William P. Tunell

Surveillance and prevention of residential-fire injuries

BACKGROUND The majority of severe and fatal burn injuries result from residential fires. We studied the effectiveness of a smoke-alarm-giveaway program in the prevention of burn injuries in an area with a high rate of such injuries. METHODS We collected data on burn injuries in Oklahoma City from September 1987 through April 1990. The target area for the intervention was an area of 24 square miles (62 km2) with the highest rate of injuries related to residential fires in the city. We distributed smoke alarms door to door in the target area and then surveyed alarm use and function in a sample of the homes that had received an alarm. We also calculated the rates of fire injury per 100,000 population and per 100 fires for both the target area and the rest of the city before and after the smoke-alarm giveaway. RESULTS Before the intervention the rate of burn injuries per 100,000 population was 4.2 times higher in the target area than in the rest of Oklahoma City. An initial survey indicated that 11,881 of the 34,945 homes in the target area (34 percent) did not have smoke alarms. A total of 10,100 smoke alarms were distributed to 9291 homes; 45 percent were functioning four years later. The annualized fire-injury rates declined by 80 percent in the target area during the four years after the intervention (from 15.3 to 3.1 per 100,000 population), as compared with a small increase in the rest of the city (from 3.6 to 3.9 per 100,000 population). There was also a 74 percent decline in the target area in the injury rate per 100 fires (from 5.0 to 1.3; rate ratio, 0.3; 95 percent confidence interval, 0.1 to 0.6), as compared with a small increase in the rest of the city. CONCLUSIONS A targeted intervention involving a smoke-alarm-giveaway program can reduce the incidence of injuries from residential fires.

Gastroesophageal reflux following percutaneous endoscopic gastrostomy in children

The frequency and clinical significance of gastroesophageal reflux (GER) in patients after percutaneous endoscopic gastrostomy (PEG) was determined. Ten children, aged 11 months to 15 years, who had normal preoperative extended esophageal pH monitoring were restudied after PEG. Of the ten patients, six developed GER with a pH score significantly higher than their initial one (40.5 +/- 3.3 pre-PEG v 129.5 +/- 24.2 post-PEG, P less than .005). Similarly, the mean post-PEG pH score was higher in patients with GER than in those without a change in score (129.5 +/- 24.2 v 33.8 +/- 2.8, P less than .005). None of these patients was symptomatic for GER immediately after the PEG, but within 10 months of surgery, three of six (50%) developed reflux-related symptoms. These data indicate that clinically significant GER is associated with PEG.

An appropriate negative bronchoscopy rate in suspected foreign body aspiration

Aspiration of foreign bodies in children can lead to illness and even death if not recognized and treated promptly. Seventy-six patients were referred to our hospital for suspected foreign body aspiration. The following is a retrospective review of their diagnosis and treatment. There was no foreign body found at bronchoscopy in seven patients (9 percent), and there were nine patients (12 percent) with bronchial foreign bodies who had a delay in diagnosis of foreign body aspiration. The delay averaged 35 days. These children, as a result of a prolonged period before diagnosis, were treated unnecessarily for pneumonia and asthma. Once correctly diagnosed, they had a significantly longer hospital stay. We propose that some negative bronchoscopies are necessary in order to prevent the morbidity that occurs from a missed foreign body aspiration.

Lower esophageal pressure changes with tube gastrostomy: a causative factor of gastroesophageal reflux in children?

In children, Stamm tube gastrostomy can initiate gastroesophageal reflux (GER) or worsen preexisting GER. We identified a possible mechanism for this problem in 25 children with GER who had esophageal manometry performed in conjunction with an antireflux operation. Intraoperative lower esophageal high pressure zone (LEHPZ) pressure and length were recorded for a simulated gastrostomy in all patients prior to performing the antireflux operation. These same parameters were then recorded for a simulated (11 patients) or real gastrostomy (14 patients) following the antireflux procedure. The LEHPZ pressure decreased with simulated Stamm gastrostomy (7.8 +/- 1.1----6.6 +/- 1.1 mm Hg, NS: Normal = 11.2 +/- 0.9 mm Hg). This decrease was less significant than the decrease in LEHPZ length (1.1 +/- 0.1----0.8 +/- 0.1 cm, P less than .01: Normal = 1.3 +/- 0.1 cm). Following Boerema gastropexy, simulated gastrostomy produced a similar decrease in LEHPZ pressure (20.8 +/- 3.8----17.1 +/- 2.7 mm Hg, NS) and length (3.3 +/- 0.4----2.5 +/- 0.3 cm, P less than .025). The LEHPZ pressure and length were not decreased by real gastrostomy performed with modified Thal fundoplication or with Nissen fundoplication. Thus, a decrease in LEHPZ length may be one mechanism whereby GER is initiated or worsened by tube gastrostomy in children. Tube gastrostomy has a similar effect when performed with a Boerema gastropexy, but not when performed with a Nissen or modified Thal fundoplication.

The risk of sudden infant death from gastroesophageal reflux

Gastroesophageal reflux (GER) has been a suspected cause of infant deaths and sudden infant death syndrome (SIDS). We examined our 10-year experience with 499 consecutive infants 6 months of age or less who had extended (18 to 24 hours) esophageal pH monitoring performed to evaluate for GER. The data extracted from the esophageal pH records included the pH score, the pattern of GER (type I, II, or III), and the mean duration of reflux during sleep (ZMD). All infants were followed to determine the occurrence and cause of death during the first year of life. Of the 19 deaths found in the series, three were classified as SIDS and two were in-hospital deaths caused by reflux-induced aspiration. All five of these infants who died had a prolonged ZMD (greater than 3.8 minutes) and received either basic medical (n = 4) or no (n = 1) antireflux therapy. Four infants also had the type I pattern of GER. There was a 9.1% (4/44; 95% confidence limits, 2.5% to 21.7%) incidence of reflux-related or SIDS deaths in infants with type I GER and a prolonged ZMD who were treated nonoperatively, compared with none (0/83, P = .03) in the same group of infants treated with antireflux surgery. The incidence of SIDS was higher in infants with type I GER and a prolonged ZMD who were treated nonoperatively (3/44, 6.8%) compared with all other infants treated nonoperatively (0/265, 0%; P = .003).(ABSTRACT TRUNCATED AT 250 WORDS)

Imperforate anus: The neurologic implication of sacral abnormalities*

The association of imperforate anus with bony sacral abnormalities and neurologic deficits is well recognized. These neurologic deficits have been considered static rather than progressive. However, recent experience indicates that some patients may develop progressive neurologic problems due to spinal cord lesions that are amenable to neurosurgical correction. To investigate the frequency of such lesions, routine myelography of imperforate anus patients with sacral anomalies was undertaken. The extraordinarily high incidence of unsuspected lesions known to cause progressive bowel, bladder, and musculoskeletal dysfunction is the basis of this interim report. Thirty percent of patients with anorectal abnormalities had sacral dysplasia. Of the nine patients undergoing myelography to date, eight have been abnormal. Six children had a tethered spinal cord, one had narrowing of the bony spinal canal and dural sac stenosis, and one an anterior meningocele. Spinal cord conditions that may cause deterioration of bowel, bladder, and extremity function should be defined and corrected before irreversible damage occurs. Because of the high incidence of spinal cord lesions detected in these patients with coexisting anorectal and sacral anomalies, routine screening for spinal cord lesions is recommended.

Abdominal wall defects in infants. Survival and implications for adult life.

OBJECTIVE The authors study reviewed patients who underwent operations for omphalocele and gastroschisis to determine survival, morbidity, and long-term quality of life. METHOD Clinical follow-up of 94 patients cared for with omphalocele and gastroschisis during a 10- to 20-year period after birth. RESULT Eighty-three patients survived initial treatment. Sixty-one had long-term follow-up. Mean follow-up in the group was 14.2 years. Survival was favorable in the absence of lethal or co-existing major congenital anomalies. Nineteen patients required 31 reoperations, most for abdominal wall hernias and the sequelae of intestinal atresia. Current quality of life was described as favorable (good) in 80% of patients. CONCLUSIONS Survival rate in patients with abdominal wall defects is favorable and deaths occur substantially in patients with co-existing lethal, or multiple, congenital anomalies. Reoperative surgery is necessary principally in those patients who have postclosure abdominal wall hernias, and in those with bowel atresia at birth. Reoperations are not likely to be necessary after school age. Quality of life in survivors is patient-perceived as entirely satisfactory.

Gastroesophageal reflux in childhood. The dilemma of surgical success.

Successful surgical correction of gastroesophageal reflux has prompted frequent and early referral of children for antireflux surgery. This report describes the results and defines the complications in a series of children treated surgically for gastroesophageal reflux. Methods are suggested to reduce the occurrence of these postoperative complications. In five years (1977–1981), 117 children, 3 weeks to 16 years old, were operated on for gastroesophageal reflux at The Oklahoma Childrens Memorial Hospital. Nissen fundoplication was performed on 111 of them. Patients have been followed for 3 months to five years. At most recent examination, clinical success (remission of symptoms) has been accomplished in 81 of 92 patients (90%). In 86 patients evaluated radiographically, gastroesophageal reflux was absent in 83 and persistent in 3. There were no operative deaths. Twenty-three major complications occurred in 21 patients, 13 of whom required reoper-ation. These major complications were paraesophageal hiatal hernia (ten patients), small bowel obstruction (eight patients), and wrap malalignment (5 patients). Observations of and re-operation on these children suggests the following necessary steps for avoidance of complications in children: (1) Nissen fundoplication in childhood should be accompanied by an accurate multi-suture crural repair and by suture fixation of the fundal wrap to the crura and to the abdominal surface of the diaphragm; (2) appropriate alignment of the fundal wrap and of the crural repair is best accomplished with a large indwelling esophageal bougie of sufficient size to efface and blanche the esophageal musculature; and (3) appropriate care in avoiding small bowel obstruction mandates meticulous avoidance of trauma to the liver capsule and small bowel serosa.

Neuroradiologic evaluation of sacral abnormalities in imperforate anus complex

Neurologic impairment and sacral spinal anomalies are a finding in children with imperforate anus. The neurologic deficits previously had been considered static rather than progressive. Recent experience at this institution has documented the frequent association of imperforate anus patients having bony sacral and other spinal deformities with progressive neurologic dysfunction. These deficits are related to underlying spinal cord anomalies, which may be amenable to neurosurgical correction. To investigate the nature and frequency of such lesions, spinal cord imaging was done in these patients. From July 1976 to June 1985, 106 patients with imperforate anus were screened with plain radiographs of the sacral spine; 37 (35%) patients had abnormalities. Of these, 26 have been evaluated with a variety of spinal cord imaging techniques, including magnetic resonance imaging (18), digital metrizamide myelotomography (14), computed tomography (10), metrizamide myelography (5), or ultrasound (4). Four patients were lost to follow-up, and seven have not yet been studied. Fifteen of the 26 patients (53%) had one or more abnormal studies. Thirteen were considered to have progressive dysfunction with operable lesions and have undergone neurosurgical correction. At follow-up, there was improved leg function in five patients and improved bladder function in two patients. No patient had additional neurologic deficits after surgery. Because of the high incidence of progressive but potentially correctable myelodysplasias in patients with coexisting anorectal and sacral anomalies, routine radiographic screening of the spine is recommended, followed by spinal cord imaging and neurosurgical evaluation if warranted.

Nonoperative management of subcapsular hematomas of the liver

The liver is the second most common organ injured in blunt abdominal trauma, and with the use of diagnostic techniques such as hepatic scanning, an increasing number of patients with intrahepatic lesions are being identified. Five patients with this type of lesion are presented. A plan of managament, including observation in an intensive care unit, repeated physical examinations, frequent reevaluation of laboratory values, bed rest, gastrointestinal tract decompression and broad spectrum antibiotics, is suggested as the treatment of choice for this type of injury. All patients in the series have done well with no abscess formation, delayed rupture of hemobilia, and all show resolution of the defect on following-up hepatic scanning.