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Biomedical subjects

J R Hiatt

Publications and source records attributed to J R Hiatt.

At least 55 records · Page 3Linked to original sources
PubMed1993

Colorectal carcinoma: analysis of management in two medical eras.

Trends in presentation, diagnosis, management, and outcome were analyzed for 503 patients with colorectal cancer seen at the UCLA Medical Center between 1960 and 1970 (Group A; n = 210) and 1980 and 1985 (Group B; n = 293). Patients in the latter group exhibited a shift in site to the right side of the colon (18% in Group A vs. 31% in Group B; P < .01), an increase in the number of primary resections without colostomy (38% vs. 61%; P < .01), a lower overall complication rate (28% vs. 18%; P = .01), and a decline in 30-day mortality (6.2% vs. 2%; P = .01). Although little difference was seen in detection of asymptomatic tumors, earlier lesions were treated in the latter group, accounting for substantially reduced rate of recurrence (69% in Group A vs. 44% in Group B; P < .01). Future management should include an emphasis on earlier detection in order to continue the trend toward enhanced survival.

Aged↗
PubMed1993

Mature fibrous cyst formation after Marlex mesh ventral herniorrhaphy: a newly described pathologic entity.

UNLABELLED: Two patients developed seromas overlying Marlex mesh repairs of ventral hernias. After repeated unsuccessful attempts at aspiration of the fluid, each patient underwent formal exploration and excision of the cystic mass to the level of the mesh. Histology showed thick, fibrous, trabeculated cysts. Postoperatively, one patient had prolonged closed suction drainage. In the other, suction drains had scant output, but she developed a recurrence of serous fluid, which resolved with two aspirations. CONCLUSIONS: 1) Mature fibrous cyst is a rare complication of Marlex mesh herniorrhaphy; 2) Chronic seroma collections may be etiologic; 3) Surgical excision and closed suction drainage, rather than simple aspiration, are required for treatment; 4) Prolonged postoperative drainage may be needed to prevent recurrence.

Aged↗
PubMed1993

Fatal cerebral gunshot wounds: factors influencing organ donation.

Patients with clinical brain death following head injury are important potential cadaveric organ donors. We analyzed our series of cranial gunshot wounds with particular attention to the frequency and patterns of organ donation after fatal injuries. Sixty-six patients with gunshot wounds to the head, including 59 with intracranial involvement (43 male, average age 26 years) were seen during a 4-year period. Injuries were limited to the head in 50 of 59 patients. Overall mortality was 66 per cent. Predictors of mortality included Glasgow Coma Scale (GCS) of six or less (93%), self-inflicted gunshot wounds (75%), and computed tomography (CT) findings of bihemispheric injury (87%) or ventricular injury (82%). Of the 39 patients who died, 28 met standard criteria for brain death, and nine of these went on to organ procurement. Thirteen families refused donation, and six patients were not harvested for reasons including old age, pregnancy, suspicion of AIDS, coroner refusal, and failure to pursue consent. Principles essential to maximal organ retrieval include: 1) Recognition that patients suffering cerebral gunshot wounds represent potential organ donors and that certain factors are predictive of mortality; 2) Critical care/trauma team approach with standardized management and timely declaration of brain death; 3) Early search for family members and prompt notification of organ procurement agencies; 4) Sensitivity to cultural issues influencing donation; and 5) Programs to increase public awareness of organ donation.

Adolescent↗
PubMed1993

Small bowel obstruction after abdominal aortic surgery.

Early postoperative small bowel obstruction (SBO) is a known complication of intestinal surgery, but its frequency, etiology, and morbidity after abdominal aortic procedures have not been reported. To study this complication, the records of 1475 patients who had an abdominal aortic operation for aneurysmal (n = 818) or occlusive (n = 657) disease on a private surgical service from 1963 to 1990 were reviewed. Forty-four patients (2.9%) developed a postoperative SBO. Small bowel obstruction occurred from 4 to 28 (mean 6) days postoperatively. All patients were treated with nasogastric suction. Eighteen of the 44 (41%) required reoperation from 6 to 30 (mean 14.2) days after the initial aortic procedure. All 18 had lysis of adhesions, and two required small bowel resections. There were no bowel infarctions and no late graft infections. Overall mortality was 5 per cent, and morbidity was 16 per cent. Incidence of pancreatitis in the entire series was 0.5 per cent, and incidence of colonic ischemia in the aneurysm group was 0.9 per cent. We conclude that 1) Early postoperative small bowel obstruction is an unusual complication of aortic surgery but is more frequent than other gastrointestinal complications such as intestinal ischemia and pancreatitis; 2) Management principles are similar to those for early postoperative bowel obstruction following other procedures; 3) Reoperation is required in nearly half of patients, particularly when SBO does not resolve within 2 weeks.

Adult↗
PubMed1992

Insulin modulation of chronotropic response to Adrenaline in diabetic dogs.

In 8 unanesthetized dogs, 10-21 days post pancreatectomy, the cardiac chronotropic response to rapid infusion of a pharmacological dosage of Adrenaline was begun. During the subsequent month, the response was recorded electrocardiographically on 19 occasions. On 8 occasions, animals were treated with continuous intravenous administration of fluids and insulin up to the time of the test; on 11, insulin was omitted for 18 hours before Adrenaline injection. Insulin treated animals responded with the typical brief initial bradycardia, followed by some 2 minutes of ventricular tachycardia, and restoration of preinjection heart rate and electrocardiograph pattern within 5 minutes. On those occasions when insulin was omitted, the tachycardia was replaced by ventricular bradycardia. The altered chronotropic response of non-insulin treated dogs indicates impairment of their cardiac beta receptors.

Animals↗
PubMed1992

Coagulopathy and catecholamines in severe head injury.

The prospective study reported here evaluated the relationship between coagulopathy, catecholamines, and outcome in severe head trauma. Thirty-six trauma patients (10 with penetrating injuries, 26 with blunt injuries, 50% overall mortality) were evaluated. These patients had severe head trauma (Glasgow Coma Scale score less than 9). Blood was analyzed for platelet count, prothrombin time (PT), partial thromboplastin time (PTT), and fibrinogen, D-dimer, antithrombin III, protein C, and protein S levels. A 24-hour urine sample was collected for vanillylmandelic acid (VMA), normetanephrine, and metanephrine determinations. A control group of five patients undergoing elective neurosurgery was also studied. Statistically significant differences between head injury survivors and nonsurvivors were present for platelet count, PT, and fibrinogen activity. There were no differences in the results of the other coagulation tests or in urinary catecholamine levels. The trauma patients differed from the elective neurosurgery patients with regard to D-dimer levels, PT, PTT, protein C levels, and urinary normetanephrine concentrations. Head trauma patients have a coagulopathy that is absent in patients following elective neurosurgical procedures. The coagulopathy may correlate with poor survival in head trauma and may be related to a catecholamine surge.

Blood Coagulation Tests↗
PubMed1992

Orbital impalement by a gearshift knob: case report.

Penetrating trauma to the orbit may cause complex injuries involving the bone, globe, and brain. Successful treatment requires a strategic scheme for preoperative assessment and management and a multidisciplinary surgical approach. These principles are demonstrated by report of a motor vehicle accident in which the driver sustained orbital impalement by a gearshift knob.

Accidents, Traffic↗
PubMed1991

Liver transplantation in children.

Although liver transplantation is now accepted as the ideal therapy for end-stage liver disease, relatively few centers have gained a large experience in children, and good results have been elusive. Technical difficulty and a high incidence of graft failure are among the obstacles to success. At the University of California at Los Angeles, 39% of our liver transplants are in the patients who are younger than 18 years. We have analyzed our experience with 103 patients to emphasize factors important to a favorable outcome with the procedure. One hundred twenty-three transplants were performed in 103 children (mean age, 5.2 years; 48% younger than 3 years). No reduced-size grafts were used. Scrupulous attention to technical details of the vascular reconstruction, including frequent use of the supraceliac aorta of the recipient and interrupted suture techniques, ensured construction of sound hepatic artery and portal vein anastomoses at the first operation. Preoperative exchange transfusions were used if the prothrombin time was prolonged beyond 7 seconds, resulting in an average blood loss of only 3.3 volumes. Cyclosporine dosage was maintained in the high therapeutic range for the first 4 weeks, and anti-T-cell antibody (OKT3) was used for rejection (38%). Amphotericin prophylaxis was used for biliary atresia patients with multiple previous operations. Eighty-two of one hundred three patients (80%) are alive. There were no intraoperative deaths. Actuarial survival rates at 6 months, 1 year, and 5 years are 80%, 79%, and 77%, respectively. Survival of patients who underwent transplantation at age less than 1 year is 65% versus 85% at age more than 1 year (p = 0.08). Retransplantation was performed in 19 patients (18%), with a survival rate of 58%. Hepatic artery thrombosis, the most frequent technical complication, occurred in only 16 patients (13%). Survival rates of ABO identical-match versus nonidentical-match grafts were 96% and 60%, respectively (p = 0.02). Graft survival was only 47% if more than one steroid cycle was needed, compared to 75% survival with OKT3 treatment. Despite impairment of renal function (glomerular filtration rate [GFR] less than 80 cc/kg/min) in 54% of patients and hypertension requiring therapy in 27%, 90% of the children demonstrated enhancement of growth, development, and functional status. The following conclusions were made. (1) Pediatric liver transplantation is the treatment of choice for all types of end-stage liver disease and should be considered early. (2) Factors that enhance survival include technical precision, aggressive retransplantation, antifungal chemoprophylaxis and therapy, and judicious immunosuppression with use of OKT3 for rejection.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1991

Early diagnosis and treatment of sinusitis in the critically ill trauma patient.

Sinusitis is an important cause of sepsis in the critically ill patient and may be difficult to diagnose. Four patients admitted to the surgical intensive care unit with closed head trauma were found to have sinusitis as the cause of persistent bacteremia. All patients received pharmacologic doses of corticosteroids for treatment of head injury and had prolonged nasotracheal and/or nasogastric intubation. A bedside procedure was used for diagnosis and management. Under local anesthesia, a 16-gauge angiocatheter was inserted under the inferior turbinate and into the maxillary sinus. After purulent fluid was aspirated, the sinuses were irrigated with normal saline. All four patients defervesced within 24 to 48 hours of this procedure, and facial x rays demonstrated clearing of the maxillary sinus. It was concluded that: 1) Sinusitis is a complication of closed head trauma in critically ill patients and should be included in the differential diagnosis when persistent bacteremia occurs; 2) The use of corticosteroids in the treatment of head injury may increase the risk of sinus infection; 3) Facial x rays showing air-fluid levels and/or opacification are a valuable screening test for paranasal sinusitis; and 4) bedside aspiration of the maxillary sinus is an effective diagnostic and therapeutic technique for management of sinusitis in the critically ill.

Adolescent↗
PubMed1991

Acalculous candida cholecystitis: a complication of critical surgical illness.

Four patients with underlying diseases including multiple trauma, aortic graft infection, and complex fistulae developed acute acalculous cholecystitis with bile cultures positive only for Candida albicans. The primary site of the candida infection included urinary tract, gastrointestinal tract, and an aortic graft in one patient each and was undetermined in the trauma victim. All had received broad-spectrum antibiotics; three of the four were in the intensive care unit (ICU) with organ failure. Ultrasonography showed a thickened gallbladder wall in three patients and sludge in one. Hepato-iminodiacetic acid scans were nonvisualizing in these three patients. Operative findings included gangrenous cholecystitis in two patients and edematous cholecystitis in one. The fourth patient was treated with percutaneous cholecystostomy and interval cholecystectomy. The interval from the onset of symptoms to recognition of the need for operation was an average of 7 days. Two of the four patients died of ongoing sepsis. Candida cholecystitis is a life-threatening complication of critical surgical illness. Risk factors are similar to those for candida infection elsewhere and include antibacterial therapy, complex fistulae, disseminated malignancy, immunosuppression, and prolonged ICU stay. A high index of suspicion for this fungal pathogen and aggressive surgical therapy offer the only chance for a favorable outcome.

Acute Disease↗
PubMed1991

Adnexal torsion. An unusual cause of abdominal pain in postmenopausal women.

Adnexal torsion is a rare cause of abdominal pain in older women. Because the presenting symptoms and signs are vague, the diagnosis is not often considered. Lower abdominal pain with nausea and vomiting are usual in patients with torsion. Ultrasonography or computed tomography are useful diagnostic tests. Two case reports of older patients with adnexal torsion are presented to emphasize the diagnostic features of this entity, including lower abdominal pain, nausea and vomiting, and abdominal mass. Although the condition is uncommon, adnexal torsion should be considered in the differential diagnosis of acute abdominal pain.

Abdominal Pain↗
PubMed1991

Trauma center closure: effects on an adjacent trauma center.

The effects of the closure of a busy trauma center on an adjacent university trauma hospital were analyzed. Significant increases were found in monthly volume (P less than .01) and frequency of penetrating injuries (P less than .05) and significant decreases in patients with insurance coverage (P less than .01) and numbers requiring intensive care (P less than .01). The authors conclude that trauma center closures have significant and measurable effects which influence allocation of scarce resources within remaining hospitals and generate pressures to transfer patients to overburdened public facilities. Transfers undermine continuity of care and education and further threaten the integrity of the trauma system.

Health Facility Closure↗
PubMed1990

Nonoperative management of major blunt liver injury with hemoperitoneum.

We evaluated the role of nonoperative therapy in 16 patients with blunt multisystem trauma, hemodynamic stability following resuscitation, and major lobar liver injury; the patients were treated with a protocol of intensive care unit observation and computed tomographic scanning to identify and follow up the hepatic lesion. Computed tomographic scans showed right-lobe or bilobar liver lacerations and/or subcapsular hematomas in all patients and associated hemoperitoneum in 8 patients. Exploration was required in 2 patients; both were found to have a hemoperitoneum and a nonbleeding liver laceration. There were no deaths. Patients with hemoperitoneum requiring transfusion had significantly greater injury severity scores and longer intensive care unit and hospital stays. The major advantage of a nonoperative approach is the opportunity to stabilize major extra-abdominal (particularly head) injuries as the first priority. Unstable hemodynamics, abdominal distension, and falling hematocrit are indications for prompt exploration. Nonoperative care of these injuries requires a strict treatment protocol.

Adolescent↗
PubMed1990

Massive splenomegaly. Superior results with a combined endovascular and operative approach.

Splenectomy for massive splenomegaly (drained splenic weight, greater than 1000 g) has an uncommonly high morbidity and mortality because of technical challenges and problems of hemostasis. In a group of 10 patients with massive splenomegaly due to myeloproliferative disorders (average splenic weight, 4193 g), we developed a management algorithm based on preoperative angiographic embolization of the splenic artery. Average operating time was 1.7 hours (range, 1 to 2.5 hours). Average blood loss was 528 mL; six of the 10 patients had blood loss less than 250 mL. There were four minor complications and one major complication (gastric ulcer requiring reoperation). There were no deaths in the perioperative period, and no patients required reoperation for hemorrhage.

Adult↗