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Biomedical subjects

J R Wheeler

Publications and source records attributed to J R Wheeler.

At least 91 records · Page 5Linked to original sources
PubMed1985

The mangled extremity syndrome (M.E.S.): a severity grading system for multisystem injury of the extremity.

The severely mangled extremity presents a challenge in appropriate surgical management. Very few objective data were found about this problem. To clarify the situation, criteria for a "mangled extremity' were defined, a multidisciplined approach employed, and a retrospective graduated grading system developed. Sixty consecutive trauma patients with severely injured extremities during the past 3 years were reviewed. Seventeen patients fit the category of Mangled Extremity Syndrome (M.E.S.). Injuries were retrospectively classified using a graduated grading system directed at four major tissue systems of the extremity involved (integument, nerve, artery, and bone). Additional scoring items were included to define the significance of trauma sustained outside the extremities. Patients who ultimately came to amputation could have been identified preoperatively at initial emergency evaluation utilizing this graduated grading system. Retrospective data suggest that a Mangled Extremity Syndrome Index (M.E.S.I.) of 20 is the dividing line below which functional limb salvage can be expected and above which limb salvage is improbable. Prospective application of this system, as well as an organized multidisciplined approach, could be useful in the identification of functionally retrievable versus probably irretrievable extremities, thus identifying and helping define the indications for amputation. The grading system criteria and results in these 17 patients form the basis of this report.

Adult↗
PubMed1984

Hospital-sponsored primary care: I. Organizational and financial effects.

Findings are presented from a seven-year (1976-83) evaluation of the Community Hospital Program (CHP), a national demonstration program sponsored by the Robert Wood Johnson Foundation to assist 54 community hospitals in improving the organization of access to primary care. Upon grant expiration, 66 per cent of hospital-sponsored group practices continued under some form of hospital sponsorship; over 90 per cent developed or were planning to develop spin-off programs; and new physicians were recruited and retained in the community. About 9 per cent of hospital admissions were accounted for by group physicians and grantee hospitals experienced a greater annual increase in their market share of admissions than competing hospitals in the area. While only three of the groups generated sufficient revenue to cover expenses during the grant period, 21 additional groups broke even during the first post-grant year. Productivity and cost per visit compared favorably with most other forms of care. Hospitalization rates from the hospital-sponsored practices were somewhat lower than those for other forms of care. Medical director leadership and involvement and the organization design of the practice were among several key factors associated with higher performing practices. The ability of such joint hospital-physician ventures to meet the needs of the poor and elderly in a time of Medicare and Medicaid cutbacks is discussed along with suggestions for targeting future initiatives in primary care.

Evaluation Studies as Topic↗
PubMed1984

Optimal techniques for harvesting and preparation of reversed autogenous vein grafts for use as arterial substitutes: a review.

Since the first successful use of an autogenous vein graft for arterial reconstruction by Gluck in 1898 and the establishment of the scientific basis for the use of veins as arterial substitutes by Carrell and Guthrie in the early 1900s, reversed autogenous veins have been used extensively in arterial reconstructive operations. Despite being the preferred material for reconstruction, reversed autogenous vein is not an ideal graft material. The primary problem is structural alterations in the implanted vein predisposing to graft failure. Most of these failures occur within the first few months after graft implantation and are though to be due, in part, to endothelial damage incurred during harvesting and preparation of the vein. This review focuses on technical aspects of vein graft harvesting associated with alterations in endothelial morphology including dissection technique, types of irrigation and storage solutions used, temperature of these solutions, distension pressures, and pharmacologic agents. An optimal technique incorporating subcutaneous and perivenous infiltration with papaverine, atraumatic dissection, controlled gradual distension, and storage of the distended vein in cold heparinized blood containing papaverine should produce grafts with improved endothelial preservation and patency rates compared with grafts harvested by techniques in widespread use at present. The importance of morphologically and functionally intact endothelium in reversed vein grafts, a comparison to that produced by in situ vein grafting, and its possible clinical implications are discussed.

Arterial Occlusive Diseases↗
PubMed1984

Carotid involvement in aortic dissection diagnosed by duplex scanning.

Symptomatic carotid dissection following repair of a proximal aortic arch dissection has been successfully diagnosed by noninvasive ultrasonic duplex scanning. Angiographic confirmation, follow-up examinations by duplex scanner, and conservative management with heparin anticoagulation and tight blood pressure control are discussed. The differing etiologies and potential neurologic complications following aortic root dissection vs. spontaneous cervical carotid dissection are considered with a review of the current literature. Although diagnosis can be achieved through arteriography, the combined modalities of duplex scanning allow evaluation of both anatomic and hemodynamic factors. Conservative therapy may prove the most appropriate mode of management in these neurologically unstable patients.

Aortic Dissection↗
PubMed1984

Hospital management contracts: institutional and community perspectives.

Previous studies have shown that external management by contract can improve the performance of managed hospitals. This article presents a conceptual framework which develops specific hypotheses concerning improved hospital operating efficiency, increased ability to meet hospital objectives, and increased ability to meet community objectives. Next, changes in the process and structure of management under contractual arrangements, based on observations from two not-for-profit hospital systems, are described. Finally, the effects of these management changes over time on hospital and community objectives are presented. These effects suggest progressive stages in the development of management contracts. The first stage focuses on stabilizing hospital financial performance. Stage two involves recruitment and retention efforts to secure necessary personnel. In the third stage, attention shifts to strategic planning and marketing.

Community-Institutional Relations↗
PubMed1983

The effects of burn severity and institutional differences on the costs of care.

Burn care treatment is among the costliest yet least studied forms of care. This paper presents estimates of the magnitude and components of burn care costs. It analyzes the extent to which burn care cost is determined by severity of burns or by characteristics of the institution in which the patient is treated, based on patient-specific data from eight hospitals representing different levels of technical sophistication in the delivery of burn care. Costs of care are higher in specialized facilities. Many patients with small burns are treated in specialized facilities, at much higher costs than patients treated in general care facilities. Among specialized facilities, patient severity accounts for a portion of the variance in costs, but significant cost differences remain after adjusting for severity. These results suggest that cost-control efforts should concentrate on specifying criteria for admission to specialized burn facilities, regional coordination of facilities and institutions, and improved facilities design and management.

Burn Units↗
PubMed1983

Autogenous graft replacement of infected prosthetic grafts in the femoral position.

Infected prosthetic grafts in the femoral position remain among the most challenging problems in vascular surgery. Over the past 2 years, 11 patients with this critical condition have undergone graft reconstruction with autogenous tissue as described by Ehrenfeld. All infected prosthetic material was removed and replaced by an autogenous graft. The autogenous grafts were constructed with endarterectomized superficial femoral, iliac, and aortic segments as well as portions of saphenous and cephalic veins. This procedure has proven successful, resulting in only one amputation (undertaken with a still functioning autogenous graft) in the series. There was one postoperative death. Six grafts failed in long-term follow-up, due in all cases to inadequate flow because of stenosis of the saphenous vein portion of the autogenous reconstruction. However, the patients were usually free of infection by this time and underwent successful prosthetic reconstruction.

Aorta, Abdominal↗
PubMed1982

Axillofemoral bypass: a ten-year review.

During a ten-year period (1969-1980), 106 grafts were implanted in the axillofemoral and axillobifemoral positions. This retrospective study is based on life table analysis of cumulative patency rates in both axillofemoral and axillobifemoral grafts, with and without thrombectomy. Dacron grafts were used exclusively from 1969 to 1979, and PTFE from 1979 to 1980. Cumulative patency for Dacron axillobifemoral grafts was 97 +/- 3% at 32 months (73 +/- 21% at 42 months). Patency in both unilateral and bifemoral grafts was significantly increased by thrombectomy. Dacron and PTFE axillobifemoral graft patency was not significantly different. Perioperative mortality was 8% in a group of patients whose survival rate at four years was only 50 +/- 10% from associated disease. Axillobifemoral grafting presents an alternative to aortoiliac reconstruction in elderly patients with severe associated disease in whom the risk of anatomic bypass is prohibitive.

Arterial Occlusive Diseases↗