Biomedical subjects

Alfred A Bartolucci

Publications and source records attributed to Alfred A Bartolucci.

33 records · Page 2Linked to original sources

PubMed2004

Video-assisted thoracoscopic surgery using single-lumen endotracheal tube anesthesia.

BACKGROUND: Most general thoracic surgeons use double-lumen endotracheal tube (DLET) anesthesia for all video-assisted thoracoscopic surgery (VATS). We evaluated a single-lumen endotracheal tube (SLET) for VATS for drainage of pleural effusions and pleural biopsies. METHODS: A consecutive series of patients with recurrent pleural effusions underwent VATS using an SLET and only one incision. Operations were accomplished via one 2-cm incision using a 5-mm rigid thoracoscope and mediastinoscopic biopsy forceps for directed pleural biopsies. A working area was accomplished with low tidal volumes. RESULTS: There were 376 patients (191 women). The indications for VATS were a nondiagnosed or benign pleural effusion in 294 patients, and a malignant effusion in 82 patients. Two hundred eight patients underwent biopsy of the parietal pleura, and mean operative time was 17 min. Adequate visibility was obtained in all. When compared to preoperative cytology, VATS was more sensitive (45% compared to 99%, p < 0.001), had a higher negative predictive value (56% compared to 99%, p < 0.001), and was more accurate (67% compared to 99%, p < 0.001). Forty-seven percent of patients with a history of cancer had false-negative preoperative cytology results. Complications occurred in seven patients (2%), and there were three operative deaths (none related to the operative procedure). CONCLUSION: VATS using SLET and only one incision is possible, and it affords excellent visualization of the pleural space, allowing pleural biopsies and talc insufflation. It avoids the risk, time, and cost of a DLET. It is significantly more sensitive and accurate than preoperative cytology, and it should be considered as the diagnostic and therapeutic procedure of choice in patients with recurrent pleural effusions.

Adult↗

PubMed2004

Fast tracking after Ivor Lewis esophagogastrectomy.

OBJECTIVES: We streamlined our care using an algorithm for the postoperative care of patients who undergo Ivor Lewis esophagogastrectomy to try to reduce hospital stay to 7 days and maintain safety and patient satisfaction. METHODS: A consecutive series of 90 patients who underwent elective esophageal resection by one general thoracic surgeon were studied. An algorithm to guide postoperative care was used, featuring avoidance of the ICU, early ambulation, jejunal tube feeds starting on postoperative day (POD) 1, removal of nasogastric tube and epidural on POD 3, a gastrograffin swallow on PODs 4 or 5, and discharge on POD 7. RESULTS: There were 90 patients (70 men). Fifty-two patients (58%) underwent preoperative radiation and chemotherapy. Esophagectomies were done for cancer or high-grade dysplasia. Forty-two of the last 55 patients (77%) went directly to the floor. Sixteen patients (17.7%) had major complications, which included pneumonia in 5 patients and aspiration pneumonia in 4 patients. There were no anastomotic leaks, and there were four operative deaths (4.4%). There was a greater incidence of failure to fast track, and to have a major complication in patients who underwent neoadjuvant treatment (p = 0.025 and p = 0.048, respectively). Median hospital stay was 7 days (range, 6 to 74 days). Complications or mortality could not be definitively attributed to fast tracking. Ninety-seven percent reported excellent satisfaction with their hospital stay, and four patients were readmitted within 1 month of discharge. CONCLUSIONS: Fast tracking patients using an algorithm after esophageal resection is safe and delivers minimal morbidity and mortality, and a high patient satisfaction rate. A median hospital stay of 7 days is possible, and the ICU can be avoided in most patients.

Adult↗

PubMed2004

Applications of Bayesian statistical methods in microarray data analysis.

Microarray technology allows one to measure gene expression levels simultaneously on the whole-genome scale. The rapid progress generates both a great wealth of information and challenges in making inferences from such massive data sets. Bayesian statistical modeling offers an alternative approach to frequentist methodologies, and has several features that make these methods advantageous for the analysis of microarray data. These include the incorporation of prior information, flexible exploration of arbitrarily complex hypotheses, easy inclusion of nuisance parameters, and relatively well developed methods to handle missing data. Recent developments in Bayesian methodology generated a variety of techniques for the identification of differentially expressed genes, finding genes with similar expression profiles, and uncovering underlying gene regulatory networks. Bayesian methods will undoubtedly become more common in the future because of their great utility in microarray analysis.

Bayes Theorem↗

PubMed2004

A critical analysis of the Chiari 1.5 malformation.

OBJECT: Although the traditional nomenclature used to describe hindbrain hernias is useful, there are certainly patients in whom these morphological entities do not strictly apply. One such group is composed of patients with the more recently described Chiari 1.5 malformation in which a Chiari I malformation is seen in combination with brain-stem herniation through the foramen magnum. In an attempt to elucidate further the best surgical strategy and to refine the descriptive terminology, the authors retrospectively analyzed all cases at their institutions in which this form of hindbrain herniation was diagnosed. METHODS: The authors reviewed the database for all patients in whom Chiari 1.5 malformation had been diagnosed. Each patient had undergone a posterior fossa decompressive surgery. Magnetic resonance images were evaluated for the extent of caudal descent of the brainstem, amount of tonsillar ectopia, inclination of the odontoid process, and any brain or brainstem abnormalities. Clinical presentations and postoperative results were correlated to the aforementioned radiological findings. Twenty-two patients were identified. The obex was a mean 14.4 mm inferior to the foramen magnum, and the medulla exhibited a flattened appearance in the midsagittal plane in all patients. Syringomyelia was documented in 50% of the cases. The cerebellar tonsils were found to lie at C-1 and C-2 in nine and 13 patients, respectively. The mean angulation of the odontoid process was 84.4 degrees. No abnormalities or caudal descent of the midbrain or pons was identified. Eighteen patients experienced resolution of preoperative symptoms. Persistence of syringomyelia prompted a second posterior fossa operation secondary to progressive scoliosis in 13.6% of the patients. CONCLUSIONS: No single sign or symptom was found to be peculiar to the Chiari 1.5 malformation, although all patients in whom this diagnosis was established had undergone a posterior fossa decompressive surgery. A significant number (13.6%) of patients required repeated operation for persistent syringomyelia. Neurosurgeons may wish to consider that many patients may not respond as well to posterior fossa decompressive surgery especially if syringomyelia is present.

Adolescent↗

PubMed2003

Intracostal sutures decrease the pain of thoracotomy.

BACKGROUND: General thoracic surgeons spend much time dealing and treating patients' pain after thoracotomy. METHODS: Two hundred eighty consecutive patients underwent elective thoracotomy for pulmonary resection. Patients with a history of chronic pain were excluded. One general thoracic surgeon performed all procedures. All patients had a functioning preoperative epidural, a skin incision the width of their latissimus dorsi muscle which was cut, sparing of the serratus anterior muscle, undercutting of the rib, preemptive analgesia of the intercostal nerve before rib spreading, and similar number of chest tubes and postoperative pain management. The first 140 patients had their chests closed with pericostal sutures (stitches placed on top of the fifth rib and on top of the seventh rib), and the next 140 patients had their chest closed with intracostal sutures (stitches placed on top of the fifth rib and through the small holes drilled in the bed of the sixth rib). Pain was objectified by a numeric pain score and by the McGill pain questionnaire at 2 weeks, and 1, 2, and 3 months postoperatively. RESULTS: There were 140 patients in each group, and the groups were matched for age, gender, race, types of pulmonary resections, number of chest tubes, number of broken ribs, length of chest tube duration, and length of hospital stay (p > 0.05 for all). The mean pain score for the pericostal group (P group) at 2 weeks, 1 month, 2 months, and 3 months postoperatively was 5.5, 3.8, 2.3, and 1.6, respectively. For the intracostal group it was 3.3, 1.7, 1.1, and 0.6, respectively (p = 0.004, p = 0.0001, p < 0.0001, and p < 0.0001, respectively). Descriptors of pain in the P group were more likely to be, hot/burning, shooting or stabbing (p < 0.003). CONCLUSIONS: Intracostal sutures seem to be less painful than pericostal sutures at 2 weeks, 1 month, 2 months, and 3 months after thoracotomy. The pain is less likely to be described as burning or shooting.

Aged↗

PubMed2003

Intraoperative solumedrol helps prevent postpneumonectomy pulmonary edema.

BACKGROUND: Postpneumonectomy pulmonary edema and pneumonia are life threatening and seemingly unavoidable complications after pneumonectomy. We theorized that an intraoperative dose of intravenous steroids (as a prophylactic measure to reduce pulmonary injury to the remaining lung) just before pulmonary artery ligation might decrease this problem. METHODS: Seventy-two patients (52 men) who had pneumonectomy during two time periods were studied prospectively. Thirty-five patients received 250 mg of methylprednisolone sodium succinate (Solumedrol; Upjohn, Kalamazoo, MI) just before pulmonary artery ligation (S group) and 37 did not (non-S group). Groups were matched for known or suspected preoperative, intraoperative, and postoperative risk factors for postpneumonectomy pulmonary edema. RESULTS: The incidence of postpneumonectomy pulmonary edema or adult respiratory distress syndrome was less in the S group (0 of 35, 0% versus 5 of 37, 13.5%, p = 0.049), the overall major complication rate was less in the S group (7 of 35, 20% versus 16 of 37, 43%, p = 0.04), and the length of hospital stay was shorter in the S group (6.1 days versus 11.9 days, p = 0.02). In addition, there were no bronchopleural fistulas in the S group compared with two (both right-sided) in the non-S group. CONCLUSIONS: The intraoperative intravenous administration of 250 mg of methylprednisolone sodium succinate just before pulmonary artery ligation during pneumonectomy may reduce the incidence of postpneumonectomy pulmonary edema and adult respiratory distress syndrome as well as decrease other major complications and shorten the hospital stay. It does not seem to increase the incidence of bronchopleural fistula. Further randomized trials are needed.

Anti-Inflammatory Agents↗

PubMed2003

A prospective, double-blinded, randomized trial evaluating the use of preemptive analgesia of the skin before thoracotomy.

BACKGROUND: Thoracic surgeons spend a lot of time treating the pain of thoracotomy. METHODS: A total of 119 consecutive patients underwent elective thoracotomy. They were prospectively randomized into two groups. One group received an injection of 1% lidocaine with epinephrine in the planned skin incision just before thoracotomy, and the other group received an equal amount of saline and epinephrine. All patients had a functioning preoperative epidural; a skin incision the width of their latissimus dorsi muscle, which was cut; sparing of the serratus anterior muscle; undercutting of the sixth rib; intercostal nerve blocks before rib spreading; a similar number of chest tubes and pulmonary resections; and comparable postoperative pain management. Pain was objectified by a numeric pain score, a visual pain score, and by the Modified McGill pain questionnaire each day in the hospital, and at 3, 6, and 12 months postoperatively. RESULTS: There were 66 patients in the lidocaine group (L group) and 53 patients in the saline group (S group). Although a trend was noted toward less pain in the L group during the first 3 postoperative days (on the numeric pain scale only) the difference was not statistically significant in overall pain in the hospital or at 3, 6, and 12 months after the operation. Other pain scores and descriptors were similar throughout. CONCLUSIONS: The injection of lidocaine and epinephrine in the skin just before thoracotomy does not decrease the amount or type of pain during the hospital stay or at 3, 6, and 12 months after surgery.

Analgesia↗

PubMed2003

Late gestational intrauterine myelomeningocele repair does not improve lower extremity function.

OBJECTIVE: To determine whether intrauterine myelomeningocele repair performed at between 20 and 28 weeks gestation improves lower extremity function (LEF). METHODS: Thirty-seven consecutive patients who had undergone intrauterine repair of their myelomeningocele at Vanderbilt University Medical Center had their lower extremity function and radiographic level (first defective vertebral level) compared to these same parameters in 40 controls who had undergone traditional postgestational repair of their myelomeningocele at the Children's Hospital in Birmingham, Ala., USA. RESULTS: Of all 77 patients (controls and study group), 13 had a LEF that matched their radiographic level, 27 had a LEF that was rostral to their radiographic level, and 37 had a LEF that was caudal to their radiographic level. Further stratification revealed that for the intrauterine repaired myelomeningoceles, 11% had no difference between LEF and radiographic level, 43% had a LEF that was rostral to their radiographic level, and 46% had a LEF that was caudal to their radiographic level. For those closed in a traditional manner, LEF matched their radiographic level, was rostral to their radiographic level, and was caudal to their radiographic level in 22.5%, 27.5%, and 50% respectively. However, the overall mean differences between institutions produced a p-value of 0.2026 (paired t-test). CONCLUSIONS: Although the current timing of intrauterine myelomeningocele repair has been found to lessen the degree of herniation of the rhombencephalon and reduce the incidence of shunt-dependent hydrocephalus, it does not statistically improve LEF. Parents should be advised of these findings prior to surgical intervention so as to focus their expectations.

Female↗

PubMed2003

Children with growth hormone deficiency and Chiari I malformation: a morphometric analysis of the posterior cranial fossa.

OBJECTIVE: The posterior fossa (PF) has been found to be small in various forms of Chiari malformation. Explanations involving a connection between growth hormone deficiency (GHD) and Chiari I malformation (CIM) have been proposed. However, to date, no quantitative analysis of the PF of patients with CIM and GHD has been performed. Our study was performed to determine the geometry of the PF in children with GHD and CIM. METHODS: Morphometric analysis of the PF was performed in 10 children with GHD and CIM (group 1), 20 children with GHD and no CIM (group 2) and 50 controls. RESULTS: PF volumes for group 1 ranged from 128 to 259 +/- 33 ml, and for group 2, they ranged from 115 to 186.2 +/- 25.4 ml. Lengths of the foramen magnum for groups 1 and 2 had means of 36 and 38 mm, respectively. The mean basiocciput length and tentorial angle for groups 1 and 2 were 20 and 19 mm and 89 and 87.5 degrees, respectively. CONCLUSIONS: We have determined that children with GHD with or without CIM have no significant difference in their PF volume compared to controls. However, our data demonstrate significant underdevelopment of portions of the bony PF in both patients with GHD alone and in patients with GHD and CIM. Tentorial angles were elevated in noncontrol groups. We propose that this association is not due to an increased rate of 'midline' defects seen in GHD but rather a structurally distorted PF that is not capacious enough to house the entire developing rhombencephalon. These data will hopefully aid in the further understanding of the pathophysiology of CIM.

Adolescent↗

PubMed2002

A comparison of methods and materials for the analysis of leaded wipes.

The purposes of this study are: (1) to determine whether proficiency analytical test (PAT) materials from the American Industrial Hygiene Association can be used to provide quality data for portable X-ray fluorescence analysis (XRF) of lead in dust wipe surface samples; (2) to provide data to determine whether the on-site analysis of field dust wipe samples by XRF and the laboratory method of inductively coupled plasma emission analysis (ICP) are comparable; and (3) to determine if differences exist between different wipe materials. Several wipes meet the ASTM E1792 performance requirements of lead background level less than 5 microg per wipe, be only one layer thick, yield recovery rates of 80- 120% from spiked samples, remain damp throughout the sampling procedure, and do not contain aloe. The wipes used in this study were Pace Wipes, which are used for the PAT materials, and, for the field samples, Palintest Wipes, which were supplied by the instrument manufacturer, and Ghost Wipes, which are popular because they digest in hot, concentrated acid, so that chemical analysis is simplified. Twenty PAT wipe samples were obtained from four different proficiency test rounds. Surface wipe samples were taken at three different locations representing different industry types. All samples were analyzed using a portable XRF spectrometer and by ICP. Strong linear relationships were found for the analysis of wipe samples by ICP and by portable XRF. For the PAT samples, the results from the ICP and XRF analysis were not statistically equivalent, which indicates a bias in the ICP analysis. The bias was not excessive, since all ICP analyses fell within the acceptable range for the proficiency samples. The good correlation between the proficiency sample reference values and the XRF determinations is not surprising considering similar proficiency samples were used to calibrate the instrument response. Users of this portable XRF analyzer could enroll in the proficiency test program as part of their quality assurance program. For field samples, the relationship was strongest for Palintest wipes, and the values found for all three industries could be combined. However, the results from the ICP and XRF analysis were not statistically equivalent using the correction factor in the calculation algorithm as supplied with the instrument, and a new coefficient was derived. The mean relative error for the XRF analysis versus the ICP analysis was greater than 25%, such that the method falls within the realm of screening procedures. For Ghost Wipe samples, the precision was different for different industries, and the results could not be pooled. Differences between the two wipe materials may be related to the number of folds required for analysis.

Dust↗

PubMed2002

Nonlinear stress-strain behavior of periodontal ligament under orthodontic loading.

Previous studies of the periodontal ligament (PDL) have applied high forces to the dental units to examine the stress-strain behavior of this soft tissue. In this study, cadaveric specimens of mandibular premolars from 2 young adult and 2 elderly adult donors were tested to determine the biomechanical behavior of the PDL over an orthodontic force range. Transverse specimens were prepared from 9 premolars and subjected to loading in intrusion and extrusion. Stress-strain curves for both loading directions had distinct toe and linear regions, demonstrating nonlinear behavior of the PDL. The average linear shear modulus was higher for intrusion than for extrusion. The toe extrusive modulus was higher for the young group, and extrusive toe size was larger for the elderly group. In extrusion, the average modulus was higher for the cervical margin and the apex regions than for the midroot regions. The size of the toe region was smaller for intrusion than extrusion. The results indicate age-dependent, location-dependent, and load-direction-dependent nonlinear properties of the human PDL and suggest that analytical computer simulations of orthodontic tooth movements might benefit from incorporating the nonlinear material properties of the PDL.

Adult↗

PubMed2002

Immunological responses are not abnormal in symptomatic Gulf War veterans.

The underlying etiology and pathogenesis of Gulf War veterans' illnesses continue to be under intense investigation. Reports have suggested the basis for these illnesses may be an altered immune system, but compelling evidence is lacking. We sought to determine whether in vitro immune responses were abnormal in symptomatic Gulf War veterans relative to matched controls. A randomized case-control study was conducted by blinded comparison of laboratory measures of in vitro immune responses in blood samples obtained from veterans in an outpatient facility of a Veterans Affairs medical center. Symptomatic Gulf War veterans with otherwise undefined illnesses (52 symptomatic subjects), asymptomatic Gulf War veterans (31 asymptomatic controls), and veterans who had applied for disability compensation and had not participated in the Gulf War (21 disability controls) represented the volunteer sample. In vitro cellular and humoral immune responses were measured to detect functional abnormalities in antigen presenting cells (autologous mixed leukocyte reactions and expression of interleukin (IL)-1beta, IL-6, IL-10, and tumor necrosis factor-alpha); T cells (lymphocyte proliferation using the polyclonal T-cell activators phytohemagglutinin and Concanavalin A; primary immune responses in allogeneic mixed leukocyte reactions; secondary immune response using the recall antigens tetanus toxoid, Candida albicans, and anthrax vaccine; and soluble IL-2 receptor expression); type-1 T-helper cells (gamma interferon expression); type-2 T-helper cells (IL-4 and IL-10 expression); and B cells (polyclonal B-cell activator pokeweed mitogen-induced immunoglobulin production). In general, immune response measures did not differ significantly between groups. Heightened responses observed in the disability control group (sporadically greater responses to one mitogen and two antigens) and the Gulf War participation control group (greater recall responses to anthrax vaccine) did not suggest impaired immune cell function in symptomatic veterans when compared with controls. We conclude that in vitro immunological responses are not abnormal in symptomatic Gulf War veterans.

Adult↗

PubMed2002

Horizontal sacrum as an indicator of a tethered spinal cord.

The horizontal sacrum has never been described as an indicator of a tethered spinal cord following myelomeningocele closure. We retrospectively analyzed 30 children with a myelomeningocele for this progressive change and its correlation with symptoms. At least two lateral radiographs over time were examined and the lumbosacral angle (LSA) was measured. We found that the majority of these children had an LSA that was greater than would be expected in patients with late and decreased ambulatory abilities. Also, we observed that the LSA was often inappropriately increased at the time many of these patients presented with symptoms indicative of a tethered spinal cord. We hypothesize that the LSA in this group of children is altered by a tethered spinal cord and that the horizontal nature of the sacrum may predate the clinically appreciable symptoms of a tethered spinal cord.

Child↗

PubMed2002

Telephone intervention with family caregivers of stroke survivors after rehabilitation.

BACKGROUND AND PURPOSE: Social problem-solving therapy shows promise as an intervention to improve the well-being of family caregivers. There is some evidence that training in problem solving may be effectively delivered by telephone. The purpose of this study was to quantify the impact of social problem-solving telephone partnerships on primary family caregiver outcomes after stroke survivors are discharged home from a rehabilitation facility. METHODS: Using a randomized 3-group repeated-measures experimental design, 74 stroke survivors with an admitting diagnosis of ischemic stroke and their primary family caregivers were entered into the study. The intervention consisted of an initial 3-hour home visit between a trained nurse and the family caregiver within 1 week after discharge to begin problem-solving skill training. This initial session was followed by weekly (the first month) and biweekly (the second and third month) telephone contacts. RESULTS: Compared with the sham intervention and control groups, family caregivers who participated in the social problem-solving telephone partnership intervention group had better problem-solving skills; greater caregiver preparedness; less depression; and significant improvement in measures of vitality, social functioning, mental health, and role limitations related to emotional problems. There were no significant differences among the groups in caregiver burden. Satisfaction with healthcare services decreased over time in the control group while remaining comparable in the intervention and sham intervention groups. CONCLUSION: These results indicate that problem-solving training may be useful for family caregivers of stroke survivors after discharge from rehabilitative facilities.

Adaptation, Psychological↗

PubMedDate not supplied

Social integration and life and family satisfaction in survivors of injury at 5 years postinjury.

This study assessed the relationship of social integration (SI) to life satisfaction and family satisfaction among survivors 5 years after injury. Thirty-four matched pairs of injured patients were interviewed by telephone 60 months after initial discharge from the acute care setting. Respondents were matched according to sex, race, education, injury severity, and employment status before comparing high and low socially integrated persons on measures of family and life satisfaction. High and low SI groups were formed based on the Craig Handicap Assessment and Reporting Technique (CHART) SI Scale. The former consisted of patients scoring 100; the latter consisted of patients scoring 50 or less. Analyses of covariance, with age and injury type as covariates, were used to test for group differences. The high and low SI groups differed on both the life and the family satisfaction measures, with the high SI group reporting greater life and family satisfaction.

Adult↗