Influence of the nature of the fat in diets high in carbohydrate (mainly derived from bread) on the serum cholesterol.
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Adult↗
Biomedical subjects
J Freeman
Publications and source records attributed to J Freeman.
Attitudes to discharge among long-stay mental hospital patients and their relation to social and clinical factors.
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Adult↗
Carcinoma of the bronchus with negative x-ray findings.
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Bronchi↗
Tumors of the skull base: outcome and survival analysis of 77 cases.
We reviewed our experience with combined approaches to lesions that transcend the bones of the skull base. Seventy-seven skull base procedures were performed on 73 patients during a 10-year period from 1982 to 1992. There were 34 patients (44%) with region lesions (anterior), seven patients (9%) with region II lesions (anterior-lateral), 25 patients (32%) with region III lesions (lateral-posterior), and 11 patients (14%) with lesions that invaded more than one anatomic site. The histopathology in this series was quite variable, with 22 patients (29%) having squamous cell carcinoma and eight patients (10%) having basal cell carcinoma. Forty-one patients had surgery by an anterior approach and 38 patients had lateral approaches, with 18 undergoing an infratemporal approach and 29 undergoing temporal bone resections. Overall, 44% of the patients had a postoperative complication. Survival of this heterogeneous group of patients is 79% at 2 years and 71% at 4 years, with those patients with region II disease having a statistically significant poorer prognosis with no survivors at 4 years.
Adolescent↗
Acute pulmonary hypertension complicating the arterial switch procedure.
Two neonates undergoing arterial switch procedure developed life-threatening pulmonary hypertension intraoperatively. In one patient, bradycardia, hypotension, and electrocardiographic (ECG) evidence of myocardial ischemia suddenly occurred 20 minutes after uneventful weaning from cardiopulmonary bypass. Lifting a palpably hypertensive main pulmonary artery (MPA) resulted in reproducible hemodynamic improvement. Because the patient was already on full ventilatory support and a nitroglycerin infusion, the MPA was suspended onto the anterior chest wall. In the other patient, after removal of intraoperative drapes, severe generalized swelling and cyanosis were noted. The central venous pressure had risen to 25 mmHg, and the PO2 had dropped to 52 mmHg on 100% FIO2. The systolic arterial pressure and ECG remained normal. Immediate reexploration revealed a palpably hypertensive MPA. The coronary arteries implanted more laterally on the neoaorta were uncompromised. Amrinone loading and infusion produced immediate improvement. We believe that surgeons should be aware that pulmonary hypertension can cause coronary artery compression and right heart failure in neonates undergoing the arterial switch procedure. Lateral placement of the coronary artery and aggressive use of pulmonary vasodilators can minimize the problem.
Acute Disease↗
Imaging features of splenic epidermoid cyst with pathologic correlation.
The spleen can be involved in a variety of cystic lesions ranging from cystic neoplasms and parasitic cysts to "true" and "false" cysts. Epidermoid splenic cyst is a rare true cyst that is developmental in origin. We present two young patients with such a cyst and illustrate their features on ultrasound, CT, and MRI with pathologic correlation.
Adult↗
Noncutaneous cavernous hemangiomas of the head and neck.
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Adult↗
An unusual antibody related to the MN blood group system.
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Black People↗
A randomized trial of solvent/detergent-treated and standard fresh-frozen plasma in the coagulopathy of liver disease and liver transplantation.
BACKGROUND: Virus inactivation of pooled fresh-frozen plasma (FFP) by the solvent/detergent (SD) method results in a loss of approximately 20 percent of factor VIII. This study aimed to assess the efficacy of SD-treated plasma in correcting the coagulopathy associated with liver disease and liver transplantation. STUDY DESIGN AND METHODS: Forty-nine patients with coagulation deficits due to liver disease, who required FFP for invasive procedures or liver transplantation, were randomly assigned to receive either FFP or SD-treated plasma. Patients were assessed for side effects, correction of coagulopathy over 24 hours, and seroconversion for viral markers 6 to 18 months after treatment. RESULTS: In the liver disease group, equal correction of clotting factors and partial thromboplastin time was seen with FFP and SD-treated plasma, with a similar return to baseline values over 24 hours. There was greater correction of the International Normalised Ratio in patients receiving SD-treated plasma (p = 0.037), but this patient group had higher baseline values than recipients of FFP (p = 0.024). Liver transplant patients also showed equivalent correction of coagulopathy with the same dose of FFP and SD-treated plasma. The use of other blood components during transplantation was identical in the two treatment groups. No seroconversions were seen for HIV or hepatitis B or C virus. One patient who had received FFP seroconverted for human parvovirus B19. Apparent seroconversion for hepatitis A virus seen at 9 to 13 months in four other patients was probably due to detection of passively transferred antibodies, as later testing of these patients gave negative results. Minor side effects were rare in both groups. CONCLUSION: SD-treated plasma is an efficacious source of coagulation factors for patients with liver disease who are undergoing biopsy or transplantation. Assessment of seroconversion for viral markers in recipients of plasma-derived products and plasma components should include consideration of the possibility that passively transferred antibodies were detected.
Adult↗
Methodologic issues in hospital epidemiology. IV. Risk ratios, confounding, effect modification, and the analysis of multiple variables.
Most information in hospital epidemiology comes from observational studies of hospitalized patients, not from planned experiments. Data from observational studies have frequently been used to investigate the effect of exposure to a single factor as a cause or determinant of a discrete outcome, such as infection or death. In such observational studies, the characteristics of study patients may vary widely even within a single hospital. In these investigations, extraneous variables such as differing severity of underlying illness, acting in concert with the exposure variable being studied, may distort the apparent effect of the exposure on the outcome through confounding or may modify the effect of the exposure on the outcome without distorting the relation between them. The data from six published studies are reanalyzed through the use of stratification by severity of underlying illness in order to demonstrate the impact of confounding and effect modification by a third, extraneous variable. Simple methods for dealing with confounding and effect modification in data from hospital epidemiology are presented.
Analysis of Variance↗
Methodologic issues in hospital epidemiology. I. Rates, case-finding, and interpretation.
Surveys of nosocomial infection that have been published in the last two decades present great diversity in both purpose and methods. These differences limit our ability to draw generalizations. Difficulties in understanding and comparing past studies derive from diverse sources. Methodologic areas where there are substantial differences included definitions of rates of infection, criteria for infection, and methods of case-finding. Studies also differ with respect to characteristics of hospital populations, their underlying diseases and their patterns of lengths of stay, clinical procedures, and efforts at prevention of infection. All of these features may change over time and vary with geographic setting. Meaningful comparisons can be made only if uniform definitions of rates are adopted, standardized methods of data collection are employed, and procedures are used to minimize problems in interpretation. These problems in interpretation arise from the confounding effects of multiple uncontrolled variables, the limited applicability of intervention trials, unmeasured perturbation in the steady-states of study populations, and subsequent difficulties in identifying causal factors and measuring their quantitative effects.
Age Factors↗
Methodologic issues in hospital epidemiology. II. Time and accuracy in estimation.
Nosocomial infections comprise a variety of diseases that have all of the characteristics and problems traditionally associated with the epidemiology of chronic disease. Each infection is multifactorial in origin, and most of these factors remain either unknown or unquantified. The microbial agent is not the sole determinant of outcome. Time is also an important variable, especially with regard to variation in incubation (latent) period for different infections, and variation in duration of hospitalization (exposure and follow-up). Methods used for the study of chronic diseases may be employed in evaluating some aspects of nosocomial infection. When time is considered as a variable, it is possible to use a common, interconvertible set of definitions of rates that includes measures of both prevalence and incidence of infection. Accuracy in estimation also may be improved by further consideration of the choice of subjects (validity of selection), experimenter effects, misclassification (validity of information), and confounding (validity of comparison.
Acute Disease↗
Methodologic issues in hospital epidemiology. III. Investigating the modifying effects of time and severity of underlying illness on estimates of cost of nosocomial infection.
Published estimates of extra cost and prolongation of hospital stay attributed to nosocomial infection obtained from epidemiologic comparisons are almost twice as large as judgements in studies based on subjective impressions. It is possible that this disparity may result from confounding by time and severity of underlying illness. Whether the effects of time and secondary disease diagnoses modified the results of an epidemiologic comparison of infected patients and comparison subjects matched on primary diagnosis and operation have been investigated. Whereas the average prolongation of hospital stay in a prevalence series of patients with nosocomial infection was 13.3 days, the average prolongation for the corresponding incidence series of infections from the same study population was only 7.3 days, or about one-half as long. No substantive changes resulted from adjusting for duration of exposure to hospital prior to infection. Five selected secondary diagnoses had the potential for substantial confounding effects on epidemiologic comparisons but had little overall effect on the estimates in this study. The large size of our estimates in both prevalence and incidence series is not the result of residual confounding by the effects of time or secondary disease diagnoses. Results from prevalence and incidence series must be clearly distinguished because the same events will be perceived differently in the two types of series.
Adult↗
From hard copy to computer integration: developing clinical indicators for quality improvement.
The Clinical Indicator Workbook is a computerized tool that allows users to develop measures of healthcare quality. The electronic workbook, which includes selected clinical indicators to measure various aspects of patient care and teaching examples, was developed by using a major word processing package and uses a point-and-click feature. Its distribution and installation are managed by a program that enables users to select one of three options: (a) installation of the required files and indicator documents, (b) duplication of material on two diskettes for future distribution within the user's facility, and (c) on-line help. Once the workbook is installed, users are able to copy and customize the indicators for use with interdisciplinary teams in clinical settings. A survey of initial users, who are, for the most part, quality managers in the Veterans Affairs system, indicated that they are satisfied with this tool overall.
Computer User Training↗
Temporal bone fractures and cholesteatoma.
Extralabyrinthine fractures of the temporal bone offer the opportunity for squamous epithelial invasion of the middle ear, petrous pyramid, and mastoid air-cell system as a late complication. Cholesteatoma, secondary acquired in this situation, can be very aggressive and difficult to manage surgically, particularly where the temporal bone air-cell system is well developed. Polytomography is extremely helpful in determining the sites of fracture and in fashioning the surgical approach. Three cases are presented to illustrate the problems in diagnosis and surgical management.
Accidents, Traffic↗
Correlation of tumor volume with local control in laryngeal carcinoma treated by radiotherapy.
An analysis of 37 patients with laryngeal carcinoma (T2 or greater) treated with radical radiotherapy, with surgery reserved for failure, was performed to determine if tumor volume, alone or in association with other prognostic factors, accurately predicted the probability of local control. Patient records were reviewed retrospectively and the following data extracted: age, sex, laryngeal region and number of sites involved by tumor, T and N categories, and success or failure of radiotherapy. Tumor volume for each patient was calculated from pretreatment computed tomograms by summing the products of the cross-sectional tumor area on each CT cut and the interval in millimeters between sequential CT cuts. The mean tumor volume for patients failing radiotherapy was 21.8 cm3, and the mean volume for patients primarily controlled by radiotherapy was 8.86 cm3. Tumor volume significantly predicted disease-free interval (p = .045) and outcome with radiotherapy (p = .02). The study suggests that tumor volume is a significant factor in determining the outcome of primary radiotherapy in advanced laryngeal carcinoma.
Adult↗
Hormonal and metabolic changes following severe head injury or noncranial injury.
In order to evaluate the effect of head injury in severely traumatized patients on the response of plasma cortisol, glucagon, insulin, glucose, and FFA as well as urinary N and catecholamines excretions, 36 patients were prospectively studied over 5 consecutive days following injury. They were divided into three groups: group I, severe isolated head injury (n = 14); group II, multiple injury combined with severe head injury (n = 12); group III multiple injury without head injury (n = 10). The results demonstrate similar hormonal and metabolic changes between these three groups of patients, characterized by elevated urinary adrenaline, noradrenaline excretion, increased cortisol, glucagon, insulin plasma levels throughout the study and elevated N urinary excretion with strongly negative N balances during the first 5 days postinjury. A significant correlation was observed between N intake and 5 day cumulated N balance (r = 0.63, p less than 0.001). In addition, N balance was negatively correlated with urinary excretion of adrenaline (r = -0.47, p less than 0.01) and noradrenaline (r = -0.44, p less than 0.05) as well as plasma levels of glucagon (r = -0.44, p less than 0.05). Isolated severe head injury seems to induce a full response in the secretion of the catabolic counterregulatory hormones comparable to that encountered in patients with multiple injury and associated with a marked increase in protein catabolism; additional noncranial major injury does not seem to enhance these responses.
Adolescent↗
Meniscal injuries associated with acute anterior cruciate ligament tears in alpine skiers.
We reviewed the records of 315 patients receiving an arthroscopically assisted stabilizing procedure for an acute anterior cruciate ligament injury incurred while alpine skiing to evaluate associated meniscal injuries. Meniscal injuries were classified by type, location, and treatment of the tear. Of the 317 knees operated on, all demonstrated an anterior cruciate ligament tear at arthroscopy. Ninety-eight percent of the injuries (310) were diagnosed within 3 days of injury, and 97% (307) were reconstructed within 28 days of injury. All tears occurred in the intrasubstance of the ligament; 32% were isolated injuries and 68% were combined with other injuries. In 159 patients with 170 meniscal tears 141 of the tears (83%) were lateral and 29 (17%) were medial. The injury triad of anterior cruciate ligament-medial collateral ligament-lateral meniscus was seen nine times as often as the anterior cruciate ligament-medial collateral ligament-medial mensicus combination.
Acute Disease↗