A simple technique to reduce the incidence of accidental dural puncture.
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Analgesia, Epidural↗
Biomedical subjects
F Bokhari
Publications and source records attributed to F Bokhari.
Experience with over 2500 diagnostic peritoneal lavages.
This study was undertaken to confirm the safety and efficacy of diagnostic peritoneal lavage (DPL) for trauma patients. A prospectively maintained database of all DPLs performed in the past 75 months was analyzed. A red blood cell count of 100,000/mm(3) was considered positive for injury in blunt trauma; 10,000/mm(3) was considered positive for peritoneal penetration in penetrating trauma. Information relative to type of injury, DPL result, laparotomy result and complications, was analysed to determine if DPL was more or less suited to any specific indication or type of patient. Over a 75 month period, 2501 DPLs were performed at our urban level I trauma center. The overall sensitivity, specificity and accuracy for the above thresholds were 95, 99 and 98%. The majority (2409, 96%) were performed using percutaneous or "closed" seldinger technique. Ninety-two (4%) were performed using open technique because of pelvic fractures, previous scars and pregnancy. Open DPL was less sensitive than closed DPL in patients who sustained blunt trauma (90 vs 95%) but slightly more sensitive in determining penetration (100 vs 96%). Overall, there were 21 complications (0.8%). There was no difference in complication rate between open and closed DPL. In conclusion, DPL remains a highly accurate, sensitive and specific test with an extremely low complication rate. It can be performed either open or closed with comparable results. We recommend its use in the evaluation of both blunt and penetrating trauma.
Abdominal Injuries↗
Prognosis of penetrating trauma in elderly patients: a comparison with younger patients.
BACKGROUND: It has previously been shown that elderly patients have a worse prognosis than their younger counterparts after sustaining blunt trauma. This is due in part to a higher incidence of comorbid conditions as well as less physiologic reserve in an elderly population sustaining largely blunt trauma. We compared the outcome after penetrating trauma in elderly patients to matched "younger" patients to determine whether they had a similarly poor prognosis. METHODS: Elderly patients (> or = 65 years) were identified from our trauma registry. Sex, mechanism of injury, and Abbreviated Injury Score/Injury Severity Score were determined from the registry. Patients presenting with traumatic arrest were excluded. The registry was then searched for patients aged 15 to 40 years with the same sex, mechanism of injury, and Abbreviated Injury Score in each region. A chart review was then performed to determine additional details of their hospital stay. The two groups were then compared using Student's t test and Fisher's exact chi2 test, as appropriate. RESULTS: Eighty-five elderly patients (OLD group) were admitted with penetrating trauma between 1983 and 1998. They were compared with 85 matched young patients (YOUNG group). Each group included 66 male and 19 female patients. In each group, gunshot wounds occurred in 45.9%, stab wounds in 52.9%, and shotgun wounds in 1.2% of patients. The average Injury Severity Score in each group was 5.5 +/- 5.6 (range, 1-29) and the regional Abbreviated Injury Scores were likewise equal in both groups. The OLD patients had an average hospital stay of 6.9 +/- 9.1 days compared with 4.3 +/- 5.7 days in the YOUNG patients (p < 0.05). Twenty-seven OLD patients spent 7.3 +/- 9.2 days in the intensive care unit compared with 19 YOUNG patients who stayed 3.4 +/- 3.2 days (p < .05). A total of 91 comorbidities were identified in 58 OLD patients compared with 18 in 15 YOUNG patients (p < .0001). Eighty-six invasive procedures were performed in the OLD group compared with 96 in the YOUNG group (p = not significant). Nineteen OLD patients (22.3%) and 15 YOUNG patients (17.6%) suffered one or more complications, including death (p = not significant). A total of 91% of surviving OLD patients were discharged to home compared with 100% of surviving YOUNG patients (p < .01). CONCLUSION: Elderly patients who sustain penetrating trauma have more comorbidities than their younger counterparts. This may account for their longer hospital stay and lesser ability to be discharged home. These patients do not have an increased complication rate and should continue to be managed aggressively.
Adolescent↗
Hemosuccus pancreaticus after penetrating trauma to the abdomen.
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Abdominal Injuries↗
Complications of angiographic embolization for traumatic hemobilia.
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Abdominal Injuries↗
Secondary rhytidectomy.
A postoperative questionnaire was sent to all secondary rhytidectomy patients inquiring about their social and physical recovery time, complications related to either the initial or secondary surgery, and the onset of any new medical problems or the commencement of any new medications between the two surgeries. The overall satisfaction rates for both surgeries, time interval between the two operations, and their perception of the years of youthful appearance gained from either operation were also investigated. The overall satisfaction rate was slightly higher for the secondary facial rhytidectomy (4.49) than for the primary rejuvenation of the face (3.97) (p < 0.06). Patients perceived themselves as looking an average of 9.31 years younger following primary surgery, as compared to an average of 10.19 years younger following the secondary rhytidectomy (p < 0.50). The average time interval between the primary and secondary rhytidectomy surgeries was 8.48 years (range = 1 to 16 years). Twenty-nine ancillary procedures were performed during the initial rhytidectomy and 70 ancillary procedures were selected during the secondary rhytidectomy (p < 0.001). There was no statistically significant difference for the physical and social recovery time between the two procedures. Fourteen of 33 patients (42.4 percent) requiring a secondary rhytidectomy had developed a new medical problem prior to the second surgery (p < 0.001) and 19 patients (57.6 percent) were started on a new medication (p < 0.001). It was concluded from this study that the secondary rhytidectomy patients are more inclined to be satisfied (approaching statistical significance), are more likely to undergo ancillary procedures, and, being 10 years older, are more prone to have medical problems with deleterious effects on surgery and to be on medications with potential ill effects. Also, observations have been made that the previous scars pose some limitations, with the anatomical changes from the previous surgeries often requiring masterful planning and execution. Skin circulation is, in general, superior, enduring more tension.
Adult↗
The African-American nose: Part II.
Nasal anthropometric studies were performed on 69 African-American adults (28 men and 41 women). Seven parameters were measured: nasal length, width of bridge, width of nose, protrusion, length of columella, nasolabial angle, and nasofrontal angle. Six area proportion indices were calculated from these measurements. Normal nasal measurements (defined as those within mean +/- 2 SD) were found in 95.2% of the 483 measurements; 72.3% of the measurements were within +/- 1 SD of the mean. The normal variation ratio ranged from 8.9 to 31.9%, indicating great variability as a result of the triethnic origin of African-Americans. Harmonious indices (mean +/- 2 SD) were present in 70% of the 414 indices. Optimal indices (mean +/- 1 SD) were present in 68.1%. The mean constituted only 1.9% of the optimal indices. Disproportionate indices (those greater than mean + 2 SD or less than mean - 2 SD) were present in 4.6%. The nasal measurements and indices were compared with those of North American Caucasians. The range of normal measurements and harmonious indices in this study define the linear parameters of the abstract concept of African-American ethnicity. Successful rhinoplasty is achieved through restoration of harmony, which is defined as optimal relationships between proportions. Our study provides those optimal values. Good preoperative measurements combined with understanding of the normal African-American nasal measurements and indices will improve aesthetic decisions at surgery and facilitate the achievement of harmony.
Adult↗
Oculonasal synkinesis.
A phenomenon the authors have termed oculonasal synkinesis has been observed in 13 individuals in two independent practices. This complex presents as simultaneous contraction of the orbicularis oculi and the compressor narium minor muscles. When the patient blinks, the compressor narium minor muscle contracts, causing depression of the ala. Its etiology is postulated as the formation of anomalous connections between the temporal and zygomatic branches of the facial nerve, innervating the orbicularis oculi muscle, and the buccal branches of the facial nerve, innervating the compressor narium minor muscle. All 13 individuals who exhibited this phenomenon are female. This anomaly was displayed bilaterally in 7 patients, on the right side in 2 patients, and on the left side in 4 patients. A 2-month-old daughter of one of the patients who had bilateral presentation, also displayed the phenomenon. In 6 patients who underwent rhinoplasty, resection of the compressor narium minor muscle resulted in complete elimination of the abnormal muscle movement. The plastic surgeon who performs rhinoplasty should be cognizant of the synkinesis and discuss its presence with the patient, since a patient may consider this a surgical sequela upon discovering the condition postoperatively. Furthermore, this unintentional muscle function is aesthetically displeasing.
Adolescent↗
High-dose, short-duration cisplatin/doxorubicin combination chemotherapy for advanced ovarian epithelial cancer.
Sixty-one patients with epithelial ovarian cancer were treated with intensive high-dose, short-course chemotherapy that consisted of cisplatin (120 mg/m2) and doxorubicin (70 mg/m2) every 3 weeks for four cycles. Patients in complete clinical remission were offered second-look laparotomy (SLL). Patients with minimal or no residual disease at SLL were randomized to either cyclophosphamide (1000 mg/m2 every 21 days for six cycles) or whole-abdominal radiation therapy. All patients completed therapy with a median leukocyte nadir 1.3/microliter and platelet nadir of 90/microliters. Forty-five patients (74%) had a complete clinical response. Results of twenty-two of 36 second-look procedures (64%) showed no evidence of disease (NED). After SLL, 19 patients received six courses of cyclophosphamide and 16 patients received whole-abdominal radiation. Nine patient who refused SLL and one patient with negative SLL findings refused additional treatment. The median survival time for all patients was 51.3 months. High-dose intensive chemotherapy regimens have high response rates, but survival needs to be compared with traditional low-dose regimens. Although high-dose cisplatin and doxorubicin were myelosuppressive, the resulting complications were manageable. There was no significant difference between the mean survival times of patients receiving Cytoxan, abdominal radiation, or no treatment as second-line therapy.
Adult↗
Initial clinical study of indium-111-labeled clone 110 anticarcinoembryonic antigen antibody in patients with colorectal cancer.
A murine monoclonal antibody directed against carcinoembryonic antigen (CEA) was labeled with indium-111 (111In) by means of a benzylisothiocyanate derivative of diethylenetriamine penta-acetic acid (DTPA) and used for clinical radioimmunodetection studies. Twenty-one patients having a history of surgically resected colorectal cancer and rising serum CEA levels suggestive of tumor recurrence were studied. Patients were infused over 20 minutes with 5, 10, or 20 mg of the monoclonal antibody labeled with 5 mCi of 111In. The mean radiochemical purity was greater than 96%. No toxicity was seen. The stability of the radiolabel on antibody in patient serum was demonstrated by high-performance liquid chromatography (HPLC), sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) with autoradiography, and immunoprecipitation for up to 96 hours after infusion. Tumor sites were identified in 20 of 21 patients. Sites of antibody accumulation in 20 patients were confirmed as tumor either by resection at laparotomy (16 patients) or fine-needle biopsy (four patients). Nine patients who had the identified lesion resected or irradiated showed return of the serum CEA antigen level to normal or near normal values. In the absence of high levels of circulating CEA (greater than 500 ng/mL), the disappearance of radioactivity from patient serum demonstrated first order elimination kinetics, with a mean half-life of 38 hours. The serum half-life was not affected by the dose of antibody administered or by serum CEA titers below 500 ng/mL. Despite a mean liver uptake of 18% injected dose (ID) 24 hours after administration, hepatic metastases were easily visualized as areas of increased uptake of radioactivity. Radioimmunodetection of recurrent colorectal cancer, not detected by computed tomographic (CT) scans, appears achievable with this agent. This may allow successful clinical intervention in selected patients.
Adult↗
Intraperitoneal immunoconjugates.
Intracavitary instillation of radioantibodies has been proposed as therapy for anatomically confined malignant disease. To evaluate this therapeutic strategy, a monoclonal antibody reactive with human transferrin receptor (7D3) was evaluated for localization in a human malignant mesothelioma transplanted i.p. in athymic nude mice. This antibody was purified and labeled with 131I, 125I, or 111In. Radiolabeled antibody was administered i.p. or i.v. to tumor-bearing mice. Three h after injection, the percentage of injected dose/g (ID/g) of tumor was higher in free-floating ascites tumor cells (31.0%/g tumor cell pellet) after i.p. injection than after i.v. injection (12.0%). However, localization of radiolabel in i.p. solid tumors was similar (5.37% ID/g i.p. versus 4.73% of ID/g i.v.), and by 24 h both routes of administration produced similar localization of radiolabel in both free-floating ascites cells and solid tumors. In contrast, uptake of radiolabel into liver, kidney, and to a lesser extent bone and bone marrow, was less with i.p. than with i.v. administration. In clinical studies with 111In and 90Y antibodies administered i.p. to patients with ovarian cancer, confined biodistribution of the radioantibody was again seen, although interpatient variability of rate of egress of the radiolabel was documented. Therefore, both preclinical and clinical data indicate that i.p. therapy with immunoconjugates may be advantageous for cancer confined to the peritoneal cavity. This advantage stems primarily from reduced localization of isotope in organs of catabolism or toxicity (liver, kidney, bone, and bone marrow), rather than greatly increased levels of isotope in tumor. Unresolved problems include degree of antibody penetration into solid tumors, microdosimetry, and radioantibody effectiveness for tumor killing.
Animals↗
A preliminary pharmacokinetic study of 111In-labeled 260F9 anti-(breast cancer) antibody in patients.
The pharmacokinetics of 111In-labeled 260F9, a murine monoclonal antibody directed against a breast-cancer-associated antigen, was determined in seven patients with advanced breast cancer. Six patients were administered 1 mg antibody containing 1 mCi 111In. The seventh patient was administered 20 mg unlabeled antibody followed by 1 mg 111In-labeled antibody all via a peripheral vein. Immunoprecipitation, HPLC and SDS-PAGE gels demonstrated the stability of radiolabel on the antibody. The serum clearance of the radiolabel closely fits (r2 greater than 0.95) a two-compartment model for the first six patients. The apparent volume of distribution of the radiolabel approximated to the plasma volume (31) and its mean residence time was 23.7 h. The radiolabel had an average t 1/2 beta of 22.9 +/- 12.21 h at the 1-mg dose. At the 20-mg dose one-compartment elimination kinetics were observed with the radiolabel and antibody showing similar mean residence times (36-41 h) and a t 1/2 beta of 26-28 h. Whole-body imaging showed that the blood-pool: liver ratio of radioactivity increased fourfold (at 48 h postinfusion) at the higher dose and the percentage of the injected dose of radioactivity in the liver decreased from 25% to 8% (24 h postinfusion). In one patient 7-14 times more radioactivity was localized in a breast tumor than in fat (normal breast). Over the first 25 h an average (cumulative) 7.5% of the total dose was excreted in urine. A study of 260F9 in CDF-1 mice demonstrated that the radiolabel remained associated with the antibody in serum. The antibody, however, cleared 60-fold slower in mice than in patients and showed an increased mean residence time of 191 h. The disparity in the pharmacokinetics of the antibody seen in the mouse and in the clinic, points to the different behavior shown by murine monoclonal antibodies in humans. This points to the need for preliminary studies of antibodies in patients for preclinical evaluations of their effectiveness as drug-targeting agents.
Adult↗
Patient satisfaction following rhinoplasty.
This retrospect study was conducted to evaluate patients satisfaction following rhinoplasty. Of the 1,062 patients who had undergone rhinoplasty and received a questionnaire, there were 468 respondents. They rated satisfaction with aesthetic and functional results of the surgery. Four groups were created: Group I comprised all the respondents: 468 patients of which there were 381 (81.4%) females and 87 (18.6%) males; 6.2% of this group was dissatisfied. Group II [373 patients: 301 (80.7%) female and 72 (19.3%) male] was composed of patients who underwent a primary rhinoplasty by the lead author, with or without revision of which 7.5% was not satisfied. Group III [95 patients: 80 (84.2%) female and 15 (15.8%) male] comprised those who underwent the initial rhinoplasty by another surgeon and the secondary procedure by the lead author. The surgery failed to satisfy only 1.1% of this group. Group IV [86 patients: 78 (90.7%) female and 8 (9.3%) male male] underwent initial surgery by the lead author and then required revision surgery. This group exhibited the highest dissatisfaction level (13.6%). This article analyzes the results of the questionnaire in detail. In summary, the percentage of dissatisfied patients in the total population was higher among male patients (12.8%) than among female patients (4.6%).
Adolescent↗