Search PubMed⌕ Search

Biomedical subjects

H Spivak

Publications and source records attributed to H Spivak.

At least 37 records · Page 2Linked to original sources
PubMed1997

Laparoscopic salvage of malfunctioning peritoneal catheters.

BACKGROUND: Malfunction of peritoneal catheters due to mechanical outflow problems is an annoying complication in patients undergoing chronic peritoneal dialysis (PD). Correction often involves catheter replacement or revision via laparotomy. METHODS: Twenty-five patients undergoing PD who developed mechanical catheter flow restriction underwent 28 laparoscopic procedures. Preoperative diagnoses were made by contrast catheter radiography and were: catheter sequestration (36%), omental wrap (64%). Pneumoperitoneum was induced after general anesthesia and laparoscopy was performed using a Storz laparoscope. The catheter was then identified and manipulation was attempted using instruments placed percutaneously. RESULTS: In 26 cases (93%), the catheter was freed and function restored. In two cases (7%), adhesions were so numerous and dense that the distal catheter could not be visualized. Four episodes of peritonitis developed subcutaneous leakage of peritoneal fluid which responded to cessation of PD for 2 weeks. Four patients had recurrent occlusions; three of these were managed laparoscopically. Two patients developed late hernias at the site of insertion of the laparoscope. Catheter patency averaged 9.2 months postoperatively. CONCLUSIONS: Laparoscopic revision is a successful technique for salvage of occluded peritoneal catheters.

Adult↗
PubMed1997

Endoluminal surgery.

BACKGROUND: Progress in laparoscopic surgery and the employment of minimally invasive techniques have led to the emergence of a new branch in this field, laparoscopic endoluminal surgery (LES). METHODS: LES encompasses all surgical procedures that involve intentional trocar or instrument penetration into the lumen of the gut in order to perform a surgical procedure. The integrity of the organ is preserved except for the small enterotomy sites and the operated area. The procedure is technically demanding and requires sound endoscopic skills. RESULTS: The experience in LES has primarily involved the stomach and right colon for two reasons. First, these organs have a larger volume/surface ratio in the gut; therefore, they are accessible for the endoluminal instruments. Second, even limited resection of the stomach or colon can potentially carry a significant morbidity. LES minimizes the extent of this resection. CONCLUSIONS: In this paper we review recent developments in LES, discuss the technical aspects of the procedure, and recommend its applicability.

Biopsy↗
PubMed1996

Analysis of the hemodynamics of a bypass with adjunctive arterio-venous fistula using a direct electrical circuit model.

BACKGROUND: The purpose of this work was to study, in a theoretical electric model the effect that an adjunctive arterio-venous fistula (AVF) produces on the flow patterns of a distal infrapopliteal bypass. METHOD: A theoretical electric model that mimics a femoro-infrapopliteal bypass with an adjunctive AVF was designed. Based on Thevenin's Theorem, flows in different areas of the circuit (bypass, collaterals, AVF, segment of artery distal to bypass anastomosis, arteriolar system) were calculated at different resistance values for AVF, collaterals, and bypass. RESULTS: This model demonstrated the following: (1) An adjunctive AVF with large resistance (smaller vein diameter) maintains distal flow, as opposed to a low-resistance AVF (2) Good collateral flow, in addition to low-resistance AVF, can produce retrograde flow in the segment of the artery distal to the AVF. (3) True distal flow (arteriolar flow) in the presence of high collateral resistance can decrease with decreasing resistance of the AVF, but it will never become retrograde. CONCLUSION: The effect of an adjunctive AVF on the hemodynamics of a bypass and its distal runoff vessels depends on the resistance of the AVF and the collateral vessels. The presence of AVF always increases the bypass flow and in this respect it may promote graft patency. However, Bypass grafting in the face of a low collateral resistance is of dubious value and the addition of a fistula in this situation is detrimental.

Arteriovenous Shunt, Surgical↗
PubMed1996

Intentional injury surveillance in a primary care pediatric setting.

OBJECTIVE: To describe intentional injuries identified by primary care providers caring for children and adolescents, as reported through a prospective surveillance system. SETTING: Pediatric departments at four sites affiliated with a large health maintenance organization in eastern Massachusetts. DESIGN: Primary care providers completed brief injury encounter reports for patients aged 3 to 18 years treated for an intentional injury during a 20-month study period. For comparison purposes, a convenience sample of medical record was reviewed. RESULTS: Two hundred eleven injury encounter reports were received, representing a reported rate of 4.1 intentional injuries per 1000 panel members per year. These injuries ranged from contusions and lacerations to sexual assault and homicide. The median age of children at the time of injury was 14 years (interquartile range, 12 to 16 years), older than the population median age of 10 years (interquartile range, 6 to 14 years) (P<.001, Wilcoxon Signed Rank Test). Boys had a relative risk 1.5 times that of girls (P<.05, binomial test). Almost half of the injuries to adolescent girls resulted from encounters with other girls; 10% were the result of dating violence. In most cases, the patient and his or her assailant were friends or acquaintances (56%). This prospective surveillance detected, at most, 67% of intentional injuries seen, while medical record review detected 59% of the total identified injuries. CONCLUSIONS: Primary care pediatricians can identify and treat children and adolescents for intentional injuries. As these patients may form an appropriate group for interventions directed at reducing the risk of future intentional injuries, more effective public health surveillance must be developed.

Adolescent↗
PubMed1996

Malignant tracheo-esophageal fistula: use of esophageal endoprosthesis.

Malignant tracheo-esophageal fistula (TEF) is a serious complication of cancer arising usually in the esophagus, lung, or tracheobronchial tree. Repeated aspiration and pneumonia lead to rapid deterioration and death. The prognosis is dismal and curative resections are curiosities. Surgical bypass of the lesion has been performed but is associated with 25-61% mortality. Other treatments have been employed, such as enterostomies, esophageal endoprostheses, and supportive care. The reported mortality of palliative procedures using endoprostheses, surgical bypass, or exclusion in almost identical. A retrospective review of the data over the past decade revealed a trend toward insertion of endoprostheses. Insertion of endoprostheses can be performed in an endoscopy suite, under sedation, and has fewer major complications than occur with a surgical approach. The periprocedure mortality rate for these patients is 15%, compared to a 29-47% perioperative mortality for patients undergoing surgery. Even so, patients after surgical procedures could survive for 8 months or more, which is better than survival after endoprosthesis intubation. We conclude that insertion of an esophageal endoprosthesis should be the usual preferred option for palliative treatment of malignant TEF. However, for special candidates a surgical procedure is a valid option.

Esophageal Neoplasms↗
PubMed1996

Treatment of chronic pilonidal disease.

PURPOSE: Pilonidal disease (PD) is a common chronic intermittent disorder of the sacrococcygeal region. Despite surgical therapy dating back more than one century, management remains controversial and recent reports have advocated different surgical approaches. METHODS: A retrospective review was conducted of 129 patients who were treated for chronic PD in our institution during a five-year period, 1990 to 1994. RESULTS: Excision with primary closure was performed in 56 patients; 47 underwent open excision without closure, and 26 had marsupialization procedure. All were performed electively, with only minor complications. Complete healing was fastest in the primary closure group, despite a 14 percent postoperative wound infection rate. Recurrence rates of 11, 13, and 4 percent were found for primary closure, wide resection, and marsupialization procedures, respectively. There was no correlation among recurrence rate, postoperative infection, or prior surgery. CONCLUSION: Considering healing time, morbidity, and recurrence rate, we conclude that surgical treatment should be directed at either excision and primary closure or marsupialization. Wide excision with secondary healing should be performed only for grossly infected and complex cysts.

Adolescent↗
PubMed1996

A model to assess the effectiveness of topical antipruritics.

A model has been developed to determine the effectiveness of topical antipruritics. It utilizes controlled, experimentally induced itch and has demonstrated the effectiveness of the direct action on cutaneous receptor sites of a topical anesthetic, benzocaine, in a topical antipruritic formulation, and has been used to differentiate between two effective topical antipruritics. Three studies are presented: The first study examined the reliability of the experimentally induced itch. Several indices of reliability were computed from the data of this first study. Cronbach's alpha was 0.92. Winer's theta also was 0.92. Simple test-retest reliability, computed at intervals of 29 min, 1 day, and 6-7 days, resulted in Pearson correlations of 0.84, 0.73, and 0.60, respectively. In the second study, the model differentiated statistically between the itch relief resulting from the topical application of a formulation with 6% benzocaine and the same formulation without benzocaine. The third study examined 2 known topical antipruritics: one containing 6% benzocaine and the other 1% hydrocortisone. Both topical antipruritics were found to relieve itch; however, the benzocaine antipruritic produced statistically significantly greater itch relief in more subjects than the hydrocortisone antipruritic at both 1 and 30 min after application. These results demonstrate that OTC antipruritics can be differentiated for effectiveness.

Administration, Topical↗
PubMed1996

Small bowel obstruction from gastrointestinal histoplasmosis in acquired immune deficiency syndrome.

Disseminated histoplasmosis is a rare condition that is associated with an underlying immune disorder in approximately 25 per cent of patients. It often leads to GI histoplasmosis, but when the disease predominantly affects the GI tract few, if any, pulmonary symptoms appear. Although histoplasmosis of the gastrointestinal system has been described, it rarely causes a small bowel obstruction. In fact, a recent review of the English literature revealed 77 cases of gastrointestinal histoplasmosis, with only none having clinical presentation solely involving of the jejunum and ileum in acquired immune deficiency syndrome (AIDS) patients. At the time of urgent abdominal exploration, both patients had several areas of bowel strictures with subjacent mesenteric adenopathy. They required resection of small bowel segments. Pathology examination established the diagnosis of histoplasmosis, and both patients were discharged home after antifungal therapy.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Colorectal surgery in octogenarians.

BACKGROUND: Elderly patients are often viewed as high-risk surgical candidates. Recent reports, however, have recommended applying the standard surgical approach to this group. Many of these series report mortality rates that are substantially higher than those in the younger population. Therefore, the applicability of these procedures for the elderly may be questionable. STUDY DESIGN: We retrospectively studied 140 patients older than 80 years who underwent colorectal surgery at our institution between January 1990 and January 1995. Of these, 123 underwent colon or rectal resections and 17 had diverting colostomy only. Ninety-seven (79 percent) of the colorectal resections were for carcinoma. In this study, perioperative care, operative results, and survival are analyzed. RESULTS: Elective and emergent colorectal resections totaled 80.5 and 19.5 percent, respectively. The mortality rate for elective resections was 3 percent and for emergency resections it was 21 percent. Postoperative morbidity was 27 percent and the average hospital stay was 13.1 days. Diverting colostomy was associated with a 24 percent mortality rate. The survival rate after colorectal resections for one, two, and five years was 85, 72, and 40 percent, respectively. CONCLUSIONS: The results support the view that elective colorectal resection in the elderly population is worthwhile and should be performed for the same indications as in younger patients. Although emergent operations were associated with a poor outcome, the majority of the patients survived and left the hospital.

Aged↗
PubMed1996

Spontaneous pneumothorax in the AIDS population.

Spontaneous pneumothorax (SP) in patients with acquired immunodeficiency syndrome (AIDS) has become the leading cause of nontraumatic pneumothorax in the urban population. However, the appropriate treatment, especially the role of surgical intervention, remains controversial. A retrospective study of 33 patients with AIDS who were treated for 38 episodes of SPs (5 bilateral SPs) at our institution was conducted. The study consisted of 25 males (76%) and 8 females (24%) with a mean age of 38 years. Concurrent Pneumocystis carinii pneumonia was detected in 29/33 patients (88%). Three forms of treatment were utilized for the 38 pneumothoraces (5 of which required two modalities): closed tube thoracostomy, 28/38 (group 1); observation alone, 10/38 (group 2); and operative procedures, 5/38 (group 3). There were eight hospital deaths, four following resolution of the SP. Follow-up was available for 14 patients, 11 of whom died a median of 3 months post-discharge. Three patients were alive 1, 3, and 18 months post-discharge. AIDS-related SP is strongly associated with Pneumocystis carinii pneumonia and is predictive of a short-term survival. The treatment should be individualized, and, although resolution of the pneumothorax can be expected, the coexisting AIDS-related illnesses determine the outcome.

AIDS-Related Opportunistic Infections↗
PubMed1995

Implementation of violence prevention education in clinical settings.

Clinical settings provide excellent opportunities for educating adolescent patients about violence prevention. This paper reports on the experience of the Violence Prevention Project of Boston in implementing comprehensive violence prevention activities in different clinical settings. The project's evaluation revealed that staff training, specialized educational materials and staff commitment are required for both initial and sustained implementation of the education. Waiting room brochures and videos are inadequate to address the problem. Conversely, clinical settings can host a variety of educational experiences that generate significant response from patients, families and friends. Clinical settings can also be integrated into broader community-based efforts.

Adolescent↗
PubMed1995

Evaluation of a community-based youth violence prevention project.

PURPOSE: To investigate the association of exposure to a community-based youth violence prevention project with adolescents' knowledge and attitudes about violence. METHODS: Two samples of 400 teens each from Boston neighborhoods were surveyed by random-digit dialed telephone techniques: one at the start of the project and one after 1 year of implementation. Regression analyses were used to investigate associations between exposure to different educational formats and outcome measures. RESULTS: Only self-reported exposure to the mass media campaign was significantly associated with higher scores in both knowledge and attitudes. An independent interaction between gender and exposure to the mass media campaign was found among males. Analyses using a historic control group support a program effect and not recall bias. Exposure to workshops or one-on-one discussions about violence prevention were not significantly associated with outcome scores. CONCLUSION: The measurable effect of the mass media may be somewhat related to the strength of that stimulus over the study period and suggests that 12 months is too short a time frame for evaluating community-based educational efforts.

Adolescent↗
PubMed1994

Adolescents' knowledge and attitudes about and experience with violence.

PURPOSE: Educational interventions directed to the prevention of youth inter-personal violence make assumptions about the educational needs of adolescents for violence-prevention despite little available data. This paper provides new information on background levels of adolescents' knowledge of, attitudes about and experience with violence. METHODS: Over 400 teens across Boston's neighborhoods were surveyed by rando-digit dialed telephone techniques. RESULTS: Results show that while boys are more often involved in violence, almost one quarter of girls report fighting. Black teens witness more violence and are threatened more often than whites, but they do not fight more. Knowledge scores indicate a need for improvement in adolescents' understanding of risk factors. Attitude scores indicate that adolescents believe fighting can and should be avoided, but they lack knowledge of behavioral options. Regression analyses show a positive relationship between violence experience and knowledge and attitudes. CONCLUSION: These data suggest that preventive interventions should be directed to both improving adolescents' knowledge and understanding of personal risk and increasing their repertoire of conflict-resolution skills.

Adaptation, Psychological↗
PubMed1994

Violence prevention in schools and other community settings: the pediatrician as initiator, educator, collaborator, and advocate.

Attention to the problem of youth violence has resulted in a proliferation of violence prevention and intervention strategies. Examined in this paper are those strategies that can be categorized as educational, environmental/technological, and recreational. In the educational category are conflict resolution and mediation, crime prevention and law-related education, handgun violence education, life skills training, self-esteem development, public education, and media education. The environmental/technological category covers a range of strategies: metal detectors, school police, concrete barriers, dress codes, and safe corridor programs, among others. The rather broad recreational category is based upon the importance of physical activity as an outlet for stress and anger and as a component of a multicomponent program. Multi-intervention programs are described as well as some of the major gaps in current violence prevention programming. The suggested role of the pediatrician in violence prevention efforts is described as both initiator and collaborator, as counselor, and as advocate. Because of their great credibility with respect to issues related to children and youth, pediatricians can influence not only parents in their contacts with them in the health care setting, but also school administrators and community leaders. Pediatricians have access to the media, and they can speak to the issue in public forums as well. Furthermore, pediatricians can join existing community efforts to determine ways in which violence prevention and intervention strategies can be incorporated into agency activities.

Adolescent↗
PubMed1992

Patterns of teen exposure to a community-based violence prevention project.

This paper describes the implementation of a community-based youth violence prevention project that utilized an educational curriculum and a mass media campaign. The extent of penetration of the intervention into target areas and the degree of contamination of control areas are assessed, and the most frequently contacted forms of educational outreach are identified. Two sources of data, provider interviews and a random digit dialed telephone survey, were used to track the source and extent of teens' exposure to the intervention. Agency provider data revealed that 40% of the 92 contacted agencies actually conducted violence prevention education, reaching 22% of the target area teens. Approximately one-half of the surveyed teens reported some exposure to the program, with 13% of the teens in target areas reporting participation in interactive educational activities associated with the project. The most common source of exposure was the media campaign. Most teens report a single exposure, usually to the media campaign, although 29% report contact with more than one form of violence prevention education. While the project did not achieve community saturation, the data show that the community-based model of intervention for violence prevention is feasible and effective in reaching teenagers. This research highlights some difficulties in evaluating prevention programs, including reconciling community ownership with project identification, the ethics of curtailing services for control purposes, and factors influencing recall of participation.

Adolescent↗