Biomedical subjects

G V Poole

Publications and source records attributed to G V Poole.

At least 37 records · Page 2Linked to original sources

PubMed1995

Pancreatic injuries from blunt trauma.

Pancreatic injuries from blunt trauma are infrequent, and their diagnosis and management can be extremely difficult. Over the past 10 years we treated 13 patients with major pancreatic injuries from blunt trauma. Twelve had been involved in motor vehicle collisions, none of whom were wearing seat belts. One patient was injured in an assault. Only five patients had physical findings suggesting intra-abdominal injury. Serum amylase levels were elevated in seven of the nine patients (78%) in whom this test was obtained. Computed tomography scans demonstrated pancreatic injury in three of the four patients in whom it was performed. The five patients in whom peritoneal lavage was performed had free intraperitoneal blood from injuries to other abdominal viscera. One injury was diagnosed by ultrasound. Injuries were equally distributed throughout the pancreas, with two injuries in the head, three in the body, five in the tail, and three with injuries in both the head and the body. Five patients had ductal injuries. All patients underwent celiotomy. Eight patients required no operative management of their pancreatic injuries other than drainage. Injury Severity Score averaged 28.5 +/- 2.6 (mean +/- standard error), and mean hospital stay was 31 +/- 9.8 days. One patient with delayed diagnosis of a pancreatic injury developed a pseudocyst, but all other complications and prolonged hospitalizations were due to injuries to the head, chest, other abdominal organs, or extremities. All patients survived. The diagnosis of blunt pancreatic injury requires a high index of suspicion, and diagnostic studies may demonstrate only subtle signs of injury. Most injuries can be managed by localized resection and/or drainage.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Injuries↗

PubMed1995

Postsurgical gout.

Although catabolic events are known to precipitate gout, postsurgical gout has rarely been reported. We identified the charts of 302 patients treated over a 10-year period in a university center who carried the diagnosis of gout and who also had a surgical procedure. Fifty-two patients (42 male, 10 female) were found to have had a postsurgical episode of gouty arthritis. Ages ranged from 20 to 82 years (mean 60.1 +/- 2.1). Forty-five patients had a history of gout, 22 of whom were receiving medication and 23 who were not receiving chronic therapy. In seven patients the postsurgical event was their first attack. Attacks occurred 1-17 days (mean 4.2 +/- 0.5 [SE]) after surgical admission. Most attacks were in the lower extremity, but classic podagra was uncommon. Essentially all patients were febrile (100.7 +/- 0.2 degrees F) compared with admission (99.0 +/- 0.1 degree) (P < 0.001). There was a trend toward leukocytosis in the group as a whole, but the relationship of leukocytosis to the gout attack was most clearly seen in patients admitted for noninflammatory conditions (9.4 +/- 0.7 versus 12.8 +/- 0.8 x 1000 WBC/mm3, P < 0.001). Uric acid levels were elevated but did not follow the course of the attack. Most patients underwent a variety of tests and consultative evaluations because of their undiagnosed febrile episode. Once the diagnosis was established, all patients responded quickly to nonsteroidal anti-inflammatory drugs or colchicine. Despite evidence of a significant inflammatory response, no patient proved to have a suppurative focus as the source of their febrile episode.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗

PubMed1995

Major gastroenteric injuries from blunt trauma.

Hollow visceral injuries are far less common in blunt abdominal trauma than in penetrating abdominal trauma. From 1982 through 1993 we treated 50 patients with 57 major blunt injuries to the gut, defined as perforation, transection, or devascularization. Thirty-two patients (64%) were injured in motor vehicle collisions. Of these, 29 wore no restraints; three were wearing lap belts (none wore lap-shoulder restraints). Mean injury Severity Score (ISS) in patients wearing lap belts was 13.3, compared with 28.6 in the 29 patients who were not using restraint devices (P < 0.01). Small bowel perforations were the most frequent injuries, followed by devascularization of the small bowel, colorectal injuries, duodenal, and gastric perforations. ISS and mortality rates were lowest in small bowel injuries and higher in the less common colonic and gastroduodenal injuries. Except for those patients with perforations of the small bowel, most patients had associated injuries to the head, chest, or abdominal solid organs that were largely responsible for morbidity and mortality. Injuries to the abdominal hollow viscera are unusual following blunt trauma, but are the result of very high energy truncal trauma, and are associated with multiple additional injuries. Most alert patients had physical findings suggestive of peritoneal irritation, but when diagnostic testing was necessary, peritoneal lavage was superior to computed tomography scanning (false negatives = 6.7% versus 36%, respectively; P < 0.05). A high index of suspicion is necessary to avoid diagnostic delays that can lead to severe complications and death.

Accidents, Traffic↗

PubMed1994

Ileal duplications in adults. Presentation and treatment.

Alimentary tract duplications are uncommon anomalies that usually present in childhood. They are most common in the ileum but can occur anywhere along the alimentary tract. In this report, we describe an adult with an ileal duplication and review 12 other reported cases of ileal duplication in adults. Abdominal pain, nausea and/or vomiting, weight loss, and hematochezia were the most common symptoms. No patient was correctly diagnosed before operation. Three patients had malignant neoplasm in the resected specimens. Resection of the duplication and adjacent bowel is recommended because of the common blood supply to both, the possibility of malignant degeneration, and the risk of gastrointestinal ulceration and hemorrhage from ectopic gastric mucosa.

Abdominal Pain↗

PubMed1994

The integration of laparoscopy into a surgical residency and implications for the training environment.

Although laparoscopic cholecystectomy is now an accepted part of resident training, the impact of operative laparoscopy (OL) upon the residency environment has not been examined in detail. We reviewed the first 3 years' experience with OL and the process by which it was introduced into our residency program. Data were obtained from our prospective computerized surgical laparoscopic registry as well as from a survey conducted midway in this experience. At that time, a questionnaire was sent to current residents in the program and residents who graduated after the inception of the OL program were interviewed by telephone. OL cases increased each year and comprised a progressively greater percentage of total cases. Residents performed over 97% of cases, with attending surgeons as first assistants. Initially, only senior-level residents participated as surgeons; however, after the first year we noted a significant tendency for cases to filter down the ranks. Junior-level residents have already participated in more laparoscopic than open cholecystectomies and expressed considerable concern about training in open procedures. Graduated residents without exception were able to obtain privileges to perform OL without additional training. They did not feel that resident education was compromised by the advent of laparoscopy. Both current and graduated residents considered didactic sessions including animal laboratories and simulators an important part of training.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed1994

Laparoscopic fenestration of a giant simple hepatic cyst. Case report and technical considerations.

The management of symptomatic large, simple hepatic cysts has evolved toward the use of wide unroofing or "fenestration" in instances where patients are not rendered asymptomatic by percutaneous aspiration. We report adoption of the technique of fenestration of such hepatic cysts to the laparoscopic route. Laparoscopic fenestration appears able to accomplish all of the aims of transabdominal fenestration in appropriately selected patients.

Cysts↗

PubMed1994

Causes of mortality in patients with pelvic fractures.

During 6 years we treated nearly 500 patients with pelvic fractures. Three hundred forty-eight were admitted directly to our hospital following blunt injuries; these patients formed the basis of this review. There were 220 men and 128 women with an average age of 31 years, a mean Injury Severity Score of 21.8, and an average hospital stay of 16.5 days. Almost two thirds of patients were injured in motor vehicle accidents, and about one eighth were pedestrians struck by a vehicle. Smaller numbers were injured in crushing accidents, motorcycle accidents, falls, and miscellaneous injuries. Only 32 patients (9%) had an isolated pelvic fracture. Associated injuries to the head, chest, abdomen, and upper and lower extremities were frequent, and these injuries often had a greater impact on outcome than the pelvic fracture. Twenty-eight patients died, an overall mortality rate of 8%. Only four deaths (14.3%) were a direct result of the pelvic fracture, and bleeding from a transected femoral artery contributed to one of these deaths. Most deaths were caused by severe head injury, nonpelvic hemorrhage, and multiple organ failure. Although the pelvic fracture may result in prolonged hospitalization, and can be a cause of extended disability, it is an infrequent cause of mortality.

Adult↗

PubMed1994

Resuscitation in uncontrolled hemorrhage.

Fluid resuscitation is considered to be an integral component of the management of hemorrhagic shock. Numerous experimental studies of hypovolemic shock have confirmed the value of volume infusions, but in these models the rate, volume, and duration of bleeding are carefully controlled. The results of such studies may not be applicable to clinical hemorrhage, in which bleeding continues unabated. Male Sprague-Dawley rats weighing 250 to 390 g were anesthetized, and a femoral artery and vein were cannulated for constant blood pressure monitoring and fluid infusion. Through a midline abdominal incision, the distal ileocolic artery and vein were transected and allowed to bleed freely into the peritoneal cavity. The abdomen was closed and the animals were randomized to one of five groups: no resuscitation; small volume lactated Ringer's solution; large volume lactated Ringer's; small volume hetastarch; or large volume hetastarch. After 3 hours or at spontaneous death, blood was withdrawn to measure hematocrit, platelet count, and fibrinogen. Blood in the peritoneal cavity was collected and measured. Animals that received either lactated Ringer's or hetastarch had more bleeding into the peritoneal cavity and a greater dilution of clotting factors than animals that received no resuscitation fluids (P < 0.05). In addition, survival was highest in unresuscitated animals, although only the small volume hetastarch group had a significantly lower survival when independently compared with no resuscitation (P < 0.05). These results suggest that in traumatic shock, fluid resuscitation should be minimized until mechanical control of bleeding can be achieved.

Abdomen↗

PubMed1994

The mangled lower extremity: can salvage be predicted?

The ability to predict amputation following combined orthopedic, vascular and soft tissue trauma to an extremity could eliminate prolonged attempts at salvage of a doomed limb. We reviewed our experience with 48 mangled lower extremities in 46 patients. Twenty-one penetrating wounds and 25 blunt injuries occurred in 37 men and nine women ranging in age from 3 to 59 years. Severity of injuries to muscle, skin, and major nerves were strongly interrelated (r = 0.49 to 0.74, P < 0.001), but there were no correlations between injuries to these tissues and severity of bone injury (r < 0.19, P > 0.20). Twenty-four limbs were salvaged, and 24 were amputated. Increased severity of soft tissue injury was associated with a greater probability of limb loss (P < 0.001), but limb salvage or amputation could not be predicted accurately by any variable or group of variables such as age, mechanism of injury, Injury Severity Score, presence of shock, level of injury, venous injury or repair, sequence of repair (vascular vs skeletal), time of fasciotomy, arteriography, blood requirement, or duration of ischemia. Amputation was best predicted by severity of injury to the sciatic or tibial nerves (P < 0.001), and by failure of arterial repair (P < 0.01). Severe extremity injuries require a coordinated approach and decisions regarding amputation require careful judgement. These decisions cannot always be made at the time of presentation or during the initial operation. If after revascularization and skeletal stabilization the extremity is clearly nonviable or remains insensate, then delayed amputation can be performed under more controlled circumstances.

Adolescent↗

PubMed1994

The anatomy of appendicitis.

Acute appendicitis is a common disorder and, ideally, should be diagnosed prior to the onset of gangrene or perforation. Nonetheless, the goal of early diagnosis remains elusive. In a prospective study, 100 appendectomies were performed for suspected acute appendicitis over 19 months. The location of the appendix was noted by the operating surgeon and was listed as anterior intraperitoneal, retrocecal, pericolic gutter, retroileal, pelvic, or retroperitoneal. The latter four positions were regarded as sites in which the appendix was hidden from the anterior parietal peritoneum. Fifteen patients did not have appendicitis. Of the 85 inflamed appendices, 25 were indurated, 19 were suppurative, and 41 were gangrenous or perforated. Patients with gangrene or perforation were more likely to have pain and tenderness at a site other than the right lower quadrant and had a higher mean heart rate on admission than patients with simple appendicitis, but there were no other differences in symptoms, signs, or laboratory findings among the groups. The appendix was in a hidden location in 15 per cent of patients with simple appendicitis or without appendicitis, compared with 68 per cent of patients with gangrenous or perforative appendicitis (P < 0.001). Complications were more frequent, and hospital stays were longer in patients with advanced appendicitis (P < 0.001). Patients and physicians were equally responsible for delays in treatment, but the high incidence of hidden appendices in those with advanced appendicitis resulted in less severe symptoms and signs than expected. Anatomic variations in the location of the appendix are often responsible for delays in the diagnosis of appendicitis.

Abdominal Pain↗

PubMed1993

Surgical approach of choice for penetrating cardiac wounds.

One hundred nineteen patients suffered penetrating cardiac trauma over a 15-year period: 59 had gunshot wounds, 49 had stab wounds, and 11 had shotgun wounds. The overall survival rate was 58%. The most commonly injured structures were the ventricles. Twenty-seven patients had injuries to more than one cardiac chamber. Thirty patients had associated pulmonary injuries. Emergency thoracotomy was performed in 47 patients with 15% survival. Median sternotomy was used in 30 patients with 90% survival. Seventeen of the 83 patients with thoracotomies required extension across the sternum for improved cardiac exposure or access to the contralateral hemithorax. Only one patient with sternotomy also required a thoracotomy. All pulmonary injuries were easily managed when sternotomy was used. We conclude that sternotomy provides superior exposure for cardiac repair in patients with penetrating anterior chest trauma. We feel it is the incision of choice in hemodynamically stable patients. Thoracotomy should be reserved for unstable patients requiring aortic cross-clamping, or when posterior mediastinal injury is highly suspected.

Adult↗

PubMed1993

Computed tomography in the management of blunt thoracic trauma.

Computed tomographic (CT) scanning has proved to be valuable in evaluating the head and abdomen of victims of blunt trauma; CT scans of the thorax often are obtained on patients with blunt torso trauma, but their value for this purpose is unclear. We conducted a prospective study to evaluate the role of chest CT scanning in thoracic trauma. Hemodynamically stable patients at least 18 years old with an estimated Abbreviated Injury Scale--Thorax score of 2 or greater underwent a contrast-enhanced CT scan of the chest, usually in conjunction with CT scans of the head, abdomen, or both. Thirteen patients were dead on arrival, 14 required emergency surgical procedures, and 13 were too unstable to undergo chest CT scan. Thirty-three patients were not included because they refused to participate or the protocol was not followed. Forty-six men (69%) and 21 women with a mean age of 42.7 years completed the study. Sixty-one were injured in motor vehicle crashes, four were injured in falls, and one each was injured by assault and by crushing forces. Injury Severity Scores ranged from 4 to 45, with a mean of 20.5. Four patients died (6%), three from head injury and one from multiple organ dysfunction. Chest roentgenography (CXR) was superior to CT scanning in identifying rib fractures, but CT scanning was more sensitive than CXR for pneumothorax, fluid collections, and infiltrates (p < 0.001); CT scanning also was more specific for aortic injury. Despite this quantitative superiority, the abnormalities missed by CXR but identified by CT scanning infrequently led to a change in management.(ABSTRACT TRUNCATED AT 250 WORDS)

Abbreviated Injury Scale↗

PubMed1993

The role of infection in outcome of Multiple Organ Failure.

It is widely assumed that infections are the principal cause and primary outcome determinant of the syndrome of Multiple Organ Failure (MOF) in critically ill patients. Infections are frequent in these patients, but the prevention and treatment of infections may not influence the course of MOF. This study tested the hypothesis that infections play a decisive role in the outcome of MOF. Data were gathered concurrently on all adult patients admitted over an 18-month period to a non-cardiac surgical ICU at a university hospital and recorded in a computer database. Sepsis was defined as a state characterized by at least three of the following: fever, tachycardia, leukocytosis or leukopenia, increased cardiac index, reduced systemic vascular resistance, and hypercatabolism manifested by nitrogen-wasting. The presence of an infection was not required for the diagnosis of sepsis. Mild sepsis was defined as the presence of three or four parameters. Severe sepsis was defined as the presence of five or six parameters. MOF was defined as the development of dysfunction of at least two of the following major organ systems: cardiac, gut, pulmonary, renal, cerebral, and hepatic. Of 749 admissions, 73 patients developed MOF. Thirty four (47%) had a documented source of infection, 37 (51%) had positive blood cultures, and all had sepsis. Hospital mortality was 66 percent (48 of 73 patients). Death could not be predicted by bacteremia (P > 0.25), nor by the presence of an infectious source (P = 1.0), but was strongly associated with severe sepsis (P < 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1993

Management of the difficult appendiceal stump: how I do it.

The appendix can usually be removed by the standard technique of stump ligation after transection, with or without inversion of the stump into the base of the cecum. When inflammation or necrosis extends into the cecum and the appendix cannot be ligated at its base, there are several options that can be employed. These include appendicocecostomy, partial cecal excision with a stapling instrument, and right colon resection. These techniques have been used 16 times in 249 patients operated upon for appendicitis. Although these techniques will be required infrequently, when they are necessary the risk of appendiceal stump breakdown with peritoneal soilage or cecal fistula can be minimized.

Acute Disease↗

PubMed1993

Adenocarcinoma of a Brooke ileostomy for adenomatous polyposis coli.

A case of primary adenocarcinoma of a Brooke ileostomy after proctocolectomy for adenomatous polyposis coli is reported, and three additional cases collected from the literature are described. This rare tumor is seen at an average interval of 22 yr after colectomy with ileostomy. In all four cases, the mucosa adjacent to tumor had straight tubular glands lined by goblet cells and an absence of villi characteristic of colonic mucosa. Mucosal biopsies in all four stained positive for colonic sulfomucin. The clinical and morphologic features indicate a progression from ileal mucosa to colonic mucosa, colonic dysplasia, and finally, adenocarcinoma. Thirteen patients with adenocarcinoma of the ileostomy after proctocolectomy for ulcerative colitis have also been reported. Annual ileostomy examination, biopsy of suspicious lesions, and wide excision of carcinoma with stomal revision are recommended.

Adenocarcinoma↗

PubMed1993

Injury severity dictates individualized antibiotic therapy in penetrating abdominal trauma.

Antibiotics play a crucial role in reducing the risk of postoperative infection in patients suffering penetrating abdominal trauma. The infection rate for patients with these injuries ranges from 7% to 16%. Single agents with broad-spectrum activity have proven efficacy, but dosage and duration are still controversial. A prospective, double-blinded study was performed on 102 patients randomized to receive one of three antibiotics for a total of 12 hours: cefoxitin (3 doses, 31 patients); ceftizoxime (2 doses, 36 patients); or mezlocillin (3 doses, 35 patients). Two distinct groups at risk for postoperative infection were evident depending on the severity of injury: Group A were those with no colon injury or a colon injury that could be repaired, no evidence of shock, or fewer than 3 organs injured; Group B were those requiring a colostomy, evidence of shock on presentation, or three or more organs injured. All comparisons of the patient populations receiving the different antibiotics showed the two groups to be equivalent. The mean penetrating abdominal trauma index for Group A was 8.8 and 28.2 for Group B. The overall infection rate for Group A was 10.3% and 42.3% for Group B. There was a significant increase in infection rate for all antibiotics except ceftizoxime in Group B compared with group A. The penetrating abdominal trauma index was significantly higher in all patients who developed infection for all antibiotics. In addition, if the surgical wound was closed primarily, patients with colon injuries developed wound infections 71% of the time, and those with small-bowel injuries did so 30% of the time.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Injuries↗

PubMed1993

Sepsis and infection in the intensive care unit: are they related?

Sepsis is a clinical syndrome characterized by fever, leukocytosis or leukopenia, tachycardia, increased cardiac index, reduced systemic vascular resistance, and hypercatabolism. It is generally believed to be a response to invasive infections, although an infectious source cannot always be identified in patients with sepsis. Over an 18-month period 287 patients were admitted for more than 48 hours to a noncardiac adult surgical intensive care unit. Data were collected concurrently and recorded in a computer database. Seventy-three patients (25%) developed sepsis, and 50 (68% of those with sepsis) had bacteremia, with a mean of 1.5 organisms and 3.5 positive blood cultures per patient. Only 22 of 50 patients with bacteremia had a potential infectious source, and there was a concordance of cultures from the putative source and the blood stream in only 10 patients. Forty-one patients with sepsis (56%) had no apparent infectious source, but 28 of these (68%) had bacteremia, often with multiple organisms. Forty of the 73 patients with sepsis died in the hospital. Mortality in sepsis could not be predicted by the presence of an infectious source (P > 0.35) and was not related to bacteremia (P > 0.75). Mortality was strongly associated with the development of multiple organ failure (P < 0.0001). Sepsis is a generic response to a number of physiologic insults and does not require infection for expression. This inflammatory response may have survival value by increasing oxygen delivery to sites of injury, but uncontrolled inflammation may cause dysfunction in several vital organ systems. The associated immunosuppression results in bacterial colonization of sites from which bacteria ordinarily are excluded.(ABSTRACT TRUNCATED AT 250 WORDS)

Bacteremia↗

PubMed1993

Trauma is a recurrent disease.

BACKGROUND: Many victims of trauma have a history of repetitive accidental or violent injuries, which implies that trauma is not necessarily a random event. Recurrent trauma is thought to be a problem of urban areas, associated with criminal activities, but there are few data from rural areas that include the victims of nonintentional injuries. METHODS: The prior trauma experience of 200 consecutive patients admitted for trauma was compared with that of 100 consecutive emergency nontrauma surgical admissions and 100 elective surgical admissions to a university hospital and level I trauma center. RESULTS: Trauma patients were younger than emergency patients and elective surgery patients. They were more likely to be male than either emergency or elective surgery patients and, along with emergency nontrauma patients, were more likely to be from a racial minority than were elective admissions. Trauma patients were more likely to have had a previous hospitalization for an injury than either emergency patients or elective surgery patients, and a greater proportion of their prior trauma admissions had been within the past 5 years than in the other two groups. There was no difference in the probability of a prior trauma admission between patients admitted with an intentional injury or an accidental injury, but patients whose current admission was for an intentional injury were three times more likely to have had a prior hospitalization as a result of an intentional injury than were patients admitted because of an accidental injury. CONCLUSIONS: Trauma is a disease with a high risk of recurrence. This may be related to chronic high-risk behaviors such as alcohol or drug abuse, preexisting psychopathology, and cultural acceptance of violent resolution of personal conflicts, all of which adversely affect patients' lives. The role of intensive preventive measures after an initial injury, and directed toward specific high-risk behavior, should be evaluated.

Adult↗