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Biomedical subjects

H H Stone

Publications and source records attributed to H H Stone.

At least 55 records · Page 3Linked to original sources
PubMed1981

Cefamandole for prophylaxis against infection in closed tube thoracostomy.

During an 18-month period, antibiotic prophylaxis in 120 patients undergoing closed tube thoracostomy was evaluated by a prospective, randomized double-blind technique. Forty-six subjects had sustained penetrating chest trauma. Either placebo (n = 60) or 1 gm/6 hours cefamandole (n = 60) was begun intravenously at the time of tube insertion and was continued intravenously or intramuscularly until the second day following tube removal. Cultures were taken of the pleural drainage, usually blood, at tube insertion, on tube removal, and on several occasions between those times. Antibiotic concentrations were determined biologically on the same specimens of pleural fluid as well as selectively on concomitant venous blood samples. Cultures were also obtained from all subsequent foci of infection, including the wound, any empyema, bronchial secretions, urine, or infected intravenous sites. Aerobic and anaerobic isolation and identification were carried out according to standard laboratory procedures with sensitivity testing (disc and tube dilution) only of the aerobes. Results demonstrated that infection of the lung and/or pleural space was eight times more common in the placebo groups (13.3%) than in the group receiving cefamandole (1.7%) (p less than 0.01). In addition, the single infection that developed despite use of the antibiotic was due to a susceptible organism. No major adverse drug reactions were noted.

Adolescent↗
PubMed1981

Immediate permanent fascial prosthesis for gastroschisis and massive omphalocele.

To obviate any limitation in abdominal volume, the girth in 44 neonates was increased significantly by the insertion of either Marlex mesh or Prolene mesh as a permanent midline fascial prosthesis. Concomitant primary wound closure was then accomplished through mobilization of laterally based skin flaps. Without exception, the resultant coelom was adequately spacious, as reflected postoperatively by both ventilation and venous return being unimpaired. Four babies died, three as a result of antecedent cerebral hypoxia complicating diaphragmatic herniation and one as a result of sepsis. Indications for the procedure were a massive omphalocele in 31 infants, gastroschisis in nine and a huge diaphragmatic hernia in four. Wound dehiscence with exposure of the fascial prosthesis occurred twice, once because of a cautery burn of the skin and after minor wound infection in the second. Revision of the initial abdominal wall repair was required in both of these babies as well as for incomplete extrusion of Marlex mesh in three older children. Prolene is now preferred for fascial prostheses. Prime advantages of the technique include immediate enlargement of the peritoneal capacity, rare necessary for ventilatory support, maintenance of abdominal support by a fascial gusset, elimination of infectious complications attending more delayed closures of wound and peritoneum and the uncommon need for later operative revision.

Abdominal Muscles↗
PubMed1980

Arrest of severe liver hemorrhage by an omental pack.

From Jan 1, 1971 through June 30, 1979, 113 cases of massive liver injury were managed by insertion of a viable omental pack. Significant active hemorrhage was present in all cases, while the source of hepatic bleeding was primarily venous in the 102 injuries due to blunt trauma. Associated injuries were present in 90% of patients, with an average of 2.4 associated injuries per patient. A total of 175 complications developed in 82 patients. Nine deaths produced a mortality of 8%. Arrest of liver hemorrhage by tamponade with viable omentum was almost uniformly successful in patients with nonpenetrating injury.

Adolescent↗
PubMed1980

Techniques for operative reduction of pubic symphysis disruptions.

Occasionally, a pelvic fracture is an exceedingly difficult injury to manage in the multiple trauma victim. Accompanying hemorrhage can not only be life-threatening but often confuses the evaluation as to sources of blood loss. Reduction of a Malgaigne's or open book pelvic fracture aids significantly in stemming this extraperitoneal venous bleeding. If operative intervention for associated injuries is required, reapproximation of any pubic disruption should be performed concomitantly. Use of the rib approximator for this reduction saves considerable time and can be accomplished with relatively little effort.

Adult↗
PubMed1979

Predictability of present outcome and future recurrence in acute pancreatitis.

Although acute pancreatitis is relatively common, factors useful in predicting immediate outcome or likelihood of recurrence have seldom been studied in greater detail. A ten-year experience with 389 patients hospitalized for 821 separate episodes of acute pancreatitis was reviewed. The overall mortality was 6.7%, being highest on the first admission and considerably greater for white males. Respiratory complications accounting for 27% of the fatalities were the most common causes of death. The incidence of considerable morbidity was 19.5%. Clinical diagnoses of "shock" and "respiratory distress" were associated with mortalities of 88% and 71%, respectively. The overall recurrence rate was 50.1%, with little variation regardless as to the number of previous bouts. Recurrence was more likely if the patient was black, male, older than 30 years of age, and had experienced a second episode of acute pancreatitis. Admission data aid considerably in identifying high-risk patients in whom major complications develop, who die during the present episode, or who have a future recurrent bout of acute pancreatitis.

Acute Disease↗
PubMed1979

Pulmonary burns in children.

Basic concepts have evolved from a 15-yr experience in the management of 101 children with inhalation injuries. Progression through three distinct clinical stages--bronchospasm (1--12 hr post-burn), pulmonary edema (6--72 hr), and bronchopneumonia (after 60 hr)--was often noted. Success in outcome appeared to depend upon treatment that conformed to the pathophysiologic state present, a pulmonary toilet being both thorough and aseptic, tracheotomy being reserved for true glottic or supraglottic airway obstructions, the sharp division of strangulating or suffocating constrictions caused by cervical or thoracic eschars, use of ventilators primarily to maintain arterial pO2 above 60 mm Hg and to reverse otherwise intractable pulmonary edema, corticosteroids being administered as a single intravenous bolus and only for overt bronchospasm, and parenteral antibiotic therapy being based upon sputum smears and cultures for established pneumonia alone, never as prophylaxis.

Adolescent↗
PubMed1979

Prophylactic and preventive antibiotic therapy: timing, duration and economics.

Previous studies have demonstrated that administered antibiotics must be active against major anticipated pathogens and must have reached sufficient concentrations in the tissue or body fluid at risk by the time of bacterial challenge if prophylactic therapy is to be maximally effective in reducing the infection rate of potentially contaminated surgery. The need for continuing antibiotic prophylaxis beyond the day of operation, however, has been uncertain. In a prospective, randomized, double-blind study of 220 patients undergoing elective gastric, biliary or colonic surgery, perioperative administration of cefamandole plus five days of placebo was compared to perioperative plus five days of postoperative antibiotic therapy; no significant difference was found between the groups in the rate of infection of wound (6 and 5%, respectively), peritoneum (2% each) and elsewhere (6% and 5%). In another prospective, randomized, nonblind study of 451 determinant cases of 1,624 patients undergoing emergency laparotomy, cephalothin was instituted preoperatively but after peritoneal contamination had occurred (i.e., abdominal trauma, etc.); continued postoperative antibiotic again failed to reduce further the wound and peritoneal infection rates, as noted on comparing perioperative therapy alone (infection rates 8 and 4%, respectively) with perioperative plus 5-7 days of postoperative treatment (10% and 5%, respectively). Analysis of these data, as well as of the extra expenses incurred by 463 patients because of infection in a previous prophylactic antibiotic study, revealed an average additional expenditure of $2,686.00 for each instance of postoperative infection of the wound and/or peritoneum; whereas savings of $300.00 per patient at risk were obtained whenever appropriate prophylactic antibiotic had been given.

Anti-Bacterial Agents↗
PubMed1979

Management of perforating colon trauma: randomization between primary closure and exteriorization.

During a 44 month trial, 268 patients with wounds of the colon were entered into a prospective, randomized, nonblinded study. Consideration for primary closure demanded that: preoperative shock was never profound, blood loss was less than 20% of estimated normal volume, no more than two intra-abdominal organ systems had been injured, fecal contamination was minimal, operation was begun within eight hours, and wounds of colon and abdominal wall were never so destructive as to require resection. Once such criteria had been satisfied, colon wound management was dictated by last digit in the randomly assigned hospital number; odd indicated primary closure; even, exteriorization of the wound or primary closure with protection by a proximal vent. Results obtained in 139 determinant patients eligible for randomization revealed that primary closure (67 patients) had a lower infection rate of the incision (48% vs S7%, p > 0.05) and a still lower infection rate for the abdomen proper (15% vs 29%, p < 0.05) on comparison to the 72 patients with a randomized colostomy. Morbidity otherwise for the randomized colostomy was tenfold greater than if a primary closure had been performed. Average postoperative stay was six days longer (p < 0.01) if a colostomy had been created, exclusive of subsequent hospitalization for colostomy closure; while the total extra cost for management of the colon wound by colostomy was approximately $2,700.00. Although immediate mortalities were identical, one late death occurred following colostomy closure. These data not only confirm the safety of primary closure for colon wounds in selected cases, but also indicate that such should become the preferred method of treatment whenever specific criteria have been met.

Clinical Trials as Topic↗
PubMed1979

Management of duodenal wounds.

A 30-year experience with 321 wounds of the duodenum was reviewed. Of the total, 302 had some form of perforation; 19 had intramural hematomas. All patients underwent laparotomy shortly after admission except six cases of radiographically diagnosed submucosal hematoma. Occasional dehiscence of the duodenal suture line and its life-threatening complications (six of 52 cases, or 12%) led to a policy of routine duodenal decompression by gastrostomy plus twin jejunostomies in 1962. Following use of the latter technique in 237 patients, only one leak occurred. By contrast, failure to decompress had an 8% leak rate; direct drainage of the suture line gave an even greater incidence of dehiscence or fistula, 23%. Associated pancreatic injuries were treated as separate wounds by sump drainage of distal pancreatectomy. None of three patients subjected to pancraticoduodenectomy for massive combined pancreatic and duodenal trauma survived. A long-armed T-tube was always inserted for recognized as well as suspected common duct wounds. Although most of the 41 deaths were due to major vascular trauma and sequelae of hemorrhagic shock, duodenal complications did contribute to significant morbidity and five mortalities during the earlier years of review.

Abdominal Injuries↗
PubMed1979

Aspergillus infection of the burn wound.

During a 15-year period, 18 patients with major burns developed a wound infection due to Aspergillus. Ages averaged 28 years, extents of burn were 54% (14-97%) BSA for total surface involvement and 42% (14-85%) BSA for full-thickness injury. Pseudomonas sepsis preceded Aspergillus infection in 16 cases. Thirteen of the episodes occurred in three epidemics, each apparently related to contaminated air-conditioner ducts and filters. Treatment was based upon wound excision in all 18 patients, with recurrence initially in each. Topical and parenteral antifungal agents were never individually successful in controlling the infection. Whenever fungal sepsis involved an extremity alone and thus amputation could rid the body of the entire infected site, survival could then be achieved. The overall mortality rate was 78%. Protection of the wound from Aspergillus colonization appeared to be the only reliable method of preventing this often lethal fungus infection.

Adolescent↗
PubMed1979

Bacteriologic considerations in perforated necrotizing enterocolitis.

During a ten-year period, 61 infants with perforated necrotizing enterocolitis were managed by bowel resection, enterostomy, and intravenous antibiotics. Aerobic and anaerobic cultures were taken of venous blood, from the peritoneal cavity at operation, and of any subsequent wound and/or intraperitoneal infection. No significant differences between fatal and nonfatal cases were noted with respect to presence of anaerobes in the peritoneal flora (six babies with two deaths) or culture-confirmed bacteremia (73% of the total). However, peritonitis participated in by Pseudomonas aeruginosa (ten babies), or beta-hemolytic streptococcus (five babies) was -niformly lethal, as were complicating bacteremias due to P aeruginosa, beta-hemolytic streptococcus, and Staphylococcus aureus (two each). Anaerobic peritoneal isolates (all gram-positive cocci) were never noted if performation occurred before the eighth day of life; they did not appear to adversely affect survival. Based upon these data, antibiotic therapy should include either gentamicin or tobramycin, with penicillin, until subsequent culture reports dictate otherwise.

Bacteria↗
PubMed1978

Factors influencing intraoperative gastric regurgitation: a prospective random study of nasogastric tube drainage.

A prospective study was conducted to determine the incidence of "silent" gastric regurgitation and aspiration during general anesthesia in 146 patients randomized with respect to presence of a nasogastric tube. A bland dye was instilled in the stomach to serve as the determinant marker. The overall incidence of regugitation was 8.9% and of aspiration, 2.1% in spite of the uniform use of an endotracheal tube. The incidence of regurgitation was twice as high when anesthesia was given by an inexperienced anesthetist (11% vs 5.6%) and in patients without nasogastric tubes (12% vs 6%), although such differences were not statistically significant. The primary agent used, difficulty of endotracheal intubation, location of surgical incision, and duration of anesthesia did not alter the incidence of regurgitation or aspiration. No correlation was found between the detection of subclinical aspiration and the development of postoperative pulmonary complications.

Adolescent↗
PubMed1978

Cefamandole in treatment of peritonitis.

Cefamandole was evaluated as the sole antimicrobial agent used to treat bacterial peritonitis in 113 patients. Dosage varied between 1 and 2 g given intravenously every 6 hr. Laparotomy for excision of infected or gangrenous tissues, closure of gastrointestinal perforations, or drainage of an established abscess was required in 99 of the cases. A good clinical response was obtained in 107 patients, or 95% of the total group. Of the six deaths only one could be attributed to infection. No evidence of renal, hepatic, or hematopoietic toxicity was noted. There were no allergic reactions, although 13 patients (12%) developed phlebitis in a vein used for antibiotic administration. Bacteriological studies revealed aerobic peritonitis in 99% of the patients, with anaerobe participation in 60% of these cases. Sensitivity testing by the disk diffusion and tube dilution methods confirmed the appropriateness of cefamandole therapy; 91% of the gram-negative rods and 61% of the anaerobes were susceptible. From results of this study, it would appear that cefamandole is a reliably effective antibiotic for use in treatment of most forms of acute peritonitis. Its role in surgical prophylaxis may be even more promising.

Adult↗