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Biomedical subjects

James F Reed

Publications and source records attributed to James F Reed.

At least 19 recordsLinked to original sources
PubMed2005

Human immunodeficiency virus infection in trauma patients: where do we stand?

OBJECTIVE: The human immunodeficiency virus (HIV) epidemic is a growing health care problem. The purpose of this study was to examine the relationship between HIV infection and trauma patient treatment, complications, and mortality. METHODS: The Pennsylvania Trauma Outcome Study database was used to identify trauma patients with known HIV-positive status (HP) and randomly selected age-matched controls (CL). Demographics, Injury Severity Score, Glasgow Coma Scale score, mechanism of injury, preexisting conditions, complications, mortality, hospital length of stay (HLOS), intensive care unit length of stay (ILOS), and operative interventions were compared. RESULTS: Demographics, vital signs on presentation, and Injury Severity Score were similar between the HP and CL groups. There was no difference in mortality between the two groups (3.6% vs. 3.1%, p = 0.6447). HP patients were more likely to present with penetrating injuries (22.6% vs. 15.8%, p < 0.0031) and had significantly fewer major orthopedic injuries than CL patients (p < 0.01). HP patients were more likely to have a history of a neurologic condition; chronic drug/alcohol use; psychiatric diagnosis; or liver, pulmonary, and/or renal disease (all p < 0.01). HP patients had more pulmonary complications (12.3% vs. 4.1%), renal complications, and infectious/septic complications (all p < 0.01) than controls. Infection/sepsis and pulmonary complications were associated with significant mortality in HP patients. HP patients underwent more thoracostomies (7.5% vs. 4.4%, p = 0.0235) and exploratory laparotomies (7.0% vs. 2.4%, p = 0.0002). HLOS (10.2 +/- 10 vs. 6.8 +/- 8.6 days, p = 0.001) and ILOS (2.3 +/- 7.2 vs. 1.5 +/- 4.9 days, p = 0.0178) were greater for HP patients. HP patients were less likely than controls to be discharged directly to home (67.8% vs. 82.7%, p = 0.0001). CONCLUSION: HP patients had more preexisting conditions and complications than controls. There was no difference in overall mortality between the two groups. However, pulmonary/infectious complications were associated with significant mortality in HP patients. HP patients consumed more health care resources than controls, as exemplified by greater ILOS and HLOS and more operative procedures.

Adolescent↗
PubMed2005

Deep venous thrombosis and pulmonary embolism in trauma patients: an overstatement of the problem?

Deep venous thrombosis (DVT) and pulmonary embolism (PE) affect high-risk trauma patients (HRTP). Accurate incidence and clinical importance of DVT and PE in HRPT may be overstated. We performed a ten-year retrospective analysis of HRTP of the Pennsylvania Trauma Outcome Study. High-risk factors (HRF) included pelvic fracture (PFx), lower extremity fracture (LEFx), severe head injury (CHI) (AIS - head > or =3), and spinal cord injury. HRF alone or in combination, age, Injury Severity Score (ISS), and Glasgow Coma Score (GCS) were examined for association with DVT/PE. A total of 73,419 HRTP were included: 1377 (1.9%) had DVT, 365 (0.5%) had PE. The incidence of DVT in level I trauma centers was 2.2 per cent and was 1.5 per cent in level II centers. The lowest incidence of DVT was 1.3 per cent for isolated LEFx; highest was 5.4% for combined PFx, LEFx, and CHI. Variables associated with DVT included age, ISS, and GCS (all P < 0.001). In logistic regression analysis, only ISS was consistently predictive for DVT and PE. Though increased during the past decade, the overall incidence of DVT in HRTP remains below 3 per cent. Only the combination of multiple injuries or an ISS >30 result in DVT incidence of > or =5 per cent. We believe that current guidelines for screening for DVT may need to be reevaluated.

Adolescent↗
PubMed2004

Early experience with retrievable inferior vena cava filters in high-risk trauma patients.

BACKGROUND: This study describes the use of retrievable IVC filters in a select group of trauma patients at high risk for deep vein thrombosis (DVT) and pulmonary embolism (PE). STUDY DESIGN: Retrievable IVC filters were placed in selected trauma patients who met high-risk criteria for deep vein thrombosis and PE according to institutional clinical management guidelines. All filters were placed percutaneously in the interventional radiology suite. Indications for filter placement were based on injury complex, weight-bearing status, and contraindications to enoxaparin or pneumatic compression devices. IVC filters were either removed or maintained. RESULTS: Retrievable IVC filters were placed in 35 patients after blunt trauma. Twenty-six patients (74%) sustained at least one orthopaedic injury; 17 patients (49%) were diagnosed with a pelvis fracture. Activity was limited to bed rest or spinal precautions in 18 patients (51%). Enoxaparin was contraindicated in 32 patients (91%) and injuries precluded the use of pneumatic compression devices in 11 (31%). IVC filters were removed in 18 patients (51%), with no reported complications. Patients with orthopaedic injuries and pelvis fractures were less likely to have their filters maintained (p = 0.040). CONCLUSIONS: Retrievable IVC filters offer a versatile option for prophylaxis in trauma patients at high risk for PE. Filter retrieval potentially spares the longterm complications of permanent filters in younger trauma patients. Retrievable filters warrant consideration in patients who meet high-risk criteria for deep vein thrombosis or PE who cannot receive effective mechanical prophylaxis and in whom contraindications to anticoagulation are expected to be temporary.

Adult↗
PubMed2004

Analysis of two-treatment, two-period crossover trials in emergency medicine.

In an AB/BA crossover trial, patients are randomly assigned to receive either treastment A in the first period followed by treatment B in the second period or treatment B in the first period followed by treatment A in the second period. The crossover trial allows for a within-patient comparison between treatments because each patient serves as his or her own control subject, removes the interpatient variability from the comparison between treatments, and can provide unbiased estimates for the differences between treatments. When applied inappropriately, crossover designs have serious problems that might adversely influence and invalidate their results. The primary concern is the residual carryover effect of a treatment in subsequent treatment periods. Rather than depending on a statistical procedure to eliminate the possibility of the presence of carryover effects, it is more important that the crossover design be used only in those situations in which the likelihood of a carryover effect is exceptionally small. Even though the AB/BA crossover trial appeals to the physician researcher, it is surprisingly difficult to take advantage of this design. The primary objective of this article is to introduce readers and trialists to some of the issues surrounding crossover trials. Researchers who use this design should explicitly examine the assumptions about crossover effects and the adequacy of the lead-in washout period and the between-period washout period and clearly indicate that the results of the study are conditional on the acceptance of those conditions.

Biomedical Research↗
PubMed2004

Rib fractures in the elderly: a marker of injury severity.

OBJECTIVES: To examine the relationship between the number of rib fractures (RIBFs) and mortality, injury severity, and resource consumption in elderly patients admitted to trauma centers. DESIGN: Thirteen-year retrospective statewide database analysis. SETTING: Participating trauma centers in Pennsylvania. PARTICIPANTS: A total of 27,855 trauma patients, including 8,648 elderly patients, admitted to a trauma center with more than one RIBF. MEASUREMENTS: Patient demographics, number of RIBFs, Injury Severity Score, complications, patient mortality, preexisting conditions (PECs), and hospital and intensive care unit length of stay. RESULTS: Mortality for elderly patients (aged>/=65) with RIBFs was greater than for patients younger than 65 (20.1% vs 11.4%, P<.001). Mortality rates increased with increasing numbers of RIBFs for both age groups and were always significantly higher in elderly trauma patients. The effect of PECs on patient mortality was inversely related to number of RIBFs and was most pronounced for patients with four or more RIBFs. Seven of 10 complications were more common in elderly patients despite lower mean+/-standard deviation Injury Severity Score (19.4+/-13.4 vs 23.2+/-14.2, P<.001). CONCLUSION: Overall trauma-related mortality is higher in elderly patients with RIBFs than younger patients with RIBFs. Mortality rates rise with increasing number of RIBFs. The number of RIBFs is easy to quantify and may be a useful predictor of overall injury severity and outcome for elderly trauma patients.

Accidental Falls↗
PubMed2004

An audit of lower extremity complications in octogenarian patients with diabetes mellitus.

Podiatric pathology is common in the elderly patient population per se. Whether the presence of diabetes mellitus in the elderly imposes an additional risk for podiatric problems is questionable. The purpose of this study was to determine if the prevalence of podiatric problems in octogenarian diabetic patients differed from that found in a similarly aged group of nondiabetic patients. For this study, the prevalence of lower extremity complications in octogenarian patients (age 80) with diabetes and without diabetes was estimated using data from the 1996 through 2002 National Hospital Discharge Survey. The diabetic octogenarian patients had twice the risk for developing an ulcer; 3 times the risk of developing a foot abscess, and a 4-fold risk of developing osteomyelitis. Furthermore, the octogenarian diabetic patient is nearly twice as likely to undergo ulceration debridement and 3 to 5 times more likely to have a lower leg amputation, toe amputation, or any amputation. The incidence of amputations, ulcerations, and other serious conditions is significantly higher in the diabetic group compared to normal age-matched control patients. This study shows that in the octogenarian patient the presence of diabetes imposes an additive risk for complications.

Journal Article↗
PubMed2004

Metastatic renal cell carcinoma-associated pleural effusion after coronary artery bypass grafting.

Pleural effusions after coronary artery bypass grafting (CABG) occur in up to 89% of patients undergoing the procedure. Effusions present days to months after surgery, and fluid characteristics relate to timing factors. Most of the effusions are left-sided and resolve spontaneously. Pleural effusions requiring treatment occur in a small percentage of patients who have undergone CABG. Post-CABG pleural effusions in temporal relation to malignant effusions are not widely reported. This report describes a 50-year-old man presenting with a malignant left-sided pleural effusion 3 months after CABG, with characteristics resembling a late post-CABG effusion.

Carcinoma, Renal Cell↗
PubMed2003

Solutions to the Behrens-Fisher problem.

When testing the equality of the means from two independent normally distributed populations given that the variances of the two populations are unknown but assumed equal the classical Student's two sample t-test is recommended. If the underlying population distributions are normal with unequal and unknown variances, either Welch's t-statistic or Satterthwaite's Approximate F test is suggested. However, Welch's procedure is non-robust under most non-normal distributions. There is a variable tolerance level around the strict assumptions of data independence, homogeneity of variances, identically and normal distributions. Few textbooks offer alternatives when one or more of the underlying assumptions are not defensible. We have developed an executable FORTRAN code for producing the statistics suggested by Cressie and Whitford, Yuen and Dixon, and Yuen. An executable FORTRAN is available from the author on request (e-mail only).

Animals↗
PubMed2003

Aggregate Health Status: a benchmark index for community health.

A qualitative review of population health assessment models used throughout the United States and Canada indicate both individual and community-level domains of health. Individual-level domains of health include health habits, education, public safety, environment, social, government, culture, and mobility. Community-level domains include the same general health domains but aggregated to the community level Aggregate Health Status (AHS). In the development of the AHS portion of our model, the dependent variable was the general health question from the Medical Outcomes Study. The remainder of the survey was partitioned into mutually exclusive individual measure subsets. A linear combination of these global variables then produces a single estimate relating the multiple domains of the broader determinants of health to health status. This global variable uniquely discriminates between the five categories of general health. This model serves as a framework and benchmark indicator that (1) provides a summary indicator of the overall health status of the population, (2) is broadly representative of populations rather than individuals, (3) is a population perspective rather than a provider perspective, and (4) emphasizes outcomes versus inputs and processes.

Benchmarking↗
PubMed2003

Methodological and statistical techniques: what do residents really need to know about statistics?

The purpose of this study was to catalog the statistical methods used in six journals two each from the fields of Family Practice, Emergency Medicine, and Obstetrics and Gynecology. We reviewed the quantitative articles from January 1998 through December 2000 from the Journal of Family Practice, the Journal of Family Medicine, the Annals of Emergency Medicine, the Journal of Academic Emergency Medicine. Articles from January 2000 through December 2000 of Obstetrics and Gynecology and the American Journal of Obstetrics and Gynecology were also included. Case reports and editorials were not included in this analysis. There were a total of 1828 articles reviewed (666 from Emergency Medicine articles, 380 from Family Practice, and 782 from Obstetrics and Gynecology). The distribution of study types (cross-sectional or survey, retrospective, or prospective) did not differ between the selected journals within Emergency Medicine, Family Practice, or Obstetrics and Gynecology. Pearson's chi-square/Fisher's Exact test was the statistic of choice overall (47.5%) followed by Student's t-test (33.1%). Analysis-of-variance was used in 23.3% of the studies, nonparametric methods (8.1%), linear regression (17.6%), and odds ratios/logistic regression (17.4%). Other statistical procedures were used less than 10% of the time. These results show that a physician who comfortably comprehends the appropriate use of descriptive statistics Student's t-test, Pearson's chi-square/Fisher's Exact test will be able to read and interpret at least 70% of the published medical literature. Educational efforts should focus on appropriate study design and analysis.

Clinical Competence↗
PubMed2003

Quality analysis of bilateral reduction mammaplasty using a state-legislated comparative database and an internal hospital-based system.

This study analyzed trends in reduction mammaplasty at our institution using Atlas and Lastword databases for calendar years 1991 to 1998 and 1993 to 1998, respectively. Cases were identified by ICD-9-CM principle procedure codes. Patients were analyzed for length of stay (LOS), discharge disposition, complications, and readmission. Readmissions to the hospital within 120 days were analyzed. Of 705 patients, 628 patients had LOS more than 24 hours, and 77 patients had LOS less than 24 hours. There was no difference in case-severity analysis in any of the 8 years. There was a significant reduction in average LOS from 2 to 1.1 days over the 8 years (p < 0.001). There was a significant increase per year in number of patients with LOS less than 24 hours (p < 0.002). There was no significant difference in readmission rates between patients with LOS less than 24 hours and LOS more than 24 hours. Reduction mammaplasty is a high-volume, relatively safe, plastic surgical procedure. There was no relationship between LOS and complications or readmissions.

Databases as Topic↗
PubMed2003

A case-control study of the risk factors for toe amputation in a diabetic population.

Toe amputations are becoming more prevalent in the diabetic population. To prevent toe amputations, those individuals with the highest risk must be identified prior to developing a precipitating event. There are obvious risk factors for toe amputations, such as digital deformity, diabetic neuropathy, and ischemia. Other, less obvious, systemic comorbidities may be linked to toe amputations. This study also shows that gender plays a significant role as a risk factor for toe amputation. A foot infection, foot abscess, osteomyelitis, diabetic retinopathy, and diabetic nephropathy were also significant risk factors for toe amputations. This suggests a significant relationship between these complications and comorbidities that put these individuals at a higher risk for toe amputations.

Journal Article↗
PubMed2003

An audit of Keller arthroplasty and metatarsophalangeal joint arthrodesis from national data.

Chronic interphalangeal ulcerations of the great toe are a frequent complication in neuropathic diabetic feet. While total contact casting is usually effective as a first-line treatment, some ulcers continue and present substantial management challenges. The objective of this study was to examine the National Hospital Discharge Survey in order to identify links between preexisting medical conditions and lower extremity pathology in patients undergoing a Keller arthroplasty. Those who received a Keller arthroplasty were more likely to have diabetes mellitus (odds ratio [OR] = 4.00, 95% confidence interval [CI]: 3.73-4.30, P = .0001), diabetic neuropathy (OR = 3.80, 95% CI: 3.48-4.15, P = .0001), coronary artery disease (OR = 1.78, 95% CI: 1.57-2.03), or peripheral vascular disease (PVD) (OR = 2.06, 95% CI: 1.49-2.84, P = .0001). Keller arthroplasty patients were less likely to have a foot abscess (OR = 0.44, 95% CI: 0.39-0.50, P = .0001) or hammer toe deformity (OR = 0.60, 95% CI: 0.57-0.63, P = .0001), but more likely to have a foot wound or ulcer (OR = 2.62, 95% CI = 2.44-2.82, P = .0001), bunions (OR = 4.52, 95% CI: 4.26-4.80, P = .0001), and osteomyelitis (OR = 2.65, 95% CI: 2.41-2.92, P = .0001). Hallux limitus or rigidus in a diabetic patient with neuropathy, peripheral vascular disease, and poor healing subjects this patient to a higher risk of ulceration, infection, and amputation. This study shows that this procedure is being performed in the diabetic population with attendant complications.

Journal Article↗
PubMed2003

Analysis of variance (ANOVA) models in lower extremity wounds.

Consider a study in which 2 new treatments are being compared with a control group. One way to compare outcomes would simply be to compare the 2 treatments with the control and the 2 treatments against each using 3 Student t tests (t test). If we were to compare 4 treatment groups, then we would need to use 6 t tests. The difficulty with using multiple t tests is that as the number of groups increases, so will the likelihood of finding a difference between any pair of groups simply by change when no real difference exists by definition a Type I error. If we were to perform 3 separate t tests each at alpha = .05, the experimental error rate increases to .14. As the number of multiple t tests increases, the experiment-wise error rate increases rather rapidly. The solution to the experimental error rate problem is to use analysis of variance (ANOVA) methods. Three basic ANOVA designs are reviewed that give hypothetical examples drawn from the literature to illustrate single-factor ANOVA, repeated measures ANOVA, and randomized block ANOVA. "No frills" SPSS or SAS code for each of these designs and examples used are available from the author on request.

Journal Article↗
PubMed2003

Crossover designs in lower extremity wounds.

In a basic AB/BA crossover trial, patients are randomly assigned to receive either treatment A in the first period followed by treatment B in the second period, or treatment B in the first period followed by treatment A in the second period. Treatment periods are separated by a suitable washout period that is long enough for the treatment effect from the first period to have no residual effect to the second treatment period. The AB/BA crossover trial has many advantages and, when used appropriately, provides an efficient means for comparing 2 treatments. If applied and conducted inappropriately, the AB/BA crossover design has fatal flaws. The objective of this article is to introduce the AB/BA crossover trial and to present some of the issues surrounding crossover trials. The crossover trial, when properly implemented and analyzed, remains a valid and efficient design alternative to the parallel group design and should not be abandoned as has been suggested by the FDA. Crossover studies have an advantage over parallel studies, for example, elimination of between-subject variability, more statistical power because of paired comparisons, and reduced sample sizes to achieve a specified power. Although a test for carryover would be desirable, at present there is no widely recognized method for doing this, and some experts feel that no method can be reliable.

Journal Article↗
PubMed2003

Off the shelf or recalibrate? customizing a risk index for assessing mortality.

BACKGROUND: Public "report cards" for cardiac surgery have been freely available from a variety of sources. These risk-adjusted indices serve as a means of benchmarking outcomes performances, allowing comparisons of outcomes between surgical programs, and quantifying quality improvement programs. We examined two alternative strategies for using previously developed risk-adjusted mortality models in a community hospital: (1) using the model "off the shelf" (OTS) and (2) recalibrating the existing model (RM) to fit the institution-specific population. METHODS: Six OTS models were used: Parsonnet (PA), Canadian (CA), Cleveland (CL), Northern New England (NNE), New York (NY), and New Jersey (NJ). The RM models were created by each model's independent variables and definitions and adjusting the weighting with logistic regression methods. The accuracy, the C statistic, and the precision of each model were assessed for in-hospital mortality. We compared the OTS version of each model to the RM version with methods detailed by Hanley and McNeil. RESULTS: The RM C statistic was improved for all risk-adjusted models, most notably in the statistical improvement seen in the PA (0.053 improvement) and NJ (0.052 improvement) indices. Statistical gains in precision were also seen in the RM models for the PA, CL, and NNE indices. Conversely, one model, the CA model, was more poorly calibrated in the RM model compared with the OTS model, despite an improved C statistic (0.062). CONCLUSIONS: The RM strategy provides institution-explicit models that demonstrate a higher degree of accuracy and precision than the OTS models.

Age Factors↗
PubMed2003

Institutioning a clinical practice guideline to decrease the rate of normal appendectomies.

With the advent of laparoscopic appendectomy, the rate of normal appendectomies increased at our institution. To decrease our rate of normal appendectomies, we instituted a clinical practice guideline in January 1999 for the preoperative evaluation and treatment of patients with possible acute appendicitis. The medical records of 464 consecutive patients who underwent either open or laparoscopic appendectomy with a preoperative diagnosis of acute appendicitis between January 1, 1997, and December 31, 2000, were reviewed. The decision of open versus laparoscopic appendectomy was made at the time of surgery by the attending surgeon. Two hundred twelve patients (116 females, 96 males) underwent an appendectomy for acute appendicitis (142 open, 70 laparoscopic) from January 1, 1997 through December 31, 1998, prior to the institution of the guideline. Two hundred fifty-two patients (117 females, 135 males) underwent an appendectomy for acute appendicitis (193 open, 59 laparoscopic) from January 1, 1999, through December 31, 2000 (after the guideline was instituted). Prior to the guideline, the normal appendectomy rate was 21.7 per cent (18.3% open, 28.6% laparoscopic). After the guideline was instituted, the normal appendectomy rate was 16.7 per cent (14.5% open, 23.7% laparoscopic). In females, the normal appendectomy rate prior to the guideline was 31.0 per cent (26.6% open, 36.5% laparoscopic) while the normal appendectomy rate after the guideline was 23.1 per cent (19.0% open, 31.6% laparoscopic), P = 0.172. In males, the normal appendectomy rate prior to the guideline was 10.4 per cent (11.5% open, 5.6% laparoscopic) while the normal appendectomy rate after the guideline was 11.1 per cent (11.4% open, 9.5% laparoscopic), P = 0.861. By instituting a guideline for the diagnosis and treatment of possible acute appendicitis, we were able to decrease our rate of normal appendectomies. Although statistical significance was not reached, there is a trend toward decreasing the rate of normal appendectomies in females after the guideline was instituted.

Acute Disease↗