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Biomedical subjects

R E Falcone

Publications and source records attributed to R E Falcone.

At least 19 recordsLinked to original sources
PubMed2000

Treatment of gram-positive nosocomial pneumonia. Prospective randomized comparison of quinupristin/dalfopristin versus vancomycin. Nosocomial Pneumonia Group.

Nosocomial pneumonia is a frequent complication in hospitalized patients. Gram-positive pathogens, particularly Staphylococcus aureus, are responsible for the increasing frequency of nosocomial pneumonia. To evaluate the efficacy and safety of intravenous quinupristin/dalfopristin (Synercid) in the treatment of nosocomial pneumonia caused by gram-positive pathogens we conducted a prospective, randomized, open-label, international, multicenter, comparative clinical trial. Two hundred ninety-eight patients with nosocomial pneumonia were enrolled in 74 active centers in five countries: a subgroup of 171 (87 quinupristin/dalfopristin-treated and 84 vancomycin-treated patients) were evaluable for the major efficacy end points. One hundred fifty received 7.5 mg/kg of quinupristin/dalfopristin every 8 h; 148 patients received 1 g of vancomycin every 12 h. Aztreonam at a dose of 2 g every 8 h could be administered in both groups for coverage of gram-negative organisms, and tobramycin was added for coverage against Pseudomonas aeruginosa. The primary efficacy end point was the clinical response between the seventh and the thirteenth day after the end of treatment in clinically evaluable patients with documented causative pathogen(s) at baseline (bacteriologically evaluable population). Therapy was clinically successful (cure or improvement) in 49 (56.3%) of patients receiving quinupristin/dalfopristin and 49 (58.3%) patients receiving vancomycin (difference, -2.0% [95% CI, -16.8% to 12.8%]) in the bacteriologically evaluable population. Equivalent clinical success rates were also observed in the all-treated population (n = 298), and in the bacteriologically evaluable patients intubated in baseline (39/72 [54%] compared with 36/67 [54%]). The by-pathogen bacteriologic response was similar in both treatment groups, with equivalent clinical success rates for Streptococcus pneumoniae, Staphylococcus aureus, and methicillin-resistant Staphylococcus aureus. Adverse events (venous and nonvenous) were equally distributed between groups; 15.3% of quinupristin/dalfopristin patients and 9.5% of vancomycin patients discontinued therapy because of an adverse clinical event. In this study quinupristin/dalfopristin was shown to be equivalent to vancomycin in the treatment of nosocomial pneumonia caused by gram-positive pathogens. Quinupristin/dalfopristin merits further evaluation for the treatment of nosocomial pneumonia caused by methicillin-resistant S. aureus.

Adult↗
PubMed1998

Glottic positioning of the endotracheal tube tip: a diagnostic dilemma.

Distal placement of the endotracheal tube tip in the glottic opening is rarely discussed in most emergency medicine, surgery, and prehospital medicine texts. We report three cases of glottic intubation recognized after the patients were thought to have been successfully intubated. Glottic positioning of the endotracheal tube tip went unrecognized initially because of the absence of air heard over the epigastrium, the presence of bilateral breath sounds, and acceptable readings by both pulse oximetry and capnography. Recognition of this complication is aided by the use of radiographic findings, inappropriate endotracheal tube depth, and the presence of inadequate ventilatory volumes. Potential complications of glottic intubation include dislodgement of the endotracheal tube, kinking of the tube, and inadequate protection of the airway.

Adult↗
PubMed1998

Confirmation of nasogastric tube placement by colorimetric indicator detection of carbon dioxide: a preliminary report.

BACKGROUND: Inadvertent insertion of nasogastric tubes into the trachea and distal airways is reported to range from 0.3% to 15% of insertions. Critically ill, mechanically ventilated patients are at a higher risk for such complications, some of which can be fatal. OBJECTIVE: This preliminary prospective clinical investigation was designed to determine whether a colorimetric carbon dioxide (CO2) indicator device (Easy-Cap, Nellcor, Inc., Hayward, CA) attached to the proximal end of a small bore feeding tube (FT) would reliably discriminate between those tubes passed into the airways and those passed into the alimentary tract. METHODS: Ten critically ill, mechanically ventilated trauma patients requiring a FT insertion were evaluated. An Easy-Cap device was adapted to the proximal port of each FT. Each patient had one tube inserted per the nasogastric route and then another through the endotracheal tube while the Easy-Cap was observed for color changes consistent with the presence of CO2. RESULTS: All transtracheal insertions showed immediate and unambiguous color changes consistent with the presence of CO2. None of the nasogastric insertions resulted in indicator color changes and all were confirmed with radiography (sensitivity 100%, specificity 100%, accuracy 100%). CONCLUSIONS: This preliminary report suggests colorimetric CO2 detection accurately and reliably identifies transtracheal FT insertion.

Adult↗
PubMed1998

Early detection of hemoperitoneum by ultrasound examination of the right upper quadrant: a multicenter study.

BACKGROUND: The focused assessment for the sonographic examination of the trauma patient (FAST) is a rapid diagnostic test that sequentially surveys for hemopericardium and then the right upper quadrant (RUQ), left upper quadrant (LUQ), and pelvis for hemoperitoneum in patients with potential truncal injuries. The sequence of the abdominal part of the examination, however, has yet to be validated. The objectives of this multicenter study were as follows: (1) to determine where hemoperitoneum is most frequently identified on positive FAST examinations; and (2) to determine if a relationship exists between that areas and the organs injured. METHODS: Ultrasound registries from four Level I trauma centers identified patients who had true-positive FAST examinations. Demographic data, areas positive on the FAST, and organs injured were recorded; injuries were classified as multiple, single solid organ (liver or spleen), isolated hollow viscus, or retroperitoneal. Relationships between positive locations on the FAST examinations and the associations of organs injured to areas positive were assessed using McNamara's chi2 test; a p value < 0.05 was considered statistically significant. RESULTS: The RUQ was the most common site where hemoperitoneum was detected, and this was statistically significant compared with either the LUQ or the pelvis. Also, statistically significant correlations (p < 0.001) were observed between positive RUQ areas on the FAST and multiple injuries, single solid organ (liver or spleen) injury, and retroperitoneal injuries. CONCLUSION: Blood is most often found on the FAST in the RUQ area in patients with multiple intraperitoneal injuries or isolated injury to the liver, spleen, or retroperitoneum, but not when there is injury to a hollow viscus.

Abdominal Injuries↗
PubMed1997

Ultrasound evaluation of blunt abdominal trauma: program implementation, initial experience, and learning curve.

OBJECTIVE: Although sonographic screening for blunt abdominal trauma is gaining acceptance, standards for implementation, training, credentialing, and quality control remain to be established. DESIGN: This prospective study examines a Level I trauma service experience with the de novo establishment of a trauma ultrasound (US) program credentialed through the Department of Surgery under the auspices of Continuous Quality Improvement. MATERIALS AND METHODS: All trauma surgeons attended a combined didactic and "hands on" 8-hour trauma US course. Abdominal sonography was subsequently performed on patients with potential blunt abdominal trauma followed by a standard diagnostic evaluation, which included computed tomographic scan, diagnostic peritoneal lavage, or observation. MEASUREMENTS AND MAIN RESULTS: Three hundred patients were studied over a 4-month period. They averaged 35 years of age with an average injury severity score of 12. The time required to perform the US examination averaged less than 3 minutes. Standard diagnostic evaluation included computed tomographic scan (21%), diagnostic peritoneal lavage (45%), and observation (34%). US examinations resulted in 277 true negatives, 17 true positives, two false positives, and four false negatives for a sensitivity of 81.0%, a specificity of 99.3%, and an accuracy of 98.0%. Annualized cost savings with the use of US evaluation versus standard diagnostic evaluation would amount to over $100,000.00. CONCLUSIONS: This experience with the de novo implementation of a trauma US program suggests that the training and credentialing requirements in this study are sufficient to provide surgeon ultrasonographers with acceptable competence in US diagnosis of blunt abdominal trauma.

Abdominal Injuries↗
PubMed1997

Safety and efficacy of diagnostic peritoneal lavage performed by supervised surgical and emergency medicine residents.

Diagnostic peritoneal lavage (DPL) remains an accurate diagnostic test for intra-abdominal injury. This study examined the safety and efficacy of DPL performed by supervised residents in an urban trauma centre. A retrospective chart review was carried out of a one year experience (July 1994-June 1995). Junior surgical and senior emergency medicine residents rotating on the Trauma Service performed an open DPL by protocol under the direct supervision of senior surgical residents. Standard criteria were used for diagnosis. During this study, 1349 injured patients were admitted to the Trauma Service. Of these 525 patients underwent DPL. Complete records were available on 516 patients. The average age of the patients was 33 years and injury was primarily blunt (95%). There were 72 true positives, 428 true negatives, two false positive and seven false negative DPLs; for a sensitivity of 91.1%, specificity of 99.5% and accuracy of 96.9%. Complications occurred in 12 patients (2.3%): non-diagnostic DPL-7 (1.3%); intraabdominal injury-4 (0.8%); wound complication-1 (0.2%). Seven patients underwent non-therapeutic laparotomy for a positive DPL. Thirty-four patients (6.6%) died, none from the DPL. DPL obviated the need for computed tomography scan of the abdomen and/or pelvis in 464 patients resulting in a cost saving of approximately $250,000. DPL performed by supervised junior surgical and senior emergency medicine residents is a safe and cost-effective method of evaluating patients with potential intra-abdominal injury.

Abdominal Injuries↗
PubMed1995

Breast reduction for symptomatic macromastia: can objective predictors for operative success be identified?

The purpose of this paper is to assess symptomatic macromastia, the relief of symptoms by operation, and predictors of symptom relief. The methods used have been retrospective chart review and a self-assessment patient questionnaire. One-hundred and thirty-three patients underwent an average 1660-gm reduction. Ninety-three percent reported a postoperative decrease in symptoms such as shoulder grooves and shoulder, neck, and back pain. Correlation between breast size and sign or symptom severity achieved significance only for the preoperative submammary rash (r = 0.33, p < 0.001). Patients lost an average of 8.9 lb postoperatively and were less overweight (49 versus 40 percent). Activity level increased postoperatively in 63 percent. Postoperative chest size correlated inversely with activity level (r = 0.35, p < 0.001). Thirty-nine percent of patients who took pain medications preoperatively were able to eliminate these postoperatively. The quantity of tissue removed did not correlate with outcome. A model predictive of symptom relief could not be developed (total R2 = 0.03). Reduction mammaplasty promoted relief of signs and symptoms of macromastia, but a predictive model of successful operation could not be developed.

Back Pain↗
PubMed1993

Is air medical scene response for illness appropriate?

The purpose of this study was to determine the appropriateness of air medical scene response for illness. The study consisted of a retrospective chart review of a two-helicopter urban air medical transport program with a transport volume of 1,700 flights annually. During the study period, January 1988 through March 1990, 68 patients were transported by helicopter from scene of illness to a tertiary care facility. In cases in which patients could be managed appropriately locally, air transport was deemed unnecessary. Of the 68 patients with illness, 40 were males and 28 were females; the average age was 39.2 years (from a range of 0 to 93). The average transport time was 46.3 minutes. Dispatch diagnoses were cardiac arrest (20), seizure (14), myocardial infarction (8), overdose (6), stroke (5), labor (4), respiratory distress (3) and miscellaneous (8). The discharge (final) diagnosis was different from dispatch diagnoses in 10 patients (14.7%). Fifty-four patients (79.4%) required no tertiary care, and 30 of them were discharged from the emergency department or were pronounced dead there or at the scene. The results of the study indicate air medical response to scene of illness did not appear justified in this study. Transport should be local, by ground, with subsequent tertiary care being arranged as needed. Further prospective study is warranted.

Aircraft↗
PubMed1993

Laparoscopic vs. open wedge biopsy of the liver.

This study was a post-hoc evaluation of laparoscopic versus open wedge biopsy of the liver performed as part of prospective phase I antibiotic trial. Consenting patients undergoing elective cholecystectomy were enrolled in a protocol which required samples of bile, blood, the gallbladder, and 1 gram of liver tissue. The study occurred during the evolution of laparoscopic surgery. Liver biopsy was done in standard fashion and laparoscopic liver biopsy was accomplished with cauterized scissors. Twenty-four patients, 4 male and 20 female averaging 42.1 years of age, were entered in this study. Eighteen patients underwent laparoscopic surgery and six patients underwent open surgery. They did not differ significantly in age (43.9 vs 42.1 years), operating room time (58.3 min vs 55.8 min), or complications (2/18 vs 2/6). Patients undergoing laparoscopic surgery, however, did have a shorter hospital stay (1.1 days vs 3.5 days, p < 0.001). All liver specimens were considered adequate. There were no complications related to the liver biopsy. Laparoscopic wedge biopsy of the liver is both a feasible and viable alternative to open wedge biopsy.

Adult↗
PubMed1993

Occurrence of nosocomial pneumonia in mechanically ventilated trauma patients: a comparison of sucralfate and ranitidine.

OBJECTIVE: To determine if there is a difference in nosocomial pneumonia frequency rate in mechanically ventilated trauma patients treated with sucralfate vs. ranitidine for stress ulcer prophylaxis. DESIGN: Prospective, randomized trial. SETTING: A 640-bed urban teaching hospital and trauma center. PATIENTS: Ninety-two mechanically ventilated trauma patients. INTERVENTIONS: Thirty-nine patients received sucralfate and 44 patients received intravenous ranitidine for stress ulcer prophylaxis; nine patients were excluded from the study for protocol breaks. MEASUREMENTS AND MAIN RESULTS: The study population was severely injured and critically ill. The Trauma Score averaged 11.3, the Injury Severity Score averaged 27.7, and the Acute Physiology and Chronic Health Evaluation (APACHE) score averaged 18.1. There were no significant differences in demographics, mechanisms of injury, Trauma Score, Injury Severity Score, APACHE score, length of hospital stay, length of surgical intensive care unit stay, or duration of endotracheal intubation between the sucralfate and ranitidine groups. Eleven (13.2%) patients developed nosocomial pneumonia: six (15.4%) of 39 patients in the sucralfate group and five (11.4%) of 44 patients in the ranitidine group; these numbers were not significantly different (chi 2 = 0.0226, p = .8805). There were no episodes of significant upper gastrointestinal bleeding. Six patients died during hospitalization, all secondary to severe head injury and none with pneumonia. CONCLUSIONS: There was no statistically significant difference in pneumonia rate in mechanically ventilated trauma patients receiving stress ulcer prophylaxis with sucralfate vs. ranitidine.

Adolescent↗
PubMed1992

Colorectal trauma: primary repair or anastomosis with intracolonic bypass vs. ostomy.

This prospective, randomized, controlled study was undertaken to compare primary repair or anastomosis with intracolonic bypass vs. ostomy in severe colon and intraperitoneal rectal injury. Patients were randomized at surgery following confirmation of injury. Data collected included demographics, mechanism and location of injury, trauma score (TS), injury severity score (ISS), penetrating abdominal trauma index (PATI), complications, length of hospital stay, and hospital charges. Twenty-two patients were studied: 11 with intracolonic bypass and 11 controls. The experimental and control groups were statistically similar in demographics and mechanism of injury, severity of injury (TS = 13.8 vs. 12.8; ISS = 27.5 vs. 24.2; PATI = 40.5 vs. 35.0), and complication rate. Length of stay (12.2 days vs. 20.7 days) and charges $27,885 vs. $53,599) tended to be greater in controls, and the comparison did not include subsequent colostomy closure. This study supports intracolonic bypass as a safe alternative to ostomy in severe colon and intraperitoneal rectal trauma.

Adolescent↗
PubMed1992

Physician review improves hospital DRG reimbursement in injury.

This was a prospective study of all DRG reimbursed trauma patients discharged during an 11-month period. Initial DRGs were assigned by hospital coding specialists (HCS). A surgeon (SURG) subsequently reviewed each chart and assigned DRGs to maximize reimbursement. The data for 244 patients were: age = 36.5 years, Trauma Score (TS) = 13.8, Injury Severity Score (ISS) = 16.9, and length of stay (LOS) = 10.3 days. Total charges for the 244 patients were $4,261,208 with an initial HCS projected reimbursement of $1,687,963. The SURG review resulted in a total projected reimbursement of $1,956,476, an increase of $268,513 in revenue (p less than 0.001). Charges correlated strongly with LOS and ISS. The HCS-coded and SURG-coded reimbursements also correlated positively with LOS and ISS, but to a lesser extent. The SURG review of DRG assignment improved hospital reimbursement for the injured patients. However, this reimbursement fell well below hospital billings.

Abstracting and Indexing↗