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Biomedical subjects

J E Barone

Publications and source records attributed to J E Barone.

At least 19 recordsLinked to original sources
PubMed1999

Outcome study of cholecystectomy during pregnancy.

BACKGROUND: Several anecdotal papers suggest that laparoscopic cholecystectomy can be done safely in pregnant patients, but few patients are reported and other patients such as those who underwent laparoscopic appendectomy are often included. A larger series would help clarify the situation. METHODS: The Connecticut Laparoscopic Cholecystectomy Registry and data from the Connecticut Hospital Association (CHA) were combined to search for all cholecystectomies performed in pregnant patients from 1992 through 1996. Information on outcomes for both mother and infant was obtained through the cooperation of most of the CHA hospitals. RESULTS: Complete data were available for 46 patients, 20 laparoscopic and 26 open cases. The groups were comparable in all demographic respects except for the timing of cholecystectomy, which was performed at a mean of 18.4 +/- 6.7 weeks (range 9 to 32) of gestation for the laparoscopic and 24.8 +/- 4.7 weeks (range 14 to 35) for the open patients (P = 0.01). A maternal-fetal mortality due to intra-abdominal hemorrhage occurred in the laparoscopic group 2 weeks postoperatively. In the open group, a fetal demise occurred at 21 weeks gestation, 5 weeks postcholecystectomy. The open patients experienced 8 episodes of premature contractions compared with one one such event in the laparoscopic group (P = 0.057). CONCLUSIONS: This represents the largest reported series of laparoscopic cholecystectomy in pregnant patients. Laparoscopic cholecystectomy does not lead to increased numbers of fetal complications. Premature uterine contractions tend to occur more frequently after open cholecystectomy and when the procedure is performed later in gestation.

Adult↗
PubMed1999

Using queueing theory to determine operating room staffing needs.

BACKGROUND: To meet American College of Surgeons criteria, Level I and II trauma centers are required to have in-house operating room (OR) staff 24 hours per day. According to the number of emergency cases occurring, hospitals may have varying needs for OR staffing during the night shift. Queueing theory, the analysis of historic data to provide optimal service while minimizing waiting, is an objective method of determining staffing needs during any time period. This study was done to determine the need to activate a backup OR team during the night shift at a designated, verified Level II trauma center. METHODS: The basic queueing theory formula for a single-phase, single-channel system was applied to patients needing the services of the OR. The mean arrival rate was determined by dividing the number of actual cases by 2,920 hours in a year (8 hours per night x 365). The mean service rate is determined by averaging the length of the actual cases during the period studied. Using the mean arrival rate and the mean service rate, the probability of two or more patients needing the OR at the same time was determined. This probability was used to reflect the likelihood of needing to activate the backup OR team. Simulation was then used to calculate the same probability and validate the results obtained from the queueing model. RESULTS: All OR cases (n = 62) beginning after 11 PM and before 7 AM from July 1, 1996, through June 30, 1997, were analyzed. During the study period, the average arrival rate (A) was one patient every 5.9 days (0.0212 patient every hour), with an average service rate (mu) of 80.79 minutes per patient (0.7427 patients per hour). According to queueing theory, lambda = 0.0212 patients per hour, mu = 0.7427 patients per hour, lambda/mu = 0.0285, the probability of no patients being in the system (P0) = 0.9714, P1 = 0.0278, P> or =2 = 1 - (0.0278 + 0.9714) = 0.0008. The probability of two or more cases occurring simultaneously on the night shift is less than 0.1%. CONCLUSION: In our institution, activation of a second OR team is unnecessary when the first team is busy with a case on the night shift because the likelihood of two cases occurring concurrently is less than one in a thousand. Queueing theory can be a valuable tool to use in determining the staffing needs of many hospital departments. Trauma centers should apply this mathematical model in optimizing the use of their operational resource.

Connecticut↗
PubMed1999

Management of blunt splenic trauma in patients older than 55 years. Southern Connecticut Regional Trauma Quality Assurance Committee.

BACKGROUND: Many experts have suggested that blunt splenic trauma in patients older than 55 years should not be managed by observation because of supposed increased fragility of the spleen and decreased physiologic reserve in elderly patients. We sought to determine the outcome of nonoperative management of blunt splenic trauma in patients older than 55 years. METHODS: For the years 1994 through 1996, data for patients with splenic injury older than 55 years from seven trauma centers in a single state were reviewed. RESULTS: Blunt splenic trauma occurred in 41 patients older than 55 years. Eight patients were excluded from further analysis because of death from massive associated injuries within 24 hours of admission. The remaining 33 patients (mean age, 72+/-10 years) were divided into two groups: immediate exploration (10 patients) and observation (23 patients). Observation of blunt splenic injury failed in 4 of 23 patients (17%). No patient deaths were related to the method of management of the splenic injury. CONCLUSIONS: Observation of the elderly patient with blunt splenic trauma has an acceptable failure rate of 17%.

Age Factors↗
PubMed1999

Hypothermia does not result in more complications after colon surgery.

Our objective was to determine the incidence of complications in postoperative patients who were either normothermic or hypothermic. A recent, widely publicized paper concluded that the maintenance of normothermia could reduce the incidence of infectious complications and shorten hospitalization in patients undergoing colorectal surgery. However, some controversy arose regarding the methods of this paper. Patients were deliberately rendered hypothermic, were given more than 3.5 days of prophylactic antibiotics and were transfused significantly more units of blood. We reviewed the charts of 150 consecutive patients who underwent elective partial or subtotal colectomy with primary anastomosis. Among the key items analyzed were intraoperative and postoperative temperature, use of warming devices, duration of surgery, transfusions, interval to oral intake and bowel function, length of stay, complications, infections, and laboratory values. Hypothermia was defined as intraoperative temperature <95.5 degrees F. There were 101 normothermic patients and 49 hypothermic patients. Hypothermic patients had a mean age of 68.7 years versus 66.8 for the normothermic patients (P = 0.472). Comorbidities were similar in both groups. Warming devices were used in >90 per cent of the patients in both groups. The rates of postoperative infections and complications were similar in both groups. Postoperative lengths of stay were also not different. Despite finding that one-third of our patients were hypothermic during elective colon resection, hypothermia had no effect on outcome variables. In contrast to the previous study, the incidence of infectious complications was identical in our patients. Before ascribing postoperative complications and increased resource utilization as adverse effects of hypothermia, further studies are indicated.

Aged↗
PubMed1997

Munchausen syndrome presenting as trauma.

Rarely, a patient with Munchausen syndrome will present with apparent trauma. A computerized literature search from 1966 until the present discovered only three such case reports, none of which appeared in a surgical journal. We report a fourth case. The characteristics of Munchausen syndrome are illustrated. The possibility that such a patient may have a true injury is also discussed.

Adult↗
PubMed1997

Expanding handgun bullets.

BACKGROUND: Many new types of expanding or fragmenting handgun ammunition have been developed. Knowledge of these unusual bullets may aid in the management of patients and their wounds. METHODS: Eleven different expanding or fragmenting .45 caliber bullets and a nondeforming, full metal jacketed bullet for comparison were fired multiple times from the same handgun into both a water reservoir and ordnance gelatin. Performance was observed and recorded. Muzzle velocities were measured using a chronograph. Bullets were disassembled and cross-sectioned to facilitate inspection. RESULTS: The distinguishing surface and internal features of each bullet are described. When fired into water and ordnance gelatin, the bullets reliably expanded to 1.49 to 1.89 times their prefired diameters. Rates of kinetic energy loss of bullets of equal mass fired into ordnance gelatin were plotted. Full metal jacketed bullets penetrated twice as deeply as deforming bullets. Jackets of some of the expanding bullets separated when fired into water. CONCLUSION: Expanding/fragmenting bullets produce larger, shallower wounds than do full metal jacketed bullets. Recognition of the wound and roentgenographic appearances of these unusual bullets will help the trauma surgeon to properly treat gunshot victims. Because of the occurrence of jacket separation in water, ordnance gelatin should be used for optimal evaluation of bullet performance.

Firearms↗
PubMed1995

Problems with the fourth-year curriculum of students entering surgical residencies.

BACKGROUND: Because of concerns about the relevance of the fourth-year curriculum of students entering surgical residencies, this study was undertaken to analyze the curriculum, electives, and grades and to compare the students' elective choices with previously documented preferences of surgical educators. METHODS: Computer profiles of all fourth-year students at New York Medical College who entered surgical residencies during a 3-year period were reviewed. The records of 115 students (92 male, 23 female), who were placed in 68 categorical and 47 preliminary positions, comprised the study. Four-week rotations in internal medicine, neurology, and ambulatory medicine were mandatory. An average of 5.1 electives per student, along with time for vacation and interviews, filled the remainder of the year. RESULTS: Students were statistically significantly more likely to receive honors grades in electives. Students, especially those in preliminary positions, frequently selected electives in their eventual specialty choice. CONCLUSIONS: Program directors interviewing prospective candidates for residency should view elective grades with care. Students often take electives that duplicate or do not enhance their career choices. Elective grades are inflated and may be based on subjective evaluations. This issue should be investigated further, and the major surgical education organizations should propose meaningful changes.

Adult↗
PubMed1993

Is 24-hour operating room staff absolutely necessary for level II trauma center designation?

Recent papers from established trauma centers reported average elapsed times from emergency department (ED) admission to the operating room (OR) of greater than 100 minutes for patients judged to be in immediate need of surgery. This study was undertaken to determine whether patients treated at an institution desiring level II trauma center designation in a geographic area with a low incidence of penetrating trauma suffered any adverse effects because of lack of a 24-hour in-house OR staff. Trauma registry data at The Stamford Hospital, a suburban community teaching hospital without OR nursing staff in-house at night, were reviewed and compared with data from three affiliated level I trauma centers and with established national standards using TRISS methodology. Of 659 major trauma patients, 86 (44 blunt, 42 penetrating) underwent surgery within 12 hours of admission. Patients' injuries were similar in severity to those seen at the affiliated trauma centers and to the Major Trauma Outcome Study population. Mortality rates were also similar. No statistically significant differences were seen in elapsed times from ED arrival to OR arrival even in the subgroup of patients with systolic blood pressure values of < or = 90 mm Hg. No unexpected adverse outcomes could be ascribed to the lack of 24-hour OR staffing in this setting. The estimated cost of providing additional OR staffing is $145,000 per year. Since times to the OR and outcomes were similar to those at level I centers, this expense may not be warranted.

Adolescent↗
PubMed1993

Splenic artery aneurysm rupture during pregnancy.

Rupture of a splenic artery aneurysm during pregnancy or delivery is an unusual event. Only 98 previous cases have been reported. The survival of both mother and fetus is even more uncommon. This paper describes the tenth case of maternal-fetal survival after splenic artery aneurysm rupture. The literature is reviewed in detail with emphasis on the epidemiology, etiology, clinical presentation, and treatment of this problem. A high index of suspicion and an awareness of the management options are necessary to achieve a successful outcome.

Adult↗
PubMed1993

Pfannenstiel syndrome.

The Pfannenstiel incision is commonly utilized for Cesarean section. Long-term complications of this incision are rare. This retrospective charts review from a community teaching hospital over a 3-year period describes seven cases of scar endometriosis in a Pfannenstiel incision after Cesarean section. In two other instances, hernias were found. Patients presented with pain and/or a mass at the incision site. Although extensive diagnostic workup including ultrasonography, computerized tomographic scan, and needle biopsy have been suggested by other authors, surgical exploration was both diagnostic and therapeutic in our experience.

Adult↗
PubMed1992

Severe hypophosphatemia in postoperative patients.

Severe hypophosphatemia may develop in postoperative patients for several reasons including alcohol withdrawal, diabetic ketoacidosis, nutritional recovery (refeeding) syndrome, and severe respiratory alkalosis. Severe hypophosphatemia may result in central nervous system abnormalities, muscle weakness, and renal, hepatic, cardiac, and respiratory dysfunction. Hypophosphatemia may be prevented by close monitoring of phosphorus concentrations in serum, especially in patients predisposed to developing this problem. Proper techniques for the maintenance and repletion of phosphate for both enteral and parenteral use are described.

Administration, Oral↗
PubMed1992

Arterial substitution in lower extremity trauma: autogenous vein vs polytetrafluoroethylene.

This review article compares the two most commonly used grafts, autogenous saphenous vein and polytetrafluoroethylene (PTFE), for treatment of arterial trauma. Late graft occlusion is more common with PTFE, but PTFE may be better in situations where infection is a concern and extra-anatomic bypass is not possible. When infected, saphenous vein is much more of a risk because of its tendency to undergo sudden hemorrhagic disruption. PTFE grafts usually show only moderate suture line bleeding, which alerts the surgeon to the presence of a problem with the graft.

Blood Vessel Prosthesis↗