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Biomedical subjects

D E Fry

Publications and source records attributed to D E Fry.

At least 37 records · Page 2Linked to original sources
PubMed1998

Admission or observation is not necessary after a negative abdominal computed tomographic scan in patients with suspected blunt abdominal trauma: results of a prospective, multi-institutional trial.

OBJECTIVES: Hospitalization for observation is the current standard of practice for patients who have sustained blunt abdominal trauma and who do not require emergent operation, despite having undergone diagnostic studies that exclude the presence of an intra-abdominal injury. The reasons for this practice are multifactorial and include the perceived false-negative rate of all standard diagnostic tests, the belief that hospitalization will allow for the prompt diagnosis of occult injuries, and medicolegal considerations about the risk of early discharge. The focus of this study was to determine whether hospitalization for observation is necessary after a negative diagnostic evaluation after blunt abdominal trauma, to determine the negative predictive value of abdominal computed tomographic (CT) scanning in a prospective series of patients, and to identify which patients can be safely released from the emergency department without observation or hospitalization after blunt abdominal trauma. METHODS: In a prospective, multi-institutional study over 22 months at four Level I trauma centers, all patients with blunt abdominal trauma suspected by either physical examination or mechanism of injury were evaluated using the following protocol: physical examination in the emergency department, followed by abdominal CT scanning, followed by hospitalization for observation. The standardized physical examination was repeated between 4 and 8 hours. Outcomes were measured at 20 hours and at discharge and included clinical deterioration, the need for celiotomy, and mortality. Other data collected included demographics, mechanism of injury, and findings on physical examination and abdominal CT scanning. RESULTS: Three thousand eight hundred twenty-two consecutive patients with suspected abdominal trauma presented to the four trauma centers. Two thousand seven hundred seventy-four of these met study eligibility criteria and were prospectively enrolled. Of these, 2299 fulfilled the entire study protocol. CT scan was negative in 1,809 patients, positive for organ injury or abdominal fluid in 389 patients, and nondiagnostic in 78 patients. Abdominal tenderness or bruising was present in 1,380 patients (61%), but only 22% had a positive CT scan. Nineteen percent of patients with a positive CT scan had no tenderness. Computed tomography detected 22 of the 25 blunt intestinal injuries in this series. Free intraperitoneal fluid without solid visceral injury was present in 90 patients, and but only 7 patients had intestinal injuries. There were nine celiotomies in patients whose CT scan was initially interpreted as negative: six were therapeutic (intestine in three, bladder in one, kidney in one, and diaphragm in one), two were nontherapeutic, and one was negative. The negative predictive power of an abdominal CT scan based on the preliminary reading and as defined by the subsequent need for a celiotomy in the population fully satisfying the protocol was 99.63% (lower 95 and 99% confidence bounds of 99.31 and 99.16%, respectively). CONCLUSION: These data indicate that abdominal tenderness is not predictive of an abdominal injury and that patients with a negative CT scan after suspected blunt abdominal trauma do not benefit from hospital admission and prolonged observation.

Abdominal Injuries↗
PubMed1997

Treatment of pneumonia in mechanically ventilated trauma patients. Results of a prospective trial.

OBJECTIVES: To determine the efficacy and magnitude of associated adverse effects of 2 different antibiotic regimens for the treatment of pneumonia in intubated surgical patients and to assay and compare blood samples and bronchoalveolar lavage fluid with respect to some host-defense parameters, especially in patients with unilateral pneumonia. DESIGN: Randomized, prospective, unblinded clinical comparison of 2 treatment arms with respect to intent to treat and clinical and microbiologically evaluable patients. SETTING: Six university surgical services in teaching hospitals with modern and well-staffed intensive care units. INTERVENTIONS: The consistency and objectively of the diagnosis of pneumonia was improved by the use of a grid of diagnostic parameters. Aggressive mechanical approaches to pneumonia in intubated surgical patients were supplemented by therapeutic use of aztreonam and vancomycin hydrochloride or combined imipenem and cilastatin sodium. RESULTS: Patients randomized to the aztreonam-vancomycin group were somewhat more ill, fared slightly better, and had fewer serious drug-related side effects than did those treated with imipenem-cilastatin (all P > .05). Immunologic parameters assessed by evaluation of bronchoalveolar lavage fluid showed differences between infected pulmonary lobes and noninfected ones; some changes were also noted in patients who recovered compared with those whose pneumonia persisted or recurred. CONCLUSIONS: Clinical studies of pneumonia in surgical patients need to be stratified to assure comparability, to identify patients in whom treatment is likely to fail, and to display differences between more and less effective therapies. Studies of blood and bronchoalveolar lavage samples showed that certain local and systemic immunologic parameters correlate with clinical status and outcome.

Aztreonam↗
PubMed1996

The reemergence of mycobacterial infections.

In the early half of this century, infections due to Mycobacterium tuberculosis were quite common and were frequent causes of death and morbidity among the world population. Surgeons in the 1930s were quite sensitive to making the diagnosis of tuberculosis. All surgeons had considerable experience with thoracic surgical procedures for pulmonary tuberculosis. Moreover, tuberculosis was a significant cause of occupational infection among surgeons and other physicians. Thus, being able to diagnose the disease quickly and accurately was not only in the patient's best interest, but also allowed appropriate precautions to be exercised so that occupational infections of the health care team could be minimized.

Antitubercular Agents↗
PubMed1996

Glycohydrolases as markers of hepatic ischemia-reperfusion injury and recovery.

Advances in liver surgery and transplantation have lead to a steady increase in the number of these interventions. Prompt quantitative assessment of hepatic of hepatic function and a patient's subsequent morbidity and mortality following surgery remain difficult despite the currently utilized historic markers of hepatic parenchymal injury (e.g., aspartate transaminase [AST], lactate dehydrogenase [LDH] gamma-glutamyl transpeptidase [GGT]). Increases in serum glycohydrolase activities appear to provide sensitive and quantitative markers of hepatic ischemia/reperfusion injury. In 10 male swine (25 to 35 kg body weight) following 30, 45, and 90 minutes of acute hepatic ischemia, the systemic release of eight different glycohydrolases and lipid peroxides into serum were determined and compared with pre- and postischemic serum levels of LDH, GGT, and AST. The rapid release of glycohydrolases into serum was directly proportional to the length of the ischemic period from 30 to 90 minutes; e.g., beta-glucosidase, mean 1.9-fold increase at 30 minutes; 8.3-fold at 45 minutes; and 22.8-fold at 90 minutes; P < .002) and the activities peaked within the first 3 hours postischemia. In constrast, AST, LDH, and GGT were released slowly and peaked 20 to 30 hours after hepatic blood flow was restored. In swine with fatal outcomes (90 minutes of ischemia), all enzyme levels increased continuously during the final hours of life. However, in swine that survived hepatic ischemia/reperfusion injury (45 minutes of ischemia) the glycohydrolases, but not AST, LDH, and GGT, declined after 2 to 3 hours' postischemia and the serum lipid peroxide levels followed the same pattern. Serum beta-galactosidase and beta-glucosidase levels are sensitive markers that rise as quickly as traditional enzyme markers (AST, LDH, GGT) following hepatic ischemic injury; moreover, the glycohydrolases have the added value of serving as predictors of survival.

Acid Phosphatase↗
PubMed1996

The importance of antibiotic pharmacokinetics in critical illness.

Antibiotics are the most commonly used drugs in the surgical patient. Pharmacokinetics is the study of processes that result in the delivery of drugs to effector sites. Drug absorption, distribution, biotransformation, and excretion are the critical elements of drug delivery to effector sites. The biologic elimination half-life (t1/2) and the volume of distribution (Vd) are terms used to describe the active processes of pharmacokinetics; t1/2 and Vd are determined for antibiotics by employing healthy volunteers or minimally ill patients. From these data, dosing schedules for each antibiotic are determined. This article reviews the literature on the impact of critical illness and sepsis on antibiotic pharmacokinetics. The data identify that t1/2 may be reduced in the hyperdynamic states of stress and sepsis and that the Vd is expanded. These changes mean that currently accepted dosing regimens of antibiotics in critically ill patients are inadequate. Subtherapeutic antibiotic concentrations in these patients may account for treatment failures and may be of significance in the emergence of bacterial resistance.

Absorption↗
PubMed1995

Effects of oligosaccharide binding on glycogen debranching enzyme activity and conformation.

Glycogen debranching enzyme contains two catalytic activities (4-alpha-glucanotransferase and amylo-1,6-glucosidase) on its single polypeptide chain, and they are affected differently by the binding of oligosaccharides. Glucose, maltose, and maltotriose are competitive inhibitors of the amylo-1,6-glucosidase activity measured by the hydrolysis of alpha-glucosyl fluoride, whereas saccharides with four or more glucose units are activators of the same activity, showing apparent "uncompetitive" kinetics. This suggests that they do not bind until the alpha-glucosyl fluoride is bound. In either case the potency of the effect increases with the length of the oligosaccharide chain. On the other hand, all oligosaccharides tested (maltose to maltohexaose, alpha-cyclodextrin, and beta-cyclodextrin) are competitive inhibitors of the transferase activity and also cause a decrease in the intrinsic fluorescence, both functions again increased by chain length, thus indicating that these saccharides do bind to the free enzyme. These interesting results can be reconciled if the extended main chain resulting from the transferase reaction has to be reoriented into a different binding mode in order to position the alpha-1,6-linked side-chain glucose into the correct position for the glucosidase reaction. Therefore, activating oligosaccharides behave kinetically as if they had not been previously bound. It is concluded that the main chain of the natural limit dextrin substrate has a different mode of binding for the two catalytic reactions in order to position properly first the maltotetraosyl side chain in the transferase catalytic site and then the glucosyl side chain in the glucosidase catalytic site.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1995

Occupational risk of infection with human immunodeficiency virus.

The risk of HIV infection in surgical settings is a composite of overlapping risks related to the local prevalence of HIV, the route of exposure to HIV-infected blood, and the susceptibility of the worker. Studies continue to suggest that the risk of blood contact, including percutaneous injuries, remains appreciable. Prevention of such exposures in the operating and delivery room by adoption of safer instruments, work practices, and techniques and by the consistent use of appropriate personnel protective equipment must be viewed as a priority.

Acquired Immunodeficiency Syndrome↗
PubMed1995

Prevention of blood exposure. Body and facial protection.

Regardless of the specific clinical setting in the operating room, it is clear that better protection of all personnel is an appropriate objective in the current environment. Better protection through improved PPE and modification of operational practices is essential. A prompt response to blood contact when it does occur is likewise appropriate. With conscientious applications of methods to reduce blood exposure, it is hoped that the operating room can become a safer place with respect to occupational infections from bloodborne pathogens.

Blood-Borne Pathogens↗
PubMed1994

Human glucocerebrosidase catalyses transglucosylation between glucocerebroside and retinol.

The basal activity of human placental glucocerebrosidase is elevated 16-fold by n-pentanol when assayed using p-nitrophenyl beta-D-glucopyranoside (pNPGlc) as the beta-glucosidase substrate. This enhancement of activity is the result of the formation of a transglucosylation product, n-pentyl beta-D-glucoside, in rate-determining competition with the hydrolytic reaction. The transglucosylation product accounts for approximately 80% of the reaction product generated in the presence of n-pentanol (0.18 M) when either glucocerebroside or pNPGlc was used as the substrate. This stimulatory effect can be increased an additional 3-fold by the inclusion of phosphatidylserine (20 micrograms/ml) or sodium taurodeoxycholate (0.3%, w/v) in the incubation medium. In the presence of retinol, glucocerebrosidase also catalyses the synthesis of a novel lipid glucoside, retinyl glucoside, when either glucocerebroside or pNPGlc serves as the substrate. The reaction product was identified as retinyl beta-D-glucoside, based on its susceptibility to hydrolysis by almond beta-D-glucosidase and the subsequent release of equimolar amounts of retinol and glucose. The rate of retinyl-beta-glucoside formation is dependent on the concentration of retinol in the incubation medium, reaching saturation at approximately 0.3 mM retinol. Retinyl beta-D-glucoside is a substrate for two broad-specificity mammalian beta-glucosidases, namely the cytosolic and membrane-associated beta-glucosidases of guinea pig liver. However, retinyl beta-D-glucoside is not hydrolysed by placental glucocerebrosidase. These data indicate that the glucocerebrosidase-catalysed transfer of glucose from glucocerebroside to natural endogenous lipid alcohols, followed by the action of a broad-specificity beta-glucosidase on the transglucosylation product, could provide mammals with an alternative pathway for the breakdown of glucocerebroside to glucose and ceramide.

Animals↗
PubMed1994

Nosocomial blood-borne infection secondary to intravascular devices.

A total of 143 patients with 159 episodes of intravascular device, blood-borne infection were studied. All infections were confirmed by the same organism being recovered from blood culture and by semiquantitative culture of the catheter tip. Sites of infection included the peripheral venous line (n = 72), central catheter (n = 49), arterial line (n = 18), subclavian dialysis catheter (n = 12), Swan-Ganz catheter (n = 4), Broviac catheter (n = 3), and transvenous pacemaker wires (n = 1). Staphylococcus aureus (n = 78) and Staphylococcus epidermidis (n = 33) predominated as pathogens. Excessive length of catheterization was implicated as directly responsible for this complication in patients with peripheral intravenous and arterial lines. Nosocomial staphylococcal bacteremia must be considered secondary to an indwelling intravascular device until proven otherwise. Appropriate therapy requires removal of the catheters, excision of the vein if suppuration or persistent bacteremia is identified, and specific antibiotic therapy.

Arteries↗
PubMed1994

Peritoneal cultures and antibiotic therapy in pediatric perforated appendicitis.

We retrospectively reviewed 70 cases of perforated appendicitis in children to examine the relationship between postoperative antibiotic selection and culture results from the peritoneal cavity. Initial antibiotic therapy chosen for the children consisted of a three-drug combination in 54 (77%) patients. Peritoneal cultures were performed in 58 (83%) patients. Escherichia coli and Bacteriodes fragilis were the most common bacterial isolates from the peritoneal culture. Only 7 (10%) patients had their antibiotic regimen changed after the culture results were available, of which 2 changes brought drug therapy into compliance with the cultures and 5 changes were inappropriate with respect to the peritoneal cultures. Of the remaining 51 patients with culture data available, 39 should have had changes to bring the antibiotic therapy into compliance with the observed culture results. These data indicate that surgeons select antibiotic therapy for perforated appendicitis in children based on assumptions of which organisms should be present in the infection and not on culture data. There appears to be no clinical usefulness to the routine culturing of the peritoneal cavity in children with perforated appendicitis.

Anti-Bacterial Agents↗
PubMed1994

Evaluation of pulmonary infections in patients with extremity fractures and blunt chest trauma.

The use of preventive antibiotics has become the standard of care in the management of patients with multiple trauma who have injuries at risk for infection. In many areas of surgical practice, preventive antibiotic utilization has been restricted to the perioperative period only. In this study we reviewed a series of trauma patients with combined blunt chest injuries and extremity fractures to determine whether the duration of postoperative antibiotic administration would have adverse effects upon nosocomial pneumonia rates and severity.

Adolescent↗
PubMed1994

Noninvasive imaging tests in the diagnosis and treatment of intra-abdominal abscesses in the postoperative patient.

The postoperative surgical patient poses special problems in the diagnosis of intra-abdominal abscess. A natural evolution has occurred over the last 20 years from purely clinical impressions being used to initiate reoperations for abscess to the present scenario, in which sophisticated CT scans permit minimally invasive drainage methods. The CT scan has become the diagnostic imaging method of choice, with other techniques serving a very limited role at the present time.

Abdomen↗
PubMed1993

Decreased renal excretion of beta-hexosaminidase in adults with insulin-dependent diabetes mellitus and normal renal function.

The activities of three lysosomal hydrolases and creatinine levels were measured in the plasma and urine of 11 adults (mean age, 28.1 years) with insulin-dependent diabetes mellitus and 14 non-diabetic controls (mean age, 27.9 years). All of the patients were free of diabetic complications and non exhibited microalbuminuria. Fractional enzyme excretion (FEE) values between the two groups of subjects were calculated and compared for the following enzymes: beta-hexosaminidase (N-acetyl-glucosaminidase), beta-glucuronidase and alpha-galactosidase. The FEE value was calculated as the ratio of enzyme clearance to creatinine clearance. Relative to the non-diabetic control group, the FEE value for beta-hexosaminidase was approximately 2-fold lower (P = 0.02) in the diabetic subjects (means, 0.424 vs. 0.242, respectively). The FEE values for beta-glucuronidase and alpha-galactosidase were not significantly different (P > 0.4) between the diabetic and control groups. These easily measured biochemical parameters in blood and urine and the resultant FEE value for beta-hexosaminidase may provide a means of assessing subtle deteriorative changes in renal function which occur in the early stage of diabetes before the onset of clinically evident complications.

Adult↗
PubMed1993

Postoperative pneumonia in the intensive care unit.

Postoperative pneumonia in the surgical patient may occur from atelectasis and inadequate postoperative TV, from ventilator-associated pathophysiology and from aspiration. Each process ultimately elicits the proinflammatory responses from the lung in the effort to eradicate the infectious pathogens. Postoperative pneumonia is best prevented by maintaining a clear understanding of the biologic basis for infection in the lung. Therapy requires aggressive tracheobronchial drainage strategies and antibiotic therapy directed toward the pathogens that are producing the pulmonary inflammatory response.

Humans↗