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Biomedical subjects

L Wise

Publications and source records attributed to L Wise.

At least 199 records · Page 11Linked to original sources
PubMed1984

Surgonomics: the cost of cholecystectomy.

Health care costs presently comprise more than one tenth of the nation's gross national product: One third of these expenditures are made by Medicare-Medicaid. National reimbursement changes for Medicare under a Diagnostic-Related Group system began October 1, 1983. Hospital charges (excluding physician charges) for all patients who underwent cholecystectomy without common bile duct exploration (Diagnostic-Related group 197 and 198) from Jan. 1, 1983 to March 31, 1983 were examined to quantify mean charges, variances, and components of hospital charges. Twenty-one patients (mean age 46.1 years) underwent elective cholecystectomy and 24 patients (mean age 64.9 years) underwent emergency cholecystectomy. The mean charge for elective cholecystectomy was $4763 +/- $1656; the mean length of stay (LOS) was 8.0 +/- 3.2 days. Low and high trim points were $3211 to $10,639 and 5 to 19 days LOS. Quartile cost analysis of the cost per patient showed that Q1 = 18.5%, Q2 = 21.2%, Q3 = 24.0%, and Q4 = 36.3%. Analysis of services showed that laboratory work (urinalysis, hematology, coagulation, microbiology, and biochemistry) averaged $451 +/- $298 (9.5% of total), room and board $2635 +/- $1044 (55.3% of total), operating and recovery room $924 +/- $167 (19.4% of total), and central supply-pharmacy $350 +/- $158 (7.4% of total). The mean charge for patients undergoing emergency cholecystectomy was $11,436 +/- $4185; mean LOS was 17.8 +/- 6.5 days. Low and high trim points were $6353 to $19,734; LOS was 9 to 30 days. Services as percent of total were laboratory 15.8%, room and board 53.7%, operating and recovery room 9.14%, central supply-pharmacy 7.3%, and radiology 8.2%. Several important findings are noted: (1) For a given disease there is marked variance of hospital charges. (2) Mean charges of emergency patients were 240% that of elective patients. (3) Consumption of services varies significantly within each group and between groups. This study demonstrates the importance of in depth financial analysis of therapies. This is a first step to identify the components of variance where reduction will not affect quality of care.

Aged↗
PubMed1984

The nipple valve as a sphincter substitute for the ileocecal valve: prevention of bacterial overgrowth in the small bowel.

We evaluated the bacteriologic effect of a nipple valve substitute for the ileocecal valve in a canine model. Resection of the ileocecal valve and the distal 40% of the jejunoileum with end-to-end anastomosis was carried out in 10 dogs. In five of the dogs chosen randomly, a nipple valve was constructed at the anastomosis; in the remainder , a two-layer jejunocolostomy was formed. Microbiologic samples were taken at operation in the ascending colon and at three sites in the small intestine before resection and at reoperation 4 weeks later. These revealed a dramatic increase in anaerobic bacteria in the distal jejunum following jejunocolostomy without valve insertion but no increase following jejunocolostomy with nipple valve. There was a seven-log difference between the two groups in the mean anaerobic bacterial counts (P less than 0.05) measured 60 cm proximal to the anastomosis at the second operation. Results of aerobic cultures were similar but less dramatic. We conclude that construction of a nipple valve jejunocolostomy prevents anaerobic bacterial colonization of the proximal small bowel and may therefore be useful in the treatment or prevention of short bowel syndrome.

Animals↗
PubMed1983

Gastric mucosal blood flow and Escherichia coli bacteremia.

The specific changes in gastric blood flow during sepsis are controversial. Previous investigations of intragastric blood flow using endotoxin models revealed decreased total gastric blood flow and decreased gastric mucosal blood flow. Endotoxin models are now thought to be inadequate due to the accompanying depression of the systemic circulation. More recently, increased gastric blood flow has been demonstrated in a septic hindlimb model. To further elucidate the changes in intragastric blood flow in sepsis, the gastric mucosal and nonmucosal blood flow were measured in the antrum and corpus of pig stomachs before and after the onset of sepsis. Increased gastric mucosal blood flow was demonstrated in both the antrum and corpus 15 minutes after the onset of E. coli bacteremia. By 75 minutes postonset, the changes were not significant, which implied partial recovery. Clinically, gastric mucosal ulcers may accompany the multiple organ system failure of sepsis. These data suggest that mucosal ischemia is not an etiologic factor as previously postulated from experiments with endotoxin.

Animals↗
PubMed1983

Indomethacin and the gastric mucosal blood flow changes of sepsis.

Recent evidence suggests that sepsis results in increased gastric mucosal blood flow (GMBF). To investigate the possible role of prostaglandins in mediating this response, the GMBF was measured in the fundus, corpus, and antrum of pig stomachs with and without pretreatment with indomethacin, an inhibitor of prostaglandin synthesis, before and after the induction of bacteremia. The studies were done in 22 piglets (seven sepsis controls, seven indomethacin controls and eight experimental [indomethacin pretreated sepsis] ). Sepsis was produced in piglets by bolus intravenous injection of 10(9) live Escherichia coli followed by an infusion of 10(9) E. coli/hr. Cardiac output (C.O.) was measured by thermodilution. GMBF was measured by microsphere trapping. Following sacrifice, hyperemia was noted in the sepsis group but not in the other groups. GMBF was determined by standard techniques (expressed as ml/min/100 gm tissue). There were significant (p less than 0.05) increases in gastric mucosal blood flow to the fundus (+47%), corpus (+50%), and antrum (+101%) at 15 minutes following the onset of E. coli infusion. At 135 minutes, the increase was only significant in the antrum. GMBF, however, did not change in the indomethacin control or indomethacin pretreated sepsis groups. These data demonstrate GMBF in the stomach following sepsis. The changes were not present in the indomethacin control or in the indomethacin pretreated sepsis groups. Since indomethacin is an inhibitor of prostaglandin synthesis, the results suggest that the GMBF may be a prostaglandin mediated response.

Animals↗
PubMed1983

Scoring system to aid in diagnoses of appendicitis.

Problems related to the diagnosis of appendicitis are evidenced by the significant negative laparotomy rate. The present study sought to assess the feasibility of decreasing this diagnostic error by studying two groups of patients and identifying and weighing details of history, physical examination and laboratory findings utilizing 23 predictive factors. One hundred consecutive cases of proven appendicitis (AAp) were retrospectively reviewed and compared with 100 consecutive cases that had normal appendices removed because of erroneous preoperative diagnosis of appendicitis (NAp). Rates of occurrence for each predictive factor were determined separately for both groups. These were converted into weights which were then added to yield a diagnostic score for each patient. A cutoff point established the score which designated one group for observation and the other for surgery. Scores were assessed at three different points by balancing risks of missed diagnoses against benefits of avoiding unnecessary operations. Seven predictive factors had differentiating weights and reached statistical significance (p less than or equal to 0.05):-sex, age, duration of symptoms, GU symptoms, involuntary right lower quadrant muscle spasm, right-sided rectal mass, and white blood cell count. Using these seven predictors, at a "-3" cutoff, 38% NAPs would have been spared laparotomy and about 5% of the AAps would have been indicated for observation. Analysis indicated little risk in observing the 5% AAp (5/7 history less than or equal to 1 day), and progressive improvement for NAps with increasing time. This simple scoring system could have eliminated over one third of the unnecessary laparotomies in the present sample, indicating potential value as an aid in surgical decision-making.

Acute Disease↗
PubMed1983

Acquired angiodysplasia as a cause of gastric hemorrhage: a possible consequence of cholesterol embolization.

A patient with aortic stenosis and gastrointestinal bleeding due to angiodysplastic (telangiectatic) lesions in the stomach is presented. Biopsy of the lesions showed cholesterol emboli with granuloma formation, intramucosal vascular obstruction, subepithelial ectatic vessels, and epithelial atrophy. The case history appeared to indicate the formation of new lesions over time and a tendency to a regression of some of the least advanced lesions. It is suggested that cholesterol showers from the aortic valve or atheromatous aortic plaques may be one cause of acquired angiodysplastic lesions in the gastrointestinal tract.

Aged↗
PubMed1982

Hemangiopericytoma of the colon: report of a case and review of literature.

A patient with a hemangiopericytoma of the colon is discussed. This is the second such case reported in the English medical literature. Soon after discovery of the tumor, the patient presented with a colonic intussusception with the tumor serving as the lead point. This was reduced by a hypaque enema, but the intussusception recurred twice more, being reduced again by hypaque enema and finally having to be reduced by colonoscopy. At surgery a left hemicolectomy with primary anastomosis was performed. The microscopic, ultrastructural, and pathologic aspects of hemangiopericytoma are discussed with special attention to lesions of the gastrointestinal tract.

Adult↗
PubMed1982

Superior vena cava syndrome in childhood and adolescence: a review of the literature and report of three cases.

Obstruction of the superior vena cava is rare in childhood and adolescence. Its etiology is now mainly iatrogenic. Mediastinal tumors are the main primary causes of the superior vena cava syndrome (SVCS) in childhood and adolescence. The most common mediastinal tumors presenting with the SVCS are the lymph node tumors and especially the lymphosarcomas. About 50% of the mediastinal tumors are primary in the mediastinum. Early treatment is designed to cause a rapid shrinking of the tumor and should not be delayed by an overly diligent pursuit of the diagnosis. Treatment should consist of a combination of radiation therapy, chemotherapy, and steroids. Surgery should be limited to obtaining tissue for diagnosis, except when the tumor is localized to the mediastinum and is completely resectable. One hundred and seventy two children and adolescents with the SVCS are reviewed and three patients are added.

Adolescent↗
PubMed1982

Changes in hepatic carbohydrate metabolism after jejunoileal bypass.

The effect of 90% jejunoileal bypass procedure on liver enzymes was evaluated in 11 obese Zucker fat rats after a 50% weight loss. Control tissues were also collected from 11 unoperated obese rats. In the jejunoileal bypass group, there was a significant decrease in phosphofructokinase, pyruvate kinase, and glucose-6-phosphate dehydrogenase activities. Pyruvate carboxylase, alanine aminotransferase, and lactate dehydrogenase activities were not altered. Fructose 1,6-biphosphatase, aldolase, aspartate aminotransferase, and phosphoenolpyruvate carboxykinase activities were increased in the jejunoileal bypass group. These studies suggest that after jejunoileal bypass glycolysis is reduced and gluconeogenesis is increased. Amino acids may provide an essential energy source for hepatic function.

Animals↗
PubMed1981

Surgical management of perforated diverticulitis.

The surgical management of perforated diverticulitis remains a subject of controversy, with some workers advocating initial drainage with decompressive colostomy and others favoring primary resection of the perforated colon. To evaluate this problem, we reviewed our experience from January 1, 1960 through December 31, 1978. This retrospective study included 25 patients treated by primary resection and 32 patients treated by staged resection. The duration of postoperative fever and ileus and the incidence and type of postoperative complications were similar in the two groups. Hospital stay and the period of disability were significantly shortened when primary resection with primary anastomosis was carried out initially. Overall, the total cumulative hospital stay was long (p < 0.05) for staged resection (48 days) than for primary resection (39 days). The period of disability was also longer (p < 0.001) for staged (134 days) than for primary resection (75 days). Finally, all patients in the primary resection group left the hospital cured, that is, restored to their premorbid condition, while in the staged resection group only 75 percent were cured; 16 percent were finally discharged with colostomies and 9 percent died. These data suggest that whenever technically feasible, primary resection is the treatment of choice for perforated colonic diverticulitis.

Adult↗
PubMed1981

Splenic pseudocyst associated with hypersplenism.

A patient with hypersplenism, who was found to have a splenic pseudocyst containing an organized hematoma, is described. There are only two patients with splenic pseudocyst and hypersplenism and an additional two patients with splenic cysts and hypersplenism reported in the world literature. The hypersplenism associated with splenic cysts and pseudocysts is explained on the basis of an expansion of the plasma volume and the total blood volume, an increased destruction of red blood cells and a pooling of blood in the enlarged spleen. The combined use of ultrasonography and computerized tomography has increased the accuracy of noninvasive diagnosis and made more invasive examinations unnecessary. When the ultrasound is technically unsuccessful or when it shows a mixed echo pattern, one should resort to computerized tomography with which it is possible, almost invariably, to differentiate between cysts and neoplasms.

Adult↗