients, diagnosed using SCID-IV-CV, and 18 consenting psychiatrically normal controls with age within 10 years of age of the patients, who did not have any history of head injury or neurological illness, were included into the study. Aseptically collected and stored CSF samples obtained from the patients and control subjects were used for glutamate estimation, which was carried out by a modification of the procedure described by Lund (1986). CSF glutamate (micromol/l) level was found to be significantly higher [F(1,31)=6.846, p=0.014] in OCD patients (47.12+/-4.25) compared to control subjects (41.36+/-3.63) on analysis of covariance. There was no effect of gender, age, duration of illness, Y-BOCS score, or CGI-S score on CSF glutamate levels. Our study provides preliminary evidence implicating glutamatergic excess in the pathophysiology of OCD, which needs to be further explored by studies from other centers involving larger sample sets from different age groups.     

Surgery for Syringomyelia: An Analysis Based on 163 Surgical Cases

Summary ? Object. The authors analyzed the cases of 163 patients with syringomyelia to assess the appropriate surgical procedure. Methods. Depending on the aetiological factors and treatment considerations the series was classified into three groups. Group I were cases where there was no definite demonstrable aetiological factor; Group II cases had basilar invagination and/or Chiari malformation; and Group III consisted of cases where the syrinx was secondary to an obvious aetiology, such as a mass lesion either in the posterior cranial fossa or in the spine or a severe kyphotic spinal deformity. Post-traumatic syringomyelia and syrinx in association with spina bifida were not studied. Conclusions. We concluded that for Group I cases syringosubarachnoid shunting is the ideal form of treatment. In Group II cases foramen magnum bony decompression is satisfactory and physiological. Good results were obtained even in cases where either a foramen magnum decompression alone or in combination with a syringo-subarachnoid shunt was done. Only syringosubarachnoid shunt (without a foramen magnum decompression) in Group II cases was found to produce poor outcome. Group III cases should be treated for the primary aetiological problem. Only syrinx drainage procedure without treatment of aetiology in these cases produced poor results. It was observed that clinical outcome rather than radiological improvement is the reliable indicator of the surgical result.     

Value of ultrasonography in laryngeal and laryngopharyngeal cancers

High-resolution sonography has improved in the past few years and has become a very valuable tool in the diagnosis of diseases of the head and neck. Ultrasonography (US) is commonly the first imaging modality after clinical examination. It is inexpensive, noninvasive and is easily tolerated by patients. It provides valuable diagnostic information with a high degree of diagnostic accuracy. This article provides the most up-to-date information about the indications, findings and limitations of high-resolution sonography in the evaluation of laryngeal and laryngopharyngeal cancers.