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Biomedical subjects

H H Stone

Publications and source records attributed to H H Stone.

At least 73 records · Page 4Linked to original sources
PubMed1978

Abdominal drainage following appendectomy and cholecystectomy.

Consecutive patients undergoing emergency appendectomy (283) or urgent cholecystectomy (51) were prospectively studied for the development of post-operative incisional or peritoneal sepsis. Severity of the original peritoneal infection was carefully recorded, while use of a Penrose dam to drain the peritoneum was randomized according to pre-assigned hospital number. Both aerobic and anaerobic cultures were taken from the abdomen at the time of operation as well as from all postoperative infectious foci. Results demonstrated no essential differences in incidence of wound and peritoneal infection following appendectomy for simple or suppurative appendicitis (187) or following cholecystectomy for acute cholecystitis (51). However, with gangrenous or perforative appendicitis (94), incisional and intra-abdominal infection rates were 43% and 45%, respectively, when a drain was used; yet only 29 and 13%, respectively, without a drain. These latter differences were significant (p < 0.001). In addition, intra-abdominal abscesses were three times as likely to drain through the incision than along any tract provided by the rubber conduit. Cultures revealed that hospital pathogens accounted for a greater proportion of wound and peritoneal sepsis after cholecystectomy and appendectomy for simple or suppurative appendicitis if a drain had been inserted than if managed otherwise. By contrast, a mixed bacterial flora was responsible for most infections following appendectomy for gangrenous or perforated appendicitis, irrespective as to use of a drain.

Abdomen↗
PubMed1977

Tobramycin in the treatment of peritonitis.

Tobramycin is a new aminoglycosidic aminocyclitol antibiotic which has a broad spectrum of activity against aerobic and facultative Gram-negative bacilli. It is particularly effective against Pseudomonas aeruginosa, including some strains of this organism which are resistant to gentamicin. The newer aminoglycosidic aminocyclitol antibiotics all consist of a "backbone" of 2-deoxystreptamine, to which are attached several amino-containing sugar groups. These agents inhibit protein synthesis in bacteria at the level of the ribosome and are bactericidal although the precise mechanism by which they kill bacteria is still not known. There are a number of processes by which bacteria can become resistant to the action of the aminoglycosidic aminocyclitol antibiotics. Among these, the ability of bacteria to produce inactivating enzymes (usually mediated by R-factors or plasmids) appears to be the most important in current clinical isolates of bacteria. Aminoglycosidic aminocyclitol antibiotics which are resistant to these enzymes may have an enhanced spectrum of activity.

Aminoglycosides↗
PubMed1977

Management of liver trauma in children.

The charts of 203 consecutive children undergoing emergency laparotomy for management of an acute liver injury were reviewed. Although drainage was all that was required in the majority of cases, massive hemorrhage, usually arising from disrupted hepatic veins, appeared to demand liver resection (as performed in 17 children, with a mortality of 18%) during earlier years of the survey. Control of exsanguinating bleeding from such liver wounds by packing with viable autogenous tissue (pedicled omentum) subsequently eliminated almost entirely the need for resection. Fatalities resulting from either hemorrhagic shock or loss of liver substance then became relatively rare. Additional significant problems were associated organ injuries, postoperative wound and intra-abdominal sepsis, bleeding diatheses, and late instances of hemobilia. The overall mortality was 6%.

Adolescent↗
PubMed1977

Renal decapsulation in the prevention of post-ischemic oliguria.

The delayed onset of anuria/oliguria in acute tubular necrosis has been theorized to represent a complicating compartment syndrome, i.e., parenchymal swelling within an unyielding capsule. To test this proposition, 12 monkeys had suprarenal aortic cross-clamping, followed by unilateral renal decapsulation to create an experimental as well as a control kidney unit in the same animal. Histologic examination uniformly confirmed tubular necrosis at death or sacrifice. Subsequent split renal function studies (creatinine, urea, and free water clearances) indicated significantly greater maintenance of renal function by the decapsulated kidney than by its paired control. Clinical evaluation in 21 hemorrhagic shock patients, with the capsule of one kidney stripped, revealed on follow-up that 15 developed a renal failure consistent with acute tubular necrosis. Although three patients with polyuric failure died before split studies could be run and two others have been too recent for computer analysis to have been completed, nine of the remaining ten had significantly greater renal plasma flows (194 versus 121 ml/min M(2), p < .01) and significantly greater urine flows (.99 versus .18 ml/min M(2), p < .01) on the decapsulated side than on the control, as determined by differential renal scans. No significant difference in these same lateralized renal functions was noted in the tenth patient with renal failure and in the six survivors without renal failure. Renal decapsulation as prophylaxis reduced the anticipated incidence of oliguria/anuria from an expected 75% to 7% (p < .01) in these 21 shock patients. Such data suggest that delayed renal ischemia, possibly based on a compartment syndrome, may be the cause for a progression of acute tubular necrosis from polyuria to oliguria and then to anuria.

Adolescent↗
PubMed1977

Gastric surgery.

In a prospective, double-blind, randomized study of patients subjected to gastric surgery, parenteral cefazolin begun before operation significantly reduced the would infection rate. Infection developed only when incisional contamination occurred during operation and either when the antibiotic was not present in the tissues of the wound at the time of inoculation or when the offending bacteria were already resistant to the antimicrobial used. To be reliably effective, antimicrobial prophylaxis should always be instituted preoperatively in patients at high risk of infection, ie, those with conditions not associated with gastric hyperacidity. On the other hand, since patients with duodenal ulcer disease and resulting gastric hypersecretion usually have a relatively sterile stomach lumen, antibiotic prophylaxis for gastric operations in these cases is probably not indicated.

Adult↗
PubMed1977

Factors involved in disruption of intestinal anastomoses.

Bowel anastomoses, as performed on 181 dogs, were studied: (1) by interposing segments of colon into small bowel and vice versa, (2) by comparing clean anastomoses to those contaminated by feces before and after suturing, (3) with and without parenteral preoperative antibiotic, and (4) with and without coaptation of an inverted serosa. All animals with a timed sacrifice as well as an unexplained death had careful autopsy. Results demonstrated no difference in the healing capacity of large (91%) versus small (92%) intestine under identical circumstances. Intraluminal bacteria were of importance only if spillage caused contamination during operation and thereby subsequent infection of the peritoneal surface of the suture line. Peritonitis preceded all 28 leaks, yet the converse never occurred. Likelihood of a complicating peritonitis (67%) and thus an anastomotic leak (24%) was significantly reduced through the preoperative administration of prophylactic cefazolin (19 and 4%, respectively). A "serosal seal" also appeared important in obviating suture line disruption. Our data emphasize the value of an inverted and serosal lined anastomosis, bowel preparatory measures, prophylactic antibiotic, and the disruptive action of local bacterial peritonitis.

Animals↗
PubMed1976

Bacterial flora of appendicitis in children.

Aerobic and anaerobic cultures were taken immediately upon operative entry to the peritoneal cavity of 114 consecutive children undergoing appendectomy. Stage of appendicitis and clinical presentation could be closely correlated to specific patterns of peritoneal bacterial flora. It was found that appendiceal gangrene and perforation uniformly produce a polymicrobial peritonitis that is based on the symbiosis of aerobes with anaerobes. Ensuing wound and intra-abdominal septic complications were likewise mixed infections. Based on these findings, refinements in the diagnosis of appendiceal gangrene and perforation as well as rationales in the treatment of appendicitis have been discussed.

Aerobiosis↗
PubMed1976

Wringer arm injuries.

During a 20-yr period, 483 children 16 yr of age or under were hospitalized for management of a wringer arm injury. Although the majority were indigent, black males, such trauma was frequently sustained by all classes and races as well as by both sexes. Principles of treatment consisted of cleansing the abrasion wound, application of a pressure dressing from axilla to finger tips, elevation, and close observation. With the exception of a destroyed brachial vein in one patien, significant vascular injuries did not occur despite a "medical fixation" on evidences of impaired circulation. Likewise, no fractures were noted even though all patients had x-rays of the full extremity. However, there were six metacarpophalangeal dislocations, five instances of neuropathy, and one traumatic amputation. Major skin sloughs occurred in 18 children, yet only 11 of them required a skin graft.

Accidents, Home↗
PubMed1976

Gunshot wounds of the ureter: a 15-year review of 63 consecutive cases.

We reviewed 63 consecutive cases of gunshot wounds of the ureter seen during a 15-year period. The importance of prompt recognition and aggressive surgical management is emphasized, with particular attention being placed on adequate debridement and spatulated splinted watertight ureteroureterostomy. Our philosophy of management for individual injuries is discussed along with our complications and results. This series is the largest reported to date of ureteral gunshot wounds.

Adolescent↗
PubMed1976

Use of aminoglycosides in surgical infections.

Most infections on the surgical ward are due to one or more gram-negative rods, acting either as the sole pathogens or as principal components in a polymicrobial flora. To date, parenteral aminoglycosides have proven to be the most effective antibiotics for control or treatment of such sepsis. Unfortunately, however, serious complications as well as therapeutic failures do occur. During a 40-month period, 405 surgical patients receiving aminoglycosides (Gentamicin, Tobramycin, Sisomicin, or Amikacin) were prospectively studied with respect to: indications for antibiotic; patient population; serum concentrations of antibiotic according to route of administration, dose in mg/kg/day, and renal function; rapidity of antibiotic excretion in the urine; causative bacteria and their sensitivities to each aminoglycoside as determined by both disc and tube dilution methods; severity and frequency of drug complications; and clinical efficacy of each study antibiotic. Results supported the contention of a superior effectiveness from aminoglycosides for established abdominal and unspecified surgical infections, more rapid development of therapeutic blood levels by intravenous administration, need to alter drug dose according to frequent serum creatinine determinations, increased drug toxicity in dehydrated and shocked patients, preventability of complicating Candida sepsis, and the importance of early as well as adequate surgical debridement and drainage.

Abscess↗
PubMed1976

Antibiotic prophylaxis in gastric, biliary and colonic surgery.

Antibiotic prophylaxis for surgery has appeared indicated whenever likelihood of infection is great or consequences of such are catastrophic. For better clarification, a prospective, randomized, double-blind study was run on 400 patients undergoing elective gastric, biliary, and colonic operations. There were four treatment categories, with antibiotic being instituted 12 hours preoperatively, just prior to operation, after operation, or not at all. During operation, samples of blood, viscera, muscle, and fat were taken for determination of antibiotic concentration. Both aerobic and anareobic cultures were also taken of any viscus entered, peritoneal cavity, and incision. Similar cultures were run on all postoperative infections. Results demonstrated that the incidence of wound infection could be reduced significantly by the preoperative administration of antibiotic in operations on the stomach (22% to 4%), on the biliary tract (11% to 2%), and large bowel (16% to 6%). Less impressive results were obtained for peritoneal sepsis. Initiation of antibiotic postoperatively gave an almost identical infection rate as if antibiotic had not been given (15% and 16%, respectively).

Adolescent↗
PubMed1976

Penetrating injuries of the face and neck.

Experience with 547 consecutive cases of cervical and facial penetrating trauma has indicated the value of an individualized approach rather than a firm policy of exploration for all wounds penetrating the platysma. In addition, the accumulated data suggest that the concept of separate classes of carotid injuries based on presence or absence of neurologic deficits bears further evaluation with respect to the advisability of reconstituting carotid artery flow.

Adolescent↗
PubMed1975

Major hepatic resections in children.

An experience with 31 hepatic resections in children has demonstrated that mortality and morbidity are primarily determined by percentage of normally functioning liver retained as well as by the experitse of both intraoperative and postoperative care. Criteria for resectability in neoplasia and trauma can readily be established. Early peripheral hypovolemia due to splanchnic pooling was observed frequently, while drains appeared to favor significantly the development of intra-abdominal spesis. Bleeding diatheses did not occur. An inability of the patient to maintain blood glucose and serum albumin were the sole metabolic derangements necessitating replacement therapy. The over-all mortality rate was 13%, with survival of two of four children subjected to 90% resections.

Adolescent↗
PubMed1975

Incidence and significance of intraperitoneal anaerobic bacteria.

To amplify recent interest in anaerobic infections following abdominal disease, trauma, or surgery, 512 consecutive patients subjected to emergency celiotomy had both aerobic and anaerobic cultures taken of peritoneal fluid as well as all complicating wound and intra-abdominal infections. Average time between peritoneal entry of abscess drainage and specimen incubating under anaerobic conditions was less than two minutes. During 4 of the seven study months, patients had antibiotic therapy randomized, with clindaymcin or cephalothin being sole parenteral agents and given intravenously prior to operation and for 5 days thereafter. Results demonstrated that anaerobes uniformly contaminate the peritoneal cavity whenever distal or obstructed intestine has been perforated, irrespective of the cause. Although all but one of the 123 complicating wound and intra-abdominal infections were due solely or at least in part to aerobic pathogens, 2/3 of such infections also contained one or more different anaerobic species acting in synergism with the aerobes. No significant difference in incidence of postoperative infection or in infecting bacteria could be found with respect to antibiotic administered or etiology of perforation. Indeed, duration of bacterial exposure to atmospheric oxygen was the most critical factor influencing culture recoverability of anaerobic organisms, likelihood of ensuing wound or peritoneal sepsis participated in by an anaerobe, and success in control of established infections harboring anaerobes.

Abdomen↗
PubMed1975

Trauma to the portal venous system.

During a 16-year period, 47 wounds of the portal and/or superior mesenteric veins were encountered. Overall mortality was 57%. Survival was greatest in patients with injury to the superior mesenteric vein, wounds repairable by lateral phleborrhaphy, absence of associated major vascular trauma, and only transient or minimal hypovolemic shock. The majority of deaths were due to uncontrollable bleeding or sequelae of profound hemorrhagic shock. Limited follow-up of survivors has demonstrated a low patency rate at the site of venous repair, suggesting that mere ligation may be all that is necessary when lateral repair is impossible.

Abdominal Injuries↗