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Biomedical subjects

Mark A Malangoni

Publications and source records attributed to Mark A Malangoni.

At least 19 recordsLinked to original sources
PubMed2006

Peritonitis - the Western experience.

Peritonitis is a common surgical emergency. This manuscript will provide an overview of recent developments in the management of peritonitis in the Western world. Emphasis is placed on the emergence of new treatments and their impact of outcomes.

Journal Article↗
PubMed2006

Improving operating room efficiency through process redesign.

BACKGROUND: Operating rooms (ORs) are important resources for patient care and revenue, yet a significant portion of OR time is taken up by nonoperative activities. We hypothesized that redesigning the process that occurs between operations would lead to a decrease in nonoperative time (NOT = room turnover time plus anesthesia induction and emergence time). METHODS: Following a 3-month multidisciplinary planning process, a prospective study to reduce NOT was initiated in 2 of 17 ORs at a tertiary care academic medical center. Unlike previous reports, which have limited the number of participants, we constructed a process that was restricted only by case duration. The plan focused on minimizing nonoperative tasks in the OR, effecting parallel performance of activities, and reducing nonclinical disruptions. Eligible cases were those with an estimated operative time of 2 hours or less. A target NOT of 35 minutes was established. Cases of similar duration in the remaining ORs served as a concurrent control group. RESULTS: Twenty-three surgeons, 13 anesthesiologists, and 11 nurses worked in the project ORs over a 3-month period. Residents participated in all cases. There was a significant reduction in NOT (42.2 +/- 12.9 vs 65 +/- 21.7 minutes), turnover time (26.4 +/- 11.2 vs 42.8 +/- 21.7 minutes), and anesthesia-related time (16.9 vs 21.9 minutes, all P < .001) in the project rooms compared with cases of similar duration in control ORs. Process-related delays were identified in 70% of cases when NOT exceeded the 35-minute target. CONCLUSIONS: These results demonstrate that a coordinated multidisciplinary process redesign can significantly reduce NOT. This process is applicable to most ORs and has optimal benefit for cases of 2 hours or less in duration. The high percentage of residual process-related delays suggests that further improvements can be anticipated.

Anesthesiology↗
PubMed2006

Improved outcome of adult blunt splenic injury: a cohort analysis.

BACKGROUND: The purpose of this study was to review our 15-year experience in the treatment of blunt splenic injury in adults. Our hypothesis was that the implementation of a change in practice, with stress on splenic preservation and splenic artery embolization for the management of splenic injury, would result in improved splenic salvage rates without negatively affecting mortality rates. METHODS: A retrospective cohort analysis was performed on all consecutive adults with blunt splenic injury who were admitted to a Level One Trauma Center. The cohorts were defined by 2 separate 7.5-year periods (1991-1998 and 1998-2005). RESULTS: Six hundred twenty-five patients with blunt splenic trauma were identified; 403 patients who were treated from 1998 to 2005 were compared with 222 patients whose cases had been reviewed previously (1991 to 1998). The present cohort differed in age (35 vs 40 years; P < .001) and injury severity score (27 vs 21; P < .0001). Nonoperative treatment was implemented in 136 patients (61%) in the initial cohort and 344 patients (85%) in the present cohort. The frequency of splenic artery embolization increased from 2.7% to 22.6% (P < .001). The success of nonoperative management increased from 77% to 96% (P < .001); the splenic salvage rate for all patients improved from 57% to 88% (P < .0001). Hospital mortality rates decreased from 12% to 6% (P < .001), and the mean hospital length of stay decreased from 15 to 9 days (P < .001). CONCLUSION: These results demonstrate that the success of nonoperative management and the splenic preservation for blunt injury has improved over time. This improvement correlated with a greater use of splenic artery embolization.

Adolescent↗
PubMed2006

Randomized controlled trial of moxifloxacin compared with piperacillin-tazobactam and amoxicillin-clavulanate for the treatment of complicated intra-abdominal infections.

OBJECTIVE: To compare the safety and efficacy of sequential intravenous (IV) to oral (PO) moxifloxacin treatment against a standard antimicrobial regimen of IV piperacillin-tazobactam followed by PO amoxicillin-clavulanate for the treatment of adults with complicated intra-abdominal infection (cIAI). SUMMARY BACKGROUND DATA: cIAIs are commonly due to mixed aerobic and anaerobic bacteria and require both source control and broad-spectrum antibiotic therapy. METHODS: A prospective, double-blind, randomized, phase III comparative trial. Patients with cIAI were stratified by disease severity (APACHE II score) and randomized to either IV/PO moxifloxacin (400 mg q24 hours) or comparator (IV piperacillin-tazobactam [3.0/0.375 g q6 hours] +/- PO amoxicillin-clavulanate [800 mg/114 mg q12 hours]), each for 5 to 14 days. The primary efficacy variable was clinical cure rate at the test-of-cure visit (days 25-50). Bacteriologic outcomes were also determined. RESULTS: : Of 656 intent-to-treat patients, 379 (58%) were valid to assess efficacy (183 moxifloxacin, 196 comparator). Demographic and baseline medical characteristics were similar between the 2 groups. Clinical cure rates at test-of-cure were 80% (146 of 183) for moxifloxacin versus 78% (153 of 196) for comparator (95% confidence interval, -7.4%, 9.3%). The clinical cure rate at test-of-cure for hospital-acquired cIAI was higher with moxifloxacin (82%, 22 of 27) versus comparator (55%, 17 of 31; P = 0.05); rates were similar for community-acquired infections (80% [124 of 156] versus 82% [136 of 165], respectively). Bacterial eradication rates were 78% (117 of 150) with moxifloxacin versus 77% (126 of 163) in the comparator group (95% confidence interval, -9.9%, 8.7%). CONCLUSIONS: Once daily IV/PO moxifloxacin monotherapy was as least as effective as standard IV piperacillin-tazobactam/PO amoxicillin-clavulanate dosed multiple times daily for the treatment of cIAIs.

Abdominal Abscess↗
PubMed2006

Nonoperative management of traumatic aortic injury.

BACKGROUND: The standard management for patients with blunt aortic injury is surgery; however, a small number of patients have been medically managed. The outcome of these nonoperatively managed patients is unknown. METHODS: Seven patients diagnosed as blunt aortic injury were managed without aortic surgery between January 1993 and April 2002, and their outcomes were retrospectively investigated. RESULTS: There were three men and four women, with a mean age of 48.7+/-22.7 years and Injury Severity Score of 37.7+/-16.9. The reason for nonoperative management was refusal of surgery (2), do-not-resuscitate order (1), diffuse brain injury (2), small intimal tear (1), and technical difficulty (1). Two patients died resulting from associated injuries. Five patients are alive, and in three patients complete resolution of aortic injury was observed. CONCLUSIONS: In selected patients with multiple associated injuries or severe comorbidity, nonoperative management after blunt aortic injury can be a treatment of choice.

Adult↗
PubMed2005

Outcome of severe acute pancreatitis.

BACKGROUND: The treatment of severe acute pancreatitis has been evolving from routine operative management to nonoperative care for patients without evidence of pancreatic infection. METHODS: Retrospective chart review of patients with severe acute pancreatitis at a single institution during a 9-year period. RESULTS: Sixty consecutive patients had severe pancreatitis. Forty-two had pancreatic necrosis on computed axial tomography (13 infected and 29 sterile). Patients with infected necrosis and 8 with sterile necrosis had operative debridement; the remaining patients were managed without operation (n = 39). The overall mortality was 15%. Mortality was directly related to the Acute Physiology and Chronic Health Examination II and Marshall organ failure scores (P <0.001). Patients who died had a greater incidence of nosocomial infection. CONCLUSIONS: Patients with infected pancreatic necrosis require early operative debridement, whereas those with sterile necrosis or severe pancreatitis without necrosis can usually be managed safely without surgery.

APACHE↗
PubMed2005

Contributions to the management of intraabdominal infections.

Intraabdominal infection represents a spectrum of diseases with a common pathogenesis. Establishing a prompt diagnosis and avoiding treatment delays are keys to achieving the best outcomes. Mortality depends on initiating early appropriate treatment to restore fluid and electrolyte imbalances, supporting the function of vital organs, providing appropriate broad-spectrum antimicrobial therapy, and achieving adequate source control. Faculty from the Department of Surgery at the University of Louisville have made significant contributions to the understanding and management of intraabdominal infections that have affected clinical practice and patient outcomes.

Abdominal Cavity↗
PubMed2005

Life after 80 hours: the impact of resident work hours mandates on trauma and emergency experience and work effort for senior residents and faculty.

BACKGROUND: The purpose of this study was to evaluate the impact of work hours mandates on (1) senior resident patient exposure and operating experience in trauma and emergency surgery and (2) faculty work effort. METHODS: We measured resident and faculty work on the trauma and emergency surgery services at our Level I trauma center during two comparable 6-month periods. Period 1 (July 1-December 31, 2002) had no call restrictions, separate trauma and emergency service resident call, and some overlap of faculty call responsibilities. Period 2 (July 1-December 31, 2003) had resident work hours compliance and complete integration of resident and faculty trauma and emergency call. Work hours were measured by surveys for faculty and residents. All data were collected prospectively. RESULTS: Resident exposure to trauma patients was similar during both time periods. Emergency surgery admissions declined during period 2; however, intensive care unit admissions increased. The number of operations performed by senior residents did not change; however, there was a shift in the median number of emergency surgery cases to more senior residents. Faculty work hours increased slightly despite a decrease in faculty call. CONCLUSION: Work hours compliance resulted in a 50% reduction in senior resident call and a 19% decrease in their work hours with no significant change in trauma/emergency patient care exposure or operative case load. Service call amalgamation reduced faculty call by 21% but did not result in a corresponding change in work hours or productivity.

Clinical Competence↗
PubMed2004

Nosocomial infections adversely affect the outcomes of patients with serious intraabdominal infections.

BACKGROUND: Patients with serious intraabdominal infections (IAI) who subsequently acquire nosocomial infections (NI) have been shown to have adverse outcomes. We evaluated factors that put patients at risk for developing NI and examined the effect of the NI on outcomes. METHODS: This study was a retrospective review of NI among 168 patients diagnosed with IAI over a seven-year period. RESULTS: Sixty-six patients (39.3%) developed 98 NI (23 urinary tract, 20 surgical site, 19 pneumonia, 14 bloodstream, 12 recurrent peritonitis, seven intravascular catheter-related, and three enteric). There were 35 males and 31 females. Patients with NI were older (56.0 +/- 18.3 vs. 47.0 +/- 15.6 years, p = 0.001), had a higher admission APACHE II score (10.7 +/- 6.1 vs. 7.5 +/- 5.1 points, p = 0.001), and more often had concomitant medical diagnoses (27.3% vs. 12.7%, OR = 2.57, 95% CI: 1.159-5.69, p = 0.018) than those who did not develop infection. Antimicrobial resistance among the IAI was higher in the NI group (19.7 vs. 5.9%, OR = 3.93, 95% CI: 1.41-10.93, p = 0.006). Patients who developed NI had an increased mortality rate (27.0% vs. 4.0%, OR = 8.87, 95% CI: 2.82-27.86, p < or = 0.0001), longer hospital stay (24.7 +/- 19.5 vs. 11.7 +/- 8.1 days, p < or = 0.0001), required more days of intravenous antibiotics (11.5 +/- 8.0 vs. 7.6 +/- 4.4 days, p < or = 0.0001), and were more likely to be admitted to an intensive care unit (54.5% vs. 25.5%, OR = 3.51, 95% CI: 1.82-6.77, p < or = 0.0001). Multivariate analysis demonstrated that antimicrobial resistance and an APACHE II score of > or = 10 independently predicted the development of a nosocomial infection. Age >/= 50 years, APACHE II score > or = 10, or the presence of a NI independently predicted death. CONCLUSIONS: The development of NI following treatment of an IAI significantly affects mortality, hospital length of stay, and treatment. Early recognition and treatment of these infections, combined with strategies to prevent NI, may be important to improve outcomes in this patient population.

Adult↗
PubMed2003

Current concepts in peritonitis.

Peritonitis is a serious and common infection. Its pathogenesis and microbiology have been well defined. Such risk factors as age, site of infection, physiologic response of the patient, presence of organ dysfunction, and malnutrition may influence the outcome of this disease process. The presence of antibiotic-resistant organisms and delays in operative intervention are also associated with treatment failure and higher mortality. Surgeons have the greatest impact on this disease in their ability to control the source of infection and to administer proper antimicrobial therapy.

Humans↗
PubMed2003

Hypoxia increases nitric oxide concentrations that are not completely inhibited by L-NMMA.

INTRODUCTION: Recent investigations have demonstrated a wealth of knowledge about the biology of nitric oxide (NO) and the synthases (NOS) that generate it, under both physiologic and pathophysiologic conditions. In this study, we investigated the generation of NO under conditions of hypoxia in the absence of confounding functions such as blood loss or hypovolemia. METHODS: Rats were subjected to either 30 or 60 min of hypoxia and sacrificed immediately or after 1 or 24 h of recuperation. Splenocyte proliferative ability and NO concentrations were determined in whole splenocytes and purified T-cell populations, with and without the use of 20 mg/kg L-NMMA, a potent NOS inhibitor. RT-PCR was performed to determine the presence or absence of inducible NOS transcription after hypoxia and hypoxia followed by reoxygenation with and without L-NMMA. RESULTS: Hypoxia followed by reoxygenation stimulated NO production in whole splenocytes, which correlated with a decrease in splenocyte proliferation. T-cell stimulation and NO production were not upregulated under these conditions. Additionally, NO generation occurred following hypoxia, even in the presence of L-NMMA. CONCLUSION: These results demonstrate that NO production after hypoxia may be due to an alternate, O2-independent pathway. Further investigations into the generation of NO through alternate pathways may identify treatments for hypoxia-related injury.

Animals↗
PubMed2003

Gastrointestinal surgery and pregnancy.

Gastrointestinal disorders during pregnancy that require surgery often mimic the symptoms and signs of conditions that do not require surgery. Anatomic and physiologic changes of pregnancy can alter the usual clinical presentation of gastrointestinal disorders that require surgery. These alterations can be a challenge to diagnosis. Prompt treatment is critical to successful management. Most elective and urgent operations can be performed during pregnancy with minimal maternal and fetal risk. The condition of the mother should always take priority because proper treatment of the mother usually benefits the fetus as well.

Digestive System Surgical Procedures↗