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Biomedical subjects

F B Miller

Publications and source records attributed to F B Miller.

At least 73 records · Page 4Linked to original sources
PubMed1989

Myocardial contusion. When can the diagnosis be eliminated?

The clinical significance of various diagnostic tests and the length of monitoring required for myocardial contusion were evaluated in 172 patients. Cardiac isoenzyme levels, electrocardiograms, and echocardiograms were evaluated. Twenty-eight patients had a documented myocardial contusion based on at least one positive diagnostic study. The majority of positive studies were detected on admission and all positive tests were present within 24 hours. No patients developed positive diagnostic studies after 24 hours and, likewise, no clinical deterioration occurred late or in patients with a negative screening examination. The electrocardiogram and the clinical course were the therapeutic intervention. Cardiac isoenzyme levels had negligible significance on outcome, and the two-dimensional echocardiogram was not particularly valuable as a screening technique, If no abnormality is detected within 24 hours post injury, further investigation or monitoring does not appear warranted.

Adolescent↗
PubMed1989

Are the risks after colostomy closure exaggerated?

One hundred twenty-one patients underwent colostomy closure for trauma. There was no mortality and a 4.9 percent incidence of major morbidity. Although there was no apparent relationship between the interval between colostomy creation and closure, three of the six major complications occurred in patients whose colostomies were closed soon after complicated initial injuries. It is recommended that if the primary operation is complicated by intraabdominal sepsis or major wound problems, 6 months should ensue before attempting closure. Long term follow-up of these patients (mean 39 months) disclosed a low incidence of late complications secondary to colostomy closure. Although the trend toward the increased use of primary repair of colon injuries in selected patients is supported, our study indicates that the risk of colostomy closure has been exaggerated and should not be a factor in the decision to create a colostomy after colon trauma.

Adolescent↗
PubMed1989

Psychiatric response to HIV spectrum disease in children and adolescents.

Five clinical situations involving children and adolescents exposed to human immunodeficiency virus illustrate the psychosocial spectrum of the disease. For at-risk gay youth, anxiety and stigma complicate developing sexual practices. Children with perinatal infection may survive for years with a chronic illness, management of which is complicated by parental illness or death. Hemophiliac families must deal with the intrusion of a lethal virus into a long illness course. "Street" adolescents and substance-abusing youth pose particular challenges to public health and education. The range of child psychiatric responses described includes individual and family therapy, neuropsychological assessment, psychopharmacological management, and consultation liaison work.

Acquired Immunodeficiency Syndrome↗
PubMed1989

Institutionally shared trauma rotations are viable solutions to deficiencies in trauma training.

Numerous national trauma leaders have expressed concern about the lack of uniformity of trauma training in this country. In 1984 we instituted a trauma rotation between the University of Louisville (U.L.), with a large trauma volume, and Loyola University (L.U.) in the planning stages of trauma center development. Third year L.U. residents rotated at U.L. in 3-month blocks with an increased level of responsibility monthly, culminating in major decision-making roles and operative treatment under the chief resident's direction. The L.U. residents functioned as full members of the team and not as passive observers. Fifteen L.U. residents and 12 U.L. residents rotated during this period. Yearly major trauma visits, helicopter flights, and trauma service admissions average 1,908, 700, and 1,520, respectively. U.L. chief residents averaged 136 major operative trauma cases and 115 nonoperative trauma cases each were managed during this time period (RRC records greater than 85th percentile for all U.L. residents). L.U. residents performed an average of 30 major operative cases, nine as teaching assistant, in 3 months. Each managed more than 75 nonoperative cases. Several elements are critical in such a multi-institutional rotation: 1) active communication among the program directors, 2) commitment to one sharing arrangement only, 3) financing and malpractice for off-site residents, 4) housing, and 5) the ability to assimilate off-site residents as true trauma team members. The resident-to-resident interplay is crucial and has succeeded because both residency staffs have had excellent early training.(ABSTRACT TRUNCATED AT 250 WORDS)

Academic Medical Centers↗
PubMed1989

Negative findings on laparotomy for trauma.

A retrospective review of 428 exploratory laparotomies for trauma included 199 patients with blunt trauma, 96 with gunshot wounds, and 133 with stab wounds. In the blunt trauma group, 16 laparotomies (8%) showed no injury and 24 (12%) showed that no repair was needed. Physical examination (68 cases) and diagnostic peritoneal lavage (DPL) (121) were used as the primary indication for laparotomy. In the stab wound group, there was a high incidence of negative or nontherapeutic operation when proximity to the abdomen or deep fascial penetration was the indication for operation. Patients sustaining gunshot wounds had a 27% incidence of negative laparotomy, with proximity being the primary indication for operation. Two deaths in the negative laparotomy group occurred due to associated injuries. Complications were minimal. DPL has decreased the number of negative operations but has increased the nontherapeutic operations. The high incidence of negative laparotomy for stab wounds shows the need for selective management rather than routine exploration.

Abdominal Injuries↗
PubMed1989

Role of CT in diagnosis of major arterial injury after blunt thoracic trauma.

The role of computed tomography (CT) in the diagnosis of blunt thoracic vascular injury is controversial. Several recent reports have advocated the use of CT to exclude aortic and major branch injuries in hemodynamically stable patients with blunt trauma. This approach potentially avoids invasive angiography and unnecessary treatment delays in multiply injured patients but risks missed aortic transections if the CT or its interpretation is not accurate. We prospectively evaluated 153 consecutive trauma patients in whom we suspected blunt aortic injury between September 1985 and August 1988. All hemodynamically stable patients underwent contrast-enhanced chest CT followed by immediate aortic arch angiography. Forty-nine unstable patients underwent immediate angiography without chest CT, and 11 (22%) had major thoracic arterial injuries. Data from the remaining 104 stable patients indicate that the sensitivity of chest CT for diagnosis of major thoracic injury is 55%; specificity, 65%. If the chest CT had been used as a screening modality to perform aortic angiography, two transected aortas and three major aortic branch injuries would have been missed. We conclude that chest CT has no screening role in the evaluation of blunt trauma patients with possible major vascular injury.

Adolescent↗
PubMed1989

Peripheral vascular complications of coronary angioplasty.

Percutaneous transluminal coronary angioplasty (PTCA) is being employed with increasing frequency for the treatment of coronary artery disease. PTCA involves the use of a larger sheath and catheter assembly than does cardiac catheterization, potentially increasing the risk of injury to the peripheral vessels used for access. Over an 18-month period, 295 angioplasty procedures resulted in six major vascular injuries (2%). The peripheral vascular complications that were recognized early included thrombosis of the common or superficial femoral artery in two patients and laceration of the iliac artery in two additional cases. Late complications included one superficial femoral artery aneurysm and one common iliac vein thrombosis. All patients required emergency operation at the time of recognition of their vascular complication, and five of six required multiple operative procedures. At operation, all but one patient had severe peripheral arterial disease. There was one death, three amputations, and multiple major complications. Although persistent dysrhythmias were common, major cardiac complications were unusual. These patients had prolonged hospital stays and high hospital costs. Although the incidence of arterial complications with PTCA is low, the consequences are potentially disastrous when they occur. Greater attention to basic evaluation for arterial disease is strongly recommended before elective PTCA, and informed consent about possible extremity complications is mandatory. These untoward results, with their prolonged stays and high costs, must be considered when evaluating the results of "nonoperative" treatment of coronary artery disease.

Aged↗
PubMed1988

Management of carotid artery trauma.

We have treated 45 patients with carotid artery injuries--33 caused by penetrating wounds and 12 secondary to blunt trauma. Preoperative angiography is useful in stable patients to rule out associated vascular injuries, and it is crucial for operative planning in cases of blunt trauma. Not unexpectedly, the results of carotid artery repair in neurologically stable patients have been excellent, as have been the results of revascularization in patients with equivocal or less-severe neurologic deficits. This has led us to be aggressive in repair of carotid artery injuries in patients with questionable neurologic deficits. In the eight patients with severe preoperative deficits, one death each followed both ligation and repair, but neurologic improvement was noted in several patients. Distal internal carotid injuries at the base of the skull that were not amenable to direct repair were observed with serial angiograms in four patients with either stabilization or improvement in the intimal injury.

Adolescent↗
PubMed1988

Fasciotomy for severe, blunt and penetrating trauma of the extremity.

Blunt or penetrating injuries to the extremity with vascular or severe soft tissue and skeletal trauma frequently require fasciotomy. Long term follow-up studies of these patients are rare. From 1976 to 1983, 85 patients underwent 39 fasciotomies upon the upper extremities and 57 upon the lower. Amputations were required in 11 patients; four due to primary vascular compromise, six to severe crush injury and one to electric burn with myonecrosis. The fasciotomy was not etiologically related to limb loss in any of these patients. Osteomyelitis occurred in two patients. Long term follow-up data was obtained by telephone and mail survey from 23 of the 61 patients five to 11 years after injury. Pain, weakness and paresthesia were major determinants of long term morbidity. Chronic edema was present in two patients. Seven of the patients interviewed were unemployed due to the injuries they received to the extremities. Most symptoms were believed to be due to the severity of the injury, and none were directly attributed to the fasciotomy. When fasciotomy is indicated, it is a safe adjunctive procedure in limb salvage and contributes very little to the long term morbidity of patients with severe trauma to the extremity.

Amputation, Surgical↗
PubMed1988

Pelvic fracture classification: correlation with hemorrhage.

Hemorrhage remains the leading cause of death in patients with pelvic fractures. To identify patients at greatest risk for massive hemorrhage, we retrospectively reviewed charts and initial emergency room anterior-posterior (AP) radiographs of 245 consecutive patients. Pelvic fractures were classified according to our modification of the Pennel and Sutherland classification scheme. A simple pelvic fracture classification scheme was developed. Using this classification, we can be 90% confident that 50 to 69% of patients with "unstable" pelvic fractures will require 4 or more units of blood, 30 to 49% will require greater than 10 units of blood, 36 to 55% will have an intra-abdominal injury, and 6 to 18% will have a pelvic arterial injury. Therefore we conclude that this pelvic fracture classification based on the initial emergency-room AP X-ray can predict a patient population at high risk for massive hemorrhage for which an aggressive treatment protocol is justified.

Adolescent↗
PubMed1987

Emergency right colon resection.

Controversy exists over the management of the stoma following emergency right colonic resection. To define the stoma management following colon resection, 70 patients who underwent an emergency right colectomy were studied retrospectively. Thirty-six underwent a primary anastomosis and 34 received a diversion with an ileostomy. Indications for resection were as follows: penetrating injury, 28 patients; blunt injury, five patients; obstruction, 13 patients; perforation, 15 patients; vascular injury, seven patients; and hemorrhage, two patients. The mortality was equal in both groups (21%). Severe morbidity directly related to the ileostomy was noted in six patients (18%), and three leaks (8%) were noted in the anastomotic group. High mortality continues to be associated with emergency right colon resection, regardless of the indication for the procedure. This high death rate is not lowered by diversion in deference to an anastomosis.

Adult↗
PubMed1987

Diagnostic pericardial window. A safe alternative to exploratory thoracotomy for suspected heart injuries.

During a five-year period, 104 patients underwent a pericardial window procedure to diagnose possible cardiac injury. Eighty-eight procedures were performed by a subxiphoid approach, and 16 were transdiaphragmatic in combination with an exploratory laparotomy. There were 51 patients with stab wounds, 45 with gunshot wounds, and eight with blunt trauma. All penetrating wounds were near the heart. In seven patients the window disclosed cardiac damage with no clinical signs of tamponade or shock. Fifty-one patients had signs of tamponade; however, only 12 of them had a cardiac injury diagnosed by pericardial window. Nineteen patients had cardiac injuries. One examination had false-negative results and one study had false-positive results. Cardiac wounds repaired included the right ventricle (eight), left ventricle (three), right atrium (five), and cardiac vein or pericardial wounds (three). Complications were negligible and consisted of minor wound infections (two) and postpericardiotomy syndromes (two). The pericardial window provides a rapid and safe means of diagnosing cardiac injuries in patients with equivocal signs of heart injury while sparing the patient without a heart wound a major operation.

Adolescent↗
PubMed1984

The efficacy of routine completion operative angiography in reducing the incidence of perioperative stroke associated with carotid endarterectomy.

Routine operative angiography was performed during a 14 1/2-year period ending June 1982, during which 603 consecutive carotid endarterectomies were performed. For the purpose of standardization, a functional classification of stroke in terms of severity was established: class I--minimal, class II--moderate, class III--marked, class IV--severe, and class V--coma or death. Patients were analyzed to determine the cause of the stroke, the severity of the stroke, and the efficacy of routine operative angiography in reducing the incidence of perioperative stroke caused by technical error. Perioperative stroke occurred in 18 patients (2.9%), with only one having been caused by technical error. Fifteen patients underwent revision of the endarterectomy before wound closure because of unsatisfactory operative angiography results. None of the patients developed permanent neurologic deficits. Permanent perioperative neurologic deficits resulted from embolization (six patients), hypertensive episodes with cerebral hemorrhage (three patients), conversion of ischemic to hemorrhagic infarcts (two patients), spontaneous thrombosis (one patient), clamp ischemia (two patients), and other factors (three patients). Nine patients died, two of myocardial infarction and seven of stroke, for a combined mortality and morbidity rate of 3.3%. There were three class II, five class III, two class IV, and eight class V strokes that were determined to be related to the procedure. In this series stroke may have been prevented in 15 patients who underwent revision of the endarterectomy because of an unacceptable technical error demonstrated on operative angiography.

Arterial Occlusive Diseases↗
PubMed1983

Oblique incision of the groin for vascular reconstruction at the femoral level.

Exposure of the common femoral artery and its branches for vascular reconstruction has most often been accomplished with a vertical or hockey stick incision which crosses the inguinal folds. An oblique skin incision placed parallel to, and slightly above, the inguinal ligament affords adequate exposure, possesses better healing characteristics and, in the obese, avoids a potentially inflamed inguinal skin crease.

Femoral Artery↗
PubMed1978

Anatomic relationship of insertion of the common bile duct into primary duodenal diverticula.

Examination of 96 postmortem specimens disclosed six diverticula of the second portion of the duodenum. In every instance, the common bile duct either emptied into, or immediately adjacent to, the diverticulum. The pancreatic duct was opacified twice; it was also intimately associated with the diverticulum on both occasions. This relationship is almost constant and should be considered in the management of patients with biliary and pancreatic disease who have primary duodenal diverticula.

Cholangiography↗
PubMedDate not supplied

The use of ERCP in the management of common bile duct stones in patients undergoing laparoscopic cholecystectomy.

The purpose of this study was to evaluate the indications and results of endoscopic retrograde cholangiopancreatography (ERCP) for gallstone disease since the advent of laparoscopic cholecystectomy. In our personal series of 410 consecutive cases of laparoscopic cholecystectomy, we found 17 common bile duct (CBD) stones; seven were identified by preop ERCP, nine at laparoscopy by intraoperative cholangiography, and one postop by ERCP. We have performed preop ERCP in 21 patients (5.1%); CBD stones were found in seven. Our indications for preop ERCP were elevated liver function tests, dilatation of the common duct by ultrasound, or a history of jaundice/pancreatitis, and all stones were successfully removed by endoscopic sphincterotomy. At laparoscopic cholecystectomy nine patients were found to have stones; one was treated with laparoscopic methods, four with open CBD exploration, and four by postop endoscopic sphinecterotomy. Post-laparoscopic cholecystectomy, five patients underwent ERCP for pain or increased liver function tests suggestive of common duct stones. One of the five was found to have stones and these were successfully removed by endoscopic sphincterotomy. ERCP is very useful as a diagnostic and therapeutic modality in laparoscopic cholecystectomy patients with suspected CBD stones. Elevated liver function tests and dilated CBD by ultrasound are the most accurate predictors of stones. Endoscopic sphincterotomy is a more effective route, at present, for stone removal than a laparoscopic approach.

Adolescent↗