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Biomedical subjects

N M Kane

Publications and source records attributed to N M Kane.

At least 37 records · Page 2Linked to original sources
PubMed1993

Cutaneous T-cell lymphoma: CT in evaluation and staging.

Among 63 patients with cutaneous T-cell lymphoma (CTCL), 29% (n = 18) had positive computed tomographic (CT) findings, with frequencies of 65% (n = 13) among patients thought to have stages II-IV disease at clinical examination and 12% (n = 5) among patients thought to have stage I. Among eight patients with atypical CTCL variants such as cutaneous large-cell lymphoma, only one had negative findings at CT; extracutaneous disease was not suspected in five before they underwent CT. In contrast, CT findings were positive in only 5% (n = 2) of patients with classic early mycosis fungoides-type CTCL (scaling patches, small epidermotropic CD4+ cells), and CT is unlikely to provide substantial information in this patient subgroup. Contrary to earlier reports, the authors' data suggest that body CT is extremely useful in staging and evaluating patients with CTCL. CT should be included in the evaluation of atypical CTCL variants, Sézary syndrome, advanced-stage mycosis fungoides, and cases in which the CTCL subtype is unclear.

Aged↗
PubMed1993

Physician influence in interorganizational relationships between academic medical centers and community hospitals.

This study analyzes cooperative interorganizational relationships (IORs) between two different types of health care organizations. It proposes a power perspective analysis to better understand why IORs which represented many rational advantages to both partners were so difficult to realize in practice and often with only modest results. Hypotheses are tested explaining how physicians, as groups, exert important controls and can largely determine the results that can be realized in any IOR aimed at modifying medical education and patient referrals.

Academic Medical Centers↗
PubMed1993

Duodenal injuries caused by blunt abdominal trauma: value of CT in differentiating perforation from hematoma.

OBJECTIVE: Traumatic duodenal perforation requires emergent surgery, whereas duodenal hematoma can often be treated nonsurgically. We assessed the CT findings in patients with blunt duodenal trauma to determine if CT can be used to differentiate these two duodenal injuries. MATERIAL AND METHODS: Seven consecutive patients with blunt duodenal trauma (three with perforation, four with hematoma) who underwent CT as part of their initial diagnostic evaluation were included in the study. All three perforations and one of four hematomas were surgically proved. Diagnoses of duodenal hematoma in the other three patients were based on typical features on upper gastrointestinal studies and complete resolution of clinical findings after conservative treatment. The CT scans were retrospectively reviewed without knowledge of the specific type of duodenal injury, and the findings were correlated with the results of the gastrointestinal studies and surgical findings. RESULTS: CT showed extraluminal gas or extravasated oral contrast material or both in the right anterior pararenal space in all three patients with duodenal perforation and in none of the patients with duodenal hematoma. Thickening of the duodenal wall and fluid in the right anterior pararenal space were seen in both groups of patients. CONCLUSION: Although the number of patients in the study was small, the results suggest that CT may be useful in differentiating duodenal perforation from hematoma without perforation. Extraluminal gas or extravasated oral contrast material or both were seen in the right anterior pararenal space in all three patients who had perforation and in none of the patients who had hematoma alone.

Abdominal Injuries↗
PubMed1991

Percutaneous biopsy of left adrenal masses: prevalence of pancreatitis after anterior approach.

Acute pancreatitis is an unusual but recognized complication of percutaneous aspiration biopsy of the pancreas. As the pancreatic tail is located anterior to the left adrenal gland, percutaneous biopsy of a left adrenal mass via the anterior approach may result in needle passage through the tail of the pancreas with subsequent potential development of pancreatitis. To evaluate this risk, we retrospectively reviewed 48 CT-directed percutaneous aspiration biopsies of left adrenal masses done between 1984 and 1989 at two institutions. Positioning of the patient, the course of the needle, the number of needle passes, and the size of the needle were analyzed. Thirty-three (69%) of 48 biopsies of a left adrenal mass were performed by using the anterior approach. The pancreas was traversed by one or more needles in 32 of 33 cases. Biopsies were performed with 20- to 22-gauge needles, and the number of needle passes varied widely. The medical records of the 33 patients in whom the anterior approach was used also were reviewed for complications. Acute pancreatitis, which required 11-13 days of hospitalization, developed in two patients (6%). None of the other 31 patients suffered a complication. We conclude that the pancreatic tail is routinely traversed by the biopsy needle when biopsy of a left adrenal mass is done via the anterior approach and that severe acute pancreatitis can occur as a result.

Acute Disease↗
PubMed1991

Traumatic pneumoperitoneum. Implications of computed tomography diagnosis.

Pneumoperitoneum detected on plain radiographs following blunt abdominal trauma is nearly pathognomonic of bowel perforation and usually mandates exploratory laparotomy. To determine the significance of computed tomography (CT)-detected pneumoperitoneum, we reviewed the clinical records and imaging studies of all trauma patients in our hospital over a seven-year period whose abdominal CT scans showed free intraperitoneal gas. Patients who had penetrating injuries or peritoneal lavage prior to CT were excluded. Of the 18 patients who met these inclusion criteria, surgically confirmed bowel injury was found in only four (22%). In the remaining 14 patients, no evidence of gastrointestinal perforation was found by exploratory laparotomy (2 patients), diagnostic peritoneal lavage (4 patients), GI studies and clinical follow-up (6 patients), or clinical follow-up alone (5 patients). Seven patients had a pneumothorax as a possible cause for pneumoperitoneum. Two additional patients were on mechanical ventilation. Unlike pneumoperitoneum seen on plain film, CT-detected pneumoperitoneum is not pathognomonic of bowel perforation. While laparotomy is not mandatory in the non-surgically explored patient, close clinical observation is essential, and additional diagnostic tests such as peritoneal lavage or radiographic contrast studies can be beneficial to confirm the absence of intestinal injury.

Abdominal Injuries↗
PubMed1990

Physician-management relationships at HCA: a case study.

The questions of whether Hospital Corporation of America (HCA), a for-profit hospital company, fostered an environment detrimental to the physician-patient relationship during the period of implementation of the Medicare Prospective Payment System (PPS) was explored. The transition to PPS provided an opportunity to evaluate whether hospital ownership differences affected responses to a payment system which encouraged institutional intervention in the practice of medicine. A case study approach was used to observe the influence of the then largest for-profit hospital corporation upon physicians' medical practice in four owned hospitals. Findings indicated that HCA hospital managers were most directly influenced by the local competitive environment and their own personal agendas in responding to PPS incentives. Corporate influence actually softened payment system incentives to intervene in medical practice by providing a generous supply of capital, and by fostering a corporate culture conducive to cooperative relationships with physicians. Better public understanding of the determinants of hospital behavior is needed to preserve or enhance important social goals such as the physician-patient relationship; easily measurable characteristics such as ownership or bed size explain little about hospital behavior or motivation.

Economic Competition↗
PubMed1989

The effect of the Medicare prospective payment system on the adoption of new technology. The case of cochlear implants.

Since the advent of Medicare's prospective payment system, beneficial but cost-increasing medical advances have been systematically assigned to existing diagnosis-related groups (DRGs) that do not cover the costs of the new technology. Recent evidence suggests that such underpayment reduces the rate at which hospitals adopt that technology. Safeguards designed to offset the negative incentives of underpayment, including the recalibration of DRG values, update factors, and the allowance of Medicare profits, appear not to have worked. We studied the case of cochlear implantation. Years after Food and Drug Administration approval and a favorable decision about Medicare coverage, payment for the device remains well below its average cost, and many hospitals ration the availability of the device to Medicare patients because of the financial losses involved. Eventually, so few patients received the implant that the original manufacturer discontinued its production. Under the DRG system, negative payment incentives compete with clinical considerations when hospitals and physicians decide whether to adopt specific cost-increasing new forms of technology of proved value. Other payment mechanisms that do not insert arbitrary financial considerations into specific treatment decisions should be considered instead.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1989

The home care crisis of the nineties.

The supply of acceptable quality, paid custodial home care is threatened by the increasingly precarious financial condition of providers. Examined were the trends of the publicly-owned, for-profit providers. Restrictive public payments and the lack of private insurance coverage have contributed to the financial woes. Changes are urgently needed which address the financing of home care.

Aged↗
PubMed1989

The value of CT in the detection of bladder and posterior urethral injuries.

To determine the value of CT in the diagnosis of bladder and posterior urethral injuries, we retrospectively evaluated the CT and urethrocystographic findings in 33 trauma patients with suspected injuries of the lower urinary tract who had both studies in their initial evaluation. In 26 (79%) of 33 patients, results of both examinations were normal. Seven (21%) of 33 patients had bladder injuries (seven--two in one patient) and/or posterior urethral injuries (three) as determined on the basis of urethrocystography. Three patients had extraperitoneal bladder tears as the only injury to the lower urinary tract. Two patients had both extraperitoneal bladder tears and posterior urethral injuries. One patient had both an extraperitoneal tear at the bladder base and an intraperitoneal rupture at the bladder dome. The seventh patient had an isolated posterior urethral injury. All seven bladder injuries were detected with CT. In these cases, CT findings included (1) free intraperitoneal contrast material (one case), (2) focal contrast extravasation (three cases), and (3) paravesical fluid collections that on delayed CT scans revealed contrast accumulation in the fluid, indicating extravasation (two cases). The seventh bladder injury was suspected on CT and confirmed with retrograde urethrography. Only one of three posterior urethral injuries was detected with CT. Our results suggest that CT is sensitive in the detection of bladder injuries, but not for the diagnosis of urethral injuries.

Adolescent↗
PubMed1988

Pediatric abdominal trauma: evaluation by computed tomography.

When indications for immediate laparotomy are not present, CT of the abdomen and pelvis can be used to evaluate pediatric blunt abdominal trauma. During 2-year period, the medical records and abdominal/pelvic CT scans of 100 consecutive pediatric patients who were evaluated for blunt abdominal trauma were retrospectively reviewed. The scans appeared normal for 73 children. Of these children, 30 had severe head injuries and a depressed sensorium. A total of 27 abdominal/pelvic CT scans were interpreted as abnormal. Findings included nine splenic fractures, six renal contusions, nine hepatic lacerations, one duodenal hematoma, one traumatic pancreatitis, four bony injuries, six miscellaneous abnormalities, and one intraperitoneal bleed. Only two of these 27 patients required abdominal surgery. The remaining 25 patients were treated conservatively based upon a stable clinical state and CT delineation of the extent of injury. No mortality resulted. CT is the radiographic examination of choice for hemodynamically stable pediatric patients with blunt abdominal trauma. CT provided a reliable adjunct examination technique when a physical examination could not be performed and a complete history could not be obtained. The extent of abdominal/pelvic injuries is well delineated and can often be followed by diagnostic imaging, usually allowing for conservative therapy.

Abdominal Injuries↗
PubMed1986

Coronary angioplasty under the prospective payment system: the need for a severity-adjusted payment scheme.

To evaluate the adequacy of Diagnosis Related Group prospective payment for percutaneous transluminal coronary angioplasty, the clinical characteristics, length of stay and hospital charges of all patients undergoing this procedure at Boston's Beth Israel Hospital during a 100 day period were examined. Of 113 such patients, the 61 patients in whom nonelective dilation was performed for unstable or postinfarction angina had a significantly greater length of stay and total hospital charge (10 +/- 6 days and $14,700 +/- $7,400, respectively) than did the 52 patients in whom elective dilation was performed (6 +/- 5 days and $8,500 +/- $7,700, respectively, p less than 0.0001). Under the current prospective payment system, however, these two groups of patients would have been placed in the same Diagnosis Related Group, and would have thus commanded equal institutional reimbursement. One potential revision of the payment system is presented to help to deal with this disparity.

Adult↗
PubMedDate not supplied

Efficacy of CT following peritoneal lavage in abdominal trauma.

Peritoneal lavage and abdominal/pelvic CT are described in the radiologic and surgical literature as alternative techniques in the evaluation of blunt abdominal trauma. The relative merits of each technique have been discussed, and it has been stated that postlavage CT is not useful because of the residual peritoneal fluid. A retrospective study of 48 patients who underwent postlavage CT was performed over 34 months. Despite residual lavage fluid, CT provided specific and clinically useful information in 58% of patients following peritoneal lavage. A variety of intraperitoneal and retroperitoneal traumatic lesions were imaged using postlavage CT. We conclude that postlavage CT is often clinically useful in the patient who has incurred blunt abdominal trauma, irrespective of the peritoneal lavage results.

Abdominal Injuries↗
PubMedDate not supplied

CT findings in tuboovarian abscess.

As there are little data in the radiologic literature regarding the CT appearance of and the associated findings of tuboovarian abscesses (TOA), we retrospectively reviewed CT from seven patients with nine TOAs. They were bilateral in two patients and unilateral in the remaining five. The most common appearance of these abscesses was that of a somewhat tubular septated cystic pelvic mass with uniform wall thickness and with loss of fat planes between the mass and the adjacent pelvic organs (usually the uterus when present). Ipsilateral ureterectasis was also seen in four of nine lesions. Although these findings are not specific for TOA, they should be considered when pelvic masses having the above configuration are seen on CT.

Abscess↗
PubMedDate not supplied

Coma outcome prediction using event-related potentials: P(3) and mismatch negativity.

The prediction of the outcome from coma is of considerable importance to the patients, their relatives and attendant medical staff, and yet current clinical methods lack sensitivity and specificity. Objective investigations can enhance the accuracy of such predictions and are an important adjuvant when reaching decisions to continue or terminate life support. Of the neurophysiological methods available, electroencephalography and short-latency somatosensory evoked potentials have proved the most useful in the clinical setting. These tests are good predictors of an adverse outcome; however, they tell us only about the ongoing cerebral activity and integrity of the primary somatosensory pathways, respectively. The presence of long-latency event-related potentials has been shown to be a useful predictor of a favourable neurological outcome, and thus their use complements other neurophysiological techniques. Their potential application in clinical practice is reviewed.

Arousal↗