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Biomedical subjects

J G Maxwell

Publications and source records attributed to J G Maxwell.

At least 37 records · Page 2Linked to original sources
PubMed1994

The financial impact of intentional violence on community hospitals.

The purpose of this study was to examine the financial impact of assault-related penetrating trauma. We specifically reviewed hospital charges and reimbursement data. Two hundred eleven patients were identified from our Trauma Registry in a 4-year period: 108 with firearm injuries and 103 with injuries related to cutting or piercing instruments. Assault-related penetrating injuries generated more than $2,000,000 in hospital charges. Sixty-seven percent of this amount was incurred by patients who had no source of third-party payment. Reimbursement covered only 30% of charges. There were no differences in demographics, procedures, or in insurance status, mean charges, and unpaid balances between patients directly admitted and those transferred from other hospitals. Financial losses incurred by community hospitals from the care of penetrating injuries are substantial, and must be borne by cost shifting or other strategies. No evidence of "dumping" was found among this group of patients. The specter of injury caused by intentional violence extends beyond urban trauma centers, and has a serious negative financial impact on community trauma centers.

Adolescent↗
PubMed1993

Oral contrast is not necessary in the evaluation of blunt abdominal trauma by computed tomography.

The administration of oral contrast (OC) is widely recommended for computed tomography (CT) of the abdomen in patients with blunt trauma. The purpose of this study was to determine whether routine abdominal CT scans performed without OC were associated with diagnostic error in patients with blunt trauma. Four hundred ninety-two patients were identified from our Trauma Registry who had CT scans for the evaluation of blunt abdominal trauma between January 1988 and December 1991. Seventy-six percent (372) of the CT scans were interpreted as negative, and 24% (120) were considered positive. OC was used in 8 (1.6%) of 492 patients. Only 1 of 372 patients whose initial non-OC--enhanced scan was negative subsequently required surgery. There were 5 bowel injuries among the 42 patients who underwent an abdominal operation; in none would the use of OC have ensured the preoperative diagnosis. We found that the omission of OC did not represent a disadvantage to patients with blunt trauma undergoing a routine abdominal CT scan. Potential time delays and the hazards associated with the use of OC were minimized.

Abdominal Injuries↗
PubMed1993

Hospital resources used to treat the injured elderly at North Carolina trauma centers.

OBJECTIVE: The purpose of this paper is to compare the hospital resources used by elderly, adult, and pediatric patients treated in hospitals reporting to the North Carolina Trauma Registry (NCTR). DESIGN: We analyzed data on all patients entered into the NCTR from 1 January 1988 to 31 December 1990. SETTING: The NCTR is a statewide registry of all trauma patients admitted for at least 24 hours or dead on arrival at the eight Level I and II trauma center hospitals in North Carolina. PATIENTS: The total number of patients included in the study was 21,214; elderly adults included those age 65 and older (n = 2808), adults included those 15 to 64 years old (n = 15,776), and pediatric patients included those 0 to 14 years old (n = 2630). MAIN OUTCOME MEASURES: We examined hospital resources using three measures: overall length of hospital stay in days, intensive care unit (ICU) length of stay in days for those admitted to the ICU, and total hospital charges billed during the hospitalization. RESULTS: Controlling for injury severity, we found that elderly adults had longer mean hospital and ICU lengths of stay and higher mean hospital charges than adults or children. Whereas only 22% of injuries to elderly adults were transportation-related, transportation injuries generated 38% of their hospital charges. Sixty-eight percent of their injuries were caused by falls, generating total hospital charges of $17.6 million, an average of 15 days in hospital stay and 9 days in ICU stay. CONCLUSION: A 10% reduction in both transportation injuries and falls among the elderly could save $3.5 million in this population over 3 years.

Accidents, Traffic↗
PubMed1993

Laparoscopic cholecystectomy: comparison of university and community experience.

We compared the first year's experience in performing laparoscopic cholecystectomy in a university hospital and a community hospital to determine the impact of postgraduate surgical training on outcome. Laparoscopic cholecystectomy was attempted on 446 patients. The conversion rate to open cholecystectomy was 8.3% and did not differ between institutions. Surgical house staff performed 43% of the cases at the university hospital compared with 8% at the community hospital. The greater use of laser and cholangiograms resulted in significantly longer mean operative time at the university hospital (141 +/- 26 min) than at the community hospital (114 +/- 52 min). The overall complication rate did not differ significantly (p = 0.15). Complications included common duct injury (three cases), bile leak (five cases), bleeding or hematoma (six cases), epigastric artery hematoma (one case), and death (one case). Operative inexperience during this first year may be a major determinant for the complication rates at both hospitals. It is too early to determine the impact of graduate surgical education on complications. Intense education and supervised instruction is requisite to minimizing the morbidity associated with laparoscopic cholecystectomy regardless of whether it is performed at a university or community hospital.

Adolescent↗
PubMed1992

Results of staged bilateral carotid endarterectomy.

To determine differences in outcome between unilateral and staged bilateral carotid endarterectomies, we reviewed 850 carotid endarterectomies done by 14 surgeons in a community hospital. Results of 528 unilateral procedures were compared with those of 161 bilateral procedures. Data were abstracted from records for an 11-year period. Twelve of the patients in the unilateral group had nonfatal strokes, and 14 died within 30 days of surgery (stroke + death rate, 4.9%). There were no nonfatal strokes among patients in the bilateral group, and nine died (stroke + death rate, 5.6%). Seven of 14 deaths in the unilateral group and six of nine deaths in the bilateral group were due to neurologic events. In the bilateral group, death was associated with postoperative hypertension and a short intersurgical interval. The stroke + death rate was not significantly different between unilateral and bilateral procedures and compared favorably with North American Symptomatic Carotid Endarterectomy Trial guidelines and other published reports. Staged bilateral carotid endarterectomy can be safely performed in a community hospital.

Carotid Artery Diseases↗
PubMed1992

Laparoscopic cholecystectomy in situs inversus totalis.

A 51-year-old woman with known dextrocardia presented with left-sided abdominal pain and symptoms consistent with biliary colic and cholelithiasis. Abdominal ultrasound confirmed the diagnosis of gallstones, as well as situs inversus with the liver and gallbladder on the left side and the spleen on the right. Laparoscopic cholecystectomy was performed without incident. The procedure was uncomplicated except for being the mirror image of that done with the gallbladder in the normal location. Cholelithiasis occurring with situs inversus is rare and may present a diagnostic problem. The extrahepatic anatomy of the biliary and venous system is the mirror image of the right sided liver. Historic and genetic aspects of situs inversus, as well as current theories regarding its etiology are presented. Situs inversus totalis does not appear to be a contraindication to laparoscopic treatment of cholelithiasis.

Cholecystectomy↗
PubMed1991

Patient awareness of health precautions after splenectomy.

Sepsis after splenectomy is a lifelong risk, and patients who have had splenectomy should be educated about this risk. This study examines patient knowledge after splenectomy. We reviewed hospital records of 118 patients who had splenectomies performed between 1982 and 1988 at New Hanover Memorial Hospital. Twenty-four patients have died since their surgery; one death was suspected to be due to postsplenectomy sepsis. Of the 89 patients alive and eligible for follow-up, we were able to query 63. Only 16% were aware of any health precautions. After prompting, patient awareness improved to 40%. We also surveyed 11 of the 14 surgeons who performed the splenectomies. They indicated that they always discuss with their patients the immunologic consequences of spleen removal and the increased risks of infection, although they do not always recommend pneumococcal vaccine. We conclude that splenectomy patients have a low level of knowledge about postsplenectomy infection risks and precautions. We developed an educational pamphlet to aid the surgeon in patient education.

Awareness↗
PubMed1991

Mirizzi's syndrome: a contraindication to coelioscopic cholecystectomy.

An impacted gallstone in the cystic duct with subsequent inflammation and edema resulting in extrinsic compression of the common bile or common hepatic duct with obstructive jaundice is known as Mirizzi's syndrome. An uncommon complication of cholelithiasis, Mirizzi's syndrome should be included in the differential diagnosis of any patient who has extrahepatic biliary obstruction. We present a case of a patient who underwent open rather than coelioscopic cholecystectomy based upon the preoperative diagnosis of Mirizzi's syndrome. A multidisciplinary approach to such patients facilitates the decision between open and endoscopic cholecystectomy. Mirizzi's syndrome may represent a contraindication to endoscopic cholecystectomy.

Adult↗
PubMed1991

Cardiac output measurement in critical care patients: Thoracic Electrical Bioimpedance versus thermodilution.

Thoracic Electrical Bioimpedance (TEB) is a method for measuring cardiac performance which is noninvasive, continuous, has minimal technical requirements, and no patient risk. We used a commercially available TEB device to measure cardiac output in patients with thermodilution catheters in place. We compared the cardiac output measurements for the two modalities. We also compared the average hospital cost for initial cardiac assessment using the two techniques. The mean difference between the two cardiac output measurements was small (0.23 +/- 0.56) and not affected by the magnitude of the cardiac output readings. There was a strong correlation between COTD and COTEB (r = 0.91) and the regression slope was 0.91 with a Y intercept of 0.76. Cost analysis demonstrated that the use of TEB was approximately $600 less than thermodilution. Thoracic electrical bioimpedance measurement of cardiac output may offer a valuable alternative to the invasive measurement of the thermodilution catheter.

Adolescent↗
PubMed1990

Community hospital carotid endarterectomy in patients over age 75.

We compared the prevalence of stroke and death in 133 patients aged 75 and older in whom 170 carotid endarterectomies were performed with that in 501 patients less than age 75 in whom 640 carotid endarterectomies were performed. There were three strokes (2%) in patients aged 75 and older and nine strokes (1%) in younger patients (p = 0.7). There were 8 deaths (5%) in patients aged 75 and older and 14 deaths (2%) in younger patients (p = 0.1). After controlling for the possible confounding effects of diabetes, prior stroke, history of angina, prior carotid artery disease, previous vascular surgery, history of myocardial infarction, preoperative hypertension requiring medication, and female gender, a logistic regression model showed that patients aged 75 and older were no more likely to have a stroke or death than patients under age 75. We conclude that age alone is not a contraindication to the safe performance of carotid endarterectomy in the community hospital.

Age Factors↗
PubMed1989

Gonococcal wound infection.

We have reported a gonococcal infection in a surgical incision made ten months before the onset of urethral discharge. Gonococcal wound infections may arise from direct contamination or possibly by blood-borne dissemination. Principles guiding therapy are similar to those for wound infections from other organisms, with attention to adequate drainage, removal of foreign body, appropriate antibiotics, and elimination of contributing sources of infection.

Adult↗
PubMed1989

Infrequency of blacks among patients having carotid endarterectomy.

We reviewed demographic data on patients having 2,256 carotid endarterectomies in eight large hospitals in North Carolina to determine the frequency of blacks among these patients. Blacks comprised only 4.6% of the patients having carotid endarterectomy even though they comprised 26% of all patients discharged and 22% of the general population of the state. Data from the National Inpatient Profile of the Commission on Professional and Hospital Activities, which represents patients discharged from short-term, nonfederal hospitals throughout the United States, show that nationwide, blacks comprise only 2.7% of the patients having carotid endarterectomy, whereas they comprise 12.0% of all patients discharged, 12.1% of the general population, and 10.7% of patients discharged following Class I surgical procedures. Blacks have only 67 carotid endarterectomies per 100,000 patients discharged; this rate is five or more times higher in whites. Among black patients having carotid endarterectomy, women predominate, whereas men predominate among white patients having carotid endarterectomy (p = 0.006). The underrepresentation of blacks among patients having carotid endarterectomy lends support to the concept that carotid vascular disease in blacks is distributed intracranially rather than extracranially as opposed to the extracranial rather than intracranial distribution in whites.

Adult↗
PubMed1989

Abdominal aortic aneurysm infected with Campylobacter fetus subspecies fetus.

We report a survivor of Campylobacter fetus septicemia from an infected abdominal aortic aneurysm who was successfully treated with an anatomic graft reconstruction and antibiotics. According to a survey of the English-language medical literature this was the fourth such patient successfully treated. C. fetus sepsis associated with an abdominal aortic aneurysm was first reported in 1971. The first patient to survive reconstruction of an aortic tube graft aneurysm infected with C. fetus was reported in 1983. Because the natural history of an aneurysm infected by C. fetus appears to be rapid progression to rupture, patients should be operated on promptly. All patients reported in the literature who were operated on before rupture survived. Survival was independent of the type of reconstruction. When the aneurysm ruptured all patients died. Whereas extraanatomic bypass is generally considered the procedure of choice for an infected abdominal aneurysm, the aneurysms of our patient and three other patients cited in the literature were reconstructed with anatomically placed prosthetic grafts. In the absence of other contraindications such as a grossly evident purulent infection, an abdominal aortic aneurysm infected by C. fetus may represent a subset of infected aneurysms that can be treated successfully with an anatomically placed prosthetic graft and antibiotics.

Amoxicillin↗