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Biomedical subjects

J R Hiatt

Publications and source records attributed to J R Hiatt.

At least 37 records · Page 2Linked to original sources
PubMed1996

Laparoscopic splenectomy for ITP. The gold standard.

BACKGROUND: A comparison of safety, efficacy, and cost of laparoscopic splenectomy (LS) vs open splenectomy (OS) for idiopathic thrombocytopenic purpura (ITP) was performed. METHODS: The records of 49 consecutive patients who underwent splenectomy for ITP (31 LS and 18 OS) at a large metropolitan teaching hospital between 3/91 and 8/95 were reviewed. Morbidity, mortality, hospital stay, operative time, blood loss, time to oral fluid intake, direct costs, and operating room (OR) costs were analyzed. RESULTS: Age, sex, comorbidity, and spleen size were similar in both groups. LS was successful in 94% of patients in whom it was attempted. Operative times showed a learning curve for LS, with average times for the last ten cases (94 +/- 35 min) significantly shorter than for the first ten (p = 0.01) and also shorter than for OS (103 +/- 45 min). Postsurgical hospital stay was 2.9 +/- 1.3 days for LS and 6.9 +/- 3. 0 days for OS (p < 0.001). Patients tolerated an oral diet 1.2 +/- 0. 5 days after LS and 3.2 + 0.7 days after OS (p < 0.001). Direct hospital cost was $5,509 +/- 3,636 for LS and $9,031 +/- 12,752 for OS. In the LS group, six patients (21%) had accessory spleens identified and removed, compared with two patients (11%) in the OS group. Platelet counts did not respond in two (7%) patients in the LS group, but no accessory spleens were identified by nuclear scan. One major complication occurred in the LS group. There were no cases of splenosis or mortality in either group. CONCLUSIONS: LS is a safe and effective treatment for ITP, with significantly shorter postoperative hospital stay than OS.

Adolescent↗
PubMed1996

Continuous use of standard process audit filters has limited value in an established trauma system.

OBJECTIVE: To evaluate the ability of five quality assurance/ quality improvement audit filters to identify opportunities for improvement in patient care in a mature trauma system. DESIGN: Retrospective analysis of prospectively collected data. MATERIALS AND METHODS: Total patient population at risk and audit filter fallouts were evaluated for the following audit filters: patients with (1) Glasgow Coma Scale (GCS) score < 14 who did not receive a CT scan within 2 hours of admission; (2) subdural/ epidural hematomas who did not undergo craniotomy within 4 hours; (3) open tibial fractures who did not undergo debridement within 8 hours; (4) abdominal gunshot wounds who did not undergo laparotomy within 4 hours; and (5) all deaths where a quality assurance action was taken. The filters were used for 1 year. Mortality was compared between fallouts and nonfallouts in each category and the frequency of corrective actions for each category were determined. RESULTS: Corrective actions were taken in 97 of the 418 fallouts from 3,787 patients at risk. The majority (77%) of these actions were for patients in the death audit filter group. There were 343 nondeath fallouts, representing 13% of the 2,719 nondeath patients at risk. Of these, 22 corrective actions were taken, representing 6.4% of the fallouts and less than 1% of the patients at risk. CONCLUSION: The non-death process based audit filters that we evaluated in our trauma system documented adherence to care process standards but found few opportunities for quality improvement, suggesting that audit filters should be periodically evaluated and changed when their goals have been accomplished.

Evaluation Studies as Topic↗
PubMed1996

Pedestrian-motor vehicle trauma: an analysis of injury profiles by age.

BACKGROUND: Pedestrian-motor vehicle trauma (PMVT) is a common mechanism of injury in urban populations. STUDY DESIGN: We performed a retrospective review of 273 PMVT victims (16 percent of all patients with blunt injuries) seen at a Level I trauma center over a three-year period. Patients were analyzed by age and grouped as children (age younger than 16 years), adults (age 16 to 59 years), or elderly (age older than 59 years). RESULTS: Children constituted 27 percent of the patients, adults 54 percent, and elderly 19 percent. This mixture had significantly more children and elderly than the population at large or the entire blunt trauma population at our hospital. The majority of patients (66 percent) were male, with females outnumbering males only in the elderly group. Elderly patients were more frequently admitted to the intensive care unit (ICU) and had significantly longer ICU and hospital stays. Injury Severity Scores were successively higher in each age group and significantly higher in the elderly. Extremity trauma was most common in all three groups, followed by head injuries. The elderly patients were more prone to chest and pelvic injuries and the children most often had femur fractures. Operations were performed in 22 percent of the patients; orthopedic procedures were most frequent. The mortality rate was 6 percent, with 69 percent of the deaths occurring during the initial resuscitation efforts. The mortality rate was significantly higher in the elderly patients (13 percent). The majority of accidents occurred during nighttime hours, especially in the adult group. Half of the accidents occurred on the weekend, with the greatest number on Saturday. One-third of the accidents occurred during the months of October to December. CONCLUSIONS: Pedestrian-motor vehicle trauma is a common injury, with distinct epidemiological features that may be useful in accident prevention strategies.

Accidents, Traffic↗
PubMed1996

Limited value of routine followup CT scans in nonoperative management of blunt liver and splenic injuries.

The objective was to determine the utility of a second CT scan in nonoperative management of blunt liver and splenic trauma. The design was a retrospective review of consecutive cases over a 2-year period in two trauma centers. Subjects were 152 patients with blunt abdominal trauma and isolated injuries to liver and/or spleen. Thirty patients received immediate laparotomy, whereas 122 patients (80%) underwent CT scanning that showed splenic (n = 64), liver (n = 44), or combined (n = 14) injuries. Nonoperative management was undertaken in 99 of the 122 (81% of the patients who received CT scans; 65% of the overall series) and was ultimately successful in 94 (95%). Second CT scans were used in 26 patients (26%), one of whom received laparotomy for drainage of a bile leak and three for ongoing bleeding. None of the followup scans showed major progression of injury, and scan findings did not influence decisions for operation in any patients. Routine followup CT scanning is not a justifiable component of nonoperative management protocols for blunt liver and splenic injuries.

Adolescent↗
PubMed1995

Bile duct stones in the laparoscopic era. Is preoperative sphincterotomy necessary?

OBJECTIVE: To evaluate treatments for common bile duct stones (CBDS). DESIGN: Retrospective review of authors' case series. SETTING: Large private metropolitan teaching hospital. PATIENTS: All patients with CBDS (N = 145) from a series of 1231 patients who underwent laparoscopic cholecystectomy, 99% with intraoperative fluorocholangiography. INTERVENTIONS: Treatments for CBDS included one or more of the following: laparoscopic transcystic duct exploration (n = 123), laparoscopic choledochotomy (n = 10), open choledochotomy (n = 7), preoperative endoscopic sphincterotomy (ES) (n = 9), intraoperative ES (n = 2), post-operative ES (n = 11), or observation (n = 10). MAIN OUTCOME MEASURES: Success of various interventions for CBDS, morbidity and mortality, frequency of retained stones, operative time, and length of postoperative hospitalization. RESULTS: Laparoscopic transcystic duct exploration was successful in 91% of attempts and resulted in the shortest postoperative stay (3.4 days), least morbidity (5%), and fewest retained stones (5%). Endoscopic sphincterotomy was successful in 56% of preoperative attempts, 50% of intraoperative attempts, and 91% of postoperative attempts. There were no reoperations and one death. CONCLUSIONS: For patients requiring cholecystectomy, laparoscopic transcystic duct exploration is safe and effective, treats CBDS in one session, and if unsuccessful still allows for open choledochotomy or postoperative ES. Preoperative endoscopic retrograde cholangiography and ES should be reserved for patients with serious illness or possible malignant disease.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1995

Vagal modulation of the insulin secretory response to KCl loading in nephrectomized dogs.

In K-loaded intact and nephrectomized control dogs there is a four-to five-fold increase of basal serum insulin. With beta receptor blockade in K-loaded intact animals the increase of basal serum insulin is less than 1/4 to that in controls; in those with nephrectomy, the increase is similar to that in controls. Cervical vagotomy in K-loaded intact dogs does not alter (influence) the increase of serum insulin; in those with nephrectomy there is a striking increase. In K-loaded intact dogs cervical vagotomy added to beta receptor blockade has no influence i.e., the response is the same as that to blockade alone; in those with nephrectomy, the increase produced by vagotomy is suppressed. Results suggest that in controls with nephrectomy, the insulin secretory response does not involve beta receptors of pancreatic islet B cells owing to restraint by efferent impulses in the cervical vagi. Interruption of the impulse by vagotomy releases the restraint, with resulting hyperactivity; the accompanying hyperinsulinemia may be the result of suppression of the hyperactive receptors by beta receptor blockade.

Adrenergic beta-Antagonists↗
PubMed1995

Monitoring the axilla in patients with silicone gel implants.

Migration of silicone beyond the breast implant capsule may occur as a result of silicone bleed, leak, or rupture, and it may indicate failure of implant envelope integrity. We report a series of 23 patients with silicone implants who had axillary lymph node biopsies for palpable masses. Group 1 (n = 15) had biopsies performed an average of 6 years following aesthetic augmentation, and Group 2 (n = 8) had biopsies performed an average of 5 years after mastectomy reconstruction. All biopsies demonstrated foreign body reaction consistent with silicone migration. Five patients in Group 1 and two in Group 2 also had breast cancer detected by the axillary biopsy. Evaluation of the axilla utilized a combination of one or more techniques, including mammography, ultrasonography, magnetic resonance imaging, and fine-needle aspiration. We conclude that (1) routine evaluation of the axilla is mandatory in all patients with silicone breast implants; (2) an algorithmic approach in diagnosing axillary masses may be helpful, especially in augmentation patients; and (3) axillary masses detected by clinical examination or other means must be biopsied, even in the face of negative screening studies, because breast cancer may be coincidental with a silicone granuloma.

Adult↗
PubMed1995

The forgotten first career of Doctor Henry Van Dyke Carter.

BACKGROUND: While Henry Gray's Anatomy: Descriptive and Surgical, first published in 1858, is distinguished by superb illustrations, its original illustrator is remembered for an entirely different set of accomplishments, notably significant contributions to tropical medicine. STUDY DESIGN: Literature review. RESULTS: Dr. Henry Van Dyke Carter, Professor of Anatomy and Physiology and subsequently Dean of the Grant Medical College in Bombay, India, was a skillful researcher and keen clinician who made significant contributions to tropical medicine, including the discovery of Spirillum minus, the spirochetal organism that causes relapsing fever. For his discoveries he was honored by both the British Medical Association and the English government. Before his departure for India in 1858, however, he and Henry Gray worked at St. George's Hospital Medical School and collaborated on the first edition of the text that is still the "Bible" of anatomy to many medical students. His drawings have appeared in every subsequent edition, up to the present day. CONCLUSIONS: During his first career as a medical illustrator, Carter was responsible for the drawings that have helped generations of physicians to master the intricacies of human anatomy.

History, 19th Century↗
PubMed1995

The laparoscopic learning curve.

To characterize the learning curve for laparoscopic cholecystectomy, we compared the first 47 cases (group A), which were performed by two senior attending surgeons who assisted each other when the procedure was introduced into clinical practice (1990-1991), with the first 46 cases (group R) performed by two surgical chief residents who were assisted by members of the teaching faculty in 1992-1993. The patient groups were comparable in terms of age, sex, and anesthetic class, but pathologically proven acute cholecystitis was more common in group R (33% vs. 9%; p < 0.005). To analyze operative procedures and outcomes, we compared operative time, frequency of successful operative cholangiography (attempted in all cases), frequency of conversion to open cholecystectomy, major complication rate, and days of postoperative stay for all patients and for those without complications. Of these parameters, only operative time for nonacute cases differed significantly between the groups (144 min for group A vs. 114 min for group R; p < 0.05). Complications in group A included one ductal injury and one case of postoperative pancreatitis; group R had one ductal injury and two cases of postoperative bleeding. We conclude that (a) the learning curve has similar structure for senior surgeons and resident trainees; and (b) the resident learning curve is not hazardous when teaching assistants are trained in the procedure, which has implications for safe instruction and proctoring of residents and staff.

Acute Disease↗
PubMed1994

Surgical anatomy of the hepatic arteries in 1000 cases.

OBJECTIVE: Anatomic variations in the hepatic arteries were studied in donor livers that were used for orthotopic transplantation. SUMMARY BACKGROUND DATA: Variations have occurred in 25% to 75% of cases. Donor livers represent an appropriate model for study because extrahepatic arterial anatomy must be defined precisely to ensure complete arterialization of the graft at time of transplantation. METHODS: Records of 1000 patients who underwent liver harvesting for orthotopic transplantation between 1984 and 1993 were reviewed. RESULTS: Arterial patterns in order of frequency included the normal Type 1 anatomy (n = 757), with the common hepatic artery arising from the celiac axis to form the gastroduodenal and proper hepatic arteries and the proper hepatic dividing distally into right and left branches; Type 3 (n = 106), with a replaced or accessory right hepatic artery originating from the superior mesenteric artery; Type 2 (n = 97), with a replaced or accessory left hepatic artery arising from the left gastric artery; Type 4 (n = 23), with both right and left hepatic arteries arising from the superior mesenteric and left gastric arteries, respectively; Type 5 (n = 15), with the entire common hepatic artery arising as a branch of the superior mesenteric; and Type 6 (n = 2), with the common hepatic artery originating directly from the aorta. CONCLUSIONS: These data are useful for the planning and conduct of surgical and radiological procedures of the upper abdomen, including laparoscopic operations of the biliary tract.

Hepatic Artery↗
PubMed1994

Future shock: trauma in the managed care era.

This study examines the effects of managed care on the treatment of 1724 trauma patients seen over a 2-year period at an urban Level I trauma center. Fifty-one per cent of all trauma patients were insured. Managed care plans represented 42 per cent of the insurance coverage overall, increasing from 39 per cent in the first year to 45 per cent in the second. All treatment was provided by the receiving general surgery trauma team and was rendered independent of insurance status. Eighty per cent of patients completed their hospitalization at the trauma center. Clinical outcome, transfer rates, and mortality were similar regardless of insurance type. We conclude that managed care plans represent a significant and increasing portion of the insurance coverage of trauma patients, and propose that national guidelines should be developed to guarantee quality and continuity of trauma care.

Forecasting↗
PubMed1994

Trauma in the elderly: an analysis of outcomes based on age.

This study evaluated the comparative outcomes of elderly trauma patients admitted to a tertiary Surgical Intensive Care Unit (SICU) over a 5-year period (4/1/87-3/31/92). A total of 289 trauma patients 65 or older (mean age 76.3 +/- 0.4 years) were compared with 1,877 trauma patients under age 65 (mean age 31.4 +/- 0.3). The Simplified Acute Physiology Score (SAPS) severity of illness on admission for elderly trauma patients was 12.2 +/- 0.3, significantly higher than the SAPS of the younger patient group, 7.9 +/- 0.1 (P < 0.0005). Elderly survivors had higher than the SAPS of admission than their younger cohorts, 11.0 +/- 0.3 versus 7.3 +/- 0.1 (P < 0.0005), but there was no significant difference in SAPS for non-survivors. The Injury Severity Score (ISS) of elderly patients, 14.2 +/- 1.0, was not significantly higher than the ISS of younger patients, 12.3 +/- 0.3 (P = 0.06). Thirty-three elderly trauma patients (11.4%) died in the SICU, compared with 90 (4.8%) deaths in younger patients (P < 0.00005). However, when patients were stratified by admission SAPS, SICU mortality was nearly equivalent between the older and younger patient groups. An additional 14 elderly patients (4.8%) died in the hospital after SICU discharge, compared with 9 additional deaths (0.5%) in the younger patient group (P < 0.00005).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Late surgical complications of choledochal cystoenterostomy.

Choledochal cyst is a rare congenital abnormality of the biliary tract characterized by dilatation and stasis. Cyst excision is now preferred to internal drainage because of the predilection for development of cancer in the unresected cyst wall. We report on four patients who required reoperations for complications of prior cystoenteric drainage from 14 to 21 years after the original operations. Gastrointestinal bleeding from cyst ulceration as occurred in one patient is heretofore unreported. This reoperative experience emphasizes the importance of cyst excision as primary therapy and underscores these principles: 1) The spectrum of complications, including infection, pancreatitis, cancer, and bleeding may occur with or without intracyst and ductal stones; 2) Radical operative procedures may be required for treatment of the complications; 3) Despite these, cholangiocarcinoma has a dismal prognosis; 4) Patients whose cysts remain unexcised require meticulous lifelong scrutiny and strong consideration for planned reoperation at the time of the first complication.

Adult↗
PubMed1994

Value of early cholescintigraphy in detection of biliary complications after laparoscopic cholecystectomy.

Cholescintigraphy using technetium-99m disofenin tracer is accepted as a routine component of preoperative evaluation of the biliary tract in selected patients but is not used regularly in postoperative management. This is a retrospective analysis of the utility of the nuclide scan in 27 patients after laparoscopic cholecystectomy (LC). Most patients had vague postoperative symptoms such as nausea, pain, and low grade fever. Two patients developed jaundice. Seven of the 27 patients had biliary leaks, and two had common bile duct obstructions. We conclude that cholescintigraphy is a sensitive noninvasive test for the evaluation of biliary complications after LC and is a pivotal component of an algorithmic approach to postoperative complications. Because of the subtle clinical findings and the potential for delayed diagnosis of biliary complications after LC, early performance of this test will minimize patient morbidity.

Adult↗
PubMed1994

Relationship of hyperglycemia and severity of illness to neurologic outcome in head injury patients.

Hyperglycemia upon hospital admission has been associated with poorer neurologic outcomes in patients with brain injury, but this relationship has not been well defined. To evaluate the relationship of hyperglycemia and severity of illness to neurologic outcome, the authors examined Surgical Intensive Care Unit (SICU) records for a 6 month period at a Level I trauma center. Of 276 trauma admissions, 97 patients had intracranial injuries. The peak glucose determination on the first day of admission was correlated with the Glasgow Coma Scale (GCS) score upon admission and discharge from the SICU and with severity of illness as measured by the Simplified Acute Physiology Score (SAPS). The mean admission GCS was 10.6 (+/- 0.49 S.E.M.), the mean glucose on the first SICU day was 146 (+/- 7.7 S.E.M.), and the mean peak glucose was 176 (+/- 8.2 S.E.M.). The peak glucose was inversely related to both GCS on admission and GCS at discharge (P < 0.001). However, stepwise multiple regression analysis revealed that the best single predictor of GCS at discharge was the GCS on admission. The next best predictor was the SAPS on the first SICU day. Peak glucose did not add to the power of admission GCS and SAPS to predict neurologic outcome. Peak glucose levels in brain-injured patients may simply reflect severity of illness and injury that is better represented by SAPS.

Adult↗
PubMed1993

Surgical intensive care in the nonagenarian. No basis for age discrimination.

OBJECTIVE: To investigate the effect of extreme age on outcome from surgical intensive care. DESIGN: Prospective data collection. SETTING: A 20-bed noncardiac surgical intensive care unit (SICU) that admits 2200 patients per year from a 1201-bed tertiary medical center. PATIENTS: Nonagenarians were compared with patients under 90 years of age over a 33-month period. Seven patients over age 100 years and 77 nonsurgical patients were excluded. MAIN OUTCOME MEASURES: Mortality and length of stay were determined for both the SICU and the entire hospitalization. The nonagenarian and younger groups were stratified by severity of illness using the first-day Simplified Acute Physiology Score (SAPS). RESULTS: One hundred forty nonagenarian patients (mean +/- SE age, 92.1 +/- 0.2 years) were compared with 5652 younger patients (mean age, 60.1 +/- 0.3 years). The mean SAPS of 11.1 for nonagenarian patients was significantly higher than the SAPS of 8.6 for younger patients (P < .001). Mortality in the SICU was 4.3% for nonagenarian patients vs 2.3% for younger patients (P = .13). SICU mortality rose with increasing SAPS in both groups, but there was no significant difference between nonagenarian and younger patients for any SAPS group. Hospital mortality differed significantly, with 17.1% for nonagenarian patients and 5.3% for younger patients (P < .001). Hospital and SICU length of stay did not differ significantly between the groups. CONCLUSIONS: Nonagenarians do not differ from younger SICU patients in survival from SICU care, although hospital mortality is greater in nonagenarians. Age alone should not be used to make decisions about the utility of SICU care for the elderly. Outcome correlates better with severity of illness, and the measure is valid in young and old alike.

Age Factors↗