Biomedical subjects

D P Jaques

Publications and source records attributed to D P Jaques.

15 recordsLinked to original sources

PubMed1997

Appendectomy. Improving care through quality improvement.

OBJECTIVE: To evaluate the practice of appendectomy in Department of Defense hospitals worldwide in a large-scale quality improvement initiative. DESIGN: Case series study. POPULATION AND SETTING: A total of 4950 consecutive nonincidental appendectomies performed in 147 Department of Defense hospitals worldwide during a 12-month period ending January 31, 1993. RESULTS: The mean age was 25.5 years, with 64% males and 36% females. The patients were assigned a diagnosis of normal appendix (negative appendectomy) in 632 cases (12.8%), acute appendicitis in 3286 cases (66.4%), and perforative appendicitis in 1032 cases (20.9%). The influence of inpatient and outpatient delays on perforation and negative appendectomy rates were studied. In at least 52% of all patients ultimately assigned a diagnosis of perforative appendicitis, the perforation occurred before the first outpatient contact with the health care system, and in at least 68% of all patients ultimately assigned the diagnosis of perforative appendicitis, the perforation occurred before surgical evaluation and admission. Neither outpatient delay in diagnosis nor inpatient delay in diagnosis and treatment was associated with a significant change in the rate of negative appendectomy. CONCLUSIONS: Perforation rates are determined predominantly by patient- and primary care-related factors over which surgeons have little control. Negative appendectomies are predominantly related to the wide overlap in presenting signs and symptoms between appendicitis and the diseases that most often mimic it but do not require operative intervention. Whereas studies of this type are useful for identifying potential problems at the health care system level, the relatively small number of appendectomies performed by each surgeon precludes analysis at the practitioner level.

Adolescent↗

PubMed1997

Appendectomy: a contemporary appraisal.

OBJECTIVE: The authors present an accurate and comprehensive snapshot of appendicitis and the practice of appendectomy in the 1990s. METHODS: Appendectomies were performed on 4950 patients in 147 Department of Defense hospitals worldwide over a 12-month period ending January 31, 1993. RESULTS: The median age was 23 years (range, 6 months to 82 years) with 64% males and 36% females. The patients were assigned a diagnosis of normal appendix in 632 (13%) cases, acute appendicitis in 3286 (66%) cases, and perforated appendicitis in 1032 (21%) cases. There were no differences in perforation and normal appendix rates between those operations performed in teaching hospitals versus community hospitals or between high-volume hospitals (> or = 100 appendectomies/year) versus low-volume hospitals. Both a preoperative temperature > or = 100.5 and a preoperative leukocyte count > or = 10,000 were incapable of discriminating between patients with appendicitis and those with a normal appendix. Multivariate analysis showed a significantly increased risk of perforation associated with age younger than or equal to 8 years (38% vs. 18%) and age older than or equal to 45 years (49% vs. 18%). Females had a significantly higher rate of normal appendices (19% vs. 9%) and a lower rate of perforation (18% vs. 23%). The complication rates to include reoperation and intraabdominal sepsis were markedly increased in those patients with perforation. There were four deaths in this series (0.08%). CONCLUSIONS: Despite a marked decline in associated mortality over the past 50 years, rates of perforation and negative appendectomy remain unchanged because they are influenced strongly by factors untouched by the intervening technologic advances.

Acute Disease↗

PubMed1996

Death and dollars: the cost of dying in the surgical intensive care unit.

INTRODUCTION: The effect of resuscitation status on the use of laboratory and radiologic studies was analyzed in patients at the Walter Reed Army Medical Center's Surgical Intensive Care Unit. METHODS: A retrospective assessment of laboratory and radiologic charges incurred during the last 48 hours of life by 81 patients who died in the Surgical Intensive Care Unit between 1990 and 1992 was performed. Data were analyzed after separation by patient's resuscitation status. Each patient was assigned a resuscitation category: no limitation, do not resuscitate (no CPR in event of arrest), or limited therapy (specific order limiting care or monitoring). RESULTS: There were 4,095 laboratory tests performed for a total charge of $191,247. Arterial blood gas testing accounted for over $75,000 of these charges. Resuscitation status significantly affected test frequency. CONCLUSIONS: During the last 48 hours of life in an intensive care unit, the use of laboratory tests and radiologic exams has a substantial effect on the cost of care and is modified by the patient's resuscitation status.

Adolescent↗

PubMed1995

Long-term impact of previous breast biopsy on breast cancer screening modalities.

Approximately 80% of breast biopsies are performed for what proves to be a benign process. The patients who undergo these procedures should continue screening with breast physical examination and mammography. The long-term impact of breast biopsy on these screening modalities has not been well studied. We performed a prospective, follow-up evaluation in 63 patients who underwent needle localization biopsy with benign histology at our institution between 6 and 7 years ago. This evaluation consisted of a directed history, breast physical examination, and follow-up mammogram. Two patients (3%) had undergone mastectomy for an interval breast cancer; 17 others (28%) had undergone subsequent biopsies. No patient had changes on physical examination of the biopsy site. All mammograms were evaluated as normal or as having benign abnormalities. Excisional breast biopsy does not generally produce long-term changes affecting the interpretation of breast physical examination or mammography.

Aged↗

PubMed1995

Pediatric appendectomy.

PURPOSE: To define patterns of care and outcome for pediatric appendectomy. METHODS: A study was designed to evaluate all pediatric appendectomies performed in the 147 Department of Defense hospitals worldwide. Cases of nonincidental appendectomy were identified through discharge diagnoses and operative logs, and 98.6% of the charts were retrieved for review. All charts were abstracted, and data were entered into a 127-field database for analysis. RESULTS: Over a 12-month period, ending January 1993, appendectomy was performed on 1,366 pediatric patients in the Department of Defense hospital system. The patients' median age was 12 years (range, 6 months to 18 years); 59% were male. The diagnosis was normal appendix for 157 patients (12%), acute nonperforated appendicitis for 930 (68%), and perforated appendicitis for 279 (20%). Age < or = 8 years was predictive (P < .001) of a higher rate of perforated appendicitis (33% v 18%) but was not predictive of normal pathology (13% v 11%). Female gender was associated with a significantly higher rate of normal pathology (17% v 8%; P < .001) but not of perforation (18% v 22%). Temperature elevation and right lower quadrant pain and tenderness did not clinically distinguish between diagnostic groups. Sixty-two percent of patients with a normal appendix had a white blood cell count of more than 10,000/mm3, as did 91% of patients with acute or perforated appendicitis. Those with perforated appendicitis received pre- and postoperative antibiotics, primarily ampicillin/gentamicin/clindamycin or Flagyl (41%), cefoxitin (34%), or Unasyn (15%). In 77% of this subgroup, intraoperative cultures were positive, with isolates for Escherichia coli (76%) Enterococcus (30%), Bacteroides (24%), and Pseudomonas (20%) predominating. There were no deaths. Major complications occurred in 1.2% of patients with acute appendicitis and in 6.4% of those with perforated appendicitis; there were no major complications in the group with normal appendectomies. The hospitalization period was more than 7 days for 1.6%, 40%, and 3.8%, respectively. CONCLUSION: This large series, from a large number of hospitals, with multiple practitioners, can serve as a community standard for pediatric appendectomy in the 1990s.

Abdominal Abscess↗

PubMed1995

Hepatic metastases from soft-tissue sarcoma.

OBJECTIVE: Hepatic metastases from soft-tissue sarcoma are evaluated to define treatment and its limitations. METHODS: From 981 adult patients with diagnoses of soft-tissue sarcoma, 65 patients with hepatic metastases were studied. RESULTS: An intra-abdominal primary site was present in 61 of 65 patients, with 85% high-grade leiomyosarcoma. Hepatic resection was performed in 14 patients (22%). All patients have had recurrences after hepatic resection-11 of 14 in the liver--with a median survival of 30 months. Chemotherapy resulted in partial response in three patients and no complete responses. Survival is not influenced by grade, type, primary site, disease-free interval, chemotherapy, or hepatic resection. CONCLUSIONS: The uncommon response to conventional chemotherapy does not support its use in the treatment of hepatic metastases from soft-tissue sarcoma. Extent of disease limits the application and success of hepatic resection for soft-tissue sarcoma, and anything less than complete resection is not indicated.

Adult↗

PubMed1994

Selective digital enhancement of conventional film mammography.

Screening mammography continues to play a key role in the early diagnosis of non-palpable breast cancer. Approximately 5% of patients will have lesions on their mammograms that appear neither clearly benign nor malignant. The proper management of these patients is not well defined. In this study, the mammograms of 64 women who underwent breast biopsy were reviewed. After the initial review, the mammograms were reevaluated using a personal computer driven digital conversion and enhancement system. The majority of indeterminate lesions were assigned a determinate diagnosis by enhancing the areas of abnormality through enlargement, contrast adjustment, and brightness adjustment. The radiologists were able to maintain baseline sensitivity and specificity throughout this process. In contrast, enhancement of lesions initially assigned a diagnosis of characteristically benign or malignant demonstrated no advantage over plain film mammography. These findings suggest a role for the selective use of digital mammography and enhancement techniques.

Adult↗

PubMed1990

Patterns of cervical node metastases from squamous carcinoma of the larynx.

We undertook a retrospective review of 247 previously untreated consecutive patients from 1965 to 1986 with primary squamous cell carcinoma of the supraglottic or glottic larynx to ascertain the prevalence of neck node metastases by neck level. The 247 patients underwent a total of 262 radical neck dissections. Patients were grouped by clinical neck status at the time of neck dissection: elective dissection in the NO neck; immediate therapeutic dissection in the N+ neck; and subsequent therapeutic dissection in the NO neck that over time converted clinically to N+. Detailed analysis revealed a predominance of neck node metastases in levels II, III, and IV for all clinical neck groups. Level V was rarely involved, but always in conjunction with neck node metastases in levels II, III, or IV (ie, N2 disease). Level I was rarely involved; involvement occurred with neck node metastases in levels II, III, or IV 75% of the time. Level I involvement correlated with T3 or T4 primary tumors exhibiting histologic extralaryngeal spread. These data support the trend toward selective limited neck dissection in both NO and N1 patients.

Carcinoma, Squamous Cell↗

PubMed1990

Suture granuloma masquerading as malignancy of the biliary tract.

Eighteen years after having a duodenal leiomyosarcoma resected, a patient presented with weight loss, pruritus, and abdominal pain. ERCP was consistent with a cholangiocarcinoma with proximal hepatic duct stricture and nonfilling of the cystic duct. CAT scan revealed no extrinsic masses compressing the gallbladder or biliary tract. At surgical exploration, the patient was found to have a suture granuloma with surrounding fibrosis within the common bile duct. There was no evidence of malignancy.

Adenoma, Bile Duct↗

PubMed1990

Management of primary and recurrent soft-tissue sarcoma of the retroperitoneum.

From 1982 to 1987, 114 patients underwent operation at Memorial Sloan-Kettering Cancer Center for soft-tissue sarcoma of the retroperitoneum. A retrospective analysis of these patients defines the biologic behavior, surgical management of primary and recurrent disease, predictive factors for outcome, and impact of multimodality therapy. Complete resection was possible in 65% of primary retroperitoneal sarcomas and strongly predicts outcome (p less than 0.001). The rate of complete resection was not altered by histologic type, size, or grade of tumor. These patients had a median survival of 60 months compared to 24 months for those undergoing partial resection and 12 months for those with unresectable tumors. Forty-nine per cent of completely resected patients have had local recurrence. This is the site of first recurrence in 75% of patients. These patients undergo reoperation when feasible. Complete resection of recurrent disease was performed in 39 of 88 (44%) operations, with a 41-month median survival time after reoperation. Tumor grade was a significant predictor of outcome (p less than 0.001). High-grade tumors (n = 65) were associated with a 20-month median survival time compared to 80 months for low-grade tumors (n = 49). Gender, histologic type, size, previous biopsy, and partial resection versus unresectable tumors did not predict outcome by univariate analysis. Adjuvant radiation therapy and chemotherapy could not be shown to have significant impact on survival. Concerted attempt at complete resection of both primary and recurrent retroperitoneal soft-tissue sarcoma is indicated.

Actuarial Analysis↗

PubMed1990

Biliary tract melanoma.

A case of melanoma of the upper extremity with a solitary metastasis to the common bile duct is reported. A comprehensive review of melanoma in the biliary tree is presented. Antemortem diagnoses of such cases are rare but are associated with a high percentage of disease clinically confined to the biliary tree. Patients with such lesions have survived long periods of time after palliative surgery. Therefore, surgical resection is recommended as the treatment of choice in patients able to tolerate surgery.

Adult↗

PubMed1989

Major amputation for advanced malignant melanoma.

The Memorial Sloan-Kettering Cancer Center experience with major amputation for advanced malignant melanoma from 1965 to 1984 is reported. This is a retrospective review of 58 patients who underwent hemipelvectomy, disarticulation of the hip and above knee or forequarter amputation for advanced or recurrent malignant melanoma. Major amputation with curative intent was performed upon 43 patients. There were three deaths that occurred 30 days postoperatively (7 per cent). Intransit metastasis was one of the indications for amputation in 33 patients, and local control of disease was achieved in 30 of 43 patients. The median time to recurrence in those patients who did have a recurrence was 12 months (a range of 18 days to 16 years). Fifteen of 40 patients who survived the operation had no evidence of disease five years after undergoing a major amputation. Age, sex, primary site, stage of disease at diagnosis and amputation, disease-free interval and positive node status at any time during the course of the disease were not predictive of the outcome. Neurovascular involvement with melanoma and positive margins of resection predicted early failure. A palliative amputation for impending major vascular disruption or extensive, fungating disease was performed upon 15 patients. There was one death 30 days after the operation, and generally, hospitalization did not exceed 30 days. Median survival time was five months. All of the patients died of local or distant disease within 33 months of treatment. Local recurrence preceded death in nine of 15 patients.

Adolescent↗

PubMed1988

Analysis of prognostic variables and results after vertical partial laryngectomy.

A consecutive series of 197 patients who underwent conservation surgery for squamous cell carcinoma of the glottic larynx was analyzed. The majority of patients were male. One hundred forty-one had stage I disease, 44 had stage II, and 12 had stage III disease at the time of treatment. Partial laryngectomy was performed in 25 patients who had recurrent cancer after previous definitive radiotherapy and in 5 patients who had previously undergone cordectomy. There was no operative mortality and postoperative morbidity was low. Local recurrence developed in 32 patients (17 percent); cervical metastasis developed in 8 patients. The determinate survival rates at 3 and 5 years were 92 percent and 87 percent, respectively. Multivariate analysis showed soft-tissue margins and tumor differentiation as the two significant covariates in predicting survival. Positive surgical margins were also significant covariates affecting local recurrence. These data suggest that conservation surgery is an effective treatment for early vocal cord carcinoma. Adequate surgical margins are essential. Postoperative irradiation should be considered in patients with inadequate margins.

Adult↗

PubMed1988

Analysis of prognostic variables and results after supraglottic partial laryngectomy.

A consecutive series of 78 patients who underwent conservation surgery for squamous cell carcinoma of the supraglottic larynx is analyzed. The majority of the patients were middle-aged men who had early-stage disease, with only 18 patients in stage III and 6 in stage IV. The epiglottis was the most frequent site, followed by the aryepiglottic fold and other sites in the supraglottic larynx. There was no operative mortality and the complication rate was low. Univariate analysis showed no influence of tumor stage, tumor differentiation, or involved surgical margins on survival. Determinate survival rates of 85 percent at 3 years and 72 percent at 5 years were observed. Local recurrences took place in 12 patients, 4 of whom were salvaged by total laryngectomy; neck failure occurred in 13 patients, 7 of whom were salvaged after further treatment; and 1 of the 2 patients with distant metastasis was salvaged after further treatment. We believe that every patient with a favorable lesion of the supraglottic larynx should be considered for conservation surgery, specifically, supraglottic partial laryngectomy, adhering to the criteria mentioned. Initial surgical treatment offers excellent local control and 5 year survival. Adjuvant postoperative radiotherapy may be considered in those patients with bulky primary tumors, positive surgical margins, and histologically confirmed cervical lymph node metastases.

Adolescent↗

PubMed1985

Mycobacterium avium infection in a silicone-injected breast.

A case of atypical mycobacterial infection (M. avium intracellulare) in a silicone-injection augmented breast is described. The silicone injection may have been a contributing factor to the development of this unusual infection. Disseminated M. avium was present in this patient, with breast involvement being suggested by the rapid appearance and disappearance of localized areas of erythema and tenderness. Aggressive treatment of these breast infections while they are still localized may prevent systemic spread. Conventional incision and drainage of the breast abscess combined with multidrug treatment directed against M. avium is the recommended therapy.

Adult↗