Biomedical subjects

J B Peoples

Publications and source records attributed to J B Peoples.

At least 19 recordsLinked to original sources

PubMed1998

Improved selection criteria for ordering stat venous ultrasounds from the emergency department.

BACKGROUND: The accuracy and convenience of venous ultrasound (VU) to exclude deep vein thrombosis (DVT) has led to indiscriminate use and low positive yield rates. METHODS: A total of 256 patients were referred from our emergency department (ED) for stat VU during a 2-year period (1995 to 1996). The VUs were interpreted as normal in 198 (77%). Positive findings were discovered in 58 (23%), with DVT accounting for 43 (17%). Retrospective multivariant analysis was used to identify predictive indicators. RESULTS: Unilateral leg swelling/edema identified 36 of 40 (90%) patients with DVT and 8 of 10 (80%) with other thrombotic disorders (saphenous and/or chronic venous thrombosis). A history of leg pain with prior DVT or recent trauma < or =3 days' duration increased DVT duration to 98% (39 of 40). Using these criteria, a 47% charge reduction would have been recognized. CONCLUSIONS: Improving ED screening criteria can safely increase yield rate and reduce charges with minimal loss of VU sensitivity.

Adolescent↗

PubMed1998

Reduced use of resources by early tracheostomy in ventilator-dependent patients with blunt trauma.

BACKGROUND: Early tracheostomy has been advocated for ventilator-dependent patients with blunt trauma, but its advantages have not been examined critically. METHODS: We retrospectively reviewed our experience with all patients with blunt trauma undergoing tracheostomy during the 6-year period from 1990 to 1995. Patients undergoing tracheostomy within the first 6 days of hospitalization were designated as early recipients (ET) and those undergoing the procedure at 7 or more days were defined as late recipients (LT). RESULTS: The entire study group consisted of 157 patients. The ET group contained 62 patients and the LT group contained 95 patients. No statistical differences were noted between the 2 groups with respect to sex distribution, injury severity scores, probability of survival scores, or mortality rates. The mean stay in the intensive care unit for the ET group was 15 days compared with 29 days for the LT group (P < or = .001). The mean total hospital stay for the ET group was 33 days compared with 68 days for the LT group (P < or = .001). The mean estimated per-patient hospital charges for only room and ventilator care were $36,609 for the ET group compared with $73,714 for the LT group. CONCLUSIONS: ET in this patient group resulted in significantly lowered use of resources with no adverse effect on outcome.

Adult↗

PubMed1995

Determination of brain death with use of color duplex scanning in the intensive care unit setting.

OBJECTIVE: To determine if color flow duplex scanning (CFDS) can be used for rapid confirmation of presumed brain death. DESIGN: Pilot cohort study comparison of CFDS with radionuclide cerebral scanning (RCS) as the criterion standard. SETTING: Community-based level I trauma center intensive care unit. PATIENTS: Twenty-four patients who satisfied criteria for presumed brain death. MAIN OUTCOME MEASURE: Confirmation of presumed brain death. RESULTS: CFDS correctly identified 16 of 24 patients as brain dead, confirmed by RCS. Eight patients with brain flow on RCS were also correctly identified by CFDS. Only two of 24 patients survived their severe injuries. CONCLUSIONS: CFDS provides a uniform, cost-effective diagnostic tool for rapid confirmation of clinical brain death with 100% accuracy. Its use should complement RCS, given its rapid interpretation, portability, and economical assessment of presumed brain death.

Adolescent↗

PubMed1995

Cost-effectiveness of laparoscopic cholecystectomy.

This study retrospectively evaluated the cost-effectiveness of laparoscopic cholecystectomy compared to open cholecystectomy in a single university-affiliated community hospital. The medical records of all patients that underwent laparoscopic cholecystectomy during 1990 and open cholecystectomy during 1989 in one hospital were reviewed. Hospital stay, hospital charges, surgeons' and anesthesiologists' fees were determined. Fifty patients from each group were contacted to determine recovery time to full activity after surgery. Those having common duct exploration and those converted to open cholecystectomy after an attempted laparoscopic cholecystectomy (n = 8) were excluded. A summary of results is included below (Table 1). In our early experience with laparoscopic cholecystectomy we found that the total charges for laparoscopic cholecystectomy were more than for open cholecystectomy when one recognizes the 1-year difference in patient accrual between the two groups. Time to full recovery was markedly reduced in patients undergoing laparoscopic cholecystectomy compared to those having an open procedure. Despite the overall increased total charge with laparoscopic cholecystectomy, the shorter recovery period allowing the patients an earlier return to full preoperative activities contributes to its cost-effectiveness when compared to open cholecystectomy. Further experience with laparoscopic cholecystectomy and refinements in management of these patients should allow for further reductions in charges for this procedure.

Analysis of Variance↗

PubMed1995

Incidental Meckel's diverticulectomy in adults.

BACKGROUND: Incidental Meckel's diverticulectomy has been advocated by some surgeons because of the lower associated morbidity and mortality in this setting than when resection is indicated. Others have argued that the low risk of complication occurrence does not justify prophylactic removal. The issue remains controversial. METHODS: Medical records of all adults undergoing Meckel's diverticulectomy at four acute care hospitals during the 5-year period 1989 through 1993 were retrospectively reviewed. Decision analysis was used to determine relative risks for incidental resection compared to indicated resection for a complication. RESULTS: Ninety patients underwent incidental diverticulectomy. Morbidity was 2% and mortality 0%. Four patients underwent resection for a complication of their diverticulum. Morbidity and mortality were each 0%. Combining these results with previously reported results and using decision analysis, the conditional probabilities of producing surgical morbidity or mortality in the adult population at risk by only resecting symptomatic diverticula are 0.2% and 0.04%, respectively. The comparable risks for resecting all incidentally discovered diverticula are 4.6% and 0.2%. CONCLUSIONS: Incidental diverticulectomy in adults should be abandoned.

Adult↗

PubMed1995

Craniofacial trauma in injured motorcyclists: the impact of helmet usage.

Helmets are effective in decreasing maxillofacial trauma in motorcycle crashes. The impact, however, of motorcycle crashes on the location and patterns of craniofacial injuries among helmeted versus unhelmeted patients has not been examined. In the present study, 331 injured motorcyclists were evaluated to compare the incidence of craniofacial and spinal injury in 77 (23%) helmeted and 254 (77%) nonhelmeted patients. Nonhelmeted motorcyclists were three times more likely to suffer facial fractures (5.2% vs. 16.1%) than those wearing helmets (p < 0.01). Skull fracture occurred in only one helmeted patient (1.2%), compared with 36 (12.3%) of nonhelmeted patients (p < or = 0.01). The incidence of spinal injury was not significantly different between the two groups. Blood alcohol levels demonstrated that 12% of the helmeted group were legally intoxicated (blood alcohol level > 100 mg/dL), in contrast to 37.9% of the nonhelmeted motorcyclists (p < or = 0.01). Failure to wear a helmet resulted in a significantly higher incidence of craniofacial injury among patients involved in motorcycle crashes, but did not affect spinal injury or mortality. Alcohol usage seemed to correlate with failure to use helmets. Helmet use should be legally mandated on a national level for all motorcyclists.

Adolescent↗

PubMed1993

Adjunctive vasodilator therapy in the treatment of murine ischemia.

Potent vasoconstrictors such as angiotensin II and vasopressin have been implicated as mediators of persistent vasoconstriction after reversible superior mesenteric artery (SMA) occlusion. Neither captopril (CAP), an angiotensin-converting enzyme (ACE) inhibitor, nor papaverine (PAP), a vasodilator, has proven effective in reversing this vasoconstriction when employed singly. The present study examined the combined effect of these agents in reducing mortality in a murine model of acute mesenteric ischemia. The SMAs of 106 adult male Sprague-Dawley rats were totally occluded for 85 minutes. Test agents were given intravenously at reperfusion over a 90-minute period. Survival rates were assessed at 48 hours. CAP was given as a single bolus (0.3 mg/kg) and PAP (0.5 mg/kg/h) as an infusion. Aortic and SMA blood flows were measured pretreatment and posttreatment in a separate group of 19 animals treated with CAP and PAP as single agents. chi 2 analysis and analysis of variance were used to test differences with p < or = 0.05 accepted as significant. PAP alone as an adjunct resulted in a significant increase in 48-hour survival (57% versus 19%, p < or = 0.005). PAP in combination with CAP produced the best outcome in this model (87% versus 19%, p < or = 0.005). Aortic blood flow decreased, whereas SMA blood flow increased after treatment both with CAP and with PAP, but not significantly. The combination of an intravenously administered vasodilator with either glucagon or an ACE inhibitor was the most effective adjunctive therapy in this mesenteric ischemia model. There was no evidence that an inotropic effect, rather than SMA vasodilation, was the responsible mechanism of action.

Animals↗

PubMed1993

Traumatic incarceration of the small bowel: case report.

While bowel injuries associated with blunt abdominal trauma are a well recognized entity, entrapment of bowel between vertebral bodies has seldom been described. The unusual case of traumatic jejunal incarceration between two lumbar vertebrae is presented.

Abdominal Injuries↗

PubMed1993

The deltopectoral triangle as a landmark for percutaneous infraclavicular cannulation of the subclavian vein.

An anatomic landmark is identified and described that simplifies the technique of central venous cannulation via the subclavian vein. The commonly used techniques are an approach to the subclavian at the junction of the medial and middle thirds of the clavicle or at the midclavicular line. A described anatomic landmark, the deltopectoral triangle, is easily identified in virtually all patients and requires no measuring or extensive knowledge of anatomy for localization. Penetration of the skin at this landmark facilitates the procedure and produces less patient discomfort. Using this technique, the authors have successfully cannulated the subclavian vein in 92.7% (51/55) of attempts with a 5.5% (3/55) complication rate. The only complications were arterial punctures, which were treated with pressure and were of no consequence to the patient.

Catheterization, Central Venous↗

PubMed1993

Risk of pulmonary emboli in patients with pelvic fractures.

Multiply-injured patients with pelvic fractures are recognized to have an increased risk of deep venous thrombosis. The incidence of pulmonary emboli in patients with this injury has been reported to range from 0.5 to 8.3 per cent in several recent reviews. One hundred ninety-eight patients with pelvic fractures treated at a regional trauma center over a 3-year period were reviewed to evaluate the factors associated with an increased risk of clinically evident pulmonary embolism. The mean age SD was 44 24 years; 51 per cent were male, and mean Injury Severity Score (ISS) was 19 15. Eighteen patients (9%) died. Mortality was significantly correlated with ISS (P < 0.05), male sex, and type and severity of fracture but not with age, mechanism of injury, or operative fixation. Four patients (2.0%) had pulmonary emboli. The occurrence of clinically apparent pulmonary emboli correlated only with ISS (ISS < 15 = 0% vs ISS > 15 = 4%, P < 0.05). During the same time period, there were eight (0.2%) pulmonary emboli in 3337 trauma patients without pelvic fracture. This difference is highly significant (P < 0.0001). Pelvic fracture is indicative of severe injury and denotes a population at higher risk for pulmonary emboli than other trauma patients. Intensive screening and prophylactic measures to prevent deep venous thrombosis and subsequent pulmonary emboli should be intensively directed at this population.

Adolescent↗

PubMed1992

Cholecystectomy during pregnancy without fetal loss.

Cholecystectomy in the pregnant patient has been generally avoided because of the reported high incidence of associated fetal loss that has been linked to spontaneous and elective abortion during the first trimester and premature labor during the third trimester. Recent developments relating to diagnostic and anesthetic management and the use of tocolytic agents have altered the over-all approach to patients. We have, therefore, retrospectively reviewed the medical records of all women discharged from four area hospitals during 1982 to 1987 with a concurrent diagnosis of cholelithiasis and pregnancy. Twenty-two patients met the review criteria. The incidence of biliary stone disease among gravid patients during the time interval was 0.05 per cent. Of 22 patients, none underwent radiation for diagnosis. Nine patients underwent cholecystectomy while pregnant; two were operated upon during the first trimester, four during the second and three during the third. Three required common bile duct exploration and three had intraoperative cholangiograms. Elective abortion was not recommended to the six patients because of radiation exposure. Two of nine had premature contractions develop that were controlled with tocolytic agents. There were no spontaneous abortions. The mean Apgar scores for neonates born subsequent to cholecystectomy was virtually identical to neonates born to patients in whom cholecystectomy was deferred. It is concluded that the diagnosis and surgical treatment of cholelithiasis can be safely undertaken in the pregnant patient without fetal loss. Delaying appropriate surgical therapy no longer seems warranted.

Adult↗

PubMed1991

Are pancreatoenteric anastomoses improved by duct-to-mucosa sutures?

The patency of anastomoses joining the pancreas to either a Roux-Y loop of jejunum or the stomach was evaluated in 26 dogs. At a preliminary operation, the head and uncinate process of the pancreas were resected while carefully preserving the duodenal blood supply. The remaining body and tail of the pancreas were totally obstructed. After obstruction for a mean of 22 (range: 6 to 42) days, one of three anastomoses was performed: (1) inversion pancreatogastrostomy with two layers of sutures; (2) a similar inversion pancreatojejunostomy to the side of a Roux-Y jejunal loop; or (3) pancreatojejunostomy in which the major duct was joined to the jejunal mucosa with interrupted sutures. Six animals were kept for controls. Anastomotic patency was assessed after 8 to 12 weeks by pancreatography, with minimal pressures to achieve anastomotic flow recorded. Weight trends were consistent with anastomotic status. The eight dogs with duct-to-mucosa sutures clearly achieved superior anastomotic patency.

Anastomosis, Surgical↗

PubMed1991

Combined use of topical and systemic antibiotics.

An animal wound model was used to compare the effectiveness of topical and systemic antibiotics and to examine the validity of using a combined regimen of both routes of antibiotic delivery. Gross infection rates and wound bacterial concentrations were determined after contamination with Staphylococcus aureus or Escherichia coli. Both moderate (10(8) colony-forming units [CFU]) and heavy (10(12) CFU) contamination were studied for each organism. Following moderate contamination, topical and systemic antibiotics were equally effective in reducing both wound bacterial content and infection rate, but there was no benefit from the combined use of both modes of antibiotic delivery. An additive effect of the combined regimen was noted only when the level of wound contamination was heavy.

Administration, Topical↗

PubMed1991

Nonfunctioning parathyroid carcinoma.

Parathyroid carcinoma is a rare clinical entity accounting for only 4 per cent of all cases of parathyroid neoplasia. Nonfunctioning parathyroid carcinoma is even rarer. Previously, virtually all patients with these lesions were treated for a nonspecific neck mass. However, in the present case, a preoperative diagnosis of nonfunctioning parathyroid carcinoma was made based on the technetium pertechnetate/thallium 201 subtraction scan. The authors report on the 14th case of nonfunctioning parathyroid carcinoma, a review of the literature, and guidelines for the preoperative and operative evaluation of neck masses suspected to be parathyroid carcinoma.

Adult↗

PubMed1991

Mesenteric venous thrombosis: ten year record review and evaluation of difficulties with the ICD coding system.

A 10-year retrospective review of mesenteric venous thrombosis was accomplished in one metropolitan city. This paper discusses 14 patients with a confirmed diagnosis of mesenteric venous thrombosis. This review also yielded an important realization of an inadequacy of the International Classification of Diseases, 9th edition in coding for mesenteric venous thrombosis. This paper discusses this difficulty in the International Classification of Diseases.

Adult↗

PubMed1990

Operative therapy for sigmoid volvulus. Identification of risk factors affecting outcome.

The medical records of 54 patients treated for sigmoid volvulus from 1983 to 1987 were reviewed. Patient demographics were very similar to previously published results. Four patients (7.4 percent) underwent emergency resection for gangrene with a mortality of 75 percent. Of the 50 patients who presented without ischemia, 23 (46 percent) were managed by nonoperative detorsion while 3 (6 percent) detorsed spontaneously. Fourteen of these 26 patients received no further treatment. Nonoperative mortality was 0 percent. Celiotomy was performed on 36 patients. The type of operative procedure performed had no significant bearing on outcome. Fifteen patients underwent resection and anastomosis; two of these patients died (13 percent). Fifteen patients underwent resection and colostomy with two deaths (13 percent), and six had open detorsion alone with one death (17 percent). The two factors associated with adverse outcome after surgical intervention were patient age and history of previous volvulus. All five deaths occurred in patients older than 70 years presenting with a first episode of volvulus (N = 15, mortality = 33 percent). No deaths occurred among patients younger than 70 years regardless of volvulus history or among those older than 70 years who were being treated for a recurrence (P less than or equal to 0.01). Patients older than 70 years with a first episode of volvulus represent a high risk if subjected to surgical intervention. Nonoperative detorsion alone should be considered for this subgroup of patients.

Age Factors↗

PubMed1990

Reassessment of primary resection of the perforated segment for severe colonic diverticulitis.

Primary resection with colostomy has been widely adopted during the past decade for the treatment of patients with severe complications of diverticulitis. Because of this, a retrospective review was performed of all patients undergoing surgery for colonic diverticular disease during the two time periods 1974 to 1978 (n = 196) and 1982 to 1986 (n = 230). Forty-three patients had abscess or peritonitis from 1974 to 1978, whereas 52 had these complications from 1982 to 1986. Colostomy and drainage alone were used for 31 of 43 patients (72%) from 1974 to 1978, while primary resection with colostomy was used for 39 of 52 patients (75%) from 1982 to 1986 (p less than or equal to 0.5). Despite this shift in treatment method, mortality increased from 14% in 1974 to 1978 to 19% in 1982 to 1986 (p = NS). Patients with peritonitis had identical mortalities (22%) during both intervals. Patients with abscess experienced an increase in mortality from 8% in 1974 to 1978 to 15% in 1982 to 1986 (p = NS). The widespread use of primary resection for patients with severe complications of diverticulitis appears not to have altered mortality for those with diffuse peritonitis and may have worsened the outcome for those with abscess.

Abscess↗

PubMed1990

Assessing the role of routine choledochoscopy during exploration of the bile duct.

Two hundred and five consecutive explorations of the common bile duct were evaluated to assess the value of routine choledoschoscopic examination in preventing retained stones. Conventional exploration was performed in 139 instances (group 1), while routine choledochoscopy was added in 66 procedures (group 2). Preoperative temperature, leukocyte count, total bilirubin, amylase and alkaline phosphatase levels were not significantly different between the groups. Nine retained stones were demonstrated by postoperative cholangiography among the patients in group 1 as compared with three retained stones noted in those in group 2. This difference was not significant. Postoperative mortality and complication rates were unaffected by the performance of an endoscopic study of the biliary tract during ductal exploration. Choledochoscopy added an average of 36 minutes to the duration of the operative procedure (p less than 0.001). Choledochoscopy may prove helpful in selected instances, but the current data do not support its routine use during exploration of the common bile duct.

Cholangiography↗