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Biomedical subjects

K G Swan

Publications and source records attributed to K G Swan.

At least 19 recordsLinked to original sources
PubMed2001

Decelerational thoracic injury.

BACKGROUND: Among the five major decelerational thoracic injuries [myocardial contusion (MC), traumatic aortic disruption (TAD), sternal fracture (SF), flail chest (FC), and tracheobronchial disruption (TBD)], coexisting injuries are seemingly rare. METHODS: To test this hypothesis, we reviewed the records of all patients, with final diagnosis (FDX) codes of these injuries, treated at our Level I trauma center for the 10 years preceding 1997. RESULTS: Among 142 patients, all victims of motor vehicle crashes, there were 38 MC, 36 TAD, 33 FC, 28 SF, and 7 TBD. There were six coexisting injuries (3.5%). Three patients with coexisting injury died in the operating room. All three had TAD; one of these three had TBD plus MC; one had additionally FC and MC and the third had FC in addition to the TAD. One patient with SF and probable MC died in the emergency room. Two patients with FC and a coexisting injury survived. One had MC, the other SF. CONCLUSION: We conclude that these decelerational thoracic injuries, with the exception of sternal fracture, are sufficiently life threatening by themselves to cause fatality. When combined, the threat to life is potentiated. Death occurs at the scene or shortly after arrival in the ER. The diagnosis of one may help exclude the diagnosis of each of the other four. The role of sternal fracture in this paradigm remains an enigma.

Accidents, Traffic↗
PubMed2001

A simplified open gastrostomy under local anesthesia.

Revision of the standard gastrostomy is often necessary in patients with neuromuscular disorders. These patients pose many anesthetic risks that frequently preclude the use of general anesthesia, intravenous sedation, or endoscopy. Modification of the Stamm gastrostomy enables it to be performed comfortably and readily under local anesthesia. The modification proposed passes the gastrostomy tube through the omentum en route to the abdominal wall. This ensures a seal to the surgical site, eliminates the need for tacking sutures, and allows for a smaller midline incision. These factors greatly reduce the discomfort of the procedure allowing it to be easily accomplished under local anesthesia. This technique of open gastrostomy under local anesthesia has been used in more than 35 patients over the past 10 years with no documented leaks.

Adolescent↗
PubMed2000

Postoperative synergistic gangrene after spinal fusion.

STUDY DESIGN: A case of synergistic necrotizing gangrenous fasciitis after spinal surgery is reported. OBJECTIVES: To describe this unusual complication, explain the rationale of treatment, and increase awareness of this serious postoperative complication. SUMMARY OF BACKGROUND DATA: Although several cases of postoperative synergistic necrotizing fasciitis have been reported, there are no previously reported cases of this condition after spinal surgery. METHODS: A rapidly progressive necrotizing spinal wound infection after fusion for degenerative disc disease was treated in a 39-year-old man. RESULTS: The infection was successfully treated with serial debridements, appropriate antibiotics, and hyperbaric wound oxygenation. CONCLUSIONS: The authors suggest adherence to the fundamental principles of treatment including radical surgical debridement and appropriate antibiosis for necrotizing gangrene after spinal surgery. In evaluation of aggressive spinal wound infections, diagnosis of synergistic necrotizing fasciitis should be kept in mind. Although hyperbaric wound oxygenation was implemented as an adjunct and appeared to aid in controlling the infection, its effect on outcome is not clear.

Adult↗
PubMed1999

Gunshot wounds: bullet caliber is increasing.

BACKGROUND: The incidence of gunshot wounds has increased over the past two decades. In the past several years at our Level I trauma center in Newark NJ, we perceived that the size of ammunition involved in these wounds has been increasing as well. We sought to document this trend by using autopsy data as well as bullets received by surgical pathology. METHODS: Measurements of bullets stored in surgical pathology were taken from alternate years between 1981 and 1993, then every year through 1997. A total of 745 bullets were studied in this 16-year period. Bullets deformed beyond measurability and shotgun pellets were excluded from the study (approximately 20%). Linear regression of mean bullet caliber over time was performed, and analysis of variance was used to assess statistical significance of apparent differences. In addition, autopsy reports from the regional medical examiner's office were surveyed for description of bullet size. Bullet caliber, in these reports, is described as "small," "medium," or "large." A total of 397 reports were studied from 1981 to 1997. Once again, shotgun wounds (<5%) were excluded. The percentage of large-caliber projectiles was plotted against time, and chi2 for trend was used to determine statistical significance. RESULTS: Results are tabulated as mean +/- standard error bullet caliber (millimeters) over time. Linear regression reveals r = 0.944, p<0.0001. Data obtained from autopsy reports are not tabulated here, but chi2 for trend reveals a statistically significant increase in the proportion of large caliber and decrease in proportion of small-caliber bullets (p<0.001). CONCLUSION: These data unveil an ominous trend toward the use of larger-caliber firearms in accidents, homicides, and suicides.

Analysis of Variance↗
PubMed1999

Giant duodenal diverticulum: presentation by blunt trauma.

Most duodenal diverticula are asymptomatic, small (i.e., less than 5 cm in greatest dimension), acquired, extraluminal, and false. The only report of a massive or giant duodenal diverticulum (i.e., 10 cm or more), in the current literature, included severe nocturnal diarrhea. The present case report is the incidental finding of a massive duodenal diverticulum in a 34-year-old male trauma victim. The insidious nature of this case and the patient's age suggest a congenital etiology. We believe this is the first report of such a case.

Adult↗
PubMed1999

Don't know, don't care. III.

The knowledge of and interest in Department of Defense programs to help medical students with their educational expenses in exchange for military service as a physician was studied at three medical schools representing the eastern (University of Medicine and Dentistry of New Jersey/New Jersey Medical School [UMDNJ/NJMS]), midwestern (University of Missouri at Kansas City), and western (University of Utah) United States. Despite staggering indebtedness (40% of the class of 1998 at the University of Medicine and Dentistry of New Jersey were in debt in excess of $100,000 at graduation), surprisingly few students were aware of programs such as the Health Professions Scholarship Program, the Health Professionals Loan Repayment Program, and the Specialized Training Assistance Program. Even fewer were interested when made aware of such financial assistance. Hostility to military service as a physician was common. "Patriotism" was seemingly anathema. Dwindling recruitment and retention of medical corps officers in the reserve components of our nation's armed forces is of grave concern to national security and flies in the face of medical students', hence young physicians', indebtedness for their education. Clearly Department of Defense programs must become more imaginative, certainly more financially appealing.

Adult↗
PubMed1998

Lowering the legal blood alcohol level for motorcyclists.

The blood alcohol concentrations (BAC) of all operators involved in motorcycle accidents (MCA) and drivers of motor vehicle accidents (MVA) admitted to a New Jersey Level I Trauma Center during 1992 (the first year such data were computerized) were evaluated. Comparable to other institutional statistics (one-third of vehicular accidents are related to alcohol consumption) our data showed 13 (33%) of 40 MCA operators and 117 (35%) of 340 MVA drivers had measurable BAC. These values, as well as their respective Injury Severity Scores (ISS), were recorded and compared for significance of apparent differences using the 't' test for unpaired observations. Mean BAC was 124 +/- 24 (SE) mg dl-1 for MCA and 180 +/- 9 mg dl-1 for MVA (p < 0.05). The respective mean ISS for MCA was 13.1 +/- 5.4 and MVA was 7.9 +/- 0.9 (p = 0.12). These data indicate that drivers involved in MVA and MCA are frequently under the influence of alcohol. The mean BAC for motorcyclists is significantly less than that for drivers of four-wheeled passenger vehicles and is likely to reflect the need for greater coordination and balance when operating a two-wheeled vehicle.

Accidents, Traffic↗
PubMed1997

Outcome of complex venous reconstructions in patients with trauma.

PURPOSE: The role of complex venous reconstructions (CVRs) in patients with major trauma remains a controversial topic. This study evaluates the patency and clinical outcome of CVRs in a major urban trauma center. METHODS: Between 1979 and 1994 the records of 92 patients with 100 injuries to the iliac, femoral, and popliteal venous system were reviewed. The incidence of edema, pulmonary embolism, and limb loss was documented in 75 men and 17 women (mean age of 27 years, range 14 to 59 years). The 30-day patencies were assessed in all patients with either impedance plethysmography (n = 16), venography (n = 40), or duplex scan (n = 36). Long-term patencies were assessed in 14 patients monitored for 0.5 to 9 years (mean 3.2 years). RESULTS: Mechanisms of injury consisted of 58 gunshot wounds, 23 stab wounds, 6 shotgun wounds, and 5 blunt injuries. There were 112 associated injuries, 41 of which were concomitant arterial injuries. Forty-five of the 100 venous injuries were repaired with CVRs and included 6 (13%) spiral vein grafts, 8 (18%) panel vein grafts, 8 (18%) reversed saphenous vein interposition grafts, 8 (18%) end-to-end repairs, and 15 (33%) vein patch repairs. Thirty-day patency rates for these repairs were 50%, 50%, 75%, 88%, and 87%, respectively, and an overall patency rate of 73% was observed. The remaining 55 injuries were treated with ligation (n = 27) or lateral venorrhaphy (n = 28). The cumulative 30-day patency rate for all venous repairs was 81% (59 of 73). Fourteen patients, nine of whom had CVRs, were available for long-term follow-up. In this group CVRs demonstrated a 100% patency. One patient with a spiral vein graft repair of the common femoral vein had severe reflux causing intermittent edema and mild lipodermatosclerosis. No pulmonary emboli, limb loss, or deaths were identified in patients undergoing CVRs. CONCLUSION: Patients with CVRs had a 30-day patency rate of 73%. Of this group panel and spiral vein grafts were less successful, exhibiting only a 50% 30-day patency rate, whereas end-to-end and vein patch repairs were successful in 88% and 87% of cases, respectively. Our overall evaluation suggests that use of CVRs results in successful venous repair; however, the postoperative patency of interposition panel and spiral grafts suggests selective use of these techniques.

Adolescent↗
PubMed1997

Carotid arterial trauma: assessment with the Glasgow Coma Scale (GCS) as a guide to surgical management.

Management of carotid arterial injuries associated with focal neurological deficit or altered state of consciousness (SCON) remains unresolved. Experience with these injuries in one particular hospital was reviewed and the Glasgow Coma Scale (GCS) utilized to assist with clinical stratification of these patients. A literature review was also conducted to better define indications for repair or ligation of carotid injuries. From 1978 to 1990, 34 patients with carotid arterial injuries were reviewed with reference to the GCS, focal deficit, hypotension, anatomic site and mechanism of injury. The literature from 1952 to 1993 was surveyed for carotid artery injuries (1316 patients). Outcome of treatment with or without repair was compared with pre-operative neurologic status. Thirty-four patients with injuries of the common (24) or internal (10) carotid arteries were managed with repair (68%), ligation (24%) or observation (9%). The SCON was normal in 18 patients; 16 patients (88%) underwent repair and all remained normal. All patients with GCS 9-14 regained a normal SCON after surgical repair, while 10 patients with GCS < 8 had repair (5), ligation (3), and non-operative management (2); five returned to normal, four died and one remained comatose. However, outcomes correlated poorly with management. Of 1316 patients cited in the surgical literature, patients with no deficit and patients with pre-operative deficits did significantly better after repair as compared with ligation (P<0.001). In comatose patients, management did not affect outcome. It is concluded that carotid arterial injuries should be repaired in patients with normal neurologic evaluation, focal pre-operative neurologic deficits and in patients with GCS > 9. Comatose patients with GCS < 8 do poorly regardless of management. The GCS provides an objective for stratification of patients with altered SCON who benefit from repair of carotid arterial injuries.

Adult↗
PubMed1997

Inferior vena caval filter use in U.S. trauma centers: a practitioner survey.

Questionnaires were mailed to 620 U.S. "trauma surgeons" to determine a consensus regarding indications for inferior vena caval (IVC) filter placement; 210 (34%) responded. Eighty-seven percent of respondents practiced in Level I trauma centers; 78% were in urban areas and 75% reported more than 1,000 trauma admissions per year. One-half (52%) of those responding were "trauma directors" at their centers. Filter insertion was done by radiologists at 81% of centers, by trauma surgeons at 34%, by vascular surgeons at 33%, and by general surgeons at 13%. Each month, 60% of trauma centers inserted zero or one filter, whereas 27% inserted two to three filters. Complications per year were reported as one or fewer in 85% of trauma centers. Respondents agreed that "absolute indications" for inserting IVC filters were pulmonary embolism while anticoagulated (93%), deep venous thrombosis present and anticoagulation contraindicated (89%), and free-floating ileofemoral thrombus by venogram (54%) and by duplex imaging (45%). "Relative indications" for placement were deep venous thrombosis by duplex imaging (41%) or by venogram (38%), spinal cord injury (40%), pelvic fractures (39%), multiple lower-extremity fractures (29%), concurrent cancer (19%), prolonged bed rest (14%), and obesity (10%). The permanent nature of the filter affected its rate of application. For example, potential removability would significantly (p < 0.01) increase prophylactic placement from 29 to 53% in the patient with multiple lower-extremity fractures. Only 12% considered sepsis and 10% young age as contraindications to IVC filter insertion. Contraindications and complications were few, yet frequency of use was surprisingly low. Radiologists insert the filter more than twice as often as surgeons.

Contraindications↗
PubMed1997

Pancreatoduodenectomy for giant benign villous adenoma of the ampulla of Vater.

The case of a 36-year-old man with a villous adenoma of the duodenum is presented. His history included jaundice, pruritus, and weight loss. Physical examination was otherwise unremarkable. Laboratory data included anemia, guaiac-positive stool, hyperamylasemia, and abnormal liver function tests. Biliary ductile dilation was seen on ultrasonography; a filling defect in the duodenum was seen on CT scan, and endoscopic biopsy revealed villous adenoma with dysplasia. Pancreatoduodenectomy was performed and recovery was uneventful. Histopathology confirmed moderate dysplasia. Review of the literature reveals this to be a rare lesion (less than 1% of duodenal neoplasms). Local excision has been advocated for small, histologically proven benign, lesions. Where doubt of benignity exists, however, and in the case of "giant" tumors (>3.0 cm greatest dimension), pancreatoduodenectomy is indicated.

Adenoma, Villous↗
PubMed1997

Don't know, don't care: medical students' knowledge of and attitudes toward military medical career opportunities and medical educational cost reimbursement.

We assessed indebtedness of graduating physicians and dentists in the class of 1996, University of Medicine and Dentistry of New Jersey, and found the percentage of students with debt to average 80% (range, 77-84%) among the five schools of the university. Mean indebtedness was $73,000 per student. We then surveyed the graduates of one of the four medical schools in the university (New Jersey Medical School) regarding attitudes toward established programs for financial assistance to medical students and physicians and alleviation of educational indebtedness in return for military service. More than half (57%) of the students were unaware of any program that would repay part of their educational loans in return for military service. Of those who professed such knowledge, few could name the programs. A similar number of students (55% of the graduates) said that they would not consider serving in the military under any circumstances. Despite considerable indebtedness among today's medical students, most do not know about career opportunities offering financial assistance with tuition or educational loans in return for military service. Worse yet, they do not care.

Adult↗
PubMed1996

Trauma life support education: a didactic and caprine laboratory course for Nigerian physicians.

The purpose of this study was to introduce the principles of initial hospital assessment and treatment of injured patients, tailored to the facilities and resources available in Nigeria. A 3-day didactic and laboratory course was presented by four trauma surgeons. The didactic session stressed the initial assessment and treatment of injured patients. The caprine laboratory taught the performance of common resuscitation manoeuvres: cricothyroidotomy, tube thoracostomy, i.v. cut-down, diagnostic peritoneal lavage, etc. The mean pre-course test score was 49.3 per cent and the mean post-course test score was 69.5 per cent; 93.5 per cent of the 124 participants increased their test scores. This represents a significant increase in knowledge in Nigerian physicians. Academic medical centres are encouraged to make such courses available in developing countries.

Animals↗